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?
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:
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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:
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:
Figure 3. Impact of common and specific therapy factors on clinical outcomes (Wampold & Imel, 2015)
For the main summary of this research, see Baldwin & Imel, 2013. [72]
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]
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]
It is possible to evaluate some of these therapist facilitative interpersonal skills through the coding manual by Anderson and Patterson available here.
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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