A First Year Doctoral Student’s Introduction to Evidence-Based Practice in Psychotherapy: What I’m Taking with me Into Sessions as a New Therapist

As a first year doctoral student in counseling psychology, I have been immersed in scholarship surrounding the topic of how to be a successful therapist. Now, as I am approaching the start of practica, I am beginning to consider how I will integrate what I have learned into my own client sessions in a more concrete way. In other words, the task in front of me is to shift from thinking about the research evidence from a more abstract level to a more practical one. To this end, we have provided a synthesis of recent articles reviewing psychotherapy research and some key take-aways for use in clinical practice for trainees (and therapists of all levels) for evidence-based therapy practice. Our hope is that it might be useful to others wishing to update their knowledge regarding psychotherapy research findings and their practical application.

Skills and Methods That Work: An Evidence-Based Overview for Trainees

In their concluding chapter in a special issue of Psychotherapy devoted to meta-analytic reviews examining effective therapy skills and methods, Hill and Norcross (2023) provide a helpful overview of the research supporting a wide range of therapy skills. This offers a valuable starting place for examining what might be beneficial (or harmful) for clients during therapy. The researchers divide these skills into several subcategories and rate the research evidence for their level of effectiveness in terms of immediate in-session, intermediate between session, and distal client outcomes. Specifically, I learned from this work that certain techniques, such as therapist affirmation and validation, were shown to be demonstrably effective in terms of achieving beneficial client outcomes (Hill & Norcross, 2023). In addition, being able to identify and repair a rupture can be used to maintain or even restore the therapeutic alliance following challenging interactions. Restoring the therapeutic alliance following a rupture is related to positive outcomes from treatment (Eubanks et al., 2018) and this skill is worthy of developing for trainees. The authors also provide a list of techniques gathered from the research that have mixed results, including approaches that could negatively impact clients. For example, the researchers note that while homework assignments were “probably effective” between sessions, homework appears to sometimes lead to therapeutic ruptures (Hill & Norcross, 2023). In addition, the authors note that metaphors were found to be less effective for clients with schizophrenia (McMullen & Tay, 2023; as cited in Hill & Norcross, 2023). Neither of these actions should be eliminated from therapy practice but knowing that some commonly used skills/techniques could have unintended negative outcomes for some clients offers a reminder about the importance of considering a client’s unique presentation. This is especially important given some of the gaps highlighted by the authors. In particular, the researchers describe that immediacy as a skill does not have clear support regarding its impact on client outcomes. They also discuss how very few studies have examined the impact of the culture or identity of the therapist or the client on outcomes (Hill & Norcross, 2023). This is a significant gap in research on skills and methods, especially since multlicultural competence (MC) – something intertwined with cultural identity – is recognized as a core clinical competency (Tao et al., 2015). Other studies have found that therapist MC has a significant effect on many different aspects of the therapeutic relationship and therapy process, such as client satisfaction, session impact, and overall treatment outcome (Tao et al., 2015).

Multicultural Orientation Framework: A Useful Therapeutic Tool for Trainees

Having positive regard for our clients appears to be significantly related to client outcomes and this may be more complex (and even more vital) in cross-cultural counseling and/or in providing therapy to clients from historically marginalized groups (Clauss-Ehlers et al., 2019; Farber et al., 2018). Carl Rogers (1957) may have been among the first to suggest that how a client interprets our positive regard is the most important aspect of positive regard (Farber et al., 2018). Conflict in any relationship, including the therapeutic relationship, is unavoidable. For instance, microaggressions and missed opportunities to discuss a client’s social identit(ies) and/or identity-based experiences can be places where ruptures occur in therapy (Davis et al., 2018). In their meta-analysis exploring the Multicultural Orientation (MCO) Framework, Davis and colleagues (2018) explored how using this framework can impact the therapeutic relationship. The MCO Framework focuses on incorporating cultural awareness and humility into therapy. While researchers have shown that microaggressions occur frequently in therapy, clients often do not bring up microaggressions until they are leaving therapy. This demonstrates the importance of therapists’ ability to notice opportunities to discuss culture when they arise in therapy, grow their comfort level with discussing culture, and do so within a framework of  cultural humility (Davis et al., 2018). Specifically, cultural humility was found to play a role in repairing ruptures in the therapeutic alliance and lessening the negative impact of missed opportunities. Davis and colleagues point to many areas where the MCO can be incorporated into therapeutic work, such as during intake, case conceptualization, and throughout therapy sessions (2018). The MCO and its component parts would be a helpful set of skills/techniques to include in a future review of psychotherapy skills and methods that work. Until then, I find the MCO to be a highly valuable framework for thinking about my upcoming clinical work.

Remember to Focus on Client Strengths as an Evidence-Based Approach

In his book, Therapeutic Communication, Paul Wachtel notes the importance of centering a client’s strengths during the therapy process, rather than making diagnosis and psychopathology the focus of therapy (Wachtel, 2011) Furthermore, strengths-based methods are research supported for in-session and post-treatment client outcomes (Hill & Norcross, 2023).  At this stage of my training, it feels easy to make diagnosis or psychopathology the focus of sessions, since generally, when individuals go to therapy, they have a problem in their life that they want to discuss. It can seem instinctual, Wachtel writes, to focus on what needs to be different, rather than what is already going well; and having significant concerns can sometimes drown out strengths or positive aspects of an individual’s daily life. This makes it vital to draw attention to a client’s strengths and sources of resilience. Furthermore, there is an “assumption that the sicker the patient appears to be through the lens of the therapist’s diagnosis the more profound and acute must be her clinical perceptions” (Wachtel, 2011, p. 191). This statement contains an important reminder that it can be easy to err on the side of over-pathologizing a client’s behavior, yet this does not necessarily benefit the patient, and in some cases can even cause harm (Paris, 2013).  

A strengths-based approach is intertwined with the therapist’s positive regard for the client.  Positive regard involves centering a client’s experiences and accepting them without judgement (Rogers, 1957). Viewing a client this way could help with the cultivation of a strengths-based approach. For instance, it might be challenging for a therapist to see a client’s strengths if they lack positive feelings about that client (or about themselves, for that matter). Research has demonstrated that using positive regard also appears to help create a therapeutic environment where clients feel accepted by their therapist and are then consequently better able to accept themselves, although the exact mechanism through which positive regard impacts client outcomes is likely complex. At any rate, positive regard likely helps clients see their own sources of strength and better understand their positive attributes (Farber et al., 2018). 

In addition, positive regard is something that is largely communicated to clients through therapists’ words: “…words are [also] the medium of relationships” (Wachtel, 2011, p. 3). Training for therapists, according to Wachtel, often focuses on what clients are saying, and that what the therapist should say will follow naturally (Wachtel, 2011). This could easily seem discouraging to trainees who are constantly encountering new situations. Knowing the perfect thing to say in response to a client sharing something very personal or challenging seems, in fact, the opposite of natural or automatic. Related to this, researchers have found that 53 to 81% of clients have experienced a microaggression while they were in therapy. This implies that relying on instinct or automatic responses when deciding how to respond to what a client is saying could be harmful (Tao et al., 2015).

Our Words Matter: The Example of Cognitive Restructuring

Focusing on the specific words that therapists say may help trainees avoid automatic responding and instead engage in some of the more challenging techniques that have demonstrated research support (Hill & Norcross, 2023; Wachtel, 2011). In particular, Wachtel describes how some of his trainees were hesitant to challenge their clients and feared that their words would offend them; a fear to which I could easily relate (Wachtel, 2011). And apparently, some research has demonstrated that this may be a concern for other therapists as well, specifically when using techniques such as cognitive restructuring (CR). CR, in some form, is an integral aspect of nearly all treatment approaches, including cognitive behavioral therapy. However, as demonstrated in their review, Ezawa and Hollon (2023) demonstrated that CR implemented poorly can lead to significant therapeutic ruptures.

In addition, hesitance to use CR has been shown to have disproportionate impacts on some groups of clients. Specifically, researchers found that therapists used fewer cognitive techniques when working with Black/African American clients than they did when working with White clients (Ezawa & Strunk, 2022). Generally, CR has been shown to have a positive impact on therapy outcomes and can also lead to longer term changes. CR gives clients skills they can continue to use to assess and change their behavior even after their therapeutic journey has ended. If some groups of clients are systematically not getting to experience these same evidence-based benefits, this is a healthcare disparity that warrants further examination as to why this happening so it can be addressed. The researchers hypothesized that the mostly White sample of therapists were afraid of engaging in microaggressions, offending a client, and/or their underuse indicated an overall lack of cultural sensitivity. To me, this warrants further investigation as this indicates a need for increased multicultural competence training for therapists and further education surrounding the implementation of CR in ways that feel positive and constructive to clients and therapists. CR as an impactful technology is about language and communication; it may be that simple changes to a sentence or better attending to tone and nonverbals can dramatically impact how a client will interpret the message they are getting from their therapist (Wachtel, 2011).

Practice-Based Evidence: Being a Local Clinical Scientist

While exploring this research, I did not find any simple answers as to what I should and should not include in my own therapeutic approach, yet the above research provided a valuable starting point. Significant gaps still remain, specifically with regard to MC and cultural adaptations (Hill & Norcross, 2023). With this in mind, it is vital for therapists to consider each individual patient with whom we are working – rather than the average client upon which research data are based – within our daily practice. Practice-based evidence is the process of gathering process and outcome data in our own practice with clients and can help each of us better understand what is working well and what is not working well for our individual (or group) clients (Paquin, 2017). This approach highlights the importance of collaboration via asking clients for feedback. Giving clients a chance to say what is working well and if they feel like there is a good therapeutic alliance could help elucidate areas where adjustments or changes might be necessary. Combining my new knowledge about what methods and techniques have empirical support, focusing on client strengths, remembering the power of positive regard, using a multicultural orientation, inviting client collaboration and engaging in practice-based evidence will help me account for the unique experiences and needs of each client I work with. These are concrete practices that will ground me when I feel lost and that I know that I can carry with me well beyond my years as a trainee.