What Works in Psychotherapy?

The Elation of Success!

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Given all the different approaches to psychotherapy available today, the obvious question is: Which of them works best? The startling answer, based on decades of research, is that they are all about equally effective. This is a puzzle, as so many approaches are so vastly different from each other in their views of humankind, their assumptions of how psychological problems arise, and their methods of treatment. This was reflected in a prior post, "What Works in Couple Therapy," which made clear that two very different approaches to couple treatment were equally effective. If many therapy approaches are so different, yet the majority are equally effective, what active ingredients do they share?

What We Know

Not to get ahead of ourselves, let's first take a look at a recent summary of the literature on just how effective psychotherapy is, and generally what works as they are effective. Wampold and Imel (2015), confirmed a set of things they said, “We know for sure” or are relatively sure about regarding the effects of psychotherapy. They conclude that:

• Psychotherapy is remarkably effective. The effects of psychotherapy are greater than the effects of many medical practices, including flu vaccines, most interventions in cardiology, and treatments for asthma, some of which are very expensive and have significant side effects. Psychotherapy is as effective as medication for most mental disorders, without the side effects. As well, psychotherapy is longer lasting than medications (lower relapse rates after treatment is discontinued) and is less resistant to additional courses of treatment. Therapists in practice achieve outcomes comparable to those achieved in randomized clinical trials (RCTs). Indeed, they seem to achieve the same benefits, in fewer sessions, then in clinical trials.
• Factors, such as the working alliance, empathy, expectations, psychoeducation about the disorder, and other so-called “common factors” are robustly related to outcome. Moreover, and importantly, those therapists who can form an alliance with a range of patients, have a sophisticated set of facilitative interpersonal skills, worry about their effectiveness, and make deliberate efforts to improve are the therapists who achieve better outcomes.
• Providing information about client progress to the therapist and the client improves the quality of psychotherapy, primarily by reducing the likelihood of treatment failures for clients not making expected progress. Monitoring client progress to improve the quality of services, which is often called practice-based evidence, is becoming more widely used.
• Adherence to a treatment protocol is not related to outcome. That is, therapists who adhere to what is expected in a treatment do not get better outcomes than therapists who deviate from the manual. Actually, it appears that therapists who, regardless of how the client responds, sticks to the treatment have poorer outcomes. It is those therapists who flexibly provide a treatment that achieve the best outcomes.
• It appears that “treatments” with no structure are less effective than treatments that have deliberate actions focused on the client’s problems. Therapists delivering non-structured treatments are not able to provide the client an explanation for his or her distress nor explain how the work the client does in therapy will help the client with his or her problems; two aspects of therapy that seem to be important for producing benefits. (Wampold & Imel, 2015).

Three Things Shared by Psychotherapies That Work

Recent research overviews suggest that there are 3 things all effective psychotherapies share:

1. Positive Relationships
2. Compelling Rationales
3. Targeted Change

A quick survey of major research summaries supports each of these critical components of therapy that works. Laska, Gurman, and Wampold, (2014) suggest the following overlapping elements underlay all effective psychotherapies:

• (a) an emotionally charged bond between the therapist and patient.
• (b) a confiding healing setting in which therapy takes place.
• (c) a therapist who provides a psychologically derived and culturally embedded explanation for emotional distress.
• (d) an explanation that is adaptive (provides viable and believable options for overcoming specific difficulties) and is accepted by the patient.
• (e) a set of procedures or rituals engaged by the patient and therapist that leads the patient to enact something that is positive, helpful, or adaptive.

What Is Effective Change?

The last sentence in the above list suggests that there must be a set of procedures that "leads the patient to enact something that is positive, helpful, or adaptive." While this sounds nice, it remains broadly vague. What does adaptive mean, or more clearly, what is effective change? The major message of the book, Unifying Effective Psychotherapies: Tracing the Process of Change (Fraser, 2018), is that change across all therapies that work is a shift or reversal in problem patterns. This was summarized in two earlier posts. The first was titled, "Nine Dots: A Key to Psychological Problems?" The second post titled, "When Our Solutions Become the Problem."

In essence, all approaches to psychotherapy view problems as vicious cycles of solution patterns, which turn back on themselves and only make our problems worse. What's more, these solution patterns inevitably make perfect sense to us. Therefore, it often feels like a risk to confront or shift our tried and true patterns, even in the face of their failure.

The Three Related Qualities of Success

In the face of the potential risk of doing something new to resolve our problems in psychotherapy, we thus need three interacting qualities in that treatment.

1. A trusted and empathetic guide in a therapist who understands our plight and will be there to support us through our journey. Research suggests that this first element may account for as much as 60 to 80 percent of the influence toward positive change.
2. A clear and understandable explanation for our dilemmas that "makes sense" to us and provides a clear rationale and related tasks toward resolution. Without a compelling explanation that is dynamically conveyed by our therapist, and rings true to us, the risky journey of change will remain tenuous. There is no shortage of different rationales for the wide array of effective treatments to choose from for this match. The bottom line is that match must fit, or make compelling sense to us as clients.
3. A clear target for change that acknowledges the vicious cycles of our ongoing failed solution patterns and aims to effectively reverse that cycle. Once the pattern is interrupted, then that shift is further supported and amplified. This key element of change in the way we have been trying to change our problem is the final key element of all psychotherapies that work. Without this final element of problem pattern reversal, no approach will work, no matter how venerable or apparently potent the approach may seem.

No matter what approach to psychotherapy might be taken, unless the process of treatment includes the three common elements of a positive relationship, a compelling rationale, and a clear target for changing the problem pattern, success is likely to be elusive. All therapies that work share these three crucial components.

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