What makes therapy work: Part II

On Psychotherapy

The debate about what accounts for therapy’s benefit has raged within the field for decades.  Back when this writer was in graduate school the debate tended to be between more psychoanalytical oriented clinicians and behaviorists (and cognitive behavioral therapists, which was an emerging school of thought at this time  – mid to late 70s).  The more psychoanalytic therapists argued that for fundamental and lasting change to occur, clients needed to work through the underlying issues and conflicts, that their model asserted, accounted for the various symptoms and problems that led people to seek therapy. The behaviorists and cognitive behavioral therapists argued that a more direct focus on symptoms was sufficient and could lead to meaningful change (including symptom reduction).  

Since this time the debate about what accounts for therapy’s effectiveness has continued to rage within the field.  Early family therapists argued for changes in family patterns and structure was critical.  In the past few decades the emphasis has shifted to salience of biological factors as accounting for many of the problems, e.g., depression, mood disorders, anxiety disorders, and inattention. The focus on biological/genetic factors have been accompanied/facilitated by a proliferation of pharmaceutical and more medically focused treatments.  More recently the impact of early trauma, and efforts to mitigate the impact of trauma has gained prominence. In addition, there has been a proliferation of treatment models (1), each with their own theories of change. 

One of the key features of the debate about the effectiveness of psychotherapy has been on whether the core or common factors shared by most all models of treatment account for the benefits of therapy or whether specific models of treatment are more effective (2).  A more sophisticated version of the latter position is whether specific models of treatment or types of interventions are more effective for specific problems, for example, are cognitive behavioral therapies more effective for the treatment of panic attacks and anxiety disorders.  While this debate remains largely unresolved, the work of John Norcross, Scott Miller, Michael Lambert, and others offers some key findings about what contributes to therapeutic effectiveness (2). Specifically, the factors that these researchers assert play essential roles in therapeutic effectiveness are: a strong therapeutic alliance (which includes empathy as well as a shared vision about treatment goals and methods); and client feedback, i.e., actively and systematically  soliciting and attending to client feedback. 

In our first blog on the topic of therapeutic effectiveness we discussed the importance of empathy.  Empathy is a key component of the therapeutic alliance.  Empathy would include the client feeling supported, understood, and accepted.  A strong therapeutic alliance has also been defined as the development of a strong working relationship between client and therapist. This would include a shared understanding of how treatment will proceed: goals and methods.  It has also been suggested that the client’s belief in the therapist’s competence is part of a strong therapeutic alliance.  In addition, the therapeutic alliance has also been defined as a collaborative effort on the part of the client and therapist to accomplish the clients goals. Finally, several writers, such as Lambert and Wampold have suggested that repairing ruptures in the therapeutic alliance can further strengthen the working relationship of client and therapist. Specifically, this refers to instances where a client may feel misunderstood or judged by the therapist and question the value of therapy or the therapist’s competence. If these issues are successfully identified, addressed and worked through, a strong working relationship is likely to exist, which has been suggested by Lambert, to increase the likelihood of successful therapeutic outcomes, i.e., for therapy to be helpful. 

Research on the effectiveness of therapy  has also emphasized the importance of client feedback.  More specifically Lambert and Miller, along with many others,  have stressed that actively soliciting and attending to client  feedback are essential elements or ingredients that account for the benefits of psychotherapy.  Both of these psychologists (and their colleagues)  have conducted extensive research in this area and have consistently found that obtaining systematic feedback (validated and reliable rating scales) improves therapeutic outcomes, i.e., clients report decreased distress and symptomatology. Michael Lambert, Scott Miller and his colleagues and a number of other researchers have provided consistent evidence to support these conclusions (3).  

In conclusion we are not suggesting that the therapist’s model or approach to treatment does not matter. There is evidence to suggest that a variety of other factors are likely relevant to therapeutic outcome, to whether therapy is helpful.  These include but are not limited to: (a)  

Psychoeducation, (help in developing a better understanding of one’s difficulties), specific recommendations and advice, skill building (including cognitive strategies), and assistance in changing patterns of interaction in families and couples, are only a few of the specific ways in which therapy can assist clients. In addition, there is some evidence to suggest that specific models may be more effective for specific problems, i.e., Cognitive Behavioral Therapy for the treatment of anxiety disorders (4). Rather, what we are suggesting is that there are 3 factors that are essential components of most successful therapy: empathy, a strong therapeutic alliance, and client feedback.  These components transcend models and are critical to our clients finding therapy to be of value. 


  1. Lambert MJ. Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change. Wiley; New Jersey: 2013. These authors estimate that there are over 400 models of psychotherapy. Others, such as John Norcross have suggested that there may be up to (or by now over) 500 models of therapy.
  2. Writers who have addressed this issue are many and varied. As we noted in our first blog on this topic this debate can be traced back many years. A good summary of this debate is available in the Scientific American article “Are All Psychotherapies Created Equal?” by Scott O. Lilienfeld, Hal Arkowitz, Scientific American, September 1, 2012.  A seminal discussion of these issues is Truax and Carkhuff’s work, noted in the prior blog on this topic. We also recommend the writings and research  of Scott Miller, Michael Lambert, John Norcorss, to name but a few who have written on this topic.  Douglas Sprenkle and his colleagues have also written on common factors in couples therapy. Below are a few references:
    1. Toward Effective Counseling and Psychotherapy: Training and Practice By Charles B. Truax, Robert Carkhuff  (1976)
    2. Common Factors in Couple and Family Therapy: The Overlooked the Overlooked Foundation for Effective Practice.  by Douglas H. Sprenkle, ‎Sean D. Davis, ‎Jay L. Lebow (2013)
    3. The Heart and Soul of Change: Delivering What works in therapy. By Hubble, M., Duncan, B, and Miller, S.
    4. The Great Psychotherapy Debate by Wampold B., and Imel, Z. (2015)
    5. Psychotherapy Relationships That Work: Evidence-Based Responsiveness by John C. Norcross  | May 4, 2011
  1. A number of psychologists have researched and written extensively on the benefits of obtaining session by session feedback. See the work of Scott Miller and his colleagues, Michael Lambert, and others. Also see the study by _  et al., supporting the benefits of the use of systematic feedback.
    1. Prevention of Treatment Failure: The Use of Measuring, Monitoring, and Feedback in Clinical Practice by Michael J. Lambert  | Apr 17, 2013
    2. Miller
    3. Bovendeerd, B, De Jon K. De Groot E et al. Enhancing the effect of psychotherapy through systematic client feedback in outpatient mental healthcare: A cluster randomized trial.   Psychotherapy Research. Volume 32, 2022 – Issue 6, page  710-722 | Published online: 23 Dec 2021  https://doi.org/10.1080/10503307.2021.2015637


  1. Research by David Tolin,  has suggested that Cognitive Behavioral Therapy may be more effective for specific problems.  However, the issue of treatment model superiority continues to be debated extensively in the psychotherapy outcome literature.
    1. Tolin, D,  Is cognitive–behavioral therapy more effective than other therapies?: A meta-analytic review.  Clinical Psychology Review. Volume 30, Issue 6, August 2010, Pages 710-720.