Psychotherapy in Scotland @ Talkingcure.co.uk - You are now entering ... The Twilight Zone

"A zone lying on the border between two indistinguishable fields, situations, subjects, or groups and exhibiting a blend of the characteristics of both without the distinctiveness of either."

Webster's Third New International Dictionary

This article, published in Ipnosis, No 9, Spring 2003, was originally developed from a training workshop held during the 2002 COSCA/European Association for Counselling conference in Edinburgh, Scotland.

Effective counsellors and psychotherapists have always appreciated the importance of accommodating the client's beliefs, values and perceptions in the therapeutic process. Conversely, we know that the successful client participates actively in counselling or psychotherapy, enthused by the professional relationship, rationale and rituals offered by the therapist. However, in their search for the common ground that will lead to progress, either or both parties to this meeting of minds may be drawn far from their usual orthodoxies or comfort zones. Then, they have entered therapy's Twilight Zone.

This article will discuss how knowledge of psychotherapy outcome research can raise our confidence and effectiveness when we find ourselves working in the Twilight Zone.

Diagram of what influences outcome We are now fortunate in having a substantial body of research evidence to understand what generally influences outcome in psychotherapy. The recent scientific appraisal by Wampold (2001) is exemplary, and the effects on outcome he determined are summarized in the figure to the right and the table below.

The very small contribution of specific effects relative to general effects convincingly demonstrates that the benefits of psychotherapy are best explained by a contextual model rather than a medical model. In the latter, a standardized treatment with specific ingredients assumed to be remedial is prescribed according to a diagnosis of the client's problem. A contextual model (for example, Frank & Frank, 1991) predicts that improvement is due primarily to general effects and takes into consideration all the circumstances of the individual case, including client, therapist, relational and situational factors. So, despite the academic effort which has been expended in recent years on the search for therapeutic specificity (so-called "empirically supported treatments" - ESTs), what really matters most to clients is much more mundane and common to all bona fide therapies.

Effect	Size
Absolute efficacy of psychotherapy							Large
Specific ingredients of a given psychotherapy	None	/	Small
Placebo (hope and expectancy) effects			Small	/	Medium
Therapeutic alliance			Small	/	Medium
Variation in therapists					Medium	/	Large
Variation in clients			Small	/	Medium
Therapist allegiance to their therapy					Medium	/	Large

An interesting paradox becomes apparent. The specific ingredients of a given therapeutic approach are relatively unimportant to clients, yet the therapist's enthusiastic belief in the efficacy of their particular brand of therapy (allegiance) has a major effect on outcome. However, research findings explain this paradox by indicating that good therapists use their approach to structure and focus the therapy, and, of course, confidence and enthusiasm are infectious, enhancing alliance and placebo effects. We note that the variation in outcome due to different therapists within a given therapeutic approach is far greater than the variation due to different approaches.

The first part of the diagram below shows where the Twilight Zone exists between the very different worldviews of a therapist and their client. Focusing on the process of therapy in the second part, we can see that the Twilight Zone also exists between the therapist's and the client's beliefs and ideas about how beneficial change may happen. It can be useful to describe these as constituting a theory of change. The therapist's theory of change is formally rooted in their therapeutic approach, but the client's theory of change will generally be much more informal, rooted in their life experience. Reconciling these theories and negotiating the goals and tasks of therapy until both parties are satisfied may take time and effort, but helps greatly to empower the factors above which improve outcome. When both the therapist and client participate actively through a good working alliance and believe that the therapy will be efficacious, it is likely to be so.

The Institute for the Study of Therapeutic Change (2002) has clearly described how the client's theory of change can be learned by the therapist:

"The process of learning a client's theory of change begins with simply listening for and then amplifying the stories, experiences, and interpretations that clients offer about their problems as well as their thoughts, feelings, and ideas about how those problems might be best addressed. Curiosity about client hunches not only provides access to their theory of change but also, by emphasizing client input, encourages more active participation in treatment - the most important determinant of outcome. Investigating clients' usual methods of or experiences with change can also provide clues to their theories of change. For example, therapist and client can consider how change usually happens in the client's life, paying particular attention to sequence of events, the way the client talks about the role they and others play in the initiation and maintenance of any change, and the success or failure of any attempts to resolve this as well as previous problems."

We can now glimpse at some real cases where the therapist initially floundered in the Twilight Zone, far from the haven of their usual way of doing therapy. In each of these situations, knowledge of the common psychotherapeutic factors and a willingness to honour the client's theory of change eventually contributed to successful outcomes. (Some details have been changed for confidentiality.)

A woman bereaved some time ago was referred by another counsellor who felt frustrated that the grieving and counselling processes were at a standstill. The client attended very reluctantly and, to the new therapist's chagrin, declared emphatically that there could be "absolutely no change" in her situation. For a change-oriented therapist, this theory of (no) change was an anathema, but the client's view was respected, and emphasis was placed on building the therapeutic relationship rather than anticipating change. The therapist's allegiance to their therapy was maintained by acknowledging that precontemplation was indeed a valid stage of change. Therapy ended after a couple of sessions, still with no change envisaged, but with the client's current coping validated and some tentative encouragement to imagine the future. Some weeks later, the therapist learned that the client had taken significant steps forward: socializing more, going on holiday, and meeting a new male friend.

A "possibly psychotic" man attending college was referred by a GP for help with stress management. At the first session, the client opened by disclosing relationship and child access frustrations and revealed some of his exceedingly rough upbringing, where each day had brought a new fight for survival. However, this was swiftly followed by a rising crescendo of grievances and provocative challenges about various agencies and authorities, the government, individuals and groups from history, and other targets. Although rather taken aback at the intensity of this tirade, the therapist felt that enough rapport had been established to debate the issues further with the client. Only afterwards did the therapist realize just how heated the "debate" had become, and real doubts set in about the wisdom of being drawn into a loud argument with such a client. However, the client had readily agreed to return, and turned up at the second session calm, saying, "I've been thinking about what we talked about ..." The client had appreciated the therapist's involvement in what was, to him, a normal way of achieving anything worthwhile in life. Therapy then moved easily to exploring options and practical problem-solving. Significant improvement was reported by the client and verified later by the referring GP.

A young woman was referred with typical symptoms of severe anxiety and lowered self-confidence. The therapist gave her the usual cognitive/behavioural spiel about relaxation and exercise and how to challenge anxiety-provoking thoughts. However, although polite, the client was not really responsive to these suggestions, and the therapist gradually opened up the discussion to explore wider issues. After a while, the client stated that she "needed to be able to say 'no' more often", but was hesitant to elaborate further. With gentle encouragement, she eventually revealed her very unusual goal for therapy: to refuse to participate in the videoing of a three-in-a-bed romp with her partner and one of his relatives! The surprised therapist, already far from typical cognitive/behavioural goals, resisted asking more about the client's lifestyle and committed to helping her reach her goal by rehearsing how she would assert herself. This was achieved successfully in practice, and a calmer, more confident client ended therapy soon after.

Working in therapy's Twilight Zone can present a counsellor or psychotherapist with unusual, and sometimes disturbing, challenges to their modus operandi. But, by facing these challenges and keeping in mind what really matters to client outcome, the Twilight Zone can exhort us to do some of our very best therapeutic work. I hope that this article will raise your confidence and expectation of success when that worried little voice in your head warns you that: "You are now entering ..."

Frank, J D, & Frank, J B (1991). Persuasion and Healing: A comparative study of psychotherapy (3rd ed). Baltimore: John Hopkins University Press.
Hubble, M A, Duncan, B L, & Miller, S D (Eds) (1999). The Heart and Soul of Change: What works in therapy. Washington, DC: American Psychological Association.
Institute for the Study of Therapeutic Change (2002). http://www.talkingcure.com.
Wampold, B E (2001). The Great Psychotherapy Debate: Models, Methods, and Findings. Mahwah, New Jersey: Lawrence Erlbaum Associates.


Therapist’s worldview		Client’s worldview

Therapist’s theory of change (formal)		Client’s theory of change (informal)


Contents Introduction What influences psychotherapy outcome Working in the Twilight Zone Case studies References		You are now entering ... The Twilight Zone *by Douglas McFadzean*
		"A zone lying on the border between two indistinguishable fields, situations, subjects, or groups and exhibiting a blend of the characteristics of both without the distinctiveness of either." Webster's Third New International Dictionary
		This article, published in Ipnosis, No 9, Spring 2003, was originally developed from a training workshop held during the 2002 COSCA/European Association for Counselling conference in Edinburgh, Scotland.