How can we tell if therapy is working? Part 1

How can we tell if therapy is working?  Some guidelines for clients and therapists were recently discussed by Prof. Nancy McWilliams, the world renowned therapist.  This is the first of two articles considering her key points that can help us know when therapy is effective.

It is all too easy for therapist and client to think the goal of psychotherapy as being the alleviation of symptoms.  This is the view of psychoactive drugs.  Identify a list of symptoms, treat the symptoms, and the problem is solved.   But an absence of symptoms does not mean that the client is living a truly good life, nor living anywhere near their potential.  So it is important that therapists consider what a truly good life might look like, and not just focus on the life without symptoms.  

The following are elements of a good life, and can be indicators of progress:

1. A sense of safety and attachment security.  An important part a good life is the ability to develop ‘epistemic trust’.  Epistemic trust refers to the ability to accept new information from another person as trustworthy, generalizable, and relevant.  In other words do we feel that we can trust others to be believable and a source of comfort rather than being a source of torment?

2. A sense of self-continuity, referring to a sense of being essentially the same person going through time and space.  While everyone gets into difficult self states, and may not have a perfectly stable sense of self over time.  In extreme cases, however, people experience themselves totally differently in one as compared to at other times.  They lack a sense of continuity through time.  

3. An ability to see both good and bad in the self and others and not to flip from all good to all bad.  

4. A sense of continuity with our body. The body can, to a greater or lesser extent, be seen and treated as a foreign object.  The body is thought of as an ‘it’ that the person may not like, that does not deserve to be cared for, that can be abused, cut, burned, or starved.

5. A sense of agency or self efficacy.   In other words, the sense that you are able to influence your life and make choices.  This manifests in a number of ways.  For example, people who don't know how to say what they want or that find themselves constantly resenting others for not automatically knowing what they need.  Often the capacity to have their needs met, or to state their needs, comes up against shame.

6. An understanding that we do not need to be perfect, only good enough. Perfectionists often struggle with this one, by having an unreasonably strict criteria for their self esteem to meet.  Nothing you do seems to be ok.  The inverse is also true, when people see everything they do as perfect and cannot tolerate any degree of failure.

7. Related to this is the ability to be criticised (or admired) without falling apart.  Can you tolerate negative feedback without becoming overly defensive or depressed?  And less obviously but equally important, can you tolerate being admired and praised without becoming overwhelmed by it.  In other words, can you keep a general sense of who you are at these times?