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The Heart and Soul of Change: What Works in Therapy[1]

Commentary: By Donna Martin

I am enjoying reading the Heart and Soul of Change and discovering that the way we teach Hakomi fits with the research on psychotherapy and the findings presented in this book, in particular with the emphasis on the importance of the therapeutic relationship and on therapy as a collaborative experience. It also supports what I say to student therapists, that when the session doesn’t go as well as you like, ask yourself, what kind of help does the client need… how can the client be supported to have a better session…?

Clearly there are certain client characteristics that can actually be encouraged and developed which make it more likely they will benefit from therapy… some of what we already do in Hakomi, such as helping the client with self-reflection and reporting their experience, and tracking the client’s reaction to the therapist and naming it…(What we call “jumping out of the system” is a lot of that… jumping out of the place where the relationship gets stuck or jammed..). Other things, (with loving presence),  like helping clients to relax, and to feel safe to be open and vulnerable, to feel more confident, to recognize their own strengths and resources, both within themselves and in their lives outside of the therapy setting… We focus on helping clients integrate and apply their new learning outside of the therapy, and following up on that. Most importantly, we have an approach that gives clients the space where they can make their own discoveries and find new perspectives, options and solutions themselves. We track the client’s experience all along the therapy process and, by attending to the client’s experience of the therapeutic relationship, we avoid the possibility of misinterpreting this most important element, a key to the success of the therapy.

Here are some excerpts and quotes from the Heart and Soul of Change, with comments about how they relate to the Hakomi Method and to our training.

Page 9: Client Factors are 40 percent of the outcome…this includes the client’s strengths, supportive elements in the environment, what clients bring to therapy…

Page 13: …the client is the most potent common factor in therapy…

Let’s talk about the most important client factors for successful outcome in therapy and how the Hakomi training prepares therapists to develop client strengths as part of the therapy process, since all evidence shows that this counts for at least 40% of the outcome. Part of the practice called Search for Inspiration involves being able to see the client’s strengths and coping skills… things like courage, independence, determination, humour, sensitivity, and particularly any degree of self-awareness. We use various practices to help train people to be able to see deeply into the inner strength and beauty of another… these include exercises from the practice of Loving Presence, including Non-egocentric Nourishment, Seeing Through, Blink, Messages, and A Larger Self.

The second most important factor is the therapeutic relationship; a “positive alliance” accounts for 30% of a successful outcome. So we want to focus on cultivating the state of mind which is most likely to create a sense of safety, of being appreciated and understood, of respect and nonviolence, of feeling supported and encouraged.

We also practice the kind of communication skills that express these qualities, including tracking and contact, acknowledgement, and appropriate verbal and nonverbal expressions of comfort. And we learn to track nonverbal signs of the person’s ongoing experience and not to make assumptions about what he or she is experiencing.

In this way we are constantly monitoring the client’s experience of the relationship and we learn to recognize and  jump out of the system when the relationship gets stuck.

Page 9: Relationship variables account for 30%… including the therapist’s empathy, caring, warmth, acceptance, affirmation, encouragement… the therapeutic “alliance”…

14: Clients’ own generative, self-healing capacities allow them to take what different therapies have to offer and use them to self-heal… the therapeutic relationship lies at the very heart of psychotherapy…

Therapists’ rank on empathy according to the clients correlated with patient outcome… argue for the importance of therapist communicative skills…

“basic capacities of human relating – warmth, affirmation… may be at the center of effective psychotherapeutic intervention…

43 Therapist relationship skills, such as acceptance, warmth, and empathy are absolutely fundamental … training in relationship skills is crucial… because they are the foundation on which all other skills and techniques are built…

47 the difference between effective and less effective therapists is their ability to form and maintain a therapeutic alliance with the client… therapists who are able to communicate warmth, understanding, and positive feelings toward the client and can facilitate a reasonable dialogue leading to understanding and agreement about therapeutic goals, techniques, and roles, will be more likely a positive treatment alliance.

48 In training student therapists… trainees can learn… how to be attuned to clients’ feelings… and to offer high levels of empathy…

This underscores the importance of learning to track the subtle nonverbal signs of the person’s experience, to contact (name) them accurately and appropriately, and to respond to the client’s unconscious needs in such a way as to provide safety, trust, and confidence in the process. A huge emphasis in our training is placed on developing the kind of relational and communication skills that will contribute to building effective therapeutic alliances. We work in various configurations, in the large group and in small groups of four or five, as well as in pairs and threes. All the learning comes from students’ personal and shared experiences. As participants in the training work through their own issues, everyone is supported to learn the kind of appropriate empathic responses that cultivate a capacity for genuine warmth and compassion.

Page 9: Hope, placebo and expectancy contribute 15%… both client and therapist need to believe that the client can heal…

Page 7: re Frank and Frank 1991… there are “four features shared by all effective therapies: (a) an emotionally charged confiding relationship with a helping person, (b) a healing setting, (c) a rationale.. or myth… that provides a plausible explanation for the client’s symptoms… and (d) a ritual or procedure that requires the active participation of both the client and the therapist…

… Models and techniques account for about 15%… therapeutic ritual, explanation for what is happening for the client, strategies, and ways to help clients help themselves… what matters most is how clients use the method and how they feel about the therapeutic relationship.

The therapeutic ritual we use in Hakomi involves the use of little experiments done in mindfulness, offered to the client and carried out only when the client is ready with a continuous referral to what the client needs and wants. With three years of ongoing experiences in personal healing using the Hakomi Method, trainees develop a lot of confidence in the efficacy of the method and in their own ability to be helpful to others.

27 … change is more likely to be long-lasting in clients who attribute their changes to their own efforts…

The Hakomi therapist allows for the client to make their own discoveries and arrive at their own insights, both through an attitude of respect and a quality of spaciousness. The approach is completely experiential and relies on the participation of the client, noticing and reporting their own experience, to make significant discoveries about old limiting habits and beliefs and new transformative possibilities. Hakomi assumes that what the client does, both within the therapy setting and outside it, will determine the success of the therapy. The therapist assumes a secondary role as supportive friend and guide.

36 … the two common variables, therapeutic alliance and patient’s emotional experiencing, were both related to improvement.

A key word, here, is “experiencing”, which involves a mindbody awareness of the feelings that arise, the time to notice the full felt sense of what happens, the safety to allow for the kind of vulnerability that this emotional experiencing both requires and  evokes, and the respectful and supportive participation of the therapist.

44… burnout decreases ability for empathy.

The focus on the practice of Loving Presence and non egocentric nourishment in our Hakomi trainings begins to inspire and cultivate the habit of being nourished by the experience of therapy for the therapist, which is the only sustainable way of avoiding burnout and maintaining the potential for consistently genuine empathic listening or generating hope and confidence in the possibility of change.

46 … communicating a belief and hope in the client’s ability to change and an optimistic expectation that change will indeed occur is essential…

49 Changing the emphasis in graduate training toward the development of the therapist as a person who prizes others can only make the enterprise of therapy more valuable, meaningful, and effective.

Here is simply another way to describe what we call the practice of loving presence… the ability to “prize others” is an attitude that arises when we see what is of value in the person… when we see something in them that inspires us or nourishes us to see it… their essential beauty, their courage or inner strength, the universality of their experience, their basic humanity, whatever it is that moves us to appreciate and honor them calls up the very attitude necessary to hold a space for the person’s healing to occur.

63 relationship factors account for 30% of client improvement…

… therapist empathy, being engaged in the process, understanding and being understood, therapist being accepting, competent, caring, supportive and personable…

64: … three kinds of therapeutic alliances: nurturant, insight oriented, collaborative…

In Hakomi we actually work to develop an alliance with each client that has all three characteristics. We want to offer clients a nourishing experience in order for them to become more aware of how they are organized around being nourished… this requires us to be both nurturing and detached enough to allow insight to arise. The method is grounded in the use of mindfulness which develops a capacity for self-awareness and experience-based insight. And the whole experience of a Hakomi session is collaborative in the way it invites clients to participate and explore and make their own discoveries. The therapist takes the role of a support person who helps to create a safe space for self-study and self-discovery.

65: … ways to enhance the therapeutic relationship: allow clients to be more involved in the process, therapist takes less of an expert role… debriefing with the client about the therapy process enhances therapy and fosters a more collaborative relationship…

72: … what clients found helpful about therapist included listening, amplifying strengths, reinforcing, and the respect the therapist had for client’s perceptions and experiences, being listened to, acknowledged,  and treated like experts on their own family experiences.

78 Graduate students could benefit from learning more about the basics of communication theory… by becoming more communication conscious, therapists… would develop a more informed ear for not only what clients are saying (the content) but also for how clients are and are not saying things (the process)… it would also be important for graduate students to learn more about the variety of ways they can engage their clients in therapy.

In Hakomi we focus a lot of our attention on the complex layers of nonverbal expression of the client and not so much on the content of the words… we want to listen to the expression of the person’s emotional experience and to what is mostly unconscious, and this is mostly expressed nonverbally. Many hours of practice is focused on learning to notice and understand nonverbal expression and to have a variety of creative ways to respond effectively.

91 clients as self-healers

…the client’s capacity for self-healing is the most potent common factor in psychotherapy… therapy facilitates naturally occurring healing aspects of clients’ lives. Therapists function as support systems and resource providers… “it is the client, not the therapist or technique, that makes therapy work.”

95 “Clients then are the magicians with the special healing powers. Therapists set the stage and serve as assistants who provide the conditions under which this magic can operate.”

96: Strupp and Hadley, 1979, found that experienced therapists were no more helpful than a group of untrained college professors selected for their relationship skills… it looks as though differences in personal qualities make some therapists more helpful.

102 … the relationship provides new learning opportunities… clients may learn how to be in a  relationship more effectively… the relationship is helpful because it provides a safe sheltered space in which clients can take a deep breath, consider their problems in context, brainstorm with another person, gain perspective, examine their “bad sides”, make mistakes, generate new alternatives, re-experience old wounds and problematic issues, think, analyze, recover the strength to re-confront life and try new behaviors…

The client’s interpretation of, or perhaps “creation” of the relationship is most crucial to outcome.

104… of client factors, the degree of client participation in therapy is key… “client involvement is the most important variable predicting whether therapy will work.” “The quality of the patient’s participation in therapy stands out as the most important determinant of outcome.”

105 Research strongly suggests that what clients find helpful in therapy has little to do with the techniques that the therapists find so important… the most helpful factor was having the time and a place to focus on themselves and talk…. having someone listen, care and understand…

106 clients reported the most helpful factors across therapies to be therapist characteristics, unburdening of distress, self-understanding, and encouragement for gradual practice.

Clients said that the most helpful components were the therapists’ faith; calm sympathetic listening; and support, approval, and advice… and having someone help you understand your problems…

110 “The ultimate change process, inside and outside of therapy, is one wherein clients actively explore their worlds, both in thought and in behavior, try out new ways of being and behaving, engage in creative variations on old learning, and solve problems as they come up.”

111… therapy being a place where clients can actively experience their problems ”live”, experience mastery over them, and reflect upon new perspectives in the context of a helpful relationship… the real therapy is living…

113 some research supports the importance of an experiential component in therapy… one of us (Bohart) has argued that experiencing is the basis of change in psychotherapy… there is a good deal of evidence that being experientially involved in therapy, and learning through experience are associated with positive therapeutic change… the degree to which clients connect verbal and nonverbal (experiential) aspects of processing is associated with change…

Experiencing is important because real change appears to involve shifts in understanding at the bodily level… sheer abstract intellectual insight by itself is not therapeutic… there must be a bodily shift in “understanding” or in reacting, as well as an intellectual one.

114 “Therapy is a prosthetic provision of contexts, experiences, and events which prompt, support or facilitate clients’ self-healing.”

116 Therapists provide a safe interpersonal atmosphere where clients can relax, take a deep breath, and begin to look at life’s problems from a new, fresh perspective. Therapists empathically listen, are nonjudgmental, and allow clients a place to tell their story…

therapists and clients can think together, explore together, even experience together in ways that facilitate the client’s generativity…

therapists [also] provide… their interpersonal interactivity. There is direct experiential learning that takes place in therapy through interaction with the therapist.

Doing therapy sessions in small group exercises in our Hakomi trainings, where no one person is designated “therapist”, is a way to help people really understand that therapy is teamwork, and that whoever is there is part of the team. This shifts the emphasis from roles… and from thinking of the therapist as some kind of expert doing something to the client… to the idea of a partnership model. All of this is supported by the research reviewted in the book, the Heart and Soul of Change…

117 therapists should be much more willing to listen to clients… and to genuinely collaborate with them…

118 We see a need to develop more genuinely collaborative models of therapy…

119 Solutions need to be collaboratively generated out of the cultural experiences and resources of the client… it is the mobilization of client resources which is therapeutic and not the application of a technique to a problem.

To conclude, the locus of change resides within clients. Therapists use their process to support clients’ natural healing tendencies.

120 …therapy is a set of processes that simply build on and enhance client’s own naturally occurring self-righting processes.

121 As people begin to feel understood, they are mobilized. But we are not “treating” them, we are listening to them, taking them seriously, and engaging in dialogue with them.

133 The quality of the therapeutic relationship has been shown to be a significant determinant of beneficial outcome across diverse therapy approaches.

137 There is general agreement that the working alliance, emphasizing the collaboration of client and therapist in the work of therapy, is a crucial ingredient…also (138) “empathic resonance”…

142 …accurate empathy, nonpossessive warmth, and genuineness represent the “necessary and sufficient” conditions of beneficial outcome…

146 … effective responses are attitudes and interventions that are appropriate to the individual client…

147 … patient involvement… is a stronger predictor of outcome than are various therapist attitudes or techniques.

The principles for training therapists… follow from our view that the client’s self-healing capacity is the primary force which makes therapy work…

1. i. pave the way for a productive therapist client relationship
2. ii. adopt a collaboration style
3. iii. teach therapists first to be effective supportive listeners
4. iv. trainees practice listening in diads and triads
5. v. encourage therapists to expect clients to get better
6. vi. allow clients to originate some of the solutions… the goal is for them to leave therapy…
7. vii. new therapists should learn to be comfortable with silence. Silence is very important when the client is thinking effectively, imagining new possibilities, and considering changes.

152 Excellent therapists… possess to a greater extent several attributes held to prevent, or at least moderate, negative reactions…self-integration, anxiety management, conceptualizing skills, empathy, and self-insight.

161… on the part of the therapist, establishing a climate of trust and safety through responsiveness; attentive listening; and the communication of understanding, liking and respect… are important characteristics of a quality relationship.

162… on the part of the client… commitment to participate and collaborate with the therapist…

163 In such joining together, the therapist and client expose themselves to the possibility of profound personal change, of being moved, inspired – and sometimes hurt as well.

Students should be provided training not only in developing a strong alliance with their clients, but they should also learn to monitor the alliance, to diagnose difficulties they encounter in building the alliance, and to recognize and repair alliance ruptures. Training efforts should also include teaching students to adapt their relationship stance and their interventions to deal with different clients… (164) students should also be encouraged in their training to reflect on their own interpersonal functioning…

165 Most reports we read pointed strongly to the importance of the embodied experience of the client… it may be time for psychotherapists to put some distance between themselves and the classical medical disease model…

182 Four factors work to combat demoralization in all psychotherapy approaches… an emotionally charged relationship, a therapeutic setting, a therapeutic myth (or rationale), and a therapeutic ritual… the presence of an emotional, confiding relationship with a therapist who is both hopeful and determined to help works to “re-moralize” clients.

183 … agency thinking (I can do it) and pathways thinking (here’s how)…

239 “It is no overstatement to say that the models of treatment that therapists choose should be good for their own mental health as well as the mental health of clients.”

410 it is important that clients come to view the change as resulting, at least in part, from something they did and can repeat in the future.

411… therapists can begin to cast their clients in the role as primary agents of change by listening for and being curious about their competencies… this approach requires a balance between listening empathically to their difficulties with a mindfulness to their strengths and resources.

416 … treatment is best understood as a partnership for change.

417 In a well-functioning alliance, therapists and clients jointly work to construct interventions that are in accordance with the clients’ preferred outcomes.

418 Therapeutic success depends on enabling and confirming the client’s resources in a partnership informed by the client’s goals and perceptions.

419 Clients are best served by helping them believe in possibilities…

420… it is not revisiting or working through the past that matters. What does count in facilitating hope and positive expectations for change is challenging or modifying the pessimistic assumptions clients have about the future.

Treatment should enhance or highlight the client’s felt sense of personal control.

421… models and techniques… become a “practice which teaches the therapist, through naming, enactment, and talking to colleagues, the attitudes and values from which [therapeutic] work is generated.”… models and techniques help provide therapist with replicable and structured ways for developing and practicing the values, attitudes, and behaviors consistent with the core ingredients of effective therapy.

The findings reported in the Heart and Soul of Change support the Hakomi approach to therapy as well as the Hakomi training approach developed by Ron Kurtz. Here are some key points about remembering that the client is the most potent factor determining the success of therapy. If the therapist is supporting the client to have the experience they want and need to have, the therapeutic process will:

• be a collaborative process with a high level of client participation
• use mindfulness and bodymind experiencing to access the limbic system
• demonstrate that it is the client’s experience that guides and directs the process
• recognize the therapist as a support person and the client as primary agent
• be experimental rather than directive or goal-focused
• allow for insights to arise from simply staying with experience
• respect and monitor the client’s reactions to what’s happening and to the therapeutic alliance itself
• make nourishing exploration and self-discovery a priority
• “enhance and highlight the client’s felt sense of personal control”
• “facilitate hope and positive expectations for change”
• “enable and confirm the client’s resources in a partnership informed by the client’s goals and perceptions”

And, for the “heart” of change, the whole process must be based on a practice of loving presence… that particular state of mind in which both therapist and client are nourished.

People come to this work of psychotherapy willing to be vulnerable in these ways:

• asking for help
• being seen
• expressing feelings
• seeing what has been hidden
• being open to feedback
• being mindful
• risking a new relationship
• being willing to change
• giving up control
• looking at “mistakes”, “problems”, parts of themselves they don’t like

So, therapists need to establish a setting that feels safe (ie accepting, non-judging, collaborative, respectful, honouring, slow, contained, quiet, uncomplicated, genuine, spacious, and warm…

The research shows that the client is the most potent variable affecting outcome of therapy… as therapists we are supporting someone to have a positive experience. This means that therapy:

• is a collaborative process
• demonstrates that the client’s experience guides and directs the process
• uses experiencing and mindfulness to access the limbic system
• sees the client as primary agent and the therapist as a support person
• is experimental, rather than directive or mechanical
• stays with experience to allow insights to arise
• respects the needs and goals of the client
• adjusts for the reactions of the client to the therapist and the process
• places nourishing self-study, exploration, and self-discovery as a priority

Since the relationship of the client with the therapist is a key factor, the therapist must be aware of relationship systems which would disrupt the therapeutic alliance. We need to be able to recognize when we are in a system and to shift it in a useful way (jumping out of the system). Some examples of such systems are:

• therapist taking care of the client (or vice versa)
• everything is hard work… serious
• client waiting for questions to answer
• therapist trying to make something happen
• not staying in or with present experience
• nothing therapist says or does is quite right
• client waiting for therapist to say or do something
• therapist is too cautious… tentative…
• therapist is too directive… overconfident and knowing
• client is self-reliant and doesn’t seem to need the therapist
• the yabbut syndrome…  consistently flipping to the opposite
• jumping from topic to topic – changing themes
• over-analyzing… trying to figure things out
• using humour as avoidance of feelings
• client mistrusts therapist… like pulling teeth…

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^[1] (Authors: Mark Hubble, Barry Duncan, Scott Miller) American Psychological Association, 1999