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]}

 

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]

• 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:

1. 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.
2. 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]
3. 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).

4. 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]

5. 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.
6. 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]}
7. ^{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:

• Castonguay, L. G., & Hill, C. E. (Eds.). (2017). How and why are some therapists better than others?: understanding therapist effects. American Psychological Association.
• Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy. American Psychological Association.
• Frank, J. D., & Frank, J. B. (1993). Persuasion and healing: A comparative study of psychotherapy. JHU Press.
• Lambert, M. J. (Ed.). (2013). Bergin and Garfield's handbook of psychotherapy and behavior change. John Wiley & Sons.
• Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York: Oxford University Press.
• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work. Routledge.

Articles (click to download):

• Hill, C. E., Spiegel, S. B., Hoffman, M. A., Kivlighan Jr, D. M., & Gelso, C. J. (2017). Therapist expertise in psychotherapy revisited. The Counseling Psychologist, 45(1), 7-53.
• Lambert, M. J., & Barley, D. E. (2001). Research summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy: Theory, research, practice, training, 38(4), 357.
• Levitt, H. M., Pomerville, A., & Surace, F. I. (2016). A qualitative meta-analysis examining clients’ experiences of psychotherapy: A new agenda. Psychological bulletin, 142(8), 801.

• Miller, S. D., Hubble, M. A., Chow, D. L., & Seidel, J. A. (2013). The outcome of psychotherapy: yesterday, today, and tomorrow.
• Safran, J. D., & Kraus, J. (2014). Alliance ruptures, impasses, and enactments: A relational perspective. Psychotherapy, 51(3), 381.
• Wampold, B. E. (2011). Qualities and actions of effective therapists. American Psychological Association.
• Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277.

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Psychotherapy is effective.