Therapy: What does work?

It is the active ingredients…

First, just a recap of my very first blog post: To find out whether therapy works, we can focus on research done in the field.

There are mainly three types of research in psychotherapy (counselling):

  1. Efficacy Research (clinical trials) are used to determine whether a treatment works under special experimental conditions or whether a new treatment works better than an existing treatment or a placebo.  The research focuses on average client responses in highly controlled conditions.
  2. Effectiveness research focuses on the average responses of clients in naturalistic settings.  This approach is used to determine if a treatment works in practice.  Researchers who focus on effectiveness research want to find out if the treatment that has been researched under strict experimental conditions also work in daily life.
  3. The last type of research focuses on the individual. It is known as client-focused research. Counsellors/therapists check in with every client at the beginning of each session and ask for feedback at the end of the session. The feedback shows a therapist and their client whether the sessions are helpful.

All three types of research are important!

Compare it with blood pressure medication. Would you be willing to swallow pills that have not been subjected to rigorous research? It is no different for therapy and the medication metaphor might be helpful.

In tablets and capsules you will find the active ingredients and the non-medical ingredients. The latter may include fillers, flavours, sugars and water. In addition to the ingredients that make the tablet more flavourful, looks are important too and therefore pills come in different shapes, colours and sizes and very well-marketed packaging. The latter is even more important for medication that is available “over the counter”.

As we all will agree upon, the inactive ingredients is like the sugar that “make the medicine go down” and it is not that there is anything wrong with that…as long as we are not pretending otherwise.

Factors that contribute to whether therapy is going to be beneficial to clients are:

  • Whether clients feel their therapist “gets it”
  • Whether clients feel that they matter to their therapist
  • Whether clients feel that their therapist listens to them
  • Whether clients feel safe and respected
  • Whether clients feel that the approach used by the therapist is a good fit for them
  • Whether clients are asked for feedback

Other factors important are readiness to make changes, and whether clients have support outside the therapy room.

Taking trauma as an example…time and time again research shows that there is not much difference between the trauma approaches used. It seems that all are equally effective. This means that research shows no or minimum differences in outcome for clients doing Cognitive Behavioural Therapy, Cognitive Therapy, Prolonged Exposure Therapy, Psychodynamic Therapy,  or EMDR. This is interesting as one wonders why this would be as the approaches are “marketed” as being different and, of course, some are claiming to be “the gold standard” in trauma therapy.

Trauma is  caused by the experience, observation or exposure to an event (or more than one) that creates intense feelings of helplessness (clients often describe the feeling of being powerless), horror and fear. In general, the part of our brain that regulates emotions can handle stressful events. Some traumatic events however, affect people so severely that the center of emotional processing (the amygdala) becomes overloaded causing disruptions in processing of information.

Those suffering from symptoms related to trauma do not get adequate rest and sleep, often due to the re-experiencing of the traumatic events during nightmares. They have symptoms of depression, extreme anxiety, are frequently triggered, which brings back painful memories, they have anger outbursts, problems concentrating and can be hyper vigilant. People often avoid certain persons and situations and may self harm in varied ways.

So, it has been found that bona fide therapeutic interventions, including trauma approaches (those are the ones that have been scrutinized in research including meta-analyses) work as they have in common the “general” active ingredients (aka the common factors) as well as the “specific” ingredients needed for successful trauma therapy.

A therapist who is successful in helping clients with trauma symptoms is knowledgeable and skilled in addressing all of the symptoms of Post Traumatic Stress Disorder (PTSD) without re-traumatizing the client. Obviously the approaches mentioned above are helpful to those suffering from PTSD symptoms as they share the active ingredients: The general and specific ones.

Grounding helps people to become present in the here and now. It can be done by talking to someone, offering a drink (water or a hot tea), and guiding a person to become aware of their environment. This helps a person who is re-experiencing a traumatic event to feel safe.

Those who avoid people, places and situations will benefit from a step for step, deliberate and well-paced plan to gradually become less anxious when approaching the anxiety provoking situation (desensitization). This activity works well when paired with a relaxation exercise.

Cognitive behavioural therapy helps a person to identify “distortions” in their thinking. The thoughts that were “automatically” negative, are scrutinized and challenged, and replaced by a more realistic evaluation or interpretation.

Relaxation followed by pleasant distractions before bed time can aid sleep. Other very general and important considerations that increase healing are being active, eating well and watching the intake of alcohol.

And then…there is the fluff “that helps the medicine go down”, which is often wrapped in nice sounding (but never new) theories, beautiful graphs, brain imaging (lots of these!) and anything looking or sounding scientific, often accompanied by phrases such as “holistic, integrative and mind-body connection”.

By the way…all of them have fluff (also the bona-fide ones) , just some of them have more than others. A few examples…

“Optimal EFT-The unseen therapist-healing that transcends all man-made methods”; “The mind narrates what the nervous system knows”; “The body remembers”; “The body keeps the score”; “Integrating traumatic memories in an ecological way”; Healing the body-mind from a quantum level”; Brainspotting [is] change and healing at the neurological level by focusing on where the person is looking”; “Brainspotting aims to ground relational attunement in brain science”; “CRM [works by] fusing elements of psychology, spirituality. neurobiology and shamanic ‘power-animal’ and the ‘don’t think ask your body, not your brain” [principle]. Accelerated Resolution Therapy (ART), which seems to be a very brief version of EMDR, minus the research evidence!

…and the emperor is still naked, if I dare to say so…

Again, not that there is anything wrong with that, as long as therapists are open and honest about this, in the first place to themselves (so do not fall for the “loud” marketing of the good looking and “newest” on the market) and of course, to their clients. It also implies that therapists implementing trauma therapy read the research in order to provide unbiased information to clients.

Regarding the third type of research: Client Focused Research, one could argue that as long as therapy works for the client, all is fine. Clients however, have a right to know the results of research and therefore be informed about what the active ingredients are. Only then can clients make informed choices.

This is no more than being ethical.

Hereby some links that inspired me to write the above…

The Skeptic Dictionary on New Age Psychotherapies: http://skepdic.com/therapy.html

EMDR: Taking a Closer Look: https://www.scientificamerican.com/article/emdr-taking-a-closer-look/

Benish, S. G., Imel, Z. E., Wampold, B.E. (2008). The relative efficacy of bona fide psychotherapies for treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical Psychology Review 28, 746–758.

Davidson, P.R. and Parker, K.C. (2001).  Eye Movement Desensitization and Reprocessing (EMDR): A Meta-Analysis. Journal of Consulting and Clinical Psychology 69(2), 305-316.

Pitman, R.K., Orr, S.P., Altman, B., Longpre, R.E., Poire, R.E., Macklin, M. (1996). Emotional processing during eye movement desensitization and reprocessing of Vietnam veterans with chronic posttraumatic stress disorder. Comprehensive Psychiatry, 37(6), 419-429.


Last, but not least: I recommend any book or article by Dr. Jon Allen:

Allen, J. G. (1995). Coping with Trauma. American Psychiatric Press, Washington, DC.

Allen, J. G. (2005). Coping with Trauma (2nd ed.). American Psychiatric Press, Washington, DC.

Allen, J.G. (2013). Mentalizing in the development and treatment of Attachment Trauma. Karnac Books, London.



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