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Why psychotherapy to work? Until relatively recently, many scientists studying methods to improve mental and behavioral health were slow to answer that question. Instead, they argued, it is better to first ask if a method works, and when we know that it works, then we can ask why.
It’s not an irrational strategy, but over the decades, thousands upon thousands of studies have turned up an ever-growing list of interventions, many of which may appear different but actually work through the same processes or mechanisms. Lists of “evidence-based therapies” maintained by scientific bodies or government agencies did not require any knowledge of change processes, so the methods proliferated. Sometimes proponents of the therapy proposed rather outlandish theories, and as long as the end results were better than a control condition, the methods were listed on those lists, encouraging proponents to claim that their theories were correct.
Maybe. Maybe not. Results alone can’t tell you. You have to answer the “why” question.
Gradually, statistical methods that identify important pathways of change, that answer the why question, became more common in psychotherapy research. The best known and most widely used method is called “mediational analysis”. Mediation applies when a) a treatment changes a short-term process more than a control condition, b) that process is related to outcomes in both groups, and taking that path “aab” significantly reduces the impact of the treatment on the result. It’s not a perfect method, but it’s a place to start and the body of study in that area is now large enough to do a full count. About five years ago, my colleagues (Stefan Hofmann at the time at Boston University; Joe Ciarrochi at Australian Catholic University; and our associates Baljinder Sahdra and Fred Chin) and I decided to review every successful mediation study that has ever been done. performed on any psychosocial intervention randomly. controlled trial targeting a mental health outcome.
We had no idea what awaited us.
It turned out to be a huge effort that required the work of nearly 50 people over the next four years to complete. We jokingly call it the “Death Star Project” because, like the space station in the Star Wars movies, the project was gigantic, took forever to build, and would (we hope) have a huge impact on the way we think about psychotherapy.
Each of 54,633 studies was scored twice to see if the analyzes were done correctly. Initially, it seemed like there were a little over 1,000 of these in the running, but as we continued to investigate, more disappeared (for example, we left out studies where one outcome mediated another). To arrive at the core findings, we focused on process measures that were replicated at least once in our database. We ended up with 281 clear findings using 73 different measures. Finally, a couple of weeks ago, the results of one of the biggest reviews I’ve ever seen appeared in the well-known journal Behavior Research and Therapy.
As you may have guessed, there is not just one path of change, but many; each supporting people differently in different contexts. The surprising finding, however, is that a single skill set proved far more effective than anything else. It was found more often than self esteem; support from friends, family, or your therapist; and even whether or not you have negative and dysfunctional thoughts. The most common path of change was his psychological flexibility and full attention skills. This small set of processes accounted for nearly 45% of all we know about why therapy works, using the demanding criteria of a successful mediational analysis. When concepts that were very similar to psychological flexibility and mindfulness were added (for example, self-compassion, behavioral activation, anxiety sensitivity) skyrocketed to nearly 55% of all successful mediational findings.
The three pillars of psychological flexibility
We can now say with certainty that psychological flexibility is the single most important skill for your mental health and emotional well-being. If you suffer from anxiety, depression, addiction, or any other type of mental anguish; psychological flexibility helps you deal with these issues more effectively and move your life in a meaningful direction.
So what does this ability entail? It’s best to think of it as three skills in one.
Pillar Awareness #1
The first pillar of psychological flexibility is awareness. This means noticing what is happening in the present moment: What thoughts appear? What feelings? And what other sensations can you notice in your body? It also means noticing these things from a more spiritual part of you: your witness or sense of perception of yourself.
The “now” cannot be experienced with words alone, it must be experienced mindfully. It’s the difference between talking about the taste of an orange and actually tasting the fruit. The latter is much richer than the former. Instead of being “stuck” in your own head, awareness is about being here and now. And even more, it involves the ability to deliberately direct, amplify, or focus on different aspects of your experience.
And all of that from the part of you that connects you in consciousness with others.
Pillar #2 Frankness
The second pillar of psychological flexibility is openness. This means allowing difficult thoughts and painful feelings, exactly as they are, without necessarily having to change in any way, shape or form before you can move forward into the kind of life you want to live. This part is counterintuitive and often hard to understand, because people tend to seek therapy precisely to get rid of their negative thoughts and feelings. Unfortunately, the mind does not work this way. Generally, the more you try to eliminate pain, the more it controls your life. Instead, opening up is about letting go of the inner struggle, allowing thoughts and feelings to be what they are, just thoughts and feelings, without them needing to control you. Ironically, in that open posture, thoughts and feelings often shift in a more positive direction.
Pillar #3 Valuable Commitment
The third and final pillar of psychological flexibility is valued commitment. This means knowing what matters to you and taking steps in that direction. It’s about staying in touch with your goals – goals you want to reach or achieve – and your values – those personal qualities you choose to manifest and are guided by, regardless of a specific outcome. These matters should be freely chosen, rather than forced by others or mindlessly pursued out of habit. But once you’re clear on what matters, you can take steps to develop sustainable habits that make your life more focused on what gives you meaning.
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Psychological flexibility is the most important skill for your mental health and emotional well-being. The first two pillars create a working focus for mindfulness skills. In close connection with other change processes, psychological flexibility and mindfulness are the smallest set of skills that do the most good in the most areas.
And now we know an important part of the answer to the question “why does therapy work?” Very often it works because it establishes a greater awareness, openness and commitment in life based on values.
When you feel frustrated at work, you can notice your frustration, allow it to be, and still take action to complete your task. When you’re in a fight with your spouse, you can acknowledge the pain, accept it as a learning opportunity, and build plans to move forward together stronger. Psychological flexibility allows you to stop fighting with yourself and guide your life in a meaningful direction. It is accessible to you here and now. And like any other skill, the more you practice it, the better you will become at it.
The history of science and human development shows that when we have a clear goal, as a human community we can learn to move it. Psychological flexibility and mindfulness are not the only important processes in creating mental health, but they are the most significant.
That gives us all a target for change.
