Bees, fish and common factors
What a beehive and a school of fish remind us — perhaps — about what works in psychotherapy.
In the psychotherapy research literature, a stubbornly recurring result emerges: when different treatment methods are carefully compared with one another — cognitive behavioural therapy, interpersonal therapy, schema therapy, psychodynamic therapy — they tend to come out, on the whole, at about the same place.
This is called the Dodo bird effect, after the character from Alice in Wonderland who decides, after a chaotic race: "Everyone has won and all must have prizes." The term was coined in 1936 by Saul Rosenzweig and has since been confirmed and contested countless times.
The question this raises is somewhat uncomfortable: if all those methods seem to work about equally well, what then is actually "effective"? It cannot, it seems, be the specific techniques — those differ. It would have to be something underlying, something present in all good therapies to some degree.
The search for the common active factor
Generations of researchers have made this their work. The current (fragile) consensus runs, as far as we can survey it, roughly as follows. There appear to be a few elements present in virtually all good therapies:
- The therapeutic relationship — the quality of the connection between patient and clinician;
- The credibility of the account — whether the patient can attribute some logic to what is happening;
- The experience of progress and hope — being able to believe, early in treatment, that something is going to change;
- A certain measure of structure — rituals, repetition, a form within which content can take place;
- The characteristics of the patient herself — motivation, own strength, social context;
- And, not as conclusion: a clinician who truly believes in what he or she does.
The specific techniques — the exposure, the schema, the cognitive restructuring — appear to explain only a small portion of the variance in outcome. The factors named above, taken together, are reported to explain considerably more.
What a beehive and a school of fish have to do with this
The school of fish or the hive of bees knows no queen or general who instructs. What appears to carry the collective is the sum of many small relations — local signals, brief touches, a tone, a direction. What the collective does is, to our minds, more than the sum of the parts, and seems to arise from simple local interactions.
Psychotherapy, to our feeling, has something of that dynamic. What makes a good treatment effective seems seldom to lie in one specific manoeuvre, but rather in the density of many small, recurrent interactions that together carry something. The question "which technique?" is perhaps less important than "what ensures that the relationship in which this technique lives is sufficiently rich and sturdy?"
A modest conclusion
This is no plea to abolish technique. Techniques — exposure, behavioural activation, mentalising — are in our experience valuable structurers. They give the relationship something to do, a rhythm, a direction. But the thought that a better technique would be the solution for difficult therapies seems to us less tenable than we sometimes pretend.
What then? Perhaps more attention to the relationship. To the credibility of the account we offer our patients. To building up progress early in treatment. To our own credibility and authenticity. These are not topics that congress programmes tend to feature, and yet they prove time after time to be where, in our impression, the matter lies.
The beehive works not on the basis of a blueprint, but on the basis of thousands of small movements. We in the consulting room, we suspect, not very differently.