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Review: The Heart and Soul of Change: What Works in Therapy by Mark Hubble, Barry Duncan, and Scott Miller
Hubble, M.A., Duncan, B.L., and Miller, S. D. (1999).
The heart and soul of change: What works in therapy.
American Psychological Association (APA); Hardcover,
462 pages, ISBN: 155798557X
They have said that God is dead, and it may be so. But I believe that the god who is dead is the god in the cage, the zoo god…. (T)he wild god, the god that cannot be captured by our wills or our intellects - the wild god who will not be domesticated - is as alive and as free as ever…. The wild god is more than the god of evolution; the wild god breathes revolution as well…. Psychotherapy that is truly the nurturing of the spirit or soul must be the search for the wild god, the god of mystery, the god back of god. (James Bugental, 1987, The Art of the Psychotherapist)
Human beings, it seems, have always been interested in change. Metanoia, conversion, transformation, regeneration, re-vitalization, alteration, rebirth, metamorphosis, reawakening, resurrection, are just some of the terms that denote the importance of and our preoccupation with change in human life. Not surprisingly then human beings create concepts, theories, techniques, and research that deal with change in human life. Even our cultural and religious myths and legends describe the process, context, and consequences of change. And yet, we are often confounded by change, wondering what happened that made change possible at this moment and not others. The paradox is that we know a great deal about change and it still remains a mystery, wild and uncaged by our concepts and theories.
Hubble, Duncan, and Miller have edited an excellent and comprehensive book, The Heart and Soul of Change, that attempts to follow and take pictures of, not capture, this wild god of change. Their ambitious goal is to help mental health practitioners (and policy makers) identify and understand some of the variables in therapy that promote change. On the one hand, this book stands in a long history of discourse that addresses, in one form or another, change in human life. On the other hand, this book is unique both in terms of its comprehensive review of the literature about change in therapy and also in its refusal to be the last or definitive word about change. The authors carefully and respectfully raise points and questions about the implications of their findings, leaving the reader to search and discover other answers and questions. I find that they retain the inherent paradox in our attempts to grasp the attributes of change. Anyone involved in the practice and teaching of counseling or therapy would benefit from reading this book.
Below I proffer a brief review of their book along with some of my own questions, in hopes that a sample will whet the reader's appetite to read and discuss the book with others. The first part of the book addresses the questions: 1) Is therapy effective? 2) If so, what are the common factors among the diverse therapy theories that are important in making therapy effective? The answer to the first question is a resounding yes. Numerous empirical studies over the past thirty years have consistently demonstrated the effectiveness of numerous therapy modalities. "The general finding of no difference in the outcome of therapy for clients participating in diverse therapies has several alternative explanations. First, different therapies can achieve similar goals through different processes. Second, different outcomes do occur but are not detected by past research strategies. Third, different therapies embody common factors that are curative" (p.29: emphasis mine). This can be reassuring, but also disturbing if we base our hopes for change in our allegiance to a theory or therapy tradition. Research confirms the helpfulness in helping people change, but what are the variables that enable change to occur?
The answer to the second question is a bit more complex and one that is explored in greater depth in the remaining chapters. Lambert and Asley group those factors involved in change under four headings, indicating which factors are more influential: client variables and extratherapeutic factors 40%, therapeutic relationship 30%, placebo effects 15%, and techniques 15%. In this chapter it becomes clear that the client and the quality of the relationship between the client and therapist are by far more significant in effecting change than theory or technique. This suggests that we give more credit to the client's ability to believe in and make use of therapy and less to the theories we hold and the therapist's personality. These findings may be upsetting to those of us who have the zoo god safely trapped and controlled by their theories. I believe this first chapter helps us realize that the wild god cannot be caged by any single theory or relationship. In realizing the wild god is not caged, we may become freed from our totalitarian tendency and thus be more open to explore and appreciate other approaches. Moreover, we might recognize and catch glimpses of the wild god in the client and therapeutic relationship.
The second part of this book is devoted to delving more deeply into each of the common factors. I briefly highlight some of the main points. Understandably the initial focus is on the client as self-healer and his/her use of therapy in obtaining symptom relief or other behavioral and personality changes. In general, the authors wish to overthrow the idea of the therapist as hero, arguing that "Therapists set the stage and serve as assistants who provide the conditions under which this magic (healing powers of the client) can operate" (p.95). In order to bolster their claims the authors cite evidence that the therapist's experience and training are not significant factors in the effectiveness of therapy. (This view is further qualified in the next chapter.) In addition, they point to studies that have noted change without professional intervention. This does not mean that the therapist is unimportant. Rather, a client changes by making use of the therapeutic relationship.
People also make use of extratherapeutic sources (e.g., self-help books) in order to change. The particular resource some people choose is therapy. The next chapter addresses those common factors within the therapeutic relationship that enable clients to make use of the relationship in order to change. The authors indicate that therapists who are recognized as excellent may have very different theoretical orientations, but they seem more alike in their practice than different (cf. Wachtel, 1991). Therapists who establish a climate of trust and relative safety through empathy, attentive listening, appropriate and contextual responsiveness, communication of understanding, respect and care are facilitating the client's use of the ritual of therapy to change. In situations of handling conflict excellent therapists "possess to a greater extent several attributes held to prevent, or at least moderate, negative reactions; these include self-integration, anxiety management, conceptualizing skills, empathy, and self-insight" (p.152). The importance of these attributes in the process of change was also found when patients were prescribed medication (chapter ten). In short, these qualities and attributes, which are also skills that can be taught, are crucial to the effective therapeutic outcome. Clients generally do not change in therapy because of the therapist's theoretical orientation, but by making use of his/her own resources (40%) and the resources of the therapist (30%).
The client and therapist are also inextricably linked to a third factor in positive therapeutic outcomes — hope (15%). It has long been recognized that possessing a positive belief can have an impact on one's physiology. The client's belief that s/he will be helped and the therapist's confident belief in helping him/her are important variables in the successful outcome of therapy. Jerome Frank's (1973) cross cultural study, which is often cited by the authors, reveals how very diverse rituals for helping people can be effective precisely because the participants believe the rituals are helpful.
The fourth variable in change — theory and techniques — is last, I believe, because the authors wish to challenge therapists' tendency to place more confidence in their theories and techniques than in the client. Clearly there are approaches the authors recognize that are particularly helpful for a specific group (e.g., exposure technique for some anxiety disorders). Notwithstanding the importance of identifying specific techniques that facilitate change, "correlations between therapist interventions and client outcome are simply insufficient to rule out common factors as primary creators of change" (p.215). They argue that therapists using one approach with good outcomes would also have good outcomes using another approach.
This does not suggest that there are not important differences in theories and techniques. It also does not imply that theories and techniques do not have consequences with regard to outcomes. However, the authors wish to stress the evidence that points to the common factors that are crucial in effecting change. By acknowledging these common factors we may be free to give up our parochial attitudes about this or that theory or technique and more free to recognize the wild god of change in the clients we serve and in ourselves. In addition, we may be more willing to consider alternative approaches with an eye toward what is best for the client given his/her particular struggle.
The next four chapters of the book examine medicine in relation to the common variables cited. While the focus is on medicine, much what is stated in these chapters supports the earlier chapters. In many respects these chapters are interesting, but I found myself having the sense of treading over this ground several times before. The last portion of the book addresses in greater detail some implications with regard to training, policy, and practice. As a counselor and teacher I was challenged to think about the impact of these four variables on my teaching students to do counseling as well as considering how often I may subtly tend to over-emphasize theory and technique despite my belief in the client's own ability to change.
While I believe this book is well worth reading, there are two areas that the authors seem to ignore. The most crucial shortcoming concerns the telos of change. What are we changing to? What are the ends of therapy? How does therapy identify what are "good" changes and what are not? During other periods of history change was inextricably yoked to specific goals, which were linked to the polis. In Western society, for example, the rituals for change (confession, spiritual direction, pastoral counseling) were directed toward character, morality, virtue, and community. It would have been difficult for Plato or St. Paul to discuss change without being clear about the final ends. I find it interesting that we have come to a point where research about change in therapy is divorced from an analysis of the ends of therapy. I wonder if it is a lingering effect of researchers and therapists who identify with science and the concomitant myths of objectivity and neutrality. Often this results in resisting the moral aims embedded in the therapeutic enterprise.
In short, one can identify the heart and soul of change in therapy, but it seems shortsighted to ignore what the goals of therapy are. Therapists may eschew the idea that therapy is a moral enterprise, but that does not make it any less so. Theories, techniques, and therapists themselves possess normative claims and values regarding the "good" life. I would add here that it is interesting to identify positive outcomes without wondering about what positive means and its relation to the ends that are bound to the process of change.
A second and understandable limitation of this book is the lack of explicit attention to those factors that clearly obstruct change. The long history of people interested in change includes explanations for why it does not take place. If the client accounts for 40% and the therapeutic relationship for 30% of the equation then specific attention to conscious and unconscious motivations regarding change would be important to consider. Why does the client (and therapist) resist changing even when there is a "good" relationship, theory, and technique? This and related questions are important to address regardless of one's therapeutic affiliations.
Identifying two shortcomings has more to do with my desire to hear what these authors think than with whether this book should be read by anyone helping people change. Therapists, counselors, and teachers would benefit by reading and discussing this book with others. If you read this book you will not find the zoo god here, but you will see glimpses of the wild god of change.
Ryan Lamothe, M.D.
University of Louisville School of Medicine