Bees, fish and common factors
What a beehive and a school of fish can teach us about what may be effective in psychotherapy.
In the psychotherapy research literature, a remarkable finding keeps returning. When different treatment methods are carefully compared with one another, such as cognitive behavioural therapy, interpersonal therapy, schema therapy and psychodynamic therapy, they seem, on the whole, to turn out roughly equally well.
This is known as the Dodo bird effect, after the dodo in Alice in Wonderland who, following a disorderly race, decides: "Everyone has won and all must have prizes." Saul Rosenzweig linked the image to psychotherapy in 1936, and since then the finding has been confirmed many times, and contested as well.
This raises a somewhat uncomfortable question: if all these methods seem to work about equally well, what exactly is the active ingredient? The specific techniques are a less obvious candidate, since it is precisely these that differ. It might rather be something underlying, something present to some degree in every good therapy.
The search for the common active factor
Several generations of researchers have occupied themselves with this question. The current, still tentative consensus runs, as far as we can survey it, roughly as follows. There seem to be a few elements that recur 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 recognise a certain logic in what is happening;
- the experience of progress and hope: being able to believe, early in treatment, that something is going to change;
- a certain degree of structure: rituals, repetition, a form within which the content finds its place;
- characteristics of the patient, such as motivation, personal strengths and social context;
- and, by no means least, a clinician who believes in what he or she is doing.
The specific techniques, such as exposure, schema work or cognitive restructuring, seem to explain only a small part of the differences in outcome. According to this literature, the common factors listed above together explain a considerably larger part.
What a beehive and a school of fish have to do with this
A school of fish or a hive of bees is not directed by a general issuing instructions; nor does the queen of a bee colony do so. The behaviour of the whole seems to be carried by many small relations: local signals, brief touches, a tone, a direction. What the collective does is more than the sum of its parts and arises from simple local interactions.
Psychotherapy, in our view, has something of this dynamic. What makes a treatment effective seldom seems to lie in one specific intervention, and more often in the density of many small, recurring interactions that together carry something. Alongside the question of which technique fits, it may be just as important to ask what makes the relationship in which that technique is applied sufficiently rich and sturdy.
A modest conclusion
This is explicitly not a plea to abandon techniques. In our experience, techniques such as exposure, behavioural activation and mentalising provide valuable structure. They give the relationship something to work on together, a rhythm and a direction. The idea that a better technique is the solution for therapies that are progressing with difficulty does, however, seem to us less tenable than we sometimes assume.
It may be worthwhile to give more attention to the relationship, to the credibility of the account we share with patients, to making progress visible early on, and to our own credibility and authenticity. These topics do not always receive the most space in conference programmes, while in our impression they often account for an important part of the difference.
A beehive functions without a blueprint, on the basis of thousands of small movements. We suspect that things are not very different in the consulting room.