Choosing an Effective Treatment
Reprinted from the "Treatments: What Works?" issue of Visions Journal, 2015 15 (4), pp. 38-41
It is estimated that one in five Canadians live with a mental health problem that significantly interferes with their life activities.1 Most of these problems can be successfully managed with appropriate treatment, but finding an effective treatment can be a daunting task.
In this article, I describe how psychotherapy reduces mental health problems and how to choose a psychotherapy service that is a good fit.
What is psychotherapy?
Psychotherapy is a treatment for mental health problems in which a mental health professional helps you change how you think, feel and behave using methods based on psychological, biological and social theories and research. Research shows that changing one’s thoughts, feelings and behaviours reduces or eliminates symptoms of many mental health problems and improves quality of life. Psychotherapy is also used successfully to help people cope with or overcome life problems, such as adjusting to a health issue or overcoming discrimination, bullying or abuse, to name just a few. However, this article focuses only on mental health problems.
Psychotherapy is sometimes referred to as “counselling,” sometimes as “talk therapy” and sometimes simply as “therapy.” While these terms tendto be used interchangeably, the term “counselling” has also been used more broadly to describe supportive conversations between a health professional and the client. These might focus on regular medication intake, housing issues or helping navigate the health system. These types of counselling, while helpful, would not qualify as psychotherapy because they are not meant to treat mental health problems.
Psychotherapy is one of the best treatments for mental health problems. This statement is supported by 50 years’ worth of research.2 The question is not if psychotherapy works, but how.
How does psychotherapy work?
Researchers have different views about how and why psychotherapy works. The “active ingredients” in psychotherapy can be broadly grouped into specific and common factors. Knowing about these “active ingredients” can help choose a psychotherapy service that is a good fit for you.
Many researchers say that psychotherapy works because it offers carefully assembled interventions tailored for specific mental health problems. An example of an intervention would be when the therapist teaches the client how to challenge worrying thoughts by comparing them to facts. A different example is when the therapist and the client explore patterns in the client’s relationships across time. Another intervention would be when the therapist teaches the client strategies to become more aware of their emotions.
These interventions are called “specific factors” because they differ from one psychotherapy to another. A “psychotherapy” is understood here as a group of interventions. Researchers who study specific factors compare different psychotherapies (e.g., cognitive-behavioural therapy, psychodynamic psychotherapy, etc.) to each other to find the most effective psychotherapy for a specific mental health problem.
Which psychotherapies might best help your mental health issue?
The table (see below) shows psychotherapies that have the most research support for selected mental health problems. This is not a complete list and it is not meant to suggest that other psychotherapies cannot be effective. Research in this area grows quickly and many psychotherapies have not yet been tested. The combinations of specific psychotherapies and mental health problem pairs that could be studied are almost endless, especially when we take into account that some people have two or more mental health problems. However, the list can help you to make an informed decision about the psychotherapy that might be a fit for you.
Other psychotherapy researchers believe that therapy works because of “common factors” that are shared across psychotherapies. According to these researchers, most psychotherapies can be helpful for most problems because the effectiveness lies in the art of how psychotherapy is done, not which interventions are used.
An example of a common factor is a positive, honest relationship between the therapist and the client, who are working toward the same goal. Another common factor is when the therapist and the client develop a shared understanding of the client’s problem and the way it can be changed. Yet another is when the client is given an opportunity to practise and master new skills that help overcome their problem.
Research supports the importance of common factors. For example, studies consistently show that a strong therapeutic relationship between the therapist and the client leads to better outcomes in various therapies and problems.58
In addition, some researchers have shown that, when some aspects of research design are improved, psychotherapies might not be as different from each other in their effectiveness as those who study “specific factors” believe they are.59,60
How do I choose a psychotherapy that works for me?
Choosing a psychotherapy service can be overwhelming at first. So it can be helpful to use a guide such as some approaches used by therapists. One approach therapists use to decide how to work with a specific client is called evidence-based practice (EBP). EBP specifies three types of information that can help decide on the appropriate psychotherapy: 1) client characteristics, 2) research evidence, and 3) therapist’s clinical expertise. EBP has been recommended by the American and Canadian psychological associations61,62 and is also used in the field of medicine, where it originated. Although the principles of the EBP were designed to help clinicians, they can also be useful for clients who are deciding on the best psychotherapy service to meet their needs.
Here are some therapist and client characteristics that, according to research, affect outcomes in psychotherapy. You might want to consider them when choosing a psychotherapy service that meets your needs.
Research suggests that the person who is delivering therapy has an impact on the treatment’s success. Most effective therapists are empathic, accepting, genuine, able to speak with you directly about any misunderstandings that happen between the two of you, and able to see strengths in your cultural worldview. They are also highly skilled, but not rigid, in the therapies that they provide.56 They will challenge you or invite you to step outside your comfort zone.64
You can monitor to see whether your therapist has these qualities. If you are not “clicking” with your therapist, it can be very helpful for both of you to have a conversation about this.
You, as the client, are the most important ingredient of change in psychotherapy. You are the one who does most of the work. Studies show that clients with better outcomes understand their problems similarly to the way their therapist views them, but are also open to changing these understandings. They are motivated and have optimistic but not idealistic expectations toward therapy (unless they have depression, because negative expectations are part of the disorder).64.65
Reviewing your attitudes toward psychotherapy can help you assess if this is a good treatment for you.
Finding a ‘fit’—It’s worth making an effort
Psychotherapies and therapists vary in their styles of work—and your preferences in how you would like to work matter. You might meet with several therapists before you find a good fit. A good fit means that you feel respected and supported by your therapist and that you ‘buy into’ the psychotherapy approach enough to work hard and step outside your comfort zone. You might decide to choose a psychotherapy that was successfully studied with a problem like yours.
While choosing a service might not be easy, it is worth the effort—psychotherapy is, after all, one of the most effective treatments available for mental health problems. This is particularly true when you find a good combination of specific and common factors that match your needs.
Psychotherapies for specific disorders*
For plain-language definitions of the 30+ psychotherapies listed in this table, please see the Glossary of Treatments prepared by Visions staff.
Acceptance and commitment therapy12,13,14
Personality disorders: Cluster B (borderline, narcissistic, histrionic, antisocial)
Personality disorders: Cluster C (obsessive-compulsive, avoidant, dependant)
Post-traumatic stress disorder
Eating disorders: Bulimia nervosa
Eating disorders: Anorexia nervosa
Psychotherapy is an effective treatment and research does not support any one approach over another for adults43
Cognitive-behavioural therapy (exposure and ritual prevention)44,45
* Note: Psychotherapies are listed alphabetically within each disorder; they are not ranked by effectiveness
** promising approach
About the author
Karolina is a PhD student in Counselling Psychology at UBC and recently completed the CIHR/MSFHR* Science Policy Fellowship at the BC Ministry of Health. Her work intersects clinical practice, academic research and public policy. She specializes in eating disorders and in psychotherapy research, and supports broad access to psychotherapeutic treatments for mental health problems
*Canadian Institutes of Health / Michael Smith Foundation for Health Research
- Ministry of Health Services & Ministry of Children and Family Development. (2010). Healthy minds, healthy people: a 10-year plan to address mental health and substance use in British Columbia. Victoria, BC: Author.
- Lambert, M. J. (Ed.). (2013). Bergin and Garfield's handbook of psychotherapy and behavior change. Hoboken, NJ: John Wiley & Sons.
- Cuijpers, P., Van Straten, A., & Warmerdam, L. (2007). Behavioral activation treatments of depression: A meta-analysis. Clinical Psychology Review, 27(3), 318-326.
- Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T., & Fang, A. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.
- Dessaulles, A., Johnson, S. M., & Denton, W. H. (2003). Emotion-focused therapy for couples in the treatment of depression: A pilot study. The American Journal of Family Therapy, 31(5), 345-353.
- Beach, S., & O’Leary, K. (1992). Treating depression in the context of marital discord: Outcome and predictors of response for marital therapy versus cognitive therapy. Behaviour Therapy, 23, 507-528.
- Emanuels-Zuurveen, L., & Emmelkamp, P. M. (1996). Individual behavioural-cognitive therapy v. marital therapy for depression in maritally distressed couples. The British Journal of Psychiatry, 169(2), 181-188.
- Leff, L., Vearnals, S., Brewin, C.,Wolff, G., Alexander, B., Asen, E., & Everitt, B. (2000). The London depression intervention trial randomised controlled trial of antidepressants v. couple therapy in the treatment and maintenance of people with depression living with a partner: Clinical outcome and costs. The British Journal of Psychiatry, 177(2), 95-100.
- Elliott, R., Greenberg, L., Watson,J., Timulak, L., & Freire, E. (2013). Research on humanistic-experiential psychotherapies. In M. J. Lambert (Ed.), Bergin and Garfield's handbook of psychotherapy and behavior change (pp. 495-538). Hoboken, NJ: John Wiley & Sons.
- Cuijpers, P., Geraedts, A. S., van Oppen, P., Andersson, G., Markowitz, J. C., & van Straten, A. (2011). Interpersonal psychotherapy for depression: A meta-analysis. American Journal of Psychiatry, 168(6), 581-592.
- Driessen, E., Cuijpers, P., de Maat, S. C., Abbass, A. A., de Jonghe, F., & Dekker, J. J. (2010). The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis. Clinical Psychology Review, 30(1), 25-36.
- Forman, E. M., Herbert, J. D., Moitra, E., Yeomans, P. D., & Geller, P. A. (2007). A randomized controlled effectiveness trial of acceptance and commitment therapy and cognitive therapy for anxiety and depression. Behavior Modification, 31(6), 772-799.
- Kocovski, N. L., Fleming, J. E., Hawley, L. L., Huta, V., & Antony, M. M. (2013). Mindfulness and acceptance-based group therapy versus traditional cognitive behavioral group therapy for social anxiety disorder: A randomized controlled trial. Behaviour Research and Therapy, 51(12), 889-898.
- Roemer, L., Orsillo, S. M., & Salters-Pedneault, K. (2008). Efficacy of an acceptance-based behavior therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76(6), 1083.
- Butler, A. C., Chapman, J. E., Forman, E. M., & Beck, A. T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26(1), 17-31.
- Hofmann, S. G., & Smits, J. A. (2008). Cognitive-behavioral treatment for adult anxiety disorders: A meta-analysis of randomized placebo-controlled trials. Journal of Clinical Psychiatry, 69, 621-632.
- Stewart, R. E., & Chambless, D. L. (2009). Cognitive-behavioral therapy for adult anxiety disorders in clinical practice: A meta-analysis of effectiveness studies. Journal of Consulting and Clinical Psychology, 77(4), 595.
- Byrne, M., Carr, A., & Clark, M. (2004). The efficacy of couples‐based interventions for panic disorder with agoraphobia. Journal of Family Therapy, 26(2), 105-125.
- Milrod, B., Leon, A. C., Busch, F., Rudden, M., Schwalberg, M., Clarkin, J., ... & Shear, M. K. (2007). A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. The American Journal of Psychiatry, 164(2), 265-272.
- Clarkin J. F., Levy K. N., Lenzenweger M. F., & Kernberg, O. F. (2007). Evaluating three treatments for borderline personality disorder: A multiwave study. The American Journal of Psychiatry, 164(6), 922–928.
- Linehan, M. M., Comtois, K. A., Murray, A. M., Brown, M. Z., Gallop, R. J., Heard, H. L., ... & Lindenboim, N. (2006). Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality disorder. Archives of General Psychiatry, 63(7), 757-766.
- McMain, S. F., Links, P. S., Gnam, W. H., Guimond, T., Cardish, R. J., Korman, L., & Streiner, D. L. (2009). A randomized trial of dialectical behavior therapy versus general psychiatric management for borderline personality disorder. The American Journal of Psychiatry, 166(12), 1365-1374.
- Bateman, A., & Fonagy, P. (2008). 8-year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. The American Journal of Psychiatry, 165(5), 631-638.
- Farrell, J. M., Shaw, I. A., & Webber, M. A. (2009). A schema-focused approach to group psychotherapy for outpatients with borderline personality disorder: A randomized controlled trial. Journal of Behavior Therapy and Experimental Psychiatry, 40(2), 317-328.
- Giesen-Bloo, J., van Dyck, R., Spinhoven, P., van Tilburg, W., Dirksen, C., van Asselt, T., … & Arntz, A. (2006). Outpatient psychotherapy for borderline personality disorder: Randomized trial of schema-focused therapy vs. transference-focused psychotherapy. Archives of General Psychiatry, 63, 649–658.
- Svartberg, M., Stiles, T. C., & Seltzer, M. H. (2004). Randomized, controlled trial of the effectiveness of short-term dynamic psychotherapy and cognitive therapy for cluster C personality disorders. American Journal of Psychiatry, 161(5), 810-817.
- Strauss, J. L., Hayes, A. M., Johnson, S. L., Newman, C. F., Brown, G. K., Barber, J. P., … Beck, A. T. (2006). Early alliance, alliance ruptures, and symptom change in a nonrandomized trial of cognitive therapy for avoidant and obsessive-compulsive personality disorders. Journal of Consulting and Clinical Psychology, 74(2), 337–345.
- Davidson, P. R., & Parker, K. C. (2001). Eye movement desensitization and reprocessing (EMDR): A meta-analysis. Journal of Consulting and Clinical Psychology, 69(2), 305.
- Bisson, J. I., Ehlers, A., Matthews, R., Pilling, S., Richards, D., & Turner, S. (2007). Psychological treatments for chronic post-traumatic stress disorder Systematic review and meta-analysis. The British Journal of Psychiatry, 190(2), 97-104.
- Cloitre, M., Koenen, K. C., Cohen, L. R., & Han, H. (2002). Skills training in affective and interpersonal regulation followed by exposure: A phase-based treatment for PTSD related to childhood abuse. Journal of Consulting and Clinical Psychology, 70(5), 1067.
- Ponniah, K., & Hollon, S. D. (2009). Empirically supported psychological treatments for adult acute stress disorder and posttraumatic stress disorder: A review. Depression and Anxiety, 26(12), 1086-1109.
- Robjant, K., & Fazel, M. (2010). The emerging evidence for Narrative Exposure Therapy: A review. Clinical Psychology Review, 30, 1030-1039.
- Hay, P.P.J, Bacaltchuk, J., Stefano, S., & Kashyap, P. (2009). Psychological treatments for bulimia nervosa and binging. Cochrane Database of Systematic Reviews, 4. doi: 10.1002/14651858.CD000562.pub3.
- Poulsen, S., Lunn, S., Daniel, S. I., Folke, S., Mathiesen, B. B., Katznelson, H., & Fairburn, C. G. (2014). A randomized controlled trial of psychoanalytic psychotherapy or cognitive-behavioral therapy for bulimia nervosa. The American Journal of Psychiatry, 171(1), 109-116.
- Lavender, A., Startup, H., Naumann, U., Samarawickrema, N., DeJong, H., Kenyon, M., ... & Schmidt, U. (2012). Emotional and social mind training: A randomised controlled trial of a new group-based treatment for bulimia nervosa. PloS one, 7(10), e46047.
- Fairburn C. G., Kirk J., O’Connor M., & Cooper P. J. (1986). A comparison of two psychological treatments for bulimia nervosa. Behavior Research & Therapy, 24, 629–643.
- Fairburn, C. G., Norman, P. A., Welch, S. L., O'Connor, M. E., Doll, H. A., & Peveler, R. C. (1995). A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Archives of General Psychiatry, 52(4), 304-312.
- Griffiths R. A., Hadzi-Pavlovic D., Channon-Little L. (1994). A controlled evaluation of hypnobehavioural treatment for bulimia nervosa: Immediate pre-post treatment effects. European Eating Disorders Review, 2, 202–220.
- Wonderlich, S. A., Peterson, C. B., Crosby, R. D., Smith, T. L., Klein, M. H., Mitchell, J. E., & Crow, S. J. (2013). A randomized controlled comparison of integrative cognitive-affective therapy (ICAT) and enhanced cognitive-behavioral therapy (CBT-E) for bulimia nervosa. Psychological Medicine, 23, 1-11.
- Agras, W.S., Walsh, B.T., Fairburn, C.G., Wilson, C.T., & Kraemer, H.C. (2000). A multicenter comparison of cognitive-behavioral therapy and interpersonal psychotherapy for bulimia nervosa. Archives of General Psychiatry, 54, 459–465.
- Fairburn, C. G., Jones, R., Peveler, R., Carr, S. J., Solomon, R. A., O’Connor, M.E., … Hope, R.A. (1991). Three psychological treatments for bulimia nervosa: A comparative trial. Archives of General Psychiatry, 48, 463–469.
- Fairburn, C. G., Jones, R., Peveler, R. C., Hope, R. A., & O’Connor, M. (1993). Psychotherapy and bulimia nervosa: Longer-term effects of interpersonal psychotherapy, behaviour therapy and cognitive behaviour therapy. Archives of General Psychiatry, 50, 419–428.
- Fairburn, C. G. (2005). Evidence‐based treatment of anorexia nervosa. International Journal of Eating Disorders, 37(S1), S26-S30.
- Foa, E. B., Liebowitz, M. R., Kozak, M. J., Davies, S., Campeas, R., Franklin, M. E., ... & Tu, X. (2007). Randomized, placebo-controlled trial of exposure and ritual prevention, clomipramine, and their combination in the treatment of obsessive-compulsive disorder. American Journal of Psychiatry, 162(1), 151-161.
- Simpson, H. B., Foa, E. B., Liebowitz, M. R., Ledley, D. R., Huppert, J. D., Cahill, S., ... & Petkova, E. (2008). A randomized, controlled trial of cognitive-behavioral therapy for augmenting pharmacotherapy in obsessive-compulsive disorder. The American Journal of Psychiatry, 165(5), 621
- Sensky, T., Turkington, D., Kingdon, D., Scott, J. L., Scott, J., Siddle, R., ... & Barnes, T. R. (2000). A randomized controlled trial of cognitive-behavioral therapy for persistent symptoms in schizophrenia resistant to medication. Archives of General Psychiatry, 57(2), 165-172.
- Zimmerman, G., Favrod, J., Trieu, V.H. & Pomini, V. (2005). The effect of cognitive behavioural therapy on the positive symptoms of schizophrenia spectrum disorders: A meta-analysis. Schizophrenia Research, 77, 1-9.
- Pilling, S., Bebbington, P., Kuipers, E., Garety, P., Geddes, J., Orbach, G., & Morgan, C. (2002). Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychological Medicine, 32(5), 763-782.
- Pharoah, F., Mari, J. J., Rathbone, J., Wong, W. (2010). Family intervention for schizophrenia. Cochrane Database of Systematic Reviews, 12, Art. No.: CD000088.
- Bach, P., & Hayes, S. C. (2002). The use of acceptance and commitment therapy to prevent the rehospitalization of psychotic patients: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 70(5), 1129.
- Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Wisniewski, S. R., Kogan, J. N., ... & Sachs, G. S. (2007). Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Archives of General Psychiatry, 64(4), 419-426.
- Isasi, A. G., Echeburúa, E., Limiñana, J. M., & González-Pinto, A. (2014). Psychoeducation and cognitive-behavioral therapy for patients with refractory bipolar disorder: A 5-year controlled clinical trial. European Psychiatry, 29(3), 134-141.
- Scott, J., Colom, F., & Vieta, E. (2007). A meta-analysis of relapse rates with adjunctive psychological therapies compared to usual psychiatric treatment for bipolar disorders. The International Journal of Neuropsychopharmacology, 10(01), 123-129.
- Rea, M. M., Tompson, M. C., Miklowitz, D. J., Goldstein, M. J., Hwang, S., & Mintz, J. (2003). Family-focused treatment versus individual treatment for bipolar disorder: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 71(3), 482.
- Miklowitz, D. J., George, E. L., Richards, J. A., Simoneau, T. L., & Suddath, R. L. (2003). A randomized study of family-focused psychoeducation and pharmacotherapy in the outpatient management of bipolar disorder. Archives of General Psychiatry, 60(9), 904-912.
- Perlick, D. A., Miklowitz, D. J., Lopez, N., Chou, J., Kalvin, C., Adzhiashvili, V., & Aronson, A. (2010). Family‐focused treatment for caregivers of patients with bipolar disorder. Bipolar Disorders, 12(6), 627-637.
- Frank, E., Kupfer, D. J., Thase, M. E., Mallinger, A. G., Swartz, H. A., Fagiolini, A. M., ... & Monk, T. (2005). Two-year outcomes for interpersonal and social rhythm therapy in individuals with bipolar I disorder. Archives of General Psychiatry, 62(9), 996-1004.
- Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A. O. (2012). How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis. Journal of Counseling Psychology, 59(1), 10.
- Wampold, B. E., Minami, T., Baskin, T. W., & Tierney, S. C. (2002). A meta-(re) analysis of the effects of cognitive therapy versus ‘other therapies’ for depression. Journal of Affective Disorders, 68(2), 159-165.
- Ahn, H., & Wampold, B. E. (2001). A meta-analysis of component studies: Where is the evidence for the specificity of psychotherapy? Journal of Counseling Psychology, 48, 251-257.
- American Psychological Association. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271-285.
- Canadian Psychological Association. (2012). Evidence based practice of psychological treatment: A Canadian perspective. Retrieved from http://www.cpa.ca/docs/file/Practice/
- Beutler, L. E., Malik, M., Alimohamed, S. T., Harwood, M., Talebi, H., Noble S., & Wong, E. (2004). Therapist variables. In M. Lambert (Ed.), Garfield & Bergin handbook of psychotherapy and behavior change (pp. 227– 306). New York: Wiley.
- Castonguay, L. G., & Beutler, L. E. (Eds.). (2006). Principles of therapeutic change that work. Oxford, UK: Oxford University Press.
- Bohart, A. C., & Wade, A. G. (2013). The client in psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (pp. 219-257). Hoboken, NJ: John Wiley & Sons.