The Dodo Bird Verdict with Erik Anderson, LMFT

What makes a "good" therapist? The answer is...incredibly frustrating.

How did you decide to become a therapist?

I hated this job I was working running Jiu Jitsu tournaments with a boss that was super corrupt and asking me to swindle people. I also knew I wasn’t good at concentrating while sitting at a desk.  My therapist was encouraging me to be a firefighter or a police officer but I didn’t want to do those things so I asked her, “can I do what you do?” She said, “well, you don’t have a personality disorder so I don’t see why not.”

I decided I just really wanted to see clients because it would keep my attention to sit down in front of someone instead of sitting in front of a computer and struggling not to browse reddit.

There’s this trend online where, when faced with a really tough question or issue, people encourage others to “see a therapist” in the same way they might say “see a doctor” when you’ve got a physical issue. People seem to say this thinking there’s “good therapists” and “bad therapists” which really must just depend on the therapist’s personality like whether they are “validating” by believing and listening to you or whether they are dismissive.

I, as a therapist, get frustrated when people online in places like r/relationshipadvice and people say “you shouldn’t be asking strangers online – you need to see a therapist.” I often think, “what the fuck am I going to tell you?” They’re asking for advice and it’s not like I’m some superhero who has completely new ideas that other people couldn’t have.

It’s not the same thing as reading an X-Ray where there’s a doctor who can help you read an X-Ray when lay people usually can’t. It’s like, “this is my life – can you read this for me and tell me what to do?”

Yeah, I’m not sure people are right to believe therapists have special skills that others don’t have or a specialized approach that lay people can’t comment on.

What did you think therapy was when you started studying it in school?

I went in to grad school thinking there were certain things I have to study that are right. I thought I was going to read the DSM and learn what the diagnoses are. I thought I was going to be able to listen to what my professors said and just know how to solve people’s problems. My therapist was really helpful with my negative thoughts and beliefs about myself and my relationships. She would help me identify automatic negative thoughts, identify cognitive distortions and challenge them which seemed to be the right answers for what I was experiencing then. I believed those were the right answers that would help me and it seemed like my therapist knew things I didn’t and could see things which I didn’t.

It felt like therapy had the right answers when my depression or whatever mental health disorder I had caused me to have the wrong answers. It seemed like therapy had a method that helped and you had to stick to the method like my therapist did.

When I was in school my professors taught me that different styles of therapy had different levels of effectiveness and I believed that. They treated the idea that different styles of therapy could be just as effective as one another as ridiculous. One of my professors did research on how specific ingredients in trauma therapy would lead to different outcomes. I studied the stuff on what my professors gave me – a lot of them were manuals for how to do a style of treatment. That’s what I thought therapy was when I started: you were going to help people with these methods and they would get better as they learned how to relate differently to their minds so they didn’t have these problems. I was sure therapy would help them get over their diagnoses whether it was cognitive behavioral therapy for depression, prolonged exposure therapy for trauma, or exposure and response prevention for obsessive compulsive disorder.

When I started working I was different than my supervisors – they liked depth psychology and Carl Jung and were somewhat psychoanalytic. In a supervision group a guy I was working there with said he heard a podcast on outcomes in psychotherapy (https://chrishoffmft.podbean.com/e/the-radical-therapist-013-%E2%80%93-common-factors-in-couple-family-therapy-w-dr-sean-davis/)  that he thought I would find interesting. They talked about this book about the evidence on what makes therapy work and I immediately bought it and read it. I read this book called The Heart and Soul of Change (https://www.apa.org/pubs/books/heart-soul-change) which reviewed research and evidence, going over what we knew and how we knew it and it had these really vague results about what works that I had a hard time with. I thought you just had to stick to a particular method and this book completely contradicted that.

For the last 40 years there’s been a lot of new styles of therapy developed: EMDR, Cognitive Behavioral Therapy, Internal Family Systems… all of these are styles that get these manuals written about them where it seems you have to just do it right. They all brag that the evidence shows they’re Evidence Based Therapies. The Heart and Soul of Change said that whole body of research suggested they were misled and that there were other things that determined the effectiveness of therapy that varied a lot from therapist to therapist and that those differences had a lot more to do with outcomes than how closely therapists were sticking to the manual.

I experienced this profound doubt about what I was doing… I didn’t like the idea of therapists being these vague healer figures doing this process of change that is not well defined.

It made me feel like a priest doing something ridiculous and woo rather than a clinician delivering an empirically supported treatment, which is what I thought I was. I went into my sessions after that experiencing so much doubt that my clients could all see it and I lost about 50-60% of the people I was working with over the course of a couple months. I had to rebuild from that place.

So you went into psychology determined to laser in on the right way to do therapy as supported by science—the research-backed formulas behind the therapy that actually work. But then you stumbled upon the Dodo Bird Verdict. Can you tell me in layman’s terms what that is?

So the Dodo Bird Verdict is a finding that has been replicated many times in research on outcomes in psychotherapy over the last hundred years (since it was first found in 1928). It’s the finding that all forms of therapy that contain things that seem to make them things we’d actually call therapy, whether this is psychodynamic, humanistic, cognitive behavioral, or something new all seem to have similar outcomes. They are all similarly helpful and similarly effective when we study how they work for many different conditions. 

That is to say, the style you use makes almost no difference in whether people get better from therapy or not.

So for those that reject this research – on what terms do they reject it?

Therapists go to a lot of trainings for new styles of therapy. If you go to a training on Emotionally Focused Couples Therapy they will talk to no end about the research showing it’s more effective than other couples therapies and they’ll point to studies that show that. But the problem with those studies is they’re typically conducted by researchers who are invested in Emotionally Focused Couples Therapy or therapists who believe it is better than other styles.

People who reject the Dodo Bird Verdict are often only vaguely aware of what it is and how big the body of research supporting it is. They say things like, “oh, I know that, we all know that the relationship is the most important thing in therapy.” But then they still point to those studies showing some therapies have better outcomes than others while never having looked into how much bias impacts those studies.

They aren’t willing to accept all of its conclusions often because they so repeatedly hear the claim that some styles are newer and more effective, which for a while insurance companies played into. But recently even insurance companies have started taking a different approach and looking at outcome measures rather than styles used. 

So how did this end up affecting your practice?

I had been sure that learning more about the right evidence based treatments was the right thing but now I was seeing the whole evidence based treatments model as flawed. I completely questioned what I was doing and what could make me a good therapist. I didn’t want to be a priest blessing people with holy water and telling them they’re getting better. It was disturbing to me as someone who wanted the right answers.

Most therapists I talked to were fine with this and would say, “we always knew therapy was about the relationship,” reflecting a vague understanding of the research while accepting that they’re some sort of healers.

The thing that got me back on track was reading more about the things effective therapists do need to do.

So what do effective therapists need to do?

Researchers find that there are some things within the therapist’s control which help people get better in therapy and most of it is about how good the therapist is at building a working relationship with the client.

A working relationship has to do with whether they make the client feel heard, understood and respected; whether they understand and agree with the client about what their goals are; and whether they’re able to use their approach in a way that helps their client make sense of their problem, clarify how they can work on their problem, and where they need to be putting effort in on their problem. Those descriptions are purposely vague because we’ve found many different therapies, even ones that seem pretty alien to one another, seem to be equivalently helpful for people trying to overcome their problems or reducing their symptoms.

How did this impact your perspective of your goals/your vision for your career/therapy in general?

I worked on trying to give my clients explanations and rationale for how they could change and trying to better instill hope and expectancy that they could change. I tried to clarify what they could do to change and how we would work on it. You work along with them but it’s also on them at this point whether they do put in effort to change their problem. The funny thing along the way is that you actually do need a therapeutic style to deliver those things but the particulars of the style doesn’t matter that much. It could be a psychodynamic style, emotionally focused style, internal family systems…

I discovered I could deliver therapy in the styles that had been helpful to me. This felt like a way to be genuine and honest with people while helping them figure out their problems. But I also decided to start measuring whether people were getting better in my care because I realized that as long as people were getting better in my care I could feel good about what I was doing.

It took a lot of work for me to feel confident delivering therapy. I felt like I had to understand what I was doing. I now understand therapy to be a process of an all too human healing ritual. Medicine doesn’t totally understand why people get better from healing rituals. In medicine when people get better without the active ingredient doing it, we call that the placebo effect. And the researchers I was reading suggested that therapy specifically targets what medicine rejects as “the placebo effect” that we might otherwise call “the internal process of healing and change.”

The research on the placebo effect shows it has large effects on pain, anxiety and immune function. Therapy seems to help people suffer less, experience less anxiety, function better in measurable ways including incurring lower medical expenses over their lifetime…

…same as placebos.

Yes, but we also know the placebo effect varies a lot from doctor to doctor the same way treatment effectiveness varies from therapist to therapist.  In fact, psychiatrists prescribing the same medication will have three times as good outcomes as other psychiatrists depending how good their “bedside manner” is.

So is all you do a placebo?

I think were you to phrase it that way, it’s like saying “so Yoga is just really hard stretching?” It’s using specific language that accurately describes what something does while also rejecting it. In philosophy it’s sometimes called Russell Conjugation when you say something like, “I stand up for myself, you won’t take no for an answer, she always needs to get her way.”

Therapy is something that activates the internal human capacity for healing and change that can turn on in social settings.

Humans seem to be able to heal and change from many conditions when given the right social conditions with healer figures. I had a hard time overcoming seeing this as odd or woo but we know that this method is one of the ways people overcome mental health conditions. Therapy seems to help people suffer less, be less sick, and have overall more wellbeing. It’s an effective treatment with a lot of evidence showing people get better from it.

I like to rephrase “therapy is just the placebo effect,” to, “therapy is a process that activates a human’s internal process for healing and change.”

Are there any misconceptions about psychology/therapy that you see on social media that particularly drive you insane? And can you give us the facts of those fictions?

Typically the depiction of therapists having all the answers about, “if you’re experiencing this that is because of that.” Like, “if you feel jumpy, that’s a trauma response…” “if you have rejection sensitivity that’s because you have ADHD.” Really? The things we know have clear relationships are usually things in the DSM. But the DSM doesn’t say much about what causes mental health disorders in the brain. Really, we don’t know what mental health conditions are but we know there seem to be certain clusters of symptoms we call and categorize as ‘disorders.’

When therapists get on social media and talk about the things they believe come along with ADHD or the reasons from your past you feel this or that way. When therapists start naming things to look for it can sometimes get dangerous because they may be making truth claims about things that just aren’t well established. One of the ways we’ve seen this go really wrong was in the 80s when therapists were very vocal about many symptoms of discomfort being related to repressed memories.  There are people still suffering the effects of being sentenced to jailtime, admitting to atrocities they didn’t commit or disowning their family because of believing in repressed memories.

Most therapists believe they can’t be harmful as long as they’re just trying to be helpful and it just isn’t the case. We know there have been some harmful therapies such as rebirthing therapy where children were smothered to death under blankets. But most harmful therapies are more subtle through teaching clients or the public harmful false beliefs.

In part, I see my role in therapy as being my client’s personal philosopher. I’m trying to help them form a more true or realistic understanding of their life, what they can do to make their life better, and how to make good moral decisions. 

I very rarely use the terms “healthy and unhealthy” because I think they’re so overused in popular psychology. I was surprised I used “healthy” the other day in talking to a client but here’s an example of a rare exception where I will use it. A client said he thought he had a masturbation addiction because he told himself and his partners he would never do it. He was also not having premarital sex so he had no outlet for sexual energy. When he inevitably would masturbate he would feel profound shame and guilt and it made him feel other symptoms like difficulty focusing and fatigue. I stated that when we look at studies of human sexuality it appears across cultures, genders and ages and thus we think of it as normal and healthy. That’s one of the few instances where I’ll say something like that. I see many other therapists going much further than that with their statements of what healthy and unhealthy are and I think those are philosophical statements that therapists are typically unjustified in making.

Where can people find out more about you?

Please check out my website.

And if you’re interested in reading what I’ve written about what makes therapy work, check out my blog series on the topic starting here.