Psychotherapy is the most common type of intervention for mental illness when the full spectrum of problems is considered. Unfortunately, progress is often limited with approximately one-third drop-out rates an indicator. For the two-thirds of clients that persist with psychotherapy, less than ideal outcomes are fairly common, generating frustration and disappointment for both the consumer and therapist. The combination of solid potential and real limitations necessitates an exploration of factors impeding the progress of psychotherapy, and application of robust strategies to reduce drop-out rates and enhance outcomes. Barriers to progress in psychotherapy span client, therapist, and interactive influences. Each category of influences includes unique contributions:
CLIENT INFLUENCES:
MOTIVATION: Progress in any endeavour relies on motivation and psychotherapy is no exception. Identifying benefits to psychotherapy and addressing perceived costs contributes to a robust benefit/cost ratio, and hence, motivation. Focusing on intrinsic motivation and appreciating that intrinsic and extrinsic motivation are additive or interactive, also assists. Motivation to change is impacted by: personality factors and most prominently open-closed to experience, fear of change, and rigid patterns of behavior, each manageable by specific interventions.
EXPECTATIONS: The relationship between expectations for psychotherapy and the reality encountered—the Expectation-Reality Match (or Mismatch)—is a very important consideration. If reality falls below expectations loss related emotions arise that demotivate, whereas when reality exceeds expectations gain related emotions occur that motivate. Expectation of linear change in psychotherapy, consistent with non-linear dynamical systems theory, is an interesting and highly workable aspect.
PERSONALITY DISORDERS: Disorders of personality comprise a common impediment to psychotherapy progress. Discrete characterizations and efforts to frame abnormal personality in terms of normal personality traits have severe limitations. However, normal psychological defensive processes expressed in an extreme and enduring fashion do produce personality disorders. Advantages of this model include a continuous organization, humanistic countering the us/them perspective, and effective strategies therapists and clients can utilize to improve psychotherapy outcomes.
REINFORCEMENT PARAMETERS: Reinforcement differs from punishment, always increasing the frequency of a behavior, positive reinforcement via reward and negative reinforcement by decreasing or eliminating an aversive state. Reinforcement parameters greatly impact on psychotherapy progress but are commonly overlooked. Structural, psychopathology, and codependence comprise three forms of reinforcement parameters impeding psychotherapy progress.
COMPLEXITY: Greater complexity usually translates into worse outcomes for any scenario. Comorbidity, severity, and practical issues provide potential barriers to progress in psychotherapy by adding complexity. Severity does seem to impede psychotherapy progress and this is clear for personality disorders.
RESISTANCE AND NONCOMPLIANCE: A distinction must be made between these concepts and nonresponse that can arise from many sources. Resistance and noncompliance comprise both a dispositional trait and an in-therapy state of oppositional, angry, irritable, and suspicious behaviors, that bodes poorly for treatment effectiveness. Emotional, dysfunctional patterns of behavior, and personality factor sources of resistance and noncompliance occur.
IMPAIRED STATES AND PROCESSES FOR MENTAL HEALTH: Activity, psychological defense mechanisms, social connectedness, psychological regulation, human specific cognition, self-acceptance, and adaptability characterize mental health, with deficits producing mental illness. From a perspective of psychotherapy progress, impairments to these states and processes for mental health limit outcomes. An understanding of this occurrence affords strategies that therapists can apply to overcome impediments to psychotherapy progress.
TRANSFERENCE: The notion of transference has a long history in psychotherapy originating with Sigmund Freud. Transference feelings are typically quite strong, consistent with the impact that they and transference interpretations have on psychotherapy outcomes. Negative transference can limit psychotherapy by blocking progress with mental health issues due to intensification of the condition, and it also contributes to resistance and noncompliance.
THERAPIST INFLUENCES:
COUNTERTRANSFERENCE: The therapist version of transference is countertransference, referring to how past relationships influence feelings and behavior towards the client. Early psychoanalytic notions of countertransference viewed it as unconscious interference and an obstacle to progress. This understanding has shifted to broader responses to the client, and how these reactions can be shaped by the client providing valuable information. Countertransference can inform about the client, impact therapy outcomes, and influence client resistance and the therapeutic alliance.
EMOTIONAL FACTORS: General categories of therapist emotional factors impacting on psychotherapy progress consist of emotional capacity and emotional stability. Emotional capacity involves several components pertaining to emotion information processing. The capacity to perceive, interpret, feel, and respond to emotions in others is crucial for empathy, which has a profound impact on psychotherapy progress. Therapist emotional instability arises from overuse of immature defense mechanisms, deficient emotion regulation, excessive reactivity, and lack of confidence.
PERSONALITY FACTORS: Both abnormal and normal personality traits of therapists can influence progress with psychotherapy. Although full-fledged personality disorders are unlikely, less intense expressions of avoidant, narcissistic, dependent, obsessive-compulsive, and borderline personality disorders can transpire and impede psychotherapy outcomes. Regarding normal personality, several traits subsumed under virtue, prosocial, and psychologically minded, enhance psychotherapy progress when robust and impede it when deficient.
SKILL FACTORS: Interpersonal skills consist of communication, collaboration, rapport building, alliance focus, boundary setting, cultural sensitivity, self-disclosure, and responsiveness. Collaboration, self-disclosure, boundary setting, and cultural sensitivity, each contribute to rapport building. Therapist interpersonal skills do influence psychotherapy progress, with deficits contributing to the general 35% dropout rate. Non-interpersonal skills include specific and general techniques, organization, and self-care.
INTERACTIVE INFLUENCES:
THERAPEUTIC ALLIANCE: The notion of a therapeutic alliance as a bond, connection, attachment between client and therapist has been around since the early days of psychotherapy, and has stood up very well as a non-specific factor. Key contributors include therapist empathy, client and therapist attachment patterns and communication, and therapist characteristics and skills with rapport building and appropriate responsiveness being very important.
INTERACTIONS BETWEEN CLIENT AND THERAPIST INFLUENCES: Numerous interactions impacting on the progress of psychotherapy transpire between client influences and the therapist influences. Transference and countertransference interactions amplify the effect of these influences. Personality interactions can really impede progress when both the client and therapist are disagreeable and/or reactive.
OVERCOMING BARRIERS TO PROGRESS IN PYSCHOTHERAPY: A CLINICIAN’S GUIDE (ROUTLEDGE, 2023), addresses the client, therapist, and interactive influences on psychotherapy progress. This comprehensive coverage reveals the spectrum of reasons accounting for why psychotherapy of diverse forms does not always progress as both the client and therapist would like it to. Effecting change can be difficult and elusive. However, by addressing the spectrum of reasons for this occurrence inclusive of client, therapist, and interactive influences, diverse impediments to psychotherapy progress can be managed with across therapy strategies, thereby reducing drop-out rates, and optimizing outcomes for the wellbeing of clients and success of psychotherapists.