The Power of Suggestion and the Problematic Insignificance of Significance

The Influence of Suggestion in Therapy

The power of suggestion operates throughout psychotherapy in ways that are both profound and often unrecognized. When clients enter therapy, they bring expectations, hopes, and beliefs about what will help them. These expectations can significantly influence outcomes, sometimes more than the specific therapeutic techniques being used.

Therapists, too, are influenced by their own beliefs about what works, their training, and their theoretical orientations. These factors shape how they understand their clients' problems and what interventions they choose. The interaction between therapist expectations and client expectations creates a complex dynamic that can powerfully influence therapeutic outcomes.

Statistical Significance vs. Clinical Meaning

In mental health research, statistical significance has become a gold standard for determining whether treatments work. A treatment that shows statistically significant results is considered effective, while one that doesn't may be dismissed. But this focus on statistical significance can obscure important questions about clinical meaning and practical significance.

A treatment might show statistically significant improvement while still leaving most clients struggling with their problems. Conversely, a treatment might not reach statistical significance while still helping many individuals in meaningful ways. The gap between statistical significance and clinical meaning is a critical issue in understanding what actually helps people.

The Placebo Effect in Psychotherapy

The placebo effect is well-known in medicine, but its role in psychotherapy is more complex and controversial. When clients improve in therapy, how much of that improvement comes from the specific techniques used, and how much comes from the therapeutic relationship, the expectation of improvement, and the meaning-making process?

This isn't to suggest that therapy is "just" placebo, but rather to recognize that the factors that create placebo effects—hope, relationship, meaning, expectation—are themselves powerful therapeutic agents. Understanding these factors helps us better understand how therapy actually works and how to make it more effective.

The Problem of Meaning in Research

Research in psychotherapy faces a fundamental challenge: how do we measure what matters? Standardized questionnaires can capture symptom reduction, but they may miss the deeper changes in meaning, identity, and relationship that clients experience. The things that make therapy meaningful to clients may not be easily quantifiable.

This creates a tension between what research can measure and what clients actually value. Therapists often see clients make profound changes that don't show up clearly in research measures. This doesn't mean the changes aren't real or important, but rather that our methods of measurement may be missing something essential.

Expectation and Therapeutic Alliance

The therapeutic alliance—the relationship between therapist and client—is consistently found to be one of the strongest predictors of therapeutic outcome. But what creates a strong alliance? Part of it is the therapist's skill, but part of it is also the client's expectation that therapy will help and the therapist's belief in their approach.

When both therapist and client believe in the process, when they share a sense of hope and possibility, the therapeutic relationship becomes more powerful. This isn't manipulation or false hope, but rather the recognition that belief and expectation are themselves therapeutic factors that deserve attention and respect.

The Complexity of Therapeutic Change

Therapeutic change is rarely simple or linear. Clients may improve in some ways while struggling in others. They may experience setbacks that are actually part of the healing process. The meaning of symptoms may shift over time, and what seemed like a problem may come to be understood differently.

This complexity makes it difficult to measure therapy's effectiveness in simple ways. A client might still experience symptoms but feel fundamentally different about themselves and their life. They might have fewer "problems" but more awareness of complexity and nuance. These changes are real and meaningful, even if they don't show up clearly in standardized measures.

Implications for Practice

Understanding the power of suggestion and the limitations of statistical significance has important implications for how we practice therapy. It suggests that we should pay attention to the therapeutic relationship, to hope and expectation, and to the meaning-making process, not just to specific techniques.

It also suggests that we should be humble about what we know and don't know. A treatment that works for one client may not work for another, and factors we don't fully understand may be influencing outcomes. This humility can make us better therapists, more open to learning from our clients and more flexible in our approaches.

The Role of Belief in Healing

Belief plays a complex role in healing. When clients believe they can change, when they have hope, when they trust their therapist, these beliefs can become self-fulfilling. This isn't to say that belief alone is sufficient, but rather that belief creates conditions that make other therapeutic factors more effective.

Therapists also benefit from believing in their work and their clients' capacity for change. This belief isn't naive optimism but rather a recognition of human resilience and the potential for growth. When therapists genuinely believe in the therapeutic process, clients often respond to that belief.

Conclusion

The power of suggestion and the problematic relationship between statistical significance and clinical meaning raise important questions about how therapy works and how we should evaluate it. These questions don't undermine therapy's value but rather help us understand it more deeply. By recognizing the complex factors that influence therapeutic outcomes, we can become more thoughtful practitioners and better serve our clients' needs.