What Works in Psychotherapy

Randy Walton, Ph.D.

Licensed Clinical Psychologist
Williamsburg, Virginia, USA

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Psychology education and training
Helps organize, develop, and skillfully use
abilities we already have:

Empathy
Communication
Support
Understanding
Respect
Trust


3
Psychotherapy Research

Thousands of research studies of
psychotherapy


Increase
understanding of
what works


Increase confusion
about what works due
to conflicting results
Meta-analytic research studies:
studies of studies
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Quiz
Question 1:

Does psychotherapy
work?


YES

40-70% of clients who
receive psychotherapy
show substantial benefit

At the end of therapy the
average treated person is
better off than the average
untreated person.

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Conclusions from Meta-analytic
Studies
Common Factors associated with Psychotherapy
Outcome

Extra-therapeutic Factors (87%)
Therapeutic Factors (13%)
Therapeutic Alliance (8%)
Therapeutic Allegiance (4%)
Therapy model or technique (1%)

Wampold, B.E. 2001. The Great Psychotherapy Debate: Models, Methods,
and Findings. Erlbaum.


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Conclusions from Meta-analytic
Studies
Common Factors associated with Psychotherapy
Outcome

Extra-therapeutic Factors (40%)
Therapeutic Alliance (30%)
Therapy Model or Technique (15%)
Placebo Effect (15%)

Hubble, Duncan, Miller 1999. The Heart and Soul of Change: What Works in
Therapy. APA

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Psychotherapy Models or
Techniques
Account for a small amount of the variance in
psychotherapy outcomes
Virtually all psychotherapy models and techniques are
effective with some people, some of the time
Differences in outcome between models is consistently
small or negligible
Outcome differences between therapists using the same
model have been found to be 2-3 times greater than the
differences between models

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Therapeutic Relationship and
Alliance
Therapeutic Relationship

Trust
Warmth
Empathy
Understanding
Acceptance
Genuineness
Kindness

Therapeutic Alliance

Clients emotional relationship
to the therapist
Client capacity to work in
therapy
Therapists empathic
understanding & involvement
Client-therapist agreement on
therapy tasks and goals

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Therapeutic Relationship and
Alliance
The most important therapeutic factors in a
positive psychotherapy outcome

A positive therapeutic relationship is considered
crucial for a successful outcome in any type of
psychotherapy

A strong therapeutic alliance is considered a
necessary condition for therapeutic change to
occur

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Therapeutic Relationship and
Alliance
Dynamic not static: relationship and
alliance change over time
More predictive of psychotherapy outcome
than diagnosis
More predictive of psychotherapy outcome
than model or technique
Predictive of client dropout
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Therapeutic Relationship and
Alliance

The conclusion for therapists:


No matter what therapeutic
technique or model is used, it is
not likely to be effective if there is
not a strong client-therapist
relationship.

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Therapeutic Relationship/Alliance
and Therapy Model/Technique
The therapeutic model or technique used
by a therapist is primarily effective if it
matches the clients theory of change:
The clients
View of the problem
View of the change process
Goals and expectations
Desired pace for treatment
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Therapeutic Relationship/Alliance
and Therapy Model/Technique

The more therapy models and techniques a
therapist can understand and use, the more
options the therapist has for helping a wider
range of clients.

An effective therapist should be able to use a
variety of therapeutic models and techniques
instead of assuming that each client will respond
equally well to a particular model or technique.


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Therapeutic Relationship/Alliance
and Therapy Model/Technique

A psychotherapist
should use a
psychotherapy model
or technique to fit the
client, rather than
trying to make the
client fit a particular
model or technique.

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Building a strong therapeutic
relationship
Active Listening Effective, powerful
Active Listening involves three main
components:
1. Listening to another person
2. Communicating to that person that we are
interested in what they have to say
3. Communicating to that person that we
understand what they have to say
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Building a strong therapeutic
relationship
Passive Listening less effective
Listening to another person
Being interested in what that person has to
say
Trying to understand what that person has to
say
NOT communicating to that person that we
are interested and understand

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Building a strong therapeutic
relationship

Competitive or Combative Listening
Least effective
Not really listening
Thinking about what we want to say next
More interested in expressing our point of view
than in understanding the other person

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Building a strong therapeutic
relationship
Active Listening Techniques
Stop talking
Let the client relax, take their time, explain things in their own way
Physically show that you are interested
Face the client
Open posture, e.g., dont fold arms
Maintain eye contact
Reflect their body position (mirroring)
Remove distractions, stop whatever else you are doing
Empathize: consider their point of view, stand in their shoes
Dont let you own emotions interfere or distract you
Be cautious about disagreeing, criticizing, or arguing
Ask questions to clarify, or encourage the client to say more or give an
example
Dont try to problem-solve (that may come later)
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Building a strong therapeutic
relationship
Active Listening Techniques
Paraphrasing
Summarize or repeat the facts of the
situation
State your understanding of the
thoughts, beliefs, feelings and emotions
you heard
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Building a strong therapeutic
relationship
Active Listening Techniques
Paraphrasing example:
Client: It seems like I cry all day. I dont
want to talk to anyone, even my friends. I
dont want to do anything, all I want to do is
stay in my bed and sleep.
Therapist: So youre crying all the time, you
dont want to do anything or talk to anyone,
and all you want to do is sleep. It sounds like
you are feeling __________.
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Building a strong therapeutic
relationship
Active Listening Techniques
If you are not sure you understand, express that to the
client: Im not sure I understand, and ask for
clarification: could you tell me more?, or could you
give me an example?
OR
If you are not sure you understand, try paraphrasing
anyway; if we are genuinely interested and trying to
understand, clients will usually appreciate the effort and
clarify for us: No, Im not really feeling sad. I just feel
empty.
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Building a strong therapeutic
relationship
Active Listening Techniques
If you disagree or disapprove of what the
client is saying
Try to be nonjudgmental
Try to be accepting
Try to be respectful
Try to understand their point of view
Dont try to shame or embarrass the other
person
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Building a strong therapeutic
relationship
Active Listening Techniques

Dont begin to problem-solve too soon

Often, if you continue to practice active listening, the
client will develop their own solution to their problems

In psychotherapy it is almost always preferable to help
clients develop their own solutions to problems
Helps clients feel better about themselves
Helps clients feel more confident in managing future problems
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Building a strong therapeutic
relationship
Active Listening Techniques
It is okay to not have the solution to every
problem or a perfect understanding of the client.

Clients are the experts on themselves

Let the client teach you and guide you
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Extra-therapeutic Factors
Account for major portion of improvement that occurs during
psychotherapy
How can a therapist use these factors in psychotherapy?
Listen for , invite, and use information about extra-therapeutic
factors
What is different about better or worse days
Ask about any between session improvement
Help clients see any changes, and maintenance of changes, as a
consequence of their own efforts
Even if clients attribute changes to luck, therapist skill, medication,
or some other factor, ask:
How they adopted the changes in their lives
What they did to use the changes to their own benefit
What they will do in the future to maintain the changes
Ask about what happens in the clients life that is helpful
Encourage clients to explore and use resources in their life and
community
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The Client is Central
The capacity for self understanding, problem-
solving, and growth, resides primarily in the
client

The most effective therapists are ones who
allow or help their clients develop their own
understanding and solutions to problems

(Its a relief to know that I dont have to have all the
answers)
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The Client is Central

Quiz
Question 2

Who is better at identifying
whether a client is making
progress in psychotherapy, the
therapist or the client?
THE CLIENT

Research shows that therapists
are remarkably bad at judging
whether a client is making
progress in psychotherapy.

The clients experience of
meaningful change , especially
early in therapy (first 4-5
sessions) is one of the best
predictors of a positive therapy
outcome.
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The Client is Central

Quiz
Question 3

Who is better at accurately
rating the quality of the
therapeutic relationship and
therapeutic alliance, the
therapist or the client?

THE CLIENT

Research shows that the
clients rating is clearly
superior to the therapists in
predicting psychotherapy
outcomes.

Research shows that the
clients rating is clearly
superior to the therapists in
predicting psychotherapy
dropouts.

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Assessing and Tracking Psychotherapy
Progress and the Therapeutic
Relationship/Alliance

Psychotherapy Effects: Progress in
psychotherapy
Continuously changing over the course of treatment
Faster or slower
Better or worse

Psychotherapy Fit: The quality of the therapeutic
relationship and therapeutic alliance
Continuously changing over the course of treatment
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Assessing and Tracking Psychotherapy
Progress and the Therapeutic
Relationship/Alliance

Psychotherapeutic processes, models, and techniques
are best informed and directed by systematic and
ongoing assessment of the fit and the effect of any
given therapeutic relationship.

Therapeutic processes, models, and techniques are not
well informed and directed by:
Static concepts such as diagnosis
Unreliable or inaccurate theories and impressions of the
therapist

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Assessing and Tracking Psychotherapy
Progress and the Therapeutic
Relationship/Alliance
Routinely check with clients about whether they
believe progress is being made:
Therapist: How do you feel were doing?
OR
Therapist: Lets look at your goals. Do you feel
like we are making progress?
OR
Therapist: You look less overwhelmed. Are you
feeling that way?
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Assessing and Tracking Psychotherapy
Progress and the Therapeutic
Relationship/Alliance

Routinely check with clients about the
relationship and alliance
Is the therapist's approach helpful?
Do they talk about what they want to talk
about?
Do they feel heard, understood, and
respected?

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Assessing and Tracking Psychotherapy
Progress and the Therapeutic
Relationship/Alliance

Use of rating scales (example)

Outcomes Rating Scale (ORS)
Measures Effect
Four rating scale items, 1-2 minutes to administer and score
Administered, scored, and graphed at beginning of every session
Discuss and use improvement, decline, or no change

Session Rating Scale (SRS)
Measures Fit
Four rating scale items, 1-2 minutes to administer and score
Administered, scored, and graphed at end of every session
Discuss any low scores


These scales, along with the administration and scoring manual, are available for free download
and printing: http://www.talkingcure.com/
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Outcome Rating Scale (ORS)

Looking back over the last week, including today, help us understand how you have been feeling by
rating how well you have been doing in the following areas of your life, where marks to the left
represent low levels and marks to the right indicate high levels. If you are filling out this form for
another person, please fill out according to how you think he or she is doing.

Individually
(Personal well-being)
I----------------------------------------------------------------------I
Interpersonally
(Family, close relationships)
I----------------------------------------------------------------------I
Socially
(Work, school, friendships)
I----------------------------------------------------------------------I
Overall
(General sense of well-being)
I----------------------------------------------------------------------I

Institute for the Study of Therapeutic Change
_______________________________________
www.talkingcure.com
2000, Scott D. Miller and Barry L. Duncan
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Session Rating Scale (SRS V.3.0)

Please rate todays session by placing a mark on the line nearest to the descriptions that best fits your
experience.
I did not feel
heard,
understood, and
respected.
Relationship
I-------------------------------------------------------------I
I felt heard,
understood, and
respected.
We did not work
on or talk about
what I wanted to
work on or talk
about.
Goals and Topics
I-------------------------------------------------------------I
We worked on
and talked about
what I wanted to
work on and talk
about.

The therapist's
approach is not
a good fit for me.

Approach or Method
I------------------------------------------------------------I

The therapists
approach is a
good fit for me.
There was
something
missing in the
session today.
Overall
I------------------------------------------------------------I
Overall, todays
session was
right for me.
Institute for the Study of Therapeutic Change
www.talkingcure.com
2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon
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Chart # Client Name Therapist Date of Intake 1 2 3 4 5 6
1 220321RH Walton 1/12/2007 17.8 18.1 22 23.6 24.6 26.8
2 DAH Walton 1/23/2007 30.1 28.6 27.8
3 219632 Walton 2/4/2007 24.1 24.9 23.9 24.8
4 220012 FAL Walton 2/10/2007 5.4 7.9
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SRS Graph
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Conclusion
Therapeutic Relationship and Alliance
o Of all therapeutic factors, it is the single best predictor of therapeutic
outcome

Client is Central
o Therapist follows the clients lead
o Clients theory of change is crucial
o Active listening

Ongoing, systematic assessment of clients rating of effect and
fit
o Client-directed, outcome informed treatment is the best guide to
treatment decisions

You already have the basic abilities needed to be a good
psychotherapist
o Relax and enjoy your work