The 4 Pillars of Effective Therapy

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by Emma Newman, with Grant Brenner

What do we want—and need—from therapy? How do we know if it’s working? Therapy is meant to help us analyze ourselves and alleviate symptoms of mental illness, aiding us in our various struggles. But it’s not always clear exactly what changes when therapy works or what to target in order to decide whether changes are in the right direction. Sometimes what we want from therapy can be very clear. Sometimes it changes over the course of treatment. And sometimes it is confusing and elusive.

Therapy isn’t solely focused on improving symptoms, of course, but also on finding ways to change and adapt in positive ways—for example, feeling better about ourselves and finding better ways of dealing with interpersonal problems. Yet, since we are so focused on symptoms, we may be distracted from how we have changed in other ways.

Defining and Measuring Real-Life Therapy Outcomes

Chui et al. (2020) created the Complementary Measure of Psychotherapy Outcome (COMPO) scale, which assesses different areas of psychological functioning deemed important by patients and therapists. We often look at the improvement of symptoms and not at the changes in how we function in important practical areas. The factors that make up COMPO fall under two broad domains: functioning with oneself, and within our relationships. COMPO consists of seven different sub-domains: improvement in interpersonal relationships, self-acceptance, self-understanding, freedom, being true to self, and balancing different aspects of life and experience.

Three studies were conducted to determine what outcomes were most valued at the end of the psychotherapy sessions. Graduate students, early career psychologists, and experienced therapists were sent statements to rate, drawn from the sub-domains of COMPO. Researchers were looking for consensus in order to create a reference group of items in a scale form.

For further validation and refinement of what the scale measures (“psychometric properties”), it was administered to people currently in psychotherapy, adults in the community, people who had experience with psychotherapy, and prospective patients. Finally, psychotherapy patients with depression, including 20 women in their mid-30s working with nine therapists at an outpatient clinic, were rated with the COMPO over the course of treatment to evaluate it in a real-world setting.

The Four Horsemen of Therapeutic Success

Four core factors emerged as most important for understanding whether therapy was effective, going beyond symptom relief. Patients and clinicians agreed these are global markers of successful therapy. The extent to which they improve reflects the treatment impact:

1. Self-Acceptance. Full self-acceptance occurs when people accept all versions of themselves. We are able to see that we are lovable and respected by the people in our lives. We understand that we are multifaceted beings and accept ourselves fully, contingent on the extent of self-knowledge. When effective, therapy improves self-acceptance.
2. Self-Knowledge. Also known as self-understanding, this is realized in those enjoying a robust, clear view of themselves and their life circumstances. We are aware of the different perspectives and feelings in any given situation, as well as understanding our own emotions and actions. Expansion of accurate self-awareness, grounded in self-acceptance, is one hallmark of effective therapy.
3. Relationship Quality. People who feel as though they’re understood and supported by the people in their lives experience more fulfilling relationships. During therapy and after it has ended, we see improvements in our relationships and derive greater satisfaction within them, a marker that therapy has been effective.
4. Consideration of Others. This includes empathy, wherein patients are able to consider and understand others’ perspectives and feelings, as well as compassion—the motivation to act to relieve others' suffering. Prior research has identified “mentalization” as a key developmental accomplishment, covering our capacity to make sense of our own inner reality while also showing an understanding of the validity of others’ reality—without necessarily agreeing with how they see things. When people do this together, making room for one another with mutual respect and understanding, psychologists call it “intersubjectivity."

Making Therapy Work

We know it's important to study just how psychotherapy affects people after therapy, not only in affecting symptoms but also in changes to individuals themselves and their interpersonal relationships. The work on COMPO identifies four key elements of therapy in a relatively limited group. In the future, it would be beneficial to repeat this work in diverse cultural settings to determine universality.

Research can also test the COMPO more extensively for application—for example using it to track therapy outcomes throughout the course of therapy, not just before and after, to adjust treatment for personalized care.

Regardless, the four factors of self-acceptance, self-knowledge, relationship quality, and consideration of others stand out as intuitively important. Psychotherapy efficacy research shows that active focus on key areas such as self-compassion improves outcomes. In addition to common factors such as support and reflection, therapy of any kind works best when collaborative efforts are directed toward key levers of change.

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There's also research suggesting that therapy can reverse some of the biological (epigenetic) changes associated with trauma, when focused and effective. People can focus on enhancing positive traits, such as zest for life, to combat chronic pain. Even personality, which may seem etched in stone, can be changed through concerted efforts

Clinical wisdom and common sense suggest that the COMPO scale can help people target areas of universal concern to improve overall quality of life, whether in therapy or in the pursuit of personal development.

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

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