Cutting through competing methods to find what really creates change

Have I caught you scrolling through profiles, trying to choose a therapist you can actually connect with?

We all sound good on paper. We describe impressive training and proven approaches. The research appears to back up whatever claims we make. Our chosen model is labelled ‘evidence-based’ or ‘gold standard’.

So how do you choose from such a dizzying array of promises?

The private therapy world can feel crowded and competitive. Weighing up every model and competing claim could take a lifetime. Who do you trust when all you really want is someone who will listen and understand where you are coming from?

Everyone claims to be working with evidence-based practice!

The phrase evidence-based originally came from medicine. It follows the medical model of symptom diagnosis followed by treatment. Psychologists were trained in medicine, and so this was a familiar framework. However, psychotherapists were still working out their models, and the only ones that fitted with this symptom-treatment approach were CBT and similar. So the term “evidence-based” started being applied to these models that were easy to assess in short-term studies.

This discounts a whole raft of therapeutic approaches: psychodynamic, humanistic, somatic, existential, and holistic. Not because they are ineffective or there is no research, but because they do not fit into that simplistic, symptom-relief category.

So what actually creates change?

Decades of psychotherapy research have led to the common factors approach. This states that all therapeutic approaches, from psychodynamic to CBT and beyond, have an equal measure of success, as long as certain common factors are in place. The most important of these is the therapeutic alliance.

The therapeutic alliance refers to the relationship between therapist and client; the trust, understanding, and emotional connection that form the foundation of the therapeutic process. A strong alliance allows clients to feel safe and supported as they work through difficult emotions and experiences.

Feeling understood, safe, and able to be honest matters as much as the method being used.

What that looks like in practice

I don’t work for insurance companies or medical institutions for very good reasons. They choose a therapist who promises quick, measurable results. I can provide that, and it can serve to stabilise someone in crisis, but I don’t always think it is in the best interests of the client.

You come because you are feeling angry and isolated.

Short term: you use calming strategies, self-care, grounding exercises, sleep routines. You identify immediate triggers and learn different ways to look at what is happening. You become less reactive and feel steadier, but still on your own with it.

Long term: we build a relationship and explore your history. As someone who has put their own career on hold for the good of the family, you may explore feelings of resentment and grief. You may discover that the way you pull away from people is something you learnt a long time ago about how to stay safe. We look at harnessing the energy of anger away from destructiveness and towards creating something new. Fight-or-flight becomes motivation and mobilisation. We move from coping to creating.

Has a therapeutic relationship been created?

Any type of therapist skilled at their game can produce breakthroughs, but only if this one element is present: the therapeutic relationship.

A therapist cannot prove they have established a relationship with a client by having them complete a feedback form. As a therapist, I have periods where I believe it is there with some clients, and then I feel it has drifted away. I know I have created a sufficient therapeutic relationship by experiencing clients move from fixed patterns of living and relating to a much more flexible and creative way of being.

A client once described it this way:

“When I came to you, I was a frightened spider crouched in a corner of the web, unable to see beyond the first few threads. If anything touched the web, it vibrated, and I was terrified. I shrank back further. I have come to see that I could no longer tell the difference between bad and good vibrations. Is it a bird that will eat me, or a fly that I can eat? Hiding in my corner, I will never know. You have encouraged me to take a peek and trust myself. Slowly, I have come to a place where I can see the whole web. If it vibrates, I can respond accordingly and not out of blind fear.”

Some clients still think I have some magic wand or superior knowledge. When clients reflect on major changes that seem embedded and compare them with previous changes that were fleeting and temporary, I tell them this: “You made these changes, not me. Sure, I’ve been there with you, pointing out some of the signposts and describing the pathways, but you did the work, and that is what matters.”

What to look for when you choose a therapist

Relational therapy is a deliberate use of the therapeutic relationship to explore attachment patterns, regulation, shame, power and dependency as they emerge in real time. Not every therapist who works this way will use that term, so it helps to know what to look for.

In a profile, look for language that points towards relationship and process rather than technique and outcome.

Phrases like “exploring patterns,” “the therapeutic relationship,” “attachment,” “long-term work,” or “understanding yourself more deeply” are good signs.

Be more cautious about profiles that lead with a list of conditions treated or techniques offered, as this tends to reflect a medical model orientation where you are a problem to be solved rather than a person to be understood.

It is also worth asking a potential therapist directly: “How do you work?” or “What does a typical session look like with you?” A relational therapist will tend to talk about the relationship itself, about curiosity, about following what emerges, rather than giving you a neat programme or a set number of sessions. If they struggle to describe their work without referencing a specific technique, that tells you something.

Some red flags: a therapist who seems very certain about what is wrong with you very quickly; one who offers a fixed package of sessions with guaranteed outcomes; or one who does most of the talking. None of these are absolute rules, but they are worth noticing.

The question to hold in mind is simple: does this person seem more interested in you, or in applying their model to you?