When I was trained to be a cognitive-behavioral psychotherapist not too long ago, my professors explained to me that there were two key components to effective therapy. Those two components were: 1) a body of technique based on theory and (as much as possible) supported by empirical research, and 2) something called "nonspecific factors", which were the non-technical parts of therapy, such as the quality of the rapport (or relationship) between the therapist and the client. The idea was, more or less, that the nonspecific factors served as a sort of foundation upon which therapy could be conducted. The implied idea (or perhaps wish) was that the active ingredient of successful therapy would come from the technical side of the house, while the nonspecific factors would serve more passively as a sort of glue that held the process together. I'm simplifying what was actually taught, for purposes of this essay; but not too much that I think I'm distorting the message that was conveyed.
There is a lot to be said for this formulation, actually, and good reasons for why my professors were so hot to emphasize the technical side of the house. Psychotherapy has historically been a sort of wild-west process, based more on testimonial and charisma than science. Therapists who were best able to sway the opinion of their fellows (Freud is a good example) became famous and got to pass on a body of techniques but it was never quite clear, when the hype was removed, whether those techniques really worked all that well in practice. My professors were trying to combat this "cult-of-personality" approach with a science-based alternative. The version of psychotherapy they were promoting to us students was based on testable theory and repeatable techniques, and had been subject to clinical trials demonstrating that it worked. The approach has been very successful, and has started to dominate the way that modern psychotherapy is conducted.
I have never questioned the soundness of the science-based approach, as to do so asks the question of whether there is a better method than science for figuring out how the world works. Though Tom Cruise and the people behind the Discovery Institute might disagree, there frankly isn't any better method than science for figuring out how things really work. Only a science based approach towards understanding reality actually tests assumptions against the world in rigorous and systematic ways. More importantly, only a science based approach provides a framework for overthrowing previously accepted theory when the accumulating data show that those theories are not sufficiently accurate.
I've previously written about the technical side of psychotherapy and may do so again in the future. For today, however, I'm interested in focusing on those nonspecific factors, because lately I have been appreciating just how completely important they are to the success of some types of psychotherapy, and also to self-acceptance, more generally.
When psychotherapists talk about nonspecific factors, they use words like "authenticity", "genuineness", and "presence". What these words boil down to is the idea that good therapists offer their clients real caring and compassion, and whole attention. They are there not just physically, but are also wholly attentive, focused on the client's difficulties, and actively listening to and thinking about what the client is describing in the hopes of finding ways to help that client. They empathize and emotionally connect with what their clients are going through, although they do not take these feelings on, or allow themselves to become overwhelmed by these feelings. They are emotionally, intellectually and physically there with their clients, in the room and receptive and without judgement. This state is not an artifice but rather a true receptivity and willingness to be present. There is no hidden or alternative agenda beyond this mission of compassion and desire to help.
I should hasten to add that all this openness, receptivity and desire to help is entirely one-sided. It is focused on the client. There is no expectation that the client should reciprocate, as would be the case in any other sort of similarly charged relationship. Good therapists keep the focus on the client, and share very little about their own lives, if anything at all.
It is incredibly difficult to fake the state of receptivity and compassion that characterizes the nonspecific factors. Almost all of the time, clients know when therapists are faking it. It's not something you have to think about; you just know when someone is really paying attention to you in an open and compassionate way, and when they are not.
When a client comes to a therapist saying, "I want help with kicking this crappy mood I've been in for the last month", and they are otherwise well adjusted and motivated to do the work, then nonspecific factors don't count for much. Motivated clients, confident clients don't require much support, and the therapist and the client can simply get down to the work of teaching and learning techniques that will help achieve the effect that is desired. However, when clients come to therapists with issues of trust, confidence, doubt, or self-esteem, the nonspecific factors become a hugely important thing that will make or break the success of the therapy. This is because techniques cannot be easily conveyed in the context of an untrusting relationship, which is what the therapy situation will be in the absence of the nonspecific factors.
Nonspecific factors are about more than simply convincing clients to trust therapists. That sounds manipulative, and if you've been following the spirit what I'm attempting to convey you'll know that manipulation is the exact opposite of what the nonspecific factors are about. Clients respond to nonspecific factors when they are present because they sense in their guts that trusting the therapist is warranted, not because they have been fooled.
The message of the nonspecific factors is one of compassion and non-judgement, in a word, "acceptance". Dr. Carl Rogers, the giant of this approach, called this thing "unconditional positive regard", but that phrase puts too much of a happy face on the thing for my taste. It's not that the therapist is necessarily conveying to the client that he or she loves them; it's more like a sort of deep acceptance that occurs. What clients frequently sense is that they are accepted by their therapist; that their therapist will not judge them and that therefore, they need not judge themselves.
Nonspecific factors are about creating an environment in which clients will not feel judged, or be judged. This is important because so much of what drives people into therapy involves judgement and rejection. People either feel judged by others or alternatively, they judge themselves (having internalized the other's voice). They react to those feelings of shame and guilt by becoming depressed or anxious, by going into denial or repressing their actual interests, and/or by developing a substance abuse disorder or eating disorder. Of course, this is not the only way that such problems develop, but it is one of the major paths leading to these destinations.
The nonspecific factor environment of non-judgement, compassion and authenticity of presence acts as a sort of solvent for shame and guilt. Shame and guilt feelings can start to dissolve away in such an environment, where in any other sort of environment, they grow instead. This is so because only in a non-judgemental environment can people feel safe expressing themselves in an uncensored and spontaneous manner. And it is only through such spontaneous and uncensored expression that people come to accept who they really are inside.
I should briefly talk here about limits of non-judgement for a moment, for in every relationship there need to be limits to non-judgement. When I talk about therapists providing a non-judgemental environment so that clients are freed to express their spontaneous and uncensored selves, I don't mean that literally everything and anything they want to talk about is fine and dandy. There are clear boundaries imposed by law and by society as to what is acceptable and what is not. Talking about an impulse to commit suicide is okay, for example, but actually making plans to kill yourself is not. No reasonable therapist would allow that discussion to proceed except under very special circumstances (for instance, possibly, in places where assisted suicide is legal, and a client is faced with a terminal disease).
Fortunately, by and large, clients' secret shames are more on the pedestrian side. Honestly, I once had a client come to me asking if she was crazy because she couldn't stop herself from sneaking a small piece of chocolate bar from her freezer each day. She was ashamed of her inability to control her desires. You would have thought she was completely out of control from the way she shamed herself, but it was just a little bit of chocolate (I had to explain to her about how many women consider chocolate to be an extra food group ... ). As this story illustrates, people find ways of being ashamed of themselves for all sorts of things. They're ashamed of having homosexual desires, or heterosexual desires, of not having pleased their parents with their choice of career, and of not feeling confident enough to speak in public. They may feel that they somehow caused their parents' divorce, or that they aren't smart enough, or they wonder if their spouse is right that they are too needy and demanding; stuff like that. Any number of secret shames that function as so much baggage, holding people back from their potential to be happy.
People simply don't share these secret desires and feelings with most people they know. There is simply too much perceived danger that seems to be involved; too much possibility of being teased or ostracized for acting funny. "Sticks and stones may break my bones ... ", right? Actually, people seem to me to be less afraid of physical damage than they are of emotional damage. Names can hurt you. For many people, rejection is perhaps the worst ordinary punishment they can contemplate. Even with close friends, family and confidants, there are frequently feelings and thoughts that cannot be shared for fear of rejection. In the absence of the certain knowledge that at least one other person can accept you knowing you feel or think in the ways you do, it is easy to doubt that such feelings and thoughts are okay. In that case, self-doubt and self-rejection become shame, and shame tends to hang around, fester, and contribute to life problems.
The point I've been working up to is this: Therapists who can be non-judgemental witnesses for their clients offer those clients a very great service precisely because of the shortage of people in most clients' lives who can otherwise wholly accept them. Many people who become psychotherapy clients are motivated to do so because they have never felt accepted by others, or felt accepted only in very constrained and artificial ways that left them feeling like they have to hide their true selves or risk rejection. Others used to feel accepted but got themselves into relationships as adults where that no longer occurs and now are hungry for it. On the surface, they may be looking to the therapist for guidance, but down below, they are also looking for acceptance; some confirmation that they are an acceptable person worthy of love and respect.
Self-regard and thus self-acceptance is ultimately modeled on how others have viewed you in the past. While you can become less dependent on others for this function as you mature, the starting place for self-acceptance remains whether others you've cared for or respected accepted you first. People need to have non-judgemental witnesses in order to learn how to accept themselves. Fulfilling this role of the non-judgemental witness is one of the more basic missions of the therapist.
What's your experience? Please share your comments below: