What makes therapy work?

August 23, 2020

Within the last decade popular doubts surrounding the efficacy of mental healthcare, alongside widespread stigma, have begun to lift. In fact, by 2015 57% of Canadians believed that the stigma associated with mental illness has been reduced compared to five years prior.(1) 

Much of this newfound confidence and acceptance in the practice of mental healthcare has been a result of rigorous research that proves psychotherapy is an effective intervention for those experiencing mental health challenges. Reviews of hundreds of studies show that - on average - a person who engages in psychotherapy is better off by the end of treatment than 75-80 percent of those who don’t receive treatment at all.(2) 

Scrutiny about mental healthcare

Despite reduced stigma and popularized research around mental healthcare, patients and providers alike continue to look to mental health professionals for an answer to the question: what makes therapy work?

“Patients' desire to solicit or even accept mental healthcare is often limited by stigma or doubt. In these cases it’s important to understand and address the root of the resistance.” - Dr. David Butler-Jones, Former Chief Public Health Officer and Head of the Public Health Agency of Canada (PHAC)

In healthcare generally it’s common for patients who are looking for or receiving care to challenge the viability of the treatment in question. Having become accustomed to the processes by which traditional healthcare validates treatment, many patients are now looking for similar backing to the validity of therapy and other mental health treatments. 

To enable successful outcomes for the patient beginning at the earliest stages of their mental health journey, the patient and their supporting team of care providers must clearly understand how and why relational factors are leading determinants of success in therapy.

Therapy defined 

The practice of psychotherapy encompasses a range of methods and techniques based on “talking work” with a therapist.(3) Many psychotherapeutic methods are built upon evidence based practice. The American Psychological Association (APA) defines Evidence Based Practice as “the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences”.(4) 



In the context of mental healthcare, the patient characteristics, culture and preferences are especially critical to successful outcomes. The explanation for how and why these factors hold such importance can be understood by taking a step back to look at something called The Contextual Model of Psychotherapy. 

The Contextual Model of Psychotherapy

In recent years, The Contextual Model of Psychotherapy has been developed as a framework to help understand and interpret the available evidence around the effectiveness of psychotherapy.

Traditional medical models of evaluating therapy stipulate that specific ingredients of treatments are responsible for the benefits of psychotherapy. In contrast, The Contextual Model emphasizes that the relationship between the client and the therapist in the context of treatment is foundational to the success of therapy.

In essence, The Contextual Model includes the following three pathways through which benefits occur.

1) The therapeutic relationship

A therapeutic relationship is developed when, throughout the course of treatment, a bond between the patient and provider is established. This relationship has been defined as “the personal relationship between therapist and patient marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that benefit the other”.(5) 

2) Creation of and alignment on expectations between the therapist and client

It is well known that expectations have a strong influence on experience. This applies to personal goals, relationships, and of course progress with therapy. By proactively aligning on and managing expectations with the client from the outset of treatment, a therapist can support the reframing of potentially negative expectations into ones that encourage alignment on future positive change. It can also improve therapeutic outcomes when a client trusts their therapist and is able to be optimistic about treatment from the outset and along the way. 

3) Specific ingredients in treatment methods

The third pathway of the contextual model involves specific techniques that are unique to a method of treatment and do not exist in other therapy models. Therapy delivered through any model will have common factors which drive a lot of the outcomes. The remaining impact of therapy - according to the Contextual Model - is driven by the unique differences or specific ingredients of the therapy model being used (for example, CBT).

About relational factors

Hundreds of studies have examined the effectiveness of therapy, and their results can all be explained through the lens of The Contextual Model.

More specifically, 50 years of meta-analytic studies of outcome research conclude that relational factors account for as much as 75 percent of success in treatment, while differences in models and techniques account for only 25 percent of success.(6)



Relational factors in psychotherapy cannot be understood in the context of a model or specific set of techniques. Instead they should be viewed as embedded in all therapeutic interactions between a client and their therapist. Some relational factors are alliance, empathy, goal consensus, affirmation, congruence, expectations, cultural adaptation, and more. 

For a closer look at the ways in which these factors influence patient outcomes, we dig into two critically important relational factors: patient-therapist alliance and cultural adaptation. 

Patient-therapist alliance

Patient-therapist “alliance” or “collaboration” is composed of three components: the bond, the agreement about the goals of therapy, and the agreement about the tasks of therapy. It is instrumental to the first two pathways of the contextual model. 



By examining the results of over 500 studies the effect size (the correlation between the factor in question and the therapeutic outcome) was measured at 0.80 for patient-therapist alliance.(6) In other words, a person receiving psychotherapy when patient-therapist alliance is achieved will be better off than 80 percent of those who are not.

When asked about the importance of patient-therapist alliance, Zell Dharsee, Registered Psychotherapist in Ontario commented that “psychotherapy, regardless of modality, is a difficult and vulnerable experience. Addressing challenging aspects of our lives is difficult to do. This process benefits greatly from a strong rapport between psychotherapist and patient.” 

With regards to the effectiveness of treatment when patient-therapist alliance is realized, Zell continued that “building a deep level of trust with the patient can help them develop the ability to open gateways that normally remain closed. The therapeutic relationship can often serve as a microcosm for what the patient is experiencing in their world. As such, the foundation of all my work rests on the creation and maintenance of a strong therapeutic alliance from the outset of treatment.”

Cultural adaptation

For successful treatment, the contextual model explains that the patient must be accepting of the explanation put forth for their distress. Of course, this requires that the explanation for the patients suffering be consistent with their culture and beliefs. 

Cultural adaptation of treatment methods is when evidence based treatments are adapted to use an explanation that is congruent with the patient’s cultural beliefs. 

Zell Dharsee, RP, explains a first hand view of cultural adaptation in practice. “In my experience I’ve found that it’s not uncommon for patients to seek treatment from a mental health provider that aligns with their cultural beliefs. The cultural experiences of an individual can often be a significant factor in the challenges they are experiencing. By being attuned to cultural overlaps and exploring curiously, I’ve been able to adapt treatment methods to the client. This has allowed me to provide more holistic explanations to the client, achieving breakthroughs and insights I may not have been able to otherwise.”

Now more than ever, the importance of cultural adaptation in mental healthcare has been brought to the forefront of conversations surrounding therapeutic care and how to achieve successful outcomes. 

The experience of seeking and receiving mental healthcare can be difficult for many people even without the added pressure that one might feel if they identify with a minority group that’s unrepresented in their community of care providers. 

The role of the patient care community 

Physicians and other health professionals are often the first point of contact with the patient in matters of mental health. In fact, as many as 40% of patients seeking help for mental health problems are seen only by family physicians.(8) 

“When a patient is in need of mental healthcare it’s important to enable a care plan that’s right for the patient, as quickly as possible. The key to this is making an appropriate patient-therapist match.” - David Jones, Dr. David Butler-Jones, Former Chief Public Health Officer and Head of the Public Health Agency of Canada (PHAC)

As a common first point of contact on the patient’s mental health journey, it is critical that the full care community understand how and why relational factors are what ultimately drive successful outcomes in therapy. By becoming familiar with what makes therapy work and the importance of relational factors, healthcare providers can properly educate, refer and treat patients in need of mental healthcare. 

References:

  1. Bell Canada (2015). Bell Let’s Talk: The first 5 years (2010-2015). Retrieved from http://letstalk.bell.ca/letstalkprogressreport 
  2. American Psychological Association (APA). (2020). Understanding Psychotherapy and How it Works. Retrieved from: https://www.apa.org/helpcenter/understanding-psychotherapy 
  3. The Centre for Addiction and Mental Health (CAMH). (2020). Psychotherapy. Retrieved from: https://www.camh.ca/en/health-info/mental-illness-and-addiction-index/psychotherapy
  4. American Psychological Association (APA). (2020). Evidence-Based Practice in Psychology. Retrieved from: https://www.apa.org/practice/resources/evidence
  5. C Gelso. (2014). A tripartite model of the therapeutic relationship: theory, research, and practice. Psychother Research. 24(2):117-31.
  6. Bruce E Wampold, & Zac E. Imel. (2015). The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work
  7. Bruce E Wampold. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry. 14(3): 270–277. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592639/
  8. Lisa Clatney, Heather MacDonald, & Syed M. Shah. (2008). Mental health care in the primary care setting: Family physicians’ perspectives. Canadian Family Physician. 54(6): 884–889.