New Paradigms for Change and Transformation:
How Psychotherapy Actually Works

Due to a significant reanalysis of the psychotherapy outcome literature, the field is beginning to adopt a new understanding of how psychotherapy actually works.  First, psychotherapy does not work like medicine.  In medicine we use a simple but effective model:  do an assessment, make a diagnosis, and then apply the most effective technique that fits that diagnosis.  This seems so common sense that psychology adopted the same paradigm.  Indeed, if you ask many therapists, they will still say they believe in that model.  Unfortunately, appealing as the medical model appears, the outcome literature suggests that it is simply wrong. 

To oversimplify a complex topic area, the new research analyses reveal two main principles:  first, virtually every approach developed in psychotherapy—and there are over 400 different schools of psychotherapy—achieves equivalent positive results.  No school is better than another;  all of them are effective with virtually the exact same effect size.  This is very different than medicine where one technique is typically superior and that superiority contributes to the evolution of the field.  Psychotherapy, like medicine, constantly develops new techniques  but they fail to evolve the field in that they simply replicate the same positive outcomes of the old techniques.

This equivalency and lack of evolution suggests that what we see as techniques are actually rituals.  It appears that in psychotherapy, when there is a consensual agreement between client and therapist about the cause of the problem and the cure for the problem, equivalent levels of success are achieved regardless of the specifics.  This leads to the second big discovery arising from the research literature: psychotherapy operates in constructed reality not in fundamental reality.

What this means is that our problems, challenges and psychopathologies exist in the world of assumptions, cultural conditioning, and personal programming.  Certainly, there are some mental health problems—such as personality changes due to a brain tumor or dementia—that have their roots in fundamental reality, but the vast majority of issues addressed by psychotherapy exist in constructed reality.  This finding is supported by the concept that interventions are rituals not techniques.  Rituals are effective in terms of altering internal assumptions and programming; they cannot change items in the fundamental world.  You can’t heal a brain tumor with a ritual but you can change immaturity with one; for example, many individuals become much more mature going through a ritual called “marriage.”

How do these new ideas play out with real-life problems such as a marital issues or depression or substance abuse?  The simple answer is that the issues become much more amenable to change.  Constructionism allows us to visualize our problems as less fixed and resistant than we had previously thought.  This plays right into a basic principle:  believe it will be hard and it will be hard.  Believe it will be easy and it will be easy.  The therapist’s assumptions about ease of change spill over to the client in either direction–positive or negative.

Constructionism is also more individualized than traditional psychotherapy.  Because traditional psychotherapy believes in the innate power of techniques, it spends a great deal of time educating clients on how to see the world and why these generic techniques should work.  Constructionism, knowing that all interventions work equally, is unattached to any particular intervention for a particular diagnosis; instead it picks an intervention that especially fits each client.  Any procedure that feels like a good fit to client and therapist will have the power to help us transform, change, and resolve issues.  The idea of applying the same basic technique to, for example, everyone with anxiety or depression is now seen as outdated and old fashioned.

Finally, psychotherapy has always emphasized working with the client’s goals and encouraging each person to find and walk their unique authentic path.  The more fluid environment of constructed reality places an additional emphasis on aligning treatment with this “inner truth.”  In this sense, the new approach is even more client-centered than the standard approach.   In sum, constructionism is more individualized, more oriented towards the client worldview and their individual path, and more flexible and unconstrained by outdated psychological assumptions.  Most importantly, it sees change as much easier and more possible than traditional methods.

While this approach is new to psychology, it has been foreshadowed by numerous traditions across human history.  In 1945 Aldous Huxley wrote a book entitled The Perennial Philosophy, which argued that essential human wisdom is discovered and then rediscovered across time and culture.  In that sense, the new approach shares a number of principles with Buddhist Psychology, Yoga and even certain shamanic and mystical traditions.  Martin Buber, in the following quote, attempts to define one aspect of this perennial philosophy—an aspect that unites this new psychotherapeutic approach to older wisdom traditions.