Introduction

In this preface, the authors introduce that idea that we do not know as much as we think about the nature of therapy and how it works. The authors note the controversial nature of some myths and misconceptions in therapy. The authors emphasize that overall effectiveness of therapy but draw attention to issues that operate under assumptions, as opposed to empirical support.

Mythology and Ethics

In Mythology and Ethics the authors note the difficulty in navigating emotional and values-based conflicts. Cases of counter-transference are common and require an awareness by the therapist to address the conflict. Sometimes a referral could be necessary. But when such conflicts are values-based, ethical bracketing is recommended, which runs counter-intuitive to countertransference. Individual change, even for therapists, can be difficult, and although the research basis for counter-transference is well-established, extant research on ethical bracketing is very limited. Such issues, along with other ethical mandates such as confidentiality, can compromise client trust. Moreover, although therapists may strive to be honest with clients, transparency and honesty are not always easy to maintain. Therapists cannot guarantee the success of a client or know that an intervention will be effective. Yet, such statements often persist in counseling.

Why the Effects of Therapy Don’t Often Last

In Why the Effects of Therapy Don’t Often Last, the authors confront the issue of longstanding change from therapy. Compared to other professions, such as a surgeon or a mechanic, the service they provide is to have a lasting effect. This is not necessarily true for counseling. Permanent and enduring change is elusive in therapy; clients may relapse or regress. Factors that lead to change range from traumatic events in internal insights to existential crises. Within the therapist’s influence, developing trust, demonstrating respect, initiating a collaborative relationship, and engaging in a directive but supportive, nonconfrontational approach are qualities that are universal to a variety of theoretical approaches and appear influential in lasting change for clients.

Who Are the Most Exceptional Clinicians?

In Who Are the Most Exceptional Clinicians? the authors dispute the assumption that the great writers and theorists were also great clinicians. If fame and notoriety do not make a great therapist, then what does? The effectiveness of the core conditions are highlighted, as well as personal characteristics, such as charisma, relational skills, knowledge and wisdom, and other personal qualities that often get little exposure in mental health literature, such as being fully present in therapy, the presence of a strong moral code, sensitivity, flexibility, and honoring the complexity of the individual. Ultimately, successful therapy is likely more dependent on therapists finding their own voice, as opposed to emulating a famous icon, who may have never been that good in the first place.

What We Know, What We Think We Know, and What We Really Don’t Know Much at All

In What We Know, What We Think We Know, and What We Really Don’t Know Much at All, we explore aspects of psychotherapy that we know or understand with a degree of certainty, such as the potential individuals to change and the effectiveness of psychotherapy. This discussion is followed by concepts that we believe to be true but show limited definitive evidence, specifically to the manner in which psychotherapy is conducted and the impact of care. We can conclude with an overview of psychotherapeutic process that occur but in which little is understood, including what makes good therapy or a good therapist, why people change, and why people do not change.

Last Chapter, But Not the End

In Last Chapter but Not the End, the authors discuss the difficulty of changing beliefs. Change is inevitable and occurs due to the mere passage of time or from seminal life moments, traumatic events, or advances in medicine and technology, to name a few. Though how therapy occurs and what people seek help for might change, it is unlikely that therapists will become obsolete. Nevertheless, it is incumbent upon therapist to maintain knowledge of trends in the field and flexibility to providing care. Moreover, therapists need to able to discern what is real and pertinent to client care and what is myth. Therapists are essential and overall effective, but not necessarily for the reasons they think. Research is not as good as what was once believed; complex problems rarely have simple solutions, and the curative factors of therapy likely occur through the context of the relationship between the client and counselor and not some superficial theory or technique.

Intake Interviews—The “Real” Problem and the Best Way to Fix It

In Intake Interviews, the “Real” Problem, and How to Fix It, the authors identify the process and unrealistic expectations of the intake interview. With a 60 to 90 minute framework, the clinician is to identify problems, diagnose, and document a treatment plan. The intake interview often is a formal or standardized process for therapy—a process that may neither be formal nor standardized. Moreover, there is very poor consistency on how to interpret information form an intake session. Clinicians will often disagree on diagnoses and problem areas. Therapists inevitably will develop very diverse treatment plans. Diagnoses tend to be highly inconsistent among clinicians and often contribute more to client stigma than care. Moreover, the formal process of the intake interview may take away from the client’s agenda, which is important to understanding the client and the client returning for therapy.

Some Tenuous Assumptions and Conceptions

In Some Tenuous Assumptions and Conceptions the authors explain how the myth of certainty affects the therapist. Therapists may often be overconfident in their ability, experience, and approach to counseling. As a result, therapists’ interpretations often lack the accuracy or understanding of clients’ feelings or behaviors. Therapists tend to underestimate the role of parallel processes, in which the impact a therapist believes to be having on a client is also impacting the therapist. Understanding that expertise, experience, and approach do not necessarily guarantee success with a client or even that the therapist has an accurate understanding of the client. Therapists are encouraged to embrace uncertainty when working with a client, as this type of vulnerability may actually enhance the working alliance and serve as a catalyst for client progress.

How Myths and Misconceptions Have Shaped Our World

In How Myths and Misconceptions Have Shaped Our World, the authors highlight differences between theories and myths. As a constantly evolving field, psychotherapy is not alone in the attachment to idea that lack an evidentiary basis, which also occur in other fields such as medicine, economics, and anthropology. Many of the traditions in psychotherapy stem from philosophy. Other myths might simply be a result of bad research or biased, core, personal beliefs. The authors provide an overview of discredited or partially discredited therapies that continue to pervade the field today. The challenge for therapists is to be open to the idea of challenging preconceptions and core beliefs, particularly when evidence counter to core beliefs is introduced.

Balancing Hope and Despair and the Real Reasons for Burnout

In Balancing Hope and Despair, and the Real Reasons for Burnout, the authors discuss how therapist deal with the despair of their clients, as well as their own personal despair. Addressing client hopelessness repeatedly may have professional consequences and serve as a precursor to burnout, as well as attention to ethical dilemmas, child welfare, abuse, moral issues, and high-risk encounters. Organizational factors can also play a role in burnout. A key to addressing despair is to rekindle hope. By admitting uncertainly, addressing feelings of hopelessness, and noting that the work of a clinician is focused on engaging in client’s feelings of hopelessness, therapists can overcome their feelings of obligation to always be effective. Admitting powerlessness is key to longevity in the profession.