Research evidence on psychotherapist skills and methods: Foreword and afterword

Figures & data

Table I. Four levels of overt therapist behavior.

Level of Abstracton	Therapist Behavior	Examples
High	Treatment packages/theoretical orientations	Psychodynamic, cognitive-behavior, experiential, systemic
High-Medium	Change principles/processes	Consciousness raising, commitment, counterconditioning
Medium	Methods	Behavioral activation, chair work, paradoxical intervention
Low	Skills	Questions, empathic reflections, affirmations, metaphors

Table II. Summary of associations between psychotherapist skills/methods and psychotherapy outcomes.

Skill/Method	Type of Outcome	# Studies	# Clients/Patients	Type of Analysis	Results of Research Review	Consensus on Research Evidence
Affirmation/Validation (skill)	Distal	64	3,528	Meta-analysis	g = 0.28–0.36	Demonstrably Effective
Self-disclosure (skill)	Immediate	5	99	Qualitative meta-analysis	Improved relationship (64%)	Insufficient Research
					Gained insight (46%)
					Better mental health (45%)
					Helpful (37%)
Immediacy (skill)	Immediate	15	78	Qualitative meta-analysis	Improved relationship (40%)	Insufficient Research
					Opened up (40%)
					Not helpful (39%)
Rupture Repair (method)	Immediate	5	21	Task analysis	Acknowledged & explored rupture	Insufficient Research
		3	10	Task analysis	Renegotiated goal
	Distal	11	1,318	Meta-analysis	d = 0.51–0.62	Probably Effective
	Training	6	407	Meta-analysis	d = 0.22
Questions (skill)	Immediate	10	328	Box score	5+, 5=, 6 -	Neutral/Mixed
Socratic Questioning (method)	Immediate	6	39	Box score	6+, 0 = , 0-	Insufficient Research
	Distal	1	55	Box score	2+, 0 = , 0-	Insufficient Research
Empathic Reflections (skill)	Immediate					Neutral/Mixed
	In-Session	24	1,217	Meta-analysis	d = 0.05
		4	44	Qual: Narrative	Increased self-understanding
		21	(1,152 egs)	Conver. analysis	Positive if therapist responds to empathic opportunity, reflects client's stance, and makes a correction
	Delayed	3	72	Meta-analysis	d = 0.04
	Distal	22	1,734	Meta-analysis	d = 0.04	Neutral/Mixed
Metaphors (skill)	Immediate					Insufficient Research
	In-Session	5	9	Box score	5+, 0=, 0-
	Delayed	5	17	Box score	4+, 0=, 3-
	Distal	5	80	Box score	3+, 5=, 0-	Insufficient Research
Interpretations (skill)	Immediate	6	88	Box score	10+. 6=, 4-	Neutral/Mixed
	In-Session
	Intermediate	4	288	Box score	8+, 5=, 3-	Neutral/Mixed
	Distal	12	866	Box score	9+, 19=, 3-	Neutral/Mixed
Paradoxical Interventions (method)	Intermediate	12	35	Box score	12+, 0=, 1-	Probably Effective
	Distal					Demonstrably Effective
	Pre-post	17	422	Meta-analysis	d = 1.1
	Compared to non-PI	17	471	Meta-analysis	d = 0.49
Advice, Suggestions, Recommendations (skill)	Immediate					Neutral/Mixed
	In-Session	5	141	Box score	2+, 14=, 4-
	Delayed	3	22	Box score	0+, 10=, 1-
	Intermediate	2	123	Box score	2+, 0=. 0-	Insufficient Research
Homework (method)	Immediate In-Session	9	322	Box score	3+, 0=, 6-, WBS = .26	Neutral/Mixed
	Intermediate	16	982	Box Score	10+, 2=, 4-, WBS = .53	Probably Effective
	Distal (previous review)	14	477	Meta-analysis	d = 0.53	Demonstrably Effective
Silences (method)	In-dialogue silences Immediate	17	276	Integrative Meta-analysis	Therapist allowing productive pauses was associated with more client emotional attunement, new symbolization, meaning making, lowered emotional distress, and increased collaboration. Therapist permitting obstructive pauses was associated with client withdrawal, relational rifts, greater emotional distress, and poorer alliance.	Probably Effective
	Extended silences Immediate	16	33	Qualitative meta-analysis	Therapist support as well understanding and identifying client experiences during silences was associated with increases in client insight/self-understanding, capacity for relationships, containment of emotions, and autonomy.	Probably Effective
Dyadic Synchrony (method)	Intermediate	8	323	Box score	WBS = .257	Neutral/Mixed
	Movement	6	259	Box score	WBS = .214
	Physiological	2	64	Box score	WBS = .479
	Distal	14	786	Box score	WBS = .343	Neutral/Mixed
	Movement	10	667	Box score	WBS = .389
	Vocal	2	116	Box score	WBS = -.222
	Physiological	1	60	Box score	WBS = .500
	Linguistic	1	7	Box score	WBS = 0
Role Induction (method)	Immediate					Probably Effective
	In-session	8	651	Meta-analysis	d = 0.64
	Delayed	3	151	Box score	3+, 0=, 0-
	Distal					Probably Effective
	Dropout	15	1,307	Meta-analysis	OR = 1.64
	Mid-Treatment	5	288	Meta-analysis	d = 0.26
	End-Treatment	8	662	Meta-analysis	d = 0.33
Collaborative Assessment Methods (method)	Distal					Probably Effective
	Process	7	320	Meta-analysis	d = 0.59
	Symptoms	7	332	Meta-analysis	d = 0.19
	Growth	5	264	Meta-analysis	d = 0.42
	Cases	6	6	Box score	6+, 0=, 0-
Routine Outcome Monitoring (method)	Distal (All clients)
	End-treatment	58	21,699	Meta-analysis	d = 0.15	Demonstrably Effective
	Follow-up
	Dropout	4	1,027	Meta-analysis	d = 0.18
	Deterioration	39	14,369	Meta-analysis	OR = 1.19
	Distal (Not-on-track)	26	10,413	Meta-analysis	OR = 1.16
	End-treatment	27	15,146	Meta-analysis	d = 0.17
Strength-based Methods (method, treatment)	Immediate	8	416	Box score	6+, 2=, 0-	Probably Effective
	Distal					Demonstrably Effective
	Disorder-specific
	Previous combined	10–51	max 6,139	Meta-analysis	g = 0.07–0.94
	Current bona fide	9	729	Meta-analysis	g = 0.18
	Other Outcomes
	Previous combined	10–51	Max 6,139	Meta-analysis	g = 0.02–0.92
	Current bona fide	9	729	Meta-analysis	g = 0.16
Emotional Regulation (method, treatment)	Immediate	8	84	Box score	6+, 2=, 0-	Probably Effective
	Intermediate	2	14	Box score	0+, 3=, 0-	Insufficient Research
	Distal	28	1,034	Meta-analysis	g = 0.82	Demonstrably Effective
Chairwork (method, treatment)	Immediate					Neutral/Mixed
	Btwn groups	4	295	Meta-analysis	d = 0.10
	Btwn groups	4	98	Meta-analysis	d = 0.90
	Distal					Probably Effective
	Pre-post single sess	7	326	Meta-analysis	d = 1.73
	Btwn grps, post-sess	3	105	Meta-analysis	d = −0.02
	Btwn grps, post-tx	5	238	Meta-analysis	d = 0.40
		4	100	Task analysis	Step 1: activate problem state
					Step 2: explore inner reaction
					Step 3: enact core concern
					Step 4: express emotion
					Step 5: change perspective
					Step 6: negotiate engagement
Dream Work and Nightmare Treatment (method, treatment)	Dream work CEDM
	Intermediate	8	539	Meta-analysis	g = 0.67–0.70	Demonstrably Effective
	Nightmare Tx
	IRT/ERRT					Demonstrably Effective
	Distal
	Previous	13	511	Meta-analysis	g = .59 to .93
	Current	6	293	Box score	24+, 1=, 0-	Insufficient Research
	NDR
	Immediate	1	11	Box score
	Distal	2	40	Box score	4+, 2=, 0-	Insufficient Research
Meditation, Mindfulness, Acceptance (methods, treatment)	Immediate					Insufficient Research
	In-session	3	176	Box score	WBS = .06
		1	9	Box score	WBS = 1.0
	Distal					Demonstrably Effective
	Previous reviews	28	3,009	Meta-analysis	g = 0.40–0.95
	(pre-post)
	MMA vs no tx	89	5,748	Meta-analysis	g = 0.55
	MMA vs bona fide
	active control	42	3,810	Meta-analysis	g = 0.23
	MMA vs evidence-based tx	28	2,806	Meta-analysis	g = −0.004
Behavioral Activation (method, treatment)	Distal	22	819	Meta-analysis	g = 0.85	Demonstrably Effective (for depression)
Cognitive Restructuring (method, treatment)	Intermediate and Distal	4	353	Meta-analysis	d = 0.85
	Intermediate	4	550	Box score	5+, 0=, 0-	Demonstrably Effective (for depression)
	Distal	2	261	Box score	3+, 0=, 0-	Demonstrably Effective (for depression)

Note. Skill = discrete verbal response mode; Method = a collection of skills oriented toward a specific aim which is implemented within an overall treatment approach; Treatment (tx) = entire treatment package focusing on and inseparable from the methods.

For Type of Outcome: Immediate includes both Immediate In-Session outcomes (typically judged by trained raters) and Immediate Delayed (ratings of in-session process typically made after sessions by therapists, clients, and trained judges); Intermediate = outcomes rated at post-session or between sessions; Distal = end-of-treatment outcome.

Tx: treatment; egs: excerpts; Qual.: Qualitative; Previous: previous published review.

For Type of Analysis: Box scores: + is a positive score, = is a neutral score, - is a negative score. WBS = weighted box score (between −1.00 to −0.50 is considered negative; between −0.49 to +0.49 is considered neutral, and between +0.50 to +1.00 is considered positive); Conver. analysis = conversational analysis.

Under Dream Work and Nightmare Tx, CEDM = cognitive-experiential dream model, IRT = imagery rehearsal therapy, ERRT = exposure, relaxation, and rescripting therapy, CDR = nightmare deconstruction and reprocessing therapy.

Consensus on Research Evidence: the consensus judgment of the Task Force Steering Committee about the strength of the research evidence for the effectiveness of each type of outcome for each skill/method: demonstrably effective, probably effective, neutral or mixed evidence, not effective, insufficient research to judge.