Beliefs and the Success of Psychotherapy
Christian Jonathan Haverkampf, M.D.
Beliefs do matter for the outcome of psychotherapy. This paper gives a brief overview of the relevance of beliefs to the successful outcome of psychotherapy. Beliefs about the treatment outcome, the aetiology and the stability of the therapeutic relationship all play a role. Internal and external communication plays an important role in psychotherapy and in the formulation and maintenance of beliefs. Working with communication thus not only helps in the therapeutic process but also in supporting and developing beliefs which are helpful in psychotherapy and in the individual’s life.
Keywords: beliefs, treatment success, psychotherapy
Table of Contents
Evidence-based Practice in Psychology, as defined by the American Psychological Association, directs practitioners to consider clients’ beliefs, expectations, and preferences when making treatment decisions (APA, 2006). This guidance is at least partially based on research that does indicate that client preferences, outcome expectations, and credibility beliefs do significantly predict and influence a number of process and outcome variables in psychotherapy, including treatment initiation, the therapeutic alliance, premature termination, and treatment outcomes (Constantino, Glass, Arnkoff, Ametrano, & Smith, 2011; Swift, Callahan, & Vollmer, 2011; Tompkins, Swift, & Callahan, 2013).
Beliefs are a product of internal and external communication. (Haverkampf, 2010a, 2017) In order to formulate a belief an individual has to be connected with the own emotions and cognitive thinking to an extent that allows information from both to be linked to a sufficient degree. External communication is important because for most believes meaningful information from the environment is required. Developing awareness in the patient for his or her own communication patterns and providing support for reflection, experimentation and insight about them should thus be important objectives in therapy.
The psychotherapeutic setting begins with a concept of it in the therapist and the patient. They both take part in the therapeutic process because there is a ‘thing’ called psychotherapy. They do not have to invent it because it exists as a model for a series of interactions. But there is another piece of information, which is commonly shared, namely that psychotherapy helps the person in the patent role to ‘deal with issues’, ‘connect with oneself emotionally’, ‘feel less anxious’, ‘feel less depressed’, and so on. It is this generally held belief which is the reason ‘the psychotherapy’ takes place, without it the patient would not be interested in participating in it. This means, there is a belief even before the patient stepped into the room.
These pre-existing beliefs are not necessarily bad for the therapeutic process. However, much depends also on how different these beliefs are from the actual practice of psychotherapy. Most patients are aware that they also have to be active in the process, and that there is no ‘magic wand’. However, patients often expect to be given ‘tips’ or ‘advice’ on what they should do to help themselves, which makes it important to point out early on that people are different, and that therapy actually helps by helping the patient to work out for himself or herself what works and what does not work, by developing new perspectives, new insights and new strategies.
There is also confusion about the specific types of psychotherapy and their usefulness. To a large extent, this is a result of the competition among schools of therapy, where one feels it needs to make itself stand out by claiming to have the answers while the others do not. One advantage of communication-focused therapy (CFT), as it was developed by the author, is to focus on the mechanisms which have helped many individuals in psychotherapy, the internal and external communication in the patient. (Haverkampf, 2010b, 2017)
What helps in psychotherapy is the interaction that takes place between two people, the exchange of messages that are meaningful to the patient and the therapist, which bring about the required change to help the patient lead a more satisfying and ultimately happier life. This process largely maintains itself if both are open to it and intent to make it work. A belief in change is maybe one of the most important beliefs both patient and therapist should have in a therapeutic setting. Equally important seems the belief that this change comes through communication processes, both on the inside and on the outside. In therapeutic approaches which use manuals and place greater emphasis on structure both beliefs may get lost, particularly the latter one. This is not to say that structure in therapy is not important. Without any structure there is no role for the therapist. However, the benefit of structure should be seen in the use of tools rather than in bringing about a process that is the same for every patient. Insight into own needs, values and aspirations and in the individual style of communicating and doing things is what moves the therapy along and leads to its success.
The purpose of belief has been described as guiding action rather than indicating truth.  Belief is the state of mind in which a person thinks something to be the case, with or without there being empirical evidence to prove that something is the case with factual certainty. Another way of defining belief sees it as a mental representation of an attitude positively oriented towards the likelihood of something being true.  If therapy would start with a factual truth in the individual case, there would no longer be a need for a therapeutic process.
In Ancient Greek thought, there were two expressions that make up what we understand as belief, pistis (“trust”, “confidence”) and doxa (“opinion”, “acceptance”). For the therapeutic process we need more than a little of both. Trust and confidence come from the patient’s internal dialogue and how this dialogue and how this information from the inside, meaningful messages the human mind produces all the time, fit with the communication received from the environment. If the discrepancy is too large, trust and confidence are harder to build. An important aspect of therapy is to help the patient build a greater sense and feeling of trust and confidence. Opinion and acceptance, on the other hand, can also be explored in therapy, but there needs to be an opinion from the very outset of therapy that psychotherapy could at least be helpful.
Beliefs are to a large extent also a social phenomenon. If everyone accepts something as a given, such as that the earth is round, it makes it more likely that the individual holds a firm belief also. Commonly held beliefs can change over time, but this often does not happen without some temporary pain or controversy. When it comes to psychotherapy, it is safe to say that there is not a clear assumption by everyone in society that it is effective. This is unfortunate because psychotherapy in many situations, such as burnout, depression, anxiety, panic attacks and much more, can not only lead to a higher quality of life but prevent worse from happening, including loss of job, relationship or physical health. The individual therapist can point out the benefits of therapy to other individuals, but changes in social beliefs require the support of society at large.
There are various models on how beliefs are formed. All of them require information which has to have been communicated to the individual. This underlines again the importance the importance of communication in belief formation. An awareness of own communication patterns, internally and externally, can help a patient make changes that leads to insights and beliefs in life which are more supportive to him or her.
When people are asked to estimate the likelihood that a statement is true, they search their memory for information that has implications for the validity of this statement. Once this information has been identified, they estimate a) the likelihood that the statement would be true if the information were true, and b) the likelihood that the statement would be true if the information were false. If their estimates for these two probabilities differ, people average them, weighting each by the likelihood that the information is true and false (respectively). Thus, information bears directly on beliefs of another, related statement. 
Unlike the previous model, this one takes into consideration the possibility of multiple factors influencing belief formation. Using regression procedures, this model predicts belief formation on the basis of several different pieces of information, with weights assigned to each piece on the basis of their relative importance. 
These models address the fact that the responses people have to belief-relevant information is unlikely to be predicted from the objective basis of the information that they can recall at the time their beliefs are reported. Instead, these responses reflect the number and meaning of the thoughts that people have about the message at the time that they encounter it. 
Awareness of how one forms belies can make a difference for the outcome of therapy. Often, patients who hold maladaptive beliefs, even about the therapeutic process itself, benefit greatly from becoming more aware of where some of their beliefs come from.
Knowledge can make one more immune to unhelpful beliefs. However, knowledge of how a belief forms in itself does not make someone immune from its appeal. If it resonates with a feeling or an opinion that seems important to the individual even a self-defeating belief can be held. The task of psychotherapy is to encourage and support greater openness to different perspective by reducing the fear that is attached to changes in viewpoint or perspective. Changing a perspective seems to change the world to the individual, but it does not change a factual situation in the moment. Patients are often not clear enough about this distinction.
Internalization of beliefs during childhood, which can form and shape our beliefs in different domains. Albert Einstein is often quoted as having said that “Common sense is the collection of prejudices acquired by age eighteen.” Political beliefs depend most strongly on the political beliefs most common in the community where we live.  Most individuals believe the religion they were taught in childhood. 
Charismatic leaders can form and/or modify beliefs (even if those beliefs fly in the face of all previous beliefs).  Is belief voluntary? Rational individuals need to reconcile their direct reality with any said belief; therefore, if belief is not present or possible, it reflects the fact that contradictions were necessarily overcome using cognitive dissonance.
Advertising can form or change beliefs through repetition, shock, and association with images of sex, love, beauty, and other strong positive emotions.  Contrary to intuition, a delay, known as the sleeper effect, instead of immediate succession may increase an advertisement’s ability to persuade viewer’s beliefs if a discounting cue is present. 
Physical trauma, especially to the head, can radically alter a person’s beliefs. 
Beliefs about the reasons and causes of depression have been suggested to play an important role (Addis, Truax, & Jacobson, 1995; Dunlop et al., 2012). An open therapeutic setting which helps the patient find his or her own answers can make the therapy more successful because there is no need to confront the patient with one’s own beliefs about what is going on inside the patient. Restoring better internal communication through more awareness for the external communication, and more refection and insight into it, will help the patient initiate a path that retrieves the information required to reduce the symptoms. Often, the question about reasons and causes becomes secondary then.
Patients’ beliefs about the causes of depression are diverse and can range from childhood events to a chemical imbalance. Similarly, each treatment option for depression has its own model for conceptualizing the aetiology of the disorder, such as the medical model favouring a biological/genetic explanation and the cognitive model favouring an explanation that acknowledges the role of thinking patterns and beliefs (Leykin, DeRubeis, Shelton, & Amsterdam, 2007). Researchers have hypothesized that clients usually prefer treatment approaches with aetiology models that most closely align with their own thoughts about why they are experiencing depression (Dunlop et al., 2012).
A relationship between etiological beliefs, preferences, and expectations for the various psychotherapy approaches has been suggested (Addis & Carpenter, 1999; Meyer & Garcia-Roberts, 2007). Preferences, expectations, and credibility beliefs for behavioural approaches would relate to beliefs about lack of activity as the cause of depression, attitudes toward cognitive therapy with the cognitive reasons, attitudes about IPT with relationship causes, attitudes about pharmacotherapy with the biological beliefs, and attitudes toward psychodynamic psychotherapy with childhood beliefs about the causes of depression. It seems important in this context to let the patient experience from the very first appointment on that the therapist is open to the patient’s journey, while at the same time bringing in his or her experience, training and skills. The therapist’s experience, training and skills should aid the therapist in supporting openness in the therapeutic setting and not lock down the communication in the therapy in mechanistic routines. Awareness, reflection and insight into communication helps shift the focus to the dynamics of the process rather than getting bogged down in details, which also promotes the patient’s autonomy and builds trust and confidence in the therapy.
Several studies have linked depressed clients’ etiological beliefs to their preferences and expectations between psychotherapy and pharmacotherapy (Dunlop et al., 2012; Khalsa, McCarthy, Sharpless, Barrett, & Barber, 2011). The credibility and expectancy questionnaire can be helpful in rating these two factors (CEQ; Devilly & Borkovec, 2000). Corsini and Wedding (2011) provide explanations of different psychotherapies.
In clinical practice, many potential patients ask about CBT, probably because it is offered more often than psychodynamic psychotherapy or any of the other therapies. In the world of the internet, information is readily available, and patients seem to orient themselves by what they find online. Unfortunately, it may sometimes be difficult to gauge the quality of the information just from looking at a website.
Form clinical experience, there seems to be more negative attitudes toward pharmacotherapy. Especially, patients without any prior treatments can be assumed to be more sceptical of medication than psychotherapy, given the more negative press medication receives as compared to psychotherapy.
However, some conditions seem more ‘biological’ than others, and it may well be assumed that for conditions like schizophrenia, severe depression and ADHD there is more openness to psychopharmacology.
Attitudes toward pharmacotherapy seem significantly predicted by biological beliefs (Khalsa et al., 2011). Patients with biological beliefs may favour behavioural rather than cognitive or psychodynamic oriented therapies. However, a therapist should then do her or her best that any mental health condition comes from the interaction, though with different weights, of the following three factors:
- Social Setting and Interactions
It may also be important to explain to a patient that the biology and psychology are inseparable. Cognitive and behavioural processes, including learning and problem solving, affect the topography and the connection strengths in the neural network, while the neural network affects the workings of the mental processes.
Dr Jonathan Haverkampf, M.D. MLA (Harvard) LL.M. trained in medicine, psychiatry and psychotherapy and works in private practice for psychotherapy, counselling and psychiatric medication in Dublin, Ireland. The author can be reached by email at jo****************@gm***.com or on the websites www.jonathanhaverkampf.com and www.jonathanhaverkampf.ie.
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