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psychotherapy in Scotland

Last updated:

17 April 2009

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psychotherapy works

Psychotherapy (also referred to as 'counselling' or 'the talking cure') is a professional form of helpful conversation which has existed for thousands of years. It is part of our humanity to air our troubles with a trusted confidant, to gain hope and a fresh perspective on our predicament, and to change our lives for the better. We instinctively know how useful this can be, given the right person to trust and the right conditions. However, it is only over the past 25 years or so that sufficient data has been gathered from research to scientifically assess the effectiveness of psychotherapy.

Psychotherapy is now supported by more, and better quality, research evidence (Wampold, 2001) than many other interventions in health care. Beyond reasonable doubt, we find that psychotherapy works remarkably well overall and that its effects are generally lasting. The average client participating in psychotherapy does better than 79% of clients who are not. The rate of improvement in psychotherapy clients is significantly greater than that arising from spontaneous remission (natural recovery) or placebo (hope and expectancy) effects. Statistically, when the outcomes for a large group of therapy clients and a no-therapy control group are compared, the difference between the means is equal to approximately 0.8 of a standard deviation. This measurement, termed the effect size, estimates the absolute efficacy of psychotherapy - see animated graphs of psychotherapeutic effects.

While the effect size for psychotherapy is considered large, it still only accounts for 13% of the variance in outcomes. The remainder of the variance, 87%, can be attributed to 'extratherapeutic factors'. These comprise the resources clients bring into therapy and the influences on their lives outside it. The client's personal strengths and experiences, supportive aspects of their environment, and serendipity all contribute to the beneficial change which is catalyzed by therapy.

what influences outcome

Having proven that psychotherapy works, research evidence (Wampold, 2001) also helps us to understand what aspects of psychotherapy are responsible for its benefits. The diagram to the right shows that the biggest influence on outcome for the client comes from factors which are common to all types of psychotherapy. These common factors include the working alliance between the client and the therapist, the gaining of hope and the expectancy of improvement (placebo and allegiance effects), and the effectiveness of the therapist. It is clear from the research that psychotherapy helps the client most when it activates the common factors and makes them responsive to the client's centrality to change. This is known as a 'common factors' or 'contextual' approach to therapy.

Despite the many different types of psychotherapy, each with its own theory and techniques, the unique ingredients of a given therapy are not, in themselves, a vital source of therapeutic effects. Therefore, psychotherapy is unlike a medical treatment, where standard therapeutic ingredients are prescribed according to a diagnosis of the patient's problem from their symptoms.

Research findings (Wampold, 2001, Messer & Wampold, 2002) can now provide a more detailed breakdown of the influences on psychotherapy outcome. The diagram below shows these influences, together with the proportion of outcome variance that they represent:

Although these figures are not simply additive, they do provide sound guidance to "what really matters", relatively speaking, in psychotherapy. Clearly, the person of the therapist and the zeal they have for their own brand of therapy are critical factors in the success of therapy. From the client's viewpoint, it is essential to have a good working relationship with the therapist and to be convinced that the therapy will really help them. Any bona fide therapy has the potential to be efficacious if both the therapist and client believe it to be so and are persuaded by its particular rationale and special techniques.

Further practical implications of these research findings are discussed below in More interesting facts and Tips for clients.

more interesting facts

There are other interesting findings which have emerged from the research data. A few of these facts may be rather surprising, but they are well established by the evidence (Wampold, 2001, Duncan & Miller, 2000, Hubble et al, 1999, and Bergin & Garfield, 1994). Aspects which are particularly pertinent to clients are considered in Tips for clients.

The outcome of therapy is very variable

Psychotherapy, although generally effective, depends on many complex and unpredictable factors in an individual case. Improvement cannot be guaranteed. The client's strengths and resources, social support, environmental circumstances, and even chance events, can all affect progress and outcome. While most clients are certainly helped by psychotherapy conducted in good faith, research suggests that some clients can deteriorate. However, reliable predictors of poor outcome have been identified (see below).

Therapeutic effectiveness varies significantly among individual therapists and service providers

Such variation cannot be explained by the nature of the cases being seen or the methods of therapy used. The variation in outcome due to different therapists within a given type of therapy is far greater than the variation due to different types of therapy. Although the personal qualities of the therapist are critical factors in the success of therapy, their qualifications, training, experience, and participation in supervision or personal therapy are not significantly linked to outcome.

Standardized treatments do not lead to improved outcomes

Adherence to therapy protocols (prescribed procedures) does not generally improve outcome. Also, differences in therapy methods, problem diagnoses, and length of therapy account for only a small amount of the variation in outcome. Therapeutic models and techniques are most useful when they provide the client with a convincing rationale for the therapy and help the therapist to structure and focus the therapy.

The client's active participation is crucial to success

The quality of the client's participation in therapy - their openness to the process and their level of active involvement - is probably the most important determinant of outcome. Also, clients who rate the therapeutic relationship highly are very likely to be successful. Therapy needs to be sensitive to the client's readiness or reluctance to make changes in their lives, both inside and outside therapy.

Response to therapy in the first few sessions is highly predictive of the eventual outcome

The client's perception of some early improvement - within the first few sessions - is one of the best predictors of an eventual good outcome. Conversely, therapies in which little or no improvement (or even worsening) occurs early on are at significant risk of a poor outcome.

Process and outcome are not the same

Clients can be satisfied with the way therapy is conducted and their relationship with the therapist, but fail to show much, if any, improvement in the presenting difficulty. Also, therapists who are not getting positive results often believe that their therapy is effective. For these reasons, satisfaction with the process of therapy and assessment of outcome each need to be considered in their own right. Several valid measures for these have been developed. It is also interesting to note that the client's perceptions of progress are generally more accurate than the therapist's.

Psychotherapy can provide more lasting benefit than medication

For many common psychological problems, even when severe, psychotherapy has been shown to be equal or superior to psychoactive medication, with fewer side effects and lower relapse rates. The benefits of medication have been found to be often overstated and drawbacks downplayed, for commercial or political reasons. Psychotherapy has also been shown to be generally cost-effective in the long run.

6-Es principles of practice

Based on our knowledge of ethics and research, we suggest that the following principles, the 6-Es, provide a sound foundation for ethical best practice in psychotherapy. They apply primarily to the client and secondarily to others concerned with, or affected by, the therapy:

1. Ethical
   • To do good
   • Not to harm
   • To respect the right to make one's own decisions
   • To be fair
2. Effective
   • To achieve the desired outcome
3. Efficient
   • To use no more time or resources than necessary
4. Essential
   • To keep to what really matters
5. Evidenced
   • To be guided by the current best knowledge from research
6. Educational
   • To extend knowledge and skills

useful resources

Topic	Link to resource	Target readership
Looking for a therapy or a therapist	Tips for clients	clients
"State of the art" information about what really matters in therapy	Institute for the Study of Therapeutic Change (ISTC)	all
	Let's face facts: Common factors are more potent than specific therapy ingredients (2002) by Stanley Messer & Bruce Wampold (PDF format, 69 kB)	all therapy professionals
	Animated graphs of psychotherapeutic effects
	Graphs showing that psychotherapy is not like medicine (based on data from Wampold, 2001)
	Charlatans and 'Gold Standards': Traversing the minefield of psychiatric psychotherapy training (1999) by Ron Morstyn (PDF format, 91 kB)
	What Really Matters: The foundation of effective counselling and psychotherapy (2000). Monograph digest of research findings by Douglas McFadzean (PDF format, 159 kB)
Concern about ineffective, harmful or pseudo therapies	ISTC's Baloney Watch	all
	Skeptic's Dictionary
	Quackwatch Mental Help: Procedures to Avoid
	Committee for the Scientific Investigation of Claims of the Paranormal (CSICOP)
Concern about psychoactive medication or psychiatric treatments Important: Although the research shows that psychotherapy can be equal or superior to medication, improperly stopping a legally prescribed medication can be dangerous and even fatal. A prescribed dosage should be altered or stopped only after consulting a medical professional	British Medical Journal - Efficacy of antidepressants in adults (PDF format, 113 kB)	all
	Prevention & Treatment - Analysis of Antidepressant Medication Data
	Peter Breggin's Psychiatric Drug Facts
	The Guardian - Brainwashed
	The Antidepressant Web
	Benzodiazepine Addiction, Withdrawal & Recovery
	ISTC's Pharmaceutical Report
	Critical Psychiatry Network
	Duncan Double's publications and blogs
Concern about the psychotherapy and counselling professions	Warning about the UK government's plans for statutory regulation	all
	Alliance for Counselling and Psychotherapy
	Models of Self-Regulation (1999) by the National Consumer Council (PDF format, 137 kB)
	Do more of the same or change for the better? by Douglas McFadzean (PDF format, 69 kB)
Essential reference books	The Heroic Client (2004) (Revised edition) by Barry Duncan, Scott Miller & Jacqueline Sparks	all
	The Great Psychotherapy Debate (2001) by Bruce Wampold	all therapy professionals
	The Heart and Soul of Change (1999) by Mark Hubble, Barry Duncan & Scott Miller (Eds)
	How Clients Make Therapy Work (1999) by Arthur Bohart & Karen Tallman
	Persuasion and Healing (1991) (Third edition) by Jerome & Julia Frank
Implementing client-directed and outcome-informed therapy in agencies	Heroic Agency Network	service providers & trainers
	Subscribe to the Heroic Agencies discussion list
	Heroic Clients, Heroic Agencies: Partners for Change (2001) by Barry Duncan & Jacqueline Sparks
Assessment of therapy process and outcome	ISTC measures: Session Rating Scale (SRS) and Outcome Rating Scale (ORS) with reliability and validity studies	all therapy professionals
	CORE System Outcome Measure
	OQ outcome measures: OQ®-45 and OQ®-10
	Treatment Outcomes OnLine
Achieving success with intractable cases	Therapeutic Alchemy: Turning heartsinks into heroes by Douglas McFadzean	therapists
Concern about therapist supervision	Supervision: Is it time to think again? by Douglas McFadzean	all therapy professionals
Working outside your usual comfort zone	You are now entering ... the Twilight Zone by Douglas McFadzean	therapists
Recommended books and other works	Bibliography and reviews	all
Recommended portable software	AppsToGo	all
Quotations to inspire therapeutic change	Therapeutic quotations	all
Miscellaneous	Mind Map® of therapist identity	all

feedback and contact

Your feedback about this website and the issues it discusses is most welcome. Please take a few moments to contribute to help develop the website and improve psychotherapy practice.

• View or sign the guestbook
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• Send us an email or use the feedback form

With regret it is not possible to answer individual queries about careers, employment, training courses, or recommended practitioners. Please consult the Frequently asked questions and Tips for clients pages for general guidance on these issues. Due to privacy concerns, we may not respond to a Gmail (or similarly compromised) address.

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notes

Disclaimer: This website only provides general information derived from research findings. It is not a substitute for a consultation with a mental health professional about an individual case. While every effort is made to ensure the accuracy and objectivity of information on this site, the authors accept no responsibility for the consequences of errors or omissions. Information about the practice of psychotherapy and counselling in Scotland and/or the United Kingdom may not be applicable in other countries. External websites are linked in good faith, but their contents cannot be vouched for.

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