1. What Works in Psychotherapy
Randy Walton, Ph.D.
Licensed Clinical Psychologist
Williamsburg, Virginia, USA

2. Psychology education and training
What Works in Psychotherapy
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

4. 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.

5. 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 The Great Psychotherapy Debate: Models, Methods, and “Findings. Erlbaum.

6. 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 The Heart and Soul of Change: What Works in Therapy. APA

7. 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

8. Therapeutic Relationship and Alliance
Trust
Warmth
Empathy
Understanding
Acceptance
Genuineness
Kindness
Therapeutic Alliance
Client’s emotional relationship to the therapist
Client’ capacity to work in therapy
Therapist’s empathic understanding & involvement
Client-therapist agreement on therapy tasks and goals

9. 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

10. 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

11. 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.

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

13. 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.

14. 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.

15. Building a strong therapeutic relationship
Active Listening – Effective, powerful
Active Listening involves three main components:
Listening to another person
Communicating to that person that we are interested in what they have to say
Communicating to that person that we understand what they have to say

16. 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

17. 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

18. 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., don’t 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”
Don’t 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
Don’t try to problem-solve (that may come later)

19. 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

20. Building a strong therapeutic relationship
Active Listening Techniques
Paraphrasing example:
Client: “It seems like I cry all day. I don’t want to talk to anyone, even my friends. I don’t want to do anything, all I want to do is stay in my bed and sleep.”
Therapist: “So you’re crying all the time, you don’t want to do anything or talk to anyone, and all you want to do is sleep. It sounds like you are feeling __________.”

21. Building a strong therapeutic relationship
Active Listening Techniques
If you are not sure you understand, express that to the client: “I’m 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, I’m not really feeling sad. I just feel empty.”

22. 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
Don’t try to shame or embarrass the other person

23. Building a strong therapeutic relationship
Active Listening Techniques
Don’t 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

24. 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

25. How can a therapist use these factors in psychotherapy?
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 client’s life that is helpful
Encourage clients to explore and use resources in their life and community

26. 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
(It’s a relief to know that I don’t have to have all the answers)

27. 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 client’s experience of meaningful change , especially early in therapy (first 4-5 sessions) is one of the best predictors of a positive therapy outcome.

28. 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 client’s rating is clearly superior to the therapist’s in predicting psychotherapy outcomes.
Research shows that the client’s rating is clearly superior to the therapist’s in predicting psychotherapy dropouts.

29. 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

30. 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

31. 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 we’re doing?” OR
Therapist: “Let’s look at your goals. Do you feel like we are making progress?”
Therapist: “You look less overwhelmed. Are you feeling that way?”

32. 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?

33. 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”
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:

34. 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)
Socially
(Work, school, friendships)
Overall
(General sense of well-being)
Institute for the Study of Therapeutic Change
_______________________________________
© 2000, Scott D. Miller and Barry L. Duncan

35. I-------------------------------------------------------------I
Session Rating Scale (SRS V.3.0) Please rate today’s 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
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 therapist’s approach is a good fit for me.
There was something missing in the session today.
Overall
Overall, today’s session was right for me.
Institute for the Study of Therapeutic Change
© 2002, Scott D. Miller, Barry L. Duncan, & Lynn Johnsaon

36. Chart 1 Chart 2 Chart # Client Name Therapist Date of Intake 1 2 3 4 56
220321RH
Walton
1/12/2007
17.8
18.1 22
23.6
24.6
26.8
DAH
1/23/2007
30.1
28.6
27.8
219632
2/4/2007
24.1
24.9
23.9
24.8
FAL
2/10/2007
5.4
7.9
Chart 1
Chart 2

37. Conclusion Therapeutic Relationship and Alliance Client is Central
Of all therapeutic factors, it is the single best predictor of therapeutic outcome
Client is Central
Therapist follows the client’s lead
Client’s theory of change is crucial
Active listening
Ongoing, systematic assessment of client’s rating of “effect” and “fit”
Client-directed, outcome informed treatment is the best guide to treatment decisions
You already have the basic abilities needed to be a good psychotherapist
Relax and enjoy your work