How to Use the Dodo Effect to Improve Your Mental Health 🦤

LIFE ON URTH - Episode 091

The Effectiveness of Psychotherapy

During my medical training, I was used to thinking about effectiveness in clear terms: Ibuprofen not only relieves pain, but it also inhibits inflammatory processes. Paracetamol, on the other hand, is more effective for fever and is gentler on the stomach lining. One can name mechanisms, compare effects, and weigh side effects.

It's less straightforward with psychotherapy.

As in all medical disciplines, there are clinical guidelines for the treatment of mental disorders. What is striking is that the depression guideline begins by addressing the methodological difficulties of psychotherapy research—and thus also explains why comparisons between different forms of treatment are only possible to a limited extent.

Among the aspects described as particularly challenging are:

Study design: Psychotherapy is not an isolatable substance but a complex, interactive intervention—far more difficult to standardize than administering a medication.
Randomization: In real-world care, therapeutic alliance, motivation, and fit play a central role—factors that are only partially captured by random assignment in clinical trials.
Lack of blinding: While medication studies can often be conducted double-blind, in psychotherapy studies, both therapists and patients know what is being done.
Outcome measurement: Depressive symptoms are usually assessed using rating scales. Even small point differences can determine “response” or “remission” without necessarily being clinically meaningful.
Publication bias: Positive results are more likely to be published, and effect sizes are therefore likely overestimated—a general problem in medical research.

The book I am currently using to prepare for my board examination describes this field as surprisingly resistant to simplification: “Even after more than 100 years of psychotherapy research, there is little robust empirical evidence that individual therapeutic approaches are overall more effective than the overarching category of properly and competently delivered psychotherapy (Wampold, Imel & Flückiger, 2018). The differences within a given therapy form are greater than the differences between therapy forms.”

There is even a name for this phenomenon: “In reference to a remark made by the Dodo bird in Lewis Carroll’s Alice in Wonderland after a peculiar race—‘Everybody has won, and all must have prizes’—psychotherapy research sometimes speaks of the so-called Dodo effect.” 🦤

The Core Conditions

If different approaches hardly differ in their overall effectiveness, then instead of focusing on their differences, we are led to focus on what they share: What are the conditions under which change becomes possible at all?

Carl Rogers articulated this shift early on. He was less interested in specific techniques and more in the therapist’s attitude toward the patient. His thesis was radical: Certain relational qualities are not merely helpful—they are sufficient for therapeutic change.

Three of these so-called basic variables have since been adopted across therapeutic schools as nonspecific factors:

Genuineness (Congruence)

The therapist meets the patient as a real person, not hidden behind a professional façade. She is willing to share what is going on within her.

Unconditional positive regard

The person of the patient is accepted—independent of specific contents or behaviors. Acceptance does not mean that the therapist must approve of everything the patient does.

Empathy

The capacity to understand the other person’s internal frame of reference through perspective-taking—and to communicate that understanding accurately.

Later in his life, Rogers emphasized an overarching quality: Presence

A state in which the therapist is physically, emotionally, and cognitively fully in the present moment of the encounter.

These variables were originally formulated within a humanistic framework. Today, they are regarded as nonspecific factors—conditions that are relevant across different therapeutic approaches.

This may not be so surprising. From an evolutionary perspective, psychotherapy as an encounter is not a new phenomenon. For hundreds of thousands of years, humans have regulated stress, fear, and shame in relationships.

The Most Important Relationship

We spend most of our lives not in dialogue with others, but in dialogue with our own inner system. What, then, do the basic variables mean for the relationship we conduct continuously—the relationship with ourselves?

Genuineness toward oneself begins with something very simple: not immediately correcting one’s inner experience. In many situations, we do not only react to a feeling—we also react to the fact that the feeling is there at all.

Anxiety is problematized.
Anger is morally judged.
Sadness is interpreted as weakness.

Genuineness here would mean stepping back and allowing oneself to say: This is my actual inner landscape right now—without immediately trying to remodel it.

Unconditional positive regard becomes particularly sharp in the relationship with oneself. We often tie our self-worth to behavior, performance, or emotional stability. The harshest judgments are reserved for our own person.

Acceptance does not mean we must approve of all our decisions. It would mean taking ourselves seriously nonetheless, being interested in our inner processes, and approaching ourselves without prejudice.

Empathy with oneself means not hastily labeling one’s own behavior as irrational or disruptive, but viewing it functionally. Many patterns that hinder us today were once necessary attempts at solving a problem. Instead of taking the perspective of the therapist toward a patient, we can take the perspective of our younger self.

Avoidance once protected us.
Perfectionism once secured belonging.
Withdrawal once regulated overwhelm.

When one begins to view one’s inner system from this angle, the tone of the inner dialogue shifts. Moral evaluation is replaced by curiosity.

All of this requires presence. This is nothing mystical, but simply the willingness to observe one’s own consciousness and its changes closely. This includes sensory impressions from the outside world—but also inner processes such as thoughts, feelings, and impulses.

Our nervous system responds to signals of safety or threat—and these signals can come from outside or from within. A condemning inner monologue can trigger the same alarm as a critical glance. Conversely, an accepting inner attitude can have a calming effect, much like an understanding counterpart.

The basic variables are not exclusive techniques of a particular therapeutic approach, but descriptions of an attitude that enables change—within the therapy room and beyond it.

If they are the central effective factors in the professional relationship between therapist and patient, why should we not also use them to improve the everyday relationship we have with ourselves?

In fact, I have come to believe that this is how psychotherapy works: Through the example of the therapist, the patient learns to adopt a new attitude toward themselves—genuine, curious, empathic, and present.

✒️ Quote of the Week: "The only way to truly forgive another person - or oneself - is to restart the clock in the present." -Sam Harris

🎧 Song of the Week: Carbon Based Lifeforms, Karin My - Central Plain

📺 Video of the Week: 45 minutes on a single paragraph of Nietzsche's Beyond Good & Evil

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Adrian / Urth

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