■ The degree to which clients reflect on, think
about, and emotionally process material within
sessions is positively associated with outcome;
■ Therapists’use of guidance and advice is gen-
erally not associated with outcome, and thera-
pists’use of support and encouragement is
inconsistently related to outcome;
■ As might be expected, clients’degree of
cooperativeness (vs. resistance) is positively
related to outcome, as is the degree to which
clients express positive affect in a session.
Findings such as these give us more clues as to
what therapeutic ingredients are associated with
positive outcome. What is especially intriguing is
that these findings are generally consistent regardless
of the“brand”of therapy or treatment used.
Recent Trends
Focus of Psychotherapy Research. As noted ear-
lier, a great deal of research is conducted to exam-
ine the efficacy and effectiveness of specific
therapeutic approaches for individual diagnoses. In
addition, recent research has refined this question
by asking whether there are specific factors (e.g.,
client motivation, socioeconomic status, etc.) that
may be related to higher efficacy and effectiveness.
In addition, research has begun to dismantle thera-
peutic approaches to determine whether specific
components of cognitive-behavioral therapy, for
instance, are the most important ingredients in ther-
apy outcome. Last, research has begun to focus
more specifically on the types of therapies that
work for each specific diagnosis. In other words,
the question of interest to contemporary researchers
is no longer“whether psychotherapy works,”but
rather “which type of psychotherapy works for
which diagnoses?” Part of this line of research
includes asking whether psychotherapy, medica-
tion, or a combination of both may lead to better
client outcome.
For example, Chorpita and colleagues (2011)
offer an analysis of several different types of thera-
peutic approaches for several different types of
disorders among youth. Their results led to a
documentation of the evidence base for several dif-
ferent approaches to therapy. For instance, their
results revealed that cognitive-behavioral therapy,
particularly involving“exposure”as a therapeutic
technique, has the best evidence base for the treat-
ment of anxiety disorders; most studies suggest that
this approach works better than no therapy at all. In
contrast, there is very little evidence to suggest that
psychodynamic or play therapy works any better in
reducing anxiety disorder symptoms than no ther-
apy at all (Chorpita et al., 2011).
Other recent studies have compared the effects of
psychotherapy, medication, or a combined form of
treatment. Many of these studies have involved large
multisite national clinical trials, involving hundreds of
clients across several U.S. geographic areas. For
instance, one of these trials involved the study of
treatment for ADHD in children (i.e., NIMH
Collaborative Multisite Multimodal Treatment Study
of Children With Attention-Deficit/Hyperactivity
Disorder; MTA, 1999). Treatments included behav-
ioral therapy, medication, combined treatment, and
community-care controls. Results at the end of
treatment indicated that youth in the combined
and medication conditions evidenced greater improve-
ment in ADHD symptoms and ODD symptoms than
did children in the behavior-therapy-only condition
and the community controls (MTA, 1999).Practice Guidelines. Increasingly, clinical psy-
chologists are being held accountable for the ser-
vices they provide. Insurers and managed care
companies no longer give clinicians free rein as to
the interventions they employ and the pace at
which treatment is administered. To maintain con-
trol over the psychotherapy enterprise, several
professional organizations have become increasingly
active in developing practice guidelines (Nathan,
1998). Practice guidelines recommend specific
forms of intervention for specific psychological pro-
blems or disorders, and they have a common goal
of“detailed specification of methods and proce-
dures to ensure effective treatment for each disor-
der” (Nathan & Gorman, 1998, p. 12). The
American Psychological Association began working
on practice guidelines in 2011.338 CHAPTER 11