The Best Type of Therapy? Evidence-Based Practice in Psychotherapy

What’s the best type of therapy? On the one hand we have empirically supported, evidence-based therapies like the cognitive-behavioral-therapy (CBT), dialectical behavior therapy (DBT), and acceptance and commitment therapy (ACT). These are therapies that randomized controlled trials have found to be effective.

But on the other hand, maybe the type of psychotherapy doesn’t matter. Maybe there are other factors common to all types of such as the therapeutic relationship that are more important. This debate has been going on for decades .

But now instead of trying to figure out which side is right, there’s more of a focus on evidence-based practice. Evidence based practice in psychotherapy reconciles both sides, focusing on finding what is best suited to each individual client.

Evidence-Based Practice in Psychotherapy

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Have you ever wondered what’s the best type of psychotherapy? In this video, we’ll look at some different ways of answering this question and talk about the main elements that go into making therapy effective.

On the one hand, there are a number of empirically supported or evidence-based psychological treatments, which are specific treatments for specific psychological issues or disorders that have been shown effective in peer-reviewed randomized controlled trials. Most of these involve some form of cognitive-behavioral therapy or therapy that integrates CBT with mindfulness, like Acceptance and Commitment Therapy, Dialectical Behavior Therapy, or Mindfulness-Based Cognitive Therapy.

The American Psychological Association has a list that evaluates the strength of the research support for a number of types of therapy. Now, they changed their criteria for evaluating research support a few years ago, and so all of these [red new content tags] indicate that the treatment is pending re-evaluation under the new criteria, but the old criteria give you an idea of the types of treatments that are generally considered evidence-based or empirically supported, and I’ll link to this website in the description.

On the other hand, there’s the common factor school of thought who believe that outcomes are similar enough regardless of the type of therapy that the type of therapy itself isn’t what’s important. It’s factors that are common to all types of therapy that are responsible for successful outcomes. In other words, there aren’t specific factors associated with one type of therapy that make it more effective than other types of therapy. What makes therapy effective are the common factors that all types of therapy share.

An example of a specific factor is that cognitive therapy uses cognitive restructuring or cognitive reappraisal to help change and modify thoughts, whereas common factors that exist in any type of therapy are things like alliance, which is your bond with your therapist. Do the two of you click and your level of agreement about the goals and tasks of therapy? And empathy, do you feel like your therapist understands you and where you’re coming from and is empathetic to you and your situation? And expectations, do you have positive expectations for your therapy and how optimistic are you about whether and how much you expect to improve as a result of therapy?

The common factors proponents argue that it’s these common factors that are responsible for the outcome of therapy and not any specific therapeutic approach or techniques, and there are a couple of studies that have come up with a breakdown along the lines of about 50% of the outcome of therapy is the result of common factors, about 33% is due to things that happen outside of therapy, and about 17% is attributed to the specific type of therapy. In general, the more severe your symptoms, the more effective specific therapies are compared to common factors and non-specific techniques, and I’ll link to this research and some articles about the debate between common versus specific factors in the description.

So who’s right in this debate? I think this chapter sums it up well. There’s good evidence to support the assertion that certain common factors of several different psychotherapies are beneficial to the process of change across different disorders and treatments. Similarly, there’s good evidence that some treatments differ meaningfully from others, and that certain specific elements of some treatments may be viewed as unique contributions from particular types of psychotherapy.

So there’s evidence supporting both sides of this debate, and instead of continuing to debate this, there’s now more focus on how to integrate both models together in ways that will be most beneficial.

Which brings us to evidence-based practice, which is different from an evidence-based treatment. According to the American Psychological Association, evidence-based practice in psychology is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. This is sometimes known as the three-legged stool of evidence-based practice. The best available research will often indicate an empirically supported or evidence-based treatment, but that’s only one component, one leg of evidence-based practice. Research into the importance of common factors would also fall into this leg.

Evidence-based practice recognizes the importance of things such as alliance and empathy in client expectations, and one aspect of the clinical expertise leg is the ability to form a therapeutic relationship creating realistic but positive expectations and responding empathetically to the patient’s experiences and concerns, as well as the flexibility to be clinically effective with patients of diverse backgrounds. The importance of these common factors is also addressed under clinical expertise, and then the patient characteristics leg refers to the individual social and cultural context of the patient.

So what does this look like in real life? According to a paper from 2010, “What Do Psychotherapists Really Do in Practice?”, the most common therapeutic techniques are conveying warmth, caring, and respect, communicating that the client is accepted and prized, communicating understanding of clients’ experience, empathizing with the client’s situation, feelings, and struggles, promoting clear, direct expression of clients’ feelings, making reflective or clarifying comments, and focusing on cultivating therapeutic relationship and alliance. It makes sense that these techniques are the most common because they’re all common factor techniques, so they’re a part of therapy regardless of a therapist’s theoretical orientation. These are the only therapeutic techniques that were used by more than 60% of therapists.

Now, in terms of specific techniques associated with a certain type of psychotherapy, instead of focusing on a single therapeutic orientation like CBT or psychodynamic therapy, most therapists use what’s known as an eclectic approach that draws on techniques from more than one type of therapy, using whatever is best suited to meet a client’s needs. This aligns with the second and third elements of evidence-based practice: using clinical expertise to guide practice and tailoring therapy to the individual client.

This paper found that only 2% of therapists identified themselves completely with one orientation, so 98% of therapists are drawing on more than one type of therapy, and 79% include CBT in their practice, 41% mindfulness, 36% psychodynamic or analytic psychotherapy, and 31% rogerian or client-centered therapy. These numbers are from 2010, and now I suspect CBT and mindfulness percentages are higher today because that seems to be the trend.

According to a 2021 paper that looked at the predicted future of psychotherapy by polling a panel of experts about what they think psychotherapy will look like in the 2030s, the therapy practices that were predicted to increase the most were multicultural therapies, so again in line with evidence-based practice and respecting the needs of individual clients, mindfulness therapies, and cognitive-behavioral therapy.

Putting all of this together, the best type of therapy is an empirically supported treatment for any specific psychological issues or symptoms you’re experiencing, which will usually be a type of CBT or CBT plus mindfulness, with a therapist you have a strong alliance with, someone who’s able to use their clinical judgment along with your individual characteristics to tailor empirically supported treatments to best suit your needs and preferences.

If you have any questions or comments, please leave them on the YouTube video page.

American Psychological Association Policy Statement on Evidence-Based Practice in Psychology: https://www.apa.org/practice/guidelines/evidence-based-statement

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