The 7 Steps of Effective Psychotherapy

The joy of success!

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There are seven steps shared by all effective psychotherapies, no matter what approach. All successful therapies follow the same path—with good reason.

Research on effective treatment agrees that:

• a set of "common factors" such as empathy need to be present,
• along with an agreed-upon explanation for the client's problems
• leading to an agreed-upon rationale for treatments and
• agreed-upon goals.

After that, all effective treatments look to reverse vicious cycles by making sense of interventions that help successful clients break their problem cycles or patterns.

What Works in Psychotherapy

My own review of the research on effective treatments (Fraser, 2018) converges on a process of change model. Research supporting that view appears in my past post, "What Works in Psychotherapy." While the PROCESS diagram below and its related research were intended for therapists, they may also be of interest to those interested in therapy. Therefore, because most of my past posts have been drawn from my 2018 book, I will help flesh out many of the seven phases of the process model with links to past posts to help explain the model to the interested reader. You, as a reader, may choose to click on any of these to learn more.

Diagramming the Seven Steps

The diagram below shows the seven phases of all effective therapy.

The PROCESS Phases of Effective Therapy

Source: J. Scott Fraser, From Ch. 11 of Unifying Effective Psychotherapies

The Seven Phases

1. Pairing

Empathy, positive regard and affirmation, congruence and genuineness, goal consensus, and collaboration are crucial for success. As clients, these elements help us build enough trust in our therapist to take the often scary step out of our problem and into a therapeutic alliance with our therapist. This phase also helps to build hope, as discussed in my post "Hope: A Foundation of all Psychotherapy that Works."

Stories, frames, and metaphors shared by our therapists help us see our problems as human and help us see our therapists as simply humans themselves. Therapists and clients are looking for a close match or fit with each other. The closer our therapist matches our values, language, metaphors, and our position on the problem, the better the fit.

2. Recognizing Patterns

All therapists look for repetitive patterns in their clients’ lives. These include both positive and problematic patterns. It is just as important to build on clients' strengths, as it is to address their identified problems. My post, "Nine Dots: A Key to Psychological Problems?" covers the essence of these vicious cycle patterns.

Here, therapists ask clients to define their problem, ask what they have done about it, find out what they usually do about it, how that has typically worked, and what others have tried to do or suggested for them to do about it (including what other therapists have suggested).

Identifying vicious cycle patterns is the ultimate target. Vicious cycle patterns in couples, for example, and commonly effective therapies to resolve them may be found in the post, "What Do All Troubled Couples Share?"

3. Orienting Toward Change

Clear, agreed-upon goals are strongly associated with successful therapy across all approaches. In all therapies, therapists target exactly what shifts clients need to make in their problem patterns. The therapist needs to know the pattern of the vicious cycle to understand how to shift it. The classic vicious cycles around depression, for example, can be tracked in the post "The Two Faces of Depression."

The therapist’s theoretical position on problems and their rationale for treatment come in here as well. This is the point when therapists need to align with what will make sense to us as clients and engage us in an alliance for change. This leads to the next phase of collaboration and building a therapeutic alliance.

4. Collaborating on a Plan

The work of therapy is done through alliance—collaboration. Finding the best fit between client and therapist on an understandable, sensible, and workable frame and rationale for treatment is crucial to building a strong alliance.

Frames and rationales may include theoretical explanations, research-based explanations, developmental explanations, frames fitting spiritual or cultural traditions, and many more. Of course, the closer the frame fits our worldview, values, and beliefs the better. This is the focus of the post, "The Hero's Journey: Finding Therapy That Fits."

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5. Engaging Treatment

1. Treatment often begins before treatment starts: Saying that treatments start at a set stage to engage treatment isn't really right. In fact, treatment begins at times even before the first session. Clients may have gotten a recommendation to a given practitioner based upon their reputation for success, creating a halo of hope even before seeing the therapist. In many ways, the same can be said about the other preceding phases—each step often starts before a client even meets their therapist.
2. Assessment and treatment are inseparable: Similarly, therapists’ theoretical perspective shapes the type of questions they ask, what they attend to, follow up on, and even whom they may include in sessions. Assessment and intervention are essentially inseparable. They influence and shape the course of interaction and information in an evolving co-created “truth” about the clients’ problem as well as about the therapist. The dance of intervention, so to speak, begins immediately. Therapist interests through the early part of any session may focus on history, interpersonal relationships, thoughts and beliefs, pure behavior sequences, social networks, the way the client reacts in the moment to the therapist, or combinations of all of these and more.
3. Treatment rationales guide interventions: The rationale our therapist used to explain therapy creates a framework for treatment. As that treatment rationale makes sense to us, so does the fit between clients and therapists. Interventions and procedures must make sense to both clients and therapists because those new solutions often seem counterintuitive from our original understanding of our problem.
4. Interventions must shift problem patterns: What matters is that the interventions create new shifts to initiate virtuous cycle patterns. Treatment techniques and procedures may include, for example, in-session enactments, two-chair dialogues, Socratic questioning, modeling, rehearsals, in-session bonding and affirmations, interpretations, homework assignments, and a range of other specific treatment techniques. What matters is that those interventions shift our problem-generating solutions.

6. Supporting Success

All effective therapists note and support positive pattern shifts, and support client ownership of those changes. The goal is to support an evolving virtuous cycle consistent with agreed-upon goals. Client ownership of these changes is important across treatments. In many ways, most treatments explain problems as reasonable reactions to the course of historical and current stressors and events. It doesn't matter if the type of treatment is dynamic, interpersonal, behavioral, cognitive, emotional, or other frames and explanations. However, they consistently affirm the clients’ distress as a product of their situation and their treatment successes as due to the client's own efforts.

Change as Personal, Positive, and Pervasive: Most treatments cast problem patterns, while distressing and understandably negative, as transient and situational. The movement is from clients viewing their problems as personal, negative, and pervasive to owning their strengths, resilience, and successes in the face of such adversity as personal, positive, and pervasive.

7. Sustaining the Change

All evidence-supported treatments include some final phase where they build resilience and engage in relapse prevention. All treatments acknowledge the potential for future life challenges and potential relapse into the original problem cycles. The goals of all treatments are to sustain changes once they occur and continue the virtuous cycles.

Predicting and Prescribing: Most all successful treatments use the idea of predicting and prescribing as treatment concludes.

1. Predicting: Clinicians usually warn clients of the hurdles ahead. They discuss future challenges and even rehearse responses in sessions. Under the idea that “forewarned is forearmed,” clients and therapists collaborate as they predict future obstacles.
2. Prescribing: Turning to the idea of prescribing, the usual approach before ending treatment is, once clients have developed a new, sustained patterned resolution, to have clients actively confront old situations, thoughts, and emotions. First, if clients find themselves relapsing into old patterns, they learn something they can discuss and address in the following sessions. Second, deliberately trying to reengage in old responses, formerly viewed as coming on spontaneously, offers another paradox. It's reassuring not to be able to bring on the old problem. It is contradictory, for example, to have a panic attack in a controlled and deliberate way.

The Family Doctor Model: In most contemporary treatments, therapists cast themselves in the same light as family practitioners. Clients always assume they will return to a trusted family doctor after recovering from a recent illness. This goes as well for psychotherapists. Most therapists now welcome clients back for booster sessions—a practice actively supported by the literature.

The PROCESS of Successful Psychotherapy

While much more may be said about each of the above phases of the PROCESS model of treatment, these seven phases offer a well-supported and flexible format for successful psychotherapies, no matter what approach is used.

To find a therapist, please visit the Psychology Today Therapy Directory.