The principles of evidence-based psychotherapy

There are over 500 different schools of therapy - for the sake of our clients, can we agree the principles of change they all have in common?

Sure, one size doesn’t fit all, but 500 different schools of therapy! How can that be possible? And how can it be helpful to clients? Psychotherapy has existed for well over a century - why can’t we agree on what works? After all, other disciplines and sciences seem to manage it. 

The argument tends to boil down to this: does change come about due to the particular ‘treatment or technique’ used, or is it due to the quality of the relationship between the therapist and client - the so-called ‘common factors’ across most therapies? 

Opponents of the ‘common-factors or relationship’ model fear it supports an anything-goes approach, undermining sincere scientific efforts to isolate what works most effectively, for who, and for which conditions. Opponents of the ‘treatment or technique’ model fear that it puts the disorder before the human-being and fails to take account of the fact that help is always provided in the context of a relationship. 

This has at times descended a ‘culture war’ within psychotherapy, with the treatment method pitted against the relationship (witness those who rail against the significant expansion of psychological services that IAPT has brought about, on the basis that it favours what is said to be an explicitly technique-based approach, i.e. CBT). 

On the face of it, it might seem straightforward to assume that specific treatments, developed for specific problems, work best. And there is some truth to this. That’s why NICE (The National Institute for Health and Care Excellence) recommend defined and specific treatment protocols for social anxiety, panic attacks and for Obsessive Compulsive Disorder, for example. Studies have shown Cognitive Behavioural Therapy (CBT) to be significantly more effective in these instances than other forms of therapy.

But, most head-to-head scientific comparisons of different treatments indicate they have broadly similar outcomes and very small differential effects. And that’s why NICE also recommends many other forms of therapy for other conditions, ranging from brief psychodynamic therapy and counselling to mentalisation and motivational interviewing. 

Moreover, clinical trials typically find that doing therapy is better than doing nothing. This suggests that the relationship and process factors shared across all psychological therapies matter and might also be a major mechanism of change. However, so far, research indicates that the most robust of relationship variables ‘the alliance’ between client and therapist, accounts for no more than 10% of the treatment outcome.

After decades of disagreement and stalemate, The American Psychological Association (APA), the largest scientific organisation of psychologists in the United States, stepped in to the debate. They set up two task forces, first to look at which treatments worked. And a second separate task force, to look at the relationship variables that affected treatment outcomes.

Ironically, but perhaps inevitably, the work of the two task forces was initially viewed as contradictory. The two initiatives were seen to exaggerate the divide, rather than heal it. Therefore a third task force was established, specifically designed to integrate the work of the two previous groups. It is that painstaking work, which took a total of six years to complete, which now provides an opportunity to establish, from the empirical literature, a number of principles of change that are common to many theoretical orientations.

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Although the task force found a large number of factors relevant to change, the five core principles of change, listed below, are a useful framework for change that can immediately be applied to clinical practice. 

1. First things first, promote the client’s expectation that therapy will help. We should let clients know that in the majority of instances psychotherapy helps and that treatment will be successful. Sure, we can’t and won’t fix everyone and everything, but research in all areas of life finds that expectation has a strong influence on experience (just think of the placebo effect in medicine). Don’t deny clients the power of hope and the very real benefit of expectation. ‍

2. Establish a strong reciprocal relationship with the client. The goal of Session 1 is Session 2! Trust is needed if clients are to be able to talk about difficult events in their lives. Humans make very rapid assessments, often measured in milliseconds. Clients, too. The first impression we make on clients is critically important. More clients terminate therapy after the first session than at any other point.‍

3. Help clients step back and notice the factors associated with their difficulties. Depending on your theoretical background, this has been called: self-observation, executive functioning, mentalisation, insight, the observing ego, metacognition, and/ or mindfulness. Whatever the label, it amounts to the same thing: clients taking perspective on their thoughts, feelings and behaviour and noticing the impact they make on others and others on them. Therapists don’t need more novel techniques; if you’re supporting or challenging your clients step back and observe, then you’re practicing one of the core principles of change.‍

4. Encourage clients to engage in corrective cognitive, behavioural, and emotional experiences. This might be thought of as challenging maladaptive thoughts in CBT or ‘interpretation’ in psychodynamic therapy – but each of those ideas is just a way of talking about a more general principle of change: providing a new understanding, or ‘learning’. Don’t be in a rush to do more. What might feel basic is actually crucial and integral to the change process.  ‍

5. Emphasise ongoing reality testing in the client’s life. What Freud called ‘working through’ all those years ago.The goal here is to link increased awareness with corrective experiences. Clients are helped to begin to recognise what they have done differently (or what they are trying to do differently) and its link to consequences in their life. New or modified behaviour has an impact on subsequent thoughts and feelings, creating a virtuous circle. 

Even with these few examples we can see the relationship and technique at play. The either/or assumption contained in the earlier debate is simply not supported by evidence. Let’s put it in its simplest terms: the complexity of the process of change requires consideration of both treatment or technique factors and relational or process factors. 

The debate between the two camps has been a distraction from the urgent need to understand the mechanisms of psychological change. It’s time to find the common ground and a common language - a language clients can understand too.

Let’s demystify therapy: Clients change when they: (a) are motivated to do so and have a positive expectation that change is possible; (b) work with someone with whom they have a cooperative relationship; (c) become better aware of what is causing or maintaining the problems in their life; (d) take steps to make changes in their thinking, feeling, and behaviour; and (e) engage in ongoing reality testing - i.e. recognising gains in therapy and consolidating them (or counting the cost of missed opportunities, as a spur to future change). 

Could it really be that simple? We think so. Psychotherapy is over 100 years old. Psychotherapy research has now produced more than enough knowledge to begin to define the basic principles that govern change.

We ought to be able to explain how and why therapy works, in simple terms, to friends and family as well as policy makers and politicians. Clients and commissioners care about what works. And we know that psychotherapy works. Across thousands of studies, since the 80’s, it has consistently yielded an overall effect size of 0.8 - that’s larger than almost all interventions in cardiology, and greater than the success rate of flu vaccinations. It means nearly three-quarters of people who have psychotherapy are better off than those who don’t. Multiple studies now show that changes brought about by therapy are visible with brain imaging. And we know from clinical trials that therapy for depression is as effective as drugs in the short run, and more effective in preventing relapse, in the long run.

People are complex and therefore so too is the process of change; one size does not fit all. But achieving consensus on a core of evidence-based principles of change, that can be tailored to individual clients, allows psychological treatments to evolve and take on the status of a mature science.

If you’d like to find out more, take a look at our short, affordable workshop, where we’ll continue to unpack the clinical implications of the evidence-based principles of change. Our CPD showcases a practical and realistic assessment of the evidence of what works.

It’s our hope that research-based training can take hold and inform the next generation of psychotherapists. If you’d like to be a part of that, and if you have an open and inquiring mind, click to find out more.