Essential Research in Psychotherapy

Psychotherapy is nowadays a very studied area of research, with over 60,000 academic articles published in the last 30 years [1]. One of the first steps in its history was the development of numerous theoretical approaches, such as the psychoanalytic, cognitive-behavioral, and humanist-existential [2]. Each of these approaches investigates and advocates a set of theories of psychological pathology and intervention. It was expected that the different psychotherapies would demonstrate significant differences not only in the type of interventions made, but also that these interventions would be the determining ingredients for the effectiveness of psychotherapy. Thus, the 20th century was marked by a climate of competition between therapeutic approaches, leading to an era of research in part focused on the direct comparison of the latter. ^{[3, 4, 5]}

^{In spite of this historical context, authors such as Rosenzweig [6]} and Jerome Frank ^[7] ], early appealed to the existence of "common factors" in psychotherapy - that is, that the greater part of clinical outcomes could be explained by a set of transversal ingredients to any therapeutic approach, such as the creation and maintenance of a sound therapeutic alliance. ^{[8, 9]}

This psychotherapeutic debate and decades of accumulated research have led to a set of relevant conclusions, suggestions and challenges. We will divide these results into the following themes: (1) the general effectiveness of psychotherapy; (2) contemporary challenges; (3) the contextual model; (4) effects of the therapist; (5) qualities and actions of effective psychotherapists.

The decade of the 1950s was marked by an intense and controversial debate between Eysenck and Strupp, where the first author argued that there was no conclusive evidence in favor of the effectiveness of psychological interventions ^[10]. This episode helped spur a new era of psychotherapeutic research, exponentially increasing the quantity and quality of available studies. More than half a century later, what can we conclude today about the effectiveness of psychological interventions?

Psychotherapy is effective. ^{[11, 12, 10]}Psychological interventions have consistently superior results in alleviating psychological distress compared to placebo or non-treatment. Research suggests that the person undergoing psychological treatment has, on average, more significant improvements than 80% of the untreated sample.

Psychotherapy is, in many cases, just as effective as drug interventions, with therapeutic gains from the former usually longer lasting.^{[13, 14, 15]}

The main psychotherapeutic approaches today have strong empirical support confirming their efficacy for a wide range of psychological disorders. The studies and meta-analyzes have demonstrated the general effectiveness of the main psychotherapeutic approaches, namely: psychodynamic ^{[16, 17]}, cognitive-behavioral ^{[18, 19]}, humanist-experiential ^[20], systemic-family ^[21]and existential ^[22]. This effectiveness has been proven repeatedly for a set of specific disorders, such as depression ^{[23, 24]}, anxiety disorders ^{[25, 26]}, posttraumatic stress disorder ^{[27, 28]} and personality disorders ^{[29, 30]}.

The meta-analyses available haven’t found significant differences in efficacy between the different approaches studied, in general and for specific disorders. ^{[4, 5, 15, 27, 31, 32, 33]} Since the first meta-analysis by Smith and Glass in 1977, research has not identified any therapeutic approach consistently and significantly more effective than the others, suggesting the existence of other factors relevant to clinical outcomes beyond the clinical model.

An influential summary by Michael J. Lambert suggests four main factors influencing therapeutic outcomes: the characteristics of the client and his or her environment (extra-therapeutic events, social support, etc.), common factors between approaches, client expectations, and the specific techniques of each orientation. ^[34]

The following image summarizes research on the impact of each of these factors:

We can see that the main factor influencing the therapeutic outcomes are the clients' own variables, encompassing their diagnostic and non-diagnostic characteristics and their ecological environment. In other words, the client and his / her variables are the greatest predictor of psychotherapeutic outcomes.

As for the variables of psychotherapy, the common factors between approaches, such as empathy for the client and the quality of the therapeutic alliance, correlate more significantly with therapeutic outcomes than the specific interventions or techniques the therapist uses.

The client's expectations for psychotherapy and psychotherapist are also particularly relevant to the outcomes.

Figure 1. Factors influencing clinical outcomes (Lambert & Barley, 2001) ^[34]

Although interventions or techniques seem to have a lower impact than common factors, it is relevant to mention that this impact can become considerably superior when studied contextually. That is, certain interventions may be particularly effective for certain people at certain stages of the therapeutic process. ^[35] This adequacy of intervention to the characteristics of the client and the process under way is often called responsiveness. ^[36]

Research also presents a set of challenges relevant to psychotherapeutic practice:

High dropout rate. The most recent meta-analysis, based on 669 studies (N = 83834), found an average pre-term dropout of 19.7%. ^[37] In other words, about 1 in 5 clients quit psychotherapy without significant therapeutic gains. As a rule, this abandonment is not related to the used approach, but rather to variables such as the quality of the therapeutic alliance. ^{[38, 39]}
High percentage of adverse/negative effects in psychotherapy. A considerable portion of clients end up worse after psychological intervention than when they started it. ^[40] Between 5% and 10% of clients worsen after therapy and 35% -40% do not experience significant improvements. ^[41] The proportion of negative effects worsens to 15% -23% in the case of psychological interventions with children. ^[42]
Most psychotherapists consistently overestimate their psychotherapeutic effectiveness. Research suggests that 25% of therapists believe to be in the 90th percentile of effectiveness, with no therapist self-evaluating as below average. ^[43^]
Most therapists are ineffective in recognizing clients in clinical deterioration and in evaluating the state of the therapeutic relationship. ^{[44, 45}^] A meta-analysis found that assessments of the therapeutic alliance, from the perspective of clients and therapists, correlated by only .36. ^[46] Therapists and clients also tend to vary in the importance attributed to different aspects of the therapeutic process. ^{[47, 48]}

There are also important challenges in explaining psychotherapists’ results. The literature has been presenting data - often surprising - about variables of the therapist that do not influence their clinical outcomes:

Therapist effectiveness is not related to their age, gender or theoretical orientation. ^{[49, 50, 51]}
Many therapists do not consistently improve their effectiveness with years of clinical experience and may even deteriorate slightly over time. In a particularly important example, and in the largest study of this type to date, an erosion in clinical performance has been reported from a sample of 170 therapists with more than 6,500 clients, assessed longitudinally over a 5-year period. ^[52] This decline in clinical effectiveness was not related to the clinical severity of the cases, the number of sessions or various other factors of the therapist (age, years of experience and theoretical orientation). Another particularly extensive study analyzing the results of 281 therapists with their respective 10812 clients reported that the years of clinical experience of therapists were not a predictive variable of therapy outcomes. ^[49^]
Professional psychotherapists and trainee therapists often achieve similar clinical outcomes. ^{[53, 54]}
The use and adherence to manualized interventions does not dissipate differences in clinical efficacy among therapists. ^{[55, 56]}

In addition to all the data presented, the discovery of mechanisms that explain therapeutic outcomes remains one of the great challenges of contemporary research. ^[57] As we have seen, literature tends to suggest more often variables that are not related to clinical outcomes, calling into question the relative importance of the theoretical models and type of psychotherapeutic training that have dominated the last decades of this area.

An extensive presentation on the origins and empirical foundations of this meta-model can be found in Wampold and Imel's book of 2015, "The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work".

The Contextual Model (CM) is a meta-model of how psychotherapy works. Summarizing the research presented so far, this evidence-based meta-model was suggested by Bruce Wampold in order to conceptualize the mechanisms and ingredients that are transversal to any therapeutic process. Thus, the CM is not an intervention model, but a theory that explains how different models of psychological intervention are effective at promoting significant results. Taking Jerome Frank's pioneering work as a starting point, the CM presents a coherent way of organizing what is currently known about psychotherapy and the processes required for effective psychotherapeutic practice.

The CM suggests three main routes of therapeutic change: (1) the real relationship between therapist and client; (2) the creation of positive expectations; (3) the promotion of in-session and out--session therapeutic actions. Although different theoretical models may emphasize the importance of one pathway in relation to the others, CM authors argue that these pathways are interdependent and that the most effective psychotherapists tend to give importance to, and make explicit use of, all of them.

Figure 2. The Contextual Model (Wampold & Imel, 2015)

Clients come to therapy demoralized for a variety of reasons, seeking a place of support and security that will help them deal with their intra and interpersonal difficulties. They also bring expectations and beliefs about therapy and the therapist, which will naturally evolve throughout the process. This context and the initial connection with the therapist serve as the basis for the three pathways of clinical change proposed by the CM.

3.1. THE REAL RELATIONSHIP

Although its importance varies among therapeutic approaches, the relationship that is established between client and therapist is considered one of the main vehicles of clinical change. Historically, humanistic and psychodynamic approaches have tended to give greater relevance to the therapeutic relationship than cognitive-behavioral approaches have. However, research has shown that the presence of an empathic, attentive and genuine therapist has significant psychological effects itself. The quality of this relationship also has an important impact on the more technical variables of psychotherapy because it influences, among other things, the client's motivation and expectations.

On the other hand, human beings are social beings and, as such, the physical and psychological effects of solitude and deprivation of safe social contact are an important risk factor. While many clients need more than a good relationship with their therapist, this ingredient is often critical to clinical change. Likewise, ruptures in the quality of the relationship are important markers of clinical deterioration and, therefore, the therapist must monitor, prevent and repair possible tensions in the relationship.

3.2. THE CREATION OF POSITIVE EXPECTATIONS

The explanations and meanings that clients bring to therapy for their problems are often non-adaptive, leaving the person feeling stuck, confused and hopeless. An important function of psychological interventions is the co-construction between client and therapist of a credible rationale that can explain the essence of his/her problems and how to deal with them.

When this path of change is skillfully implemented, the explanation empowers clients with positive expectations about psychotherapy. In turn, these contribute to the hope that it is possible for the client to live and feel in a different way, and that the implementation of therapeutic actions may lead to an improvement. This way therapists help clients to replace their non-adaptive explanations with potentially adaptive new ones.

Different therapeutic approaches tend to provide or co-construct different explanations for the clients' problems. Nonetheless, it is critical that clients accept the explanation and believe that it will lead, through the therapeutic process and in-session and out-session actions, to a reduction in their suffering and increase in quality of life. That is, patients must believe that participating and successfully completing therapeutic tasks will be helpful in dealing with their problems, which, in turn, creates the positive expectation that clients can take responsibility for their problems and take control of them.

Psychologically unstructured therapeutic interventions without a minimally defined therapeutic rationale tend to be less effective than those that deliberately focus on conceptualizing and solving client problems. According to the contextual model, the most effective therapists are more persuasive in constructing a reliable explanation for a particular client, creating new meanings for their difficulties and for how therapeutic work will help them.

3.3. THE USE OF THERAPEUTIC TASKS

Generally, it’s not enough for therapeutic success to create expectations through a reliable explanation for the client's difficulties and for how psychotherapy can help (Path nr. 2). A set of in-session and/ or out-session therapeutic actions, consistent with the constructed rationale, will also have to be implemented. Again, different approaches will focus on the implementation of different actions. For example, the psychodynamic therapist may focus on the expression of previously repressed emotions, while the cognitive-behavioral therapist may plan with the client an exposure to an anxiogenic stimulus. It is important to understand that very different therapies, with completely different interventions, have already demonstrated their efficacy for the same psychological disorders.

The real relationship and the creation of positive expectations thus allow the promotion, initially tentative, of new adaptive behaviors in the client. What all effective interventions have in common is that clients are persuaded, in a more implicit or explicit way, to do something that promotes their health and well-being.

The CM is based on a perspective of common factors in psychotherapy. ^[58]

As we have seen previously, these common factors (formerly referred to as “non-specific”) tend to better explain the clinical results than the technical or "specific ingredients" to each approach. ^[8]
The main therapeutic approaches promote a set of cross-cutting clinical strategies, such as increasing client awareness and a greater test of reality. ^{[59, 60]} Thus, therapists of different orientations tend to promote similar psychological processes by different technical means. According to this perspective, the effectiveness of the therapy is not so much due to the specific use of "technique A" or "technique B", as it is to the responsive use of these techniques in order to more effectively promote a transversal clinical strategy.
Two meta-analysis concluded that therapeutic approaches were equally effective when their specific ingredients were withdrawn. ^{[61, 62]} For example, studies where cognitive interventions were withdrawn from cognitive-behavioral treatments showed that the outcomes were not significantly influenced.
An important set of literature reviews, gathered by Norcross (2011), revealed that the therapeutic variables with the best correlation to clinical outcomes are transversal to any approach. Of these variables, the quality of the therapeutic alliance stands out, which represents to date the best predictor of outcomes in psychotherapy, regardless of the theoretical model used. ^[9]. The therapeutic alliance, defined as the agreement on goals and therapeutic tasks and the emotional connection between client and therapist ^[63],is the common "sine qua non" factor in psychotherapy. The remaining variables demonstrated to be transversely correlated with clinical outcomes include adequate therapist empathy ^[64], therapy adaptation to client expectations, culture, preferences, reactance and stage of change ^{[65, 66, 67, 68, 69]}, and the therapist's ability to repair ruptures in the therapeutic alliance. ^[70]

The following table summarizes the investigated variables in psychotherapy and their correlation to clinical outcomes. These variables are divided into common factors (congruent with the Contextual Model) and specific ingredients to specific therapeutic approaches. The thickness of the bars represents the number of studies done for each variable.

Figure 3. Impact of common and specific therapy factors on clinical outcomes (Wampold & Imel, 2015)

In addition to the consistently superior effects of common factors, we can also see how the therapist, as an isolated variable, better explains the results than the type of administered treatment. ^[71] This impact of the therapist's person represents one of the most relevant areas of contemporary research. Therefore, we will now focus on the studies of the effects and characteristics of the therapist, and their relation to clinical outcomes.

For the main summary of this research, see Baldwin & Imel, 2013. ^[72]

“Therapist effects” refer to the variability of results among psychotherapists, regardless of their theoretical model. Whenever the efficacy of one or more approaches is studied in a significantly large sample, some therapists consistently obtain better clinical outcomes than others. In fact, research has consistently demonstrated a greater outcome variability between psychotherapists than between psychotherapies. In other words, who does the intervention and how it is done matters more than what intervention or approach is being used. ^[72, 12] The Contextual Model, previously presented, predicts the existence of these differences among therapists of the same theoretical orientation - as when implementing the same specific ingredients, some therapists will do so with greater interpersonal ability and, consequently, obtain better clinical outcomes. ^[73]

These differences in effectiveness between therapists reach up to quite high levels. For example, in a study by Okiishi et al., data from 1841 clients followed by 91 therapists was analyzed, concluding that therapists whose clients showed faster improvements had, on average, a 10 times higher change rate than the average. ^[74] In another important study by Wampold and Brown, therapists on the top quartile of effectiveness (best 25%) were twice as effective compared to the lower quartile. ^[50]

Even though “therapist effects" are today one of the main factors of psychotherapeutic outcomes, they have been avoided for decades by researchers. The eagerness to develop "evidence-based interventions” and the interest in comparing therapeutic approaches across specific disorders has made the person of the therapist the neglected variable in research. ^[75] Despite this, studies systematically indicate that the therapist is, above any specific intervention, "the" active ingredient of psychological intervention.

Combining available literature, therapist effects tend to account for 5 to 9% of outcome variability in psychotherapy. This result, in turn, contrasts with the 1% variability attributable to the specific techniques used in therapy. ^[72, 12] These conclusions were elegantly summarized by Okishii and colleagues, who argued in favor of a paradigm shift: from evidence-based therapies to the study of effective therapists. ^{[74] However, as previously reviewed, these differences in outcomes among therapists do not correlate with age, gender, therapeutic orientation, years of clinical experience of the therapist, their amount of training or supervision, nor with the degree of adherence to manualized protocols of psychological interventions.} ^{[50, 52, 73, 12]}

How can we better investigate these therapist effects? Baldwin and Imel suggest a set of strategies, including the need for more therapists and studies focused on monitoring clinical outcomes, thus identifying the most effective therapists and proceeding to the systematic study of these therapists. [72] This monitoring of clinical outcomes is possible using feedback systems.

These accumulated results lead us to a new era of psychotherapy research, still in its early stages. We now begin to focus on the systematic study of the person of the therapist, their features and actions both in and out of session. Specifically, the last decade was marked by renewed interest in the study of variables that distinguish therapists with better clinical outcomes.

We know that certain therapists have consistently superior results compared to their peers, but what are the qualities of these highly effective therapists? The following table presents the main therapist variables that have been identified by research as having a robust correlation with clinical outcomes. We develop each of these variables in the next section.

Table 1. The characteristics of effective therapistists supported by research. Baseado em Wampold ^[76] e Wampold et al. ^[77]

The ability to create and maintain a good therapeutic alliance with a wide range of patients. The alliance consists of the emotional bond between therapist and client, and their consensus regarding objectives and therapeutic tasks. ^[63] It’s the most studied therapeutic process construct and common factor, showing a consistently strong correlation with outcome. ^[9] More effective therapists are better able to promote a good emotional bond with different types of clients and to establish an agreement on therapeutic goals and ways to achieve them (tasks). ^{[78]The level of therapist-client collaboration is also one of the most important outcome predictors, indicating that more effective therapists tend to promote dialogue, negotiation, and ongoing adjustments to the alliance dimensions.} ^[79]
Therapist’s facilitative interpersonal skills. The facilitative interpersonal skills ("FIS") construct encompasses a set of important therapist qualities which have been demonstrating a significant impact on psychotherapy outcome. ^{[80, 81, 82]} Specifically, the most effective therapists tend to have the following characteristics:

Verbal fluency: Regardless of the theoretical approach, the effective therapist can communicate clearly and succinctly, adapting their speech to the client in question. Verbal fluency is also central to the co-construction of a compelling clinical rationale.
Empathy for the client: This variable refers to the complex ability to "understand the world through the eyes of the other", with the reflection and deepening of this experience in dialogue with the other. ^[83] Adequate empathy is a strong predictor of clinical outcomes. ^[64]
Creating Positive Expectations: Effective therapists can access client expectations and foster a sense of hope about the potential benefits of psychotherapy. For a review of the impact of client expectations and recommended interventions, see Constantino et al. (2012).
Persuasion / convincing rationale: Persuasion is the ability to induce a new perspective or idea in other people. In psychotherapy, it involves the transmission or co-creation of a clear understanding (rationale) of the source of the client's problems and how to deal with them. Congruent with the Contextual Model, this co-creation of a credible and accepted clinical rationale by the client is one of the main tasks of the effective psychotherapist. This rationale should, in turn, promote new adaptive strategies that positively impact the client's psychological well-being. ^[73]
Emotional Expressiveness: The therapist's speech is relevant not only for its content, but also for its nonverbal markers, such as the tone of voice which is used. More effective therapists tend not to speak monotonously or in a way that seems "off", but rather convey a genuine interest and emotional presence through the expressiveness of their words, modeling this expressiveness according to the client's state.
Flexibility: The abilities to introduce novelty in the session, to flexibly "follow" and "lead" the client and to creatively adapt established clinical plans, are also characteristics of effective therapists. Rather than rigidly following their own ideas, they seek to adapt, using appropriate responsiveness in their posture and interventions to the emerging needs of the client. ^{[56, 84]}
^{Repairing alliance ruptures: Ruptures in the therapeutic alliance are a frequent and possibly inevitable event. The ability to identify and repair these ruptures influences outcomes in psychotherapy, allowing one to transform a sign of deterioration into a therapeutic opportunity. [85, 70]} Specific training in these skills is an important development of recent research and is recommended for all training therapists. ^[86]

It is possible to evaluate some of these therapist facilitative interpersonal skills through the coding manual by Anderson and Patterson available here.

Monitoring clinical progress. Continuously assessing the effectiveness of psychotherapy and adapting interventions according to client feedback is one of the practices demonstrated to have the greatest positive impact on therapeutic outcomes. ^[87] For more information, visit our page on monitoring results and feedback systems.
The most effective therapists allow themselves to doubt more of their own clinical judgment. ^[88]
Deliberate practice. Deliberate practice is one of the distinguishing characteristics of top-performing professionals, defined as the conscious effort to routinely assess their personal performance, to receive professional feedback and reflect on it, to identify specific areas where performance fails, and to develop, rehearse, execute and evaluate plans to improve this personal performance. Recent studies support that the psychotherapists which are more effective spend more time on deliberate practice activities. ^[89] For more information, read the Academy page dedicated to this topic..

We also recommend the reviews by Ackerman and Hilsenroth on therapist characteristics that positively and negatively influence the therapeutic alliance.

Books:

Articles (click to download):

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