Evaluating Therapeutic Effectiveness in Counselling And Psychotherapy

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Despite clear evidence demonstrating the effectiveness of counselling and psychotherapy, pinning down specific reasons for effectiveness or identifying particularly effective approaches remains tricky. (NOTE: The review of Hubble, et al 1999 includes a great deal of additional information on the topic of effectiveness in therapy.)

Overall Effectiveness vs. Individual Effectiveness

Research evidence about the effectiveness of counselling and psychotherapy overall is relatively unambiguous: counselling does work. For a wide range of types of psychological distress, both subjective client reports and more objective measurements indicate that counselling and psychotherapy are effective, both in the short term and over longer time periods. For certain kinds of psychological distress, such as depression, some evidence also suggests that the benefits of counselling can interact positively with medications such as anti-depressants: in other words, counselling and medication together sometimes offer better results than either counselling or medication on their own.

What is more ambiguous, however, is the research evidence on the effectiveness of specific types of counselling or psychotherapy. Overall, no one therapeutic approach stands out as offering better results than any other — the so-called ‘dodo bird verdict’. (However, evidence from efficacy studies is gradually accumulating to indicate that some kinds of distress are particularly well addressed by certain approaches; clients with panic disorders, for instance, often respond particularly well to cognitive behavioural therapy.) At first glance, it might seem that this failure to discriminate between therapeutic approaches in terms of overall effectiveness could be attributed simply to the fact that different people will respond in their own ways to different types of counselling: if clients choose the ‘right’ or ‘wrong’ types of therapy only by accident, this might result in particular types offering good results in some areas and bad results in others, with the overall result that no one type of counselling would stand out. But because studies are typically designed to detect and isolate these types of regularities, we know that random choice about therapy type does not, by itself, provide a sufficient explanation of the evidence.

While no one type of therapy stands out in terms of overall effectiveness, however, individual counsellors clearly do. Within given approaches, research shows very significant variation between individual counsellors. Indeed, the evidence suggests that the abilities of individual therapists may be a more significant factor in determining outcome than therapeutic orientation! So there may not be a clear answer to the question of whether there are better or worse therapeutic orientations, but there certainly are better and worse therapists. Pinning down exactly why this is so — exactly what kinds of factors account for the variation in individual results — is much more difficult. The research evidence cannot yet help the client to understand exactly why one therapist might be better or worse for them than any other. Worse, there is no evidence that any of the various counsellor accreditation schemes serve to pick out better therapists, and neither years of counsellor experience nor duration of their training have any strong bearing on therapeutic outcome. (Indeed, some research has even suggested that counsellors in training and newly-qualified counsellors are more effective than their more experienced peers!)

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What Effectiveness Research Might Mean for Clients

If the aggregate effect of all main types of counselling and psychotherapy is positive, and if the individual therapeutic approaches do not distinguish themselves clearly in terms of overall effectiveness, does this mean that therapeutic orientation is irrelevant from an individual client’s point of view? Definitely not!

While the quality of the relationship which a client can establish with a particular counsellor probably heads the list of factors to consider when entering counselling, the match between an individual client’s preferences and a particular style of counselling remains extremely important. This match (or mismatch) can strongly influence how the client feels about the process and the relationship and consequently bears on how easy it is for that client to make progress. Virtually all relevant empirical studies agree that clients benefit more when they are committed to working within the therapeutic approach offered in their particular counselling environment — and some studies suggest that client variables such as this account for about 40% of therapeutic change, more than any other factors. A client who doubts whether a cognitive model adequately represents their experience probably will find less benefit from cognitive or cognitive behavioural therapy, while a client who would like their counsellor to give them a great deal of advice and instruction may not get very much from person-centred counselling. By analogy, while it is probably possible to walk 5 miles in shoes that are either much too big or painfully small or have too much traction or not enough, the right choice of footwear can make it much easier to do so in comfort, enjoying the scenery along the way, and having some energy left at the end. Likewise, many different kinds of shoes will do for such a walk, but some will be a help while others may actually be a hindrance. Some time spent considering the different types of counselling and psychotherapy available before embarking on a therapeutic journey will be time well spent.

As for the question of individual counsellor effectiveness, perhaps the most important lesson to be drawn from the research is that clients should make up their own minds based upon their own experience with a counsellor, rather than relying entirely on evidence such as paper qualifications, years of experience, or recognition via professional accreditation schemes. (The section “About Counselling and Psychotherapy” includes some suggestions both on finding counsellors and on selecting one.) Remember that the quality of the relationship which the client can establish with the counsellor probably heads the list of factors influencing therapeutic outcome, so at the end of the day, the client’s judgement of this relationship probably carries the most weight.

What Effectiveness Research Might Mean for Counsellors

One of the more pernicious conclusions occasionally drawn from the absence of evidence favouring any one type of counselling or psychotherapy over any other is that individual counsellors needn’t concern themselves very much with orientation. This line of thought seems to go along with a kind of ‘therapeutic relativism’ which suggests that everything has its value, and no way of working with a given client is really better than any other. Similarly, one sometimes hears the view expressed that critically evaluating the theoretical differences between approaches is unimportant, and one can just be entirely pragmatic: do what works. Perhaps the most defeatist approach is that there is just no point learning about various therapeutic approaches, given that none has ever demonstrated a clear overall advantage over others.

There are good reasons for rejecting each of these responses. First among them is that there is no justification for inferring from the evidence that a specific individual client (as opposed to the aggregate set of all clients) will be helped just as much by one approach as by any other. We don’t yet have the evidence to answer unambiguously the question of what works for which types of clients, but that doesn’t relieve the counsellor of the responsibility to consider what will work for his or her specific clients. Moreover, the absence of evidence about overall differences in effectiveness does not imply that there are no differences in how to be effective. (Indeed, there patently are differences in counsellor effectiveness, but research has yet to separate out the most relevant variables at work.) The same is true of why a given approach or counsellor is effective. In fact, some theorists and researchers have gone to considerable effort to account for the success of a given approach in terms of what it might accomplish in light of the theoretical model espoused by another. There may be considerable benefits for the client (not least among them, speed and cost) if the counsellor is effective because he or she is getting it ‘right’ by design, rather than by accident.

(As one example of accounting for the success of one approach in terms of another, the cognitive therapist — and former psychoanalyst — Aaron Beck provides convincing arguments in terms of cognitive therapy for why the therapeutic interventions of a psychoanalyst might have a successful outcome; the cognitive explanation is entirely consistent with the falsity of psychoanalytic theory. In other words, the psychoanalyst might be acting on an entirely mistaken view of the client’s psychology, yet these misguided interventions might inadvertently hit right on target in terms of eventual outcome.)

The response that counsellors should just be pragmatic, doing what works, is actually very credible. But even here, it is difficult to see how a counsellor could just do what works without some grasp of the theoretical underpinnings of whatever overall approach or technique he or she might be inclined to employ with a given client. It is preferable for the client if any suggestions from the counsellor that a particular approach might be helpful are made on the basis of some informed view of why it might work: a counsellor’s suggestion of a particular way of working should not be made by default, it should be both deliberate and informed. In other words, it may be true that one should ‘do what works’, but doing that requires some effort to understand and evaluate underlying theory.

One last curious conclusion about the evidence is worth addressing. Namely, some proponents of person-centred theory suggest that it is unsurprising that different therapeutic orientations do not differ in terms of aggregate effectiveness. They suggest that only individual therapists who manifest the ‘core conditions’ of person-centred theory will be effective, and that anyone from any orientation could do a good job of offering the core conditions. The evidence does not support this conclusion: these conditions have been researched along with many others, and there is no evidence to suggest that success can be picked out just by looking at the core conditions. (It is entirely possible that the view is true, but for now it remains an item of faith, not a conclusion correctly derived from reliable empirical evidence.) Moreover, if it were true, it would imply an interesting conclusion which person-centred proponents would presumably find unpalatable: namely, that counsellors who successfully manifest the core conditions are no more likely to be found in the ranks of the person-centred tradition than within any other therapeutic tradition. In other words, it would imply than person-centred counsellors are no more likely to be person-centred than any other type of counsellor.

Finally, all this might strike some practitioners as being entirely tangential to their own take on counselling and psychotherapy. For some, scientific research is irrelevant anyway, and even if the particular benefits of a given approach became empirically evident, they would still prefer to maintain the purity of their own particular therapeutic orientation and their own ways of dealing with individual clients. (One psychologist wrote that “one can no more argue someone out of a counselling model by advancing empirical evidence than one could argue them out of a religious belief”.) One way of getting at whether there is any tension in this view — and there needn’t necessarily be any at all — is by way of a question which is worth asking for any counsellor: what would it take to convince you that you are approaching a given client in the wrong way? The client telling you so? A scientific study? The client telling you so twenty times? Twenty scientific studies? Alternatively: what would it take to convince you that a given client would benefit more from something other than what you are doing?

These questions will probably be answered differently by every counsellor or psychotherapist.

Further Reading on the Effectiveness of Counselling and Psychotherapy

The annotated bibliography contains pointers to additional literature in this area. Probably the single best source of specific research data on the effectiveness of counselling and psychotherapy is Bergin and Garfield (1994). In that volume, Lambert and Bergin (1994) include useful results on individual counsellor effectiveness, while Beutler et al. (1994) cover cross-study correlational data indicating that levels of experience and therapist training are almost irrelevant to therapeutic outcome. The data on client variables’ contribution to therapeutic change come from Asay and Lambert (1999). Seligman (1995) comments on the 1995 Consumer Reports survey on the effectiveness of psychotherapy and clearly explains the distinction between controlled efficacy studies and the less-stringent effectiveness study.

UK readers especially may be interested in the Department of Health’s treatment guidelines, which summarize some of the available data about best matches between specific types of psychological distress and specific types of therapy. See Beck (1976) for details of the comparisons mentioned above between psychoanalysis and cognitive therapy. The psychologist quoted above on counselling models and religious beliefs is Legg (1998), p. 4.

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