The document summarizes research on the evolution of psychotherapy over the past 50 years. It finds that while the number of treatment approaches has grown significantly, outcomes are largely due to common or "nonspecific" factors like the therapeutic alliance rather than specific treatment techniques. Over 190 studies with over 2630 patients found strong effect sizes for factors like the alliance, empathy, and collaboration between therapist and patient. In contrast, differences between treatment approaches and adherence to treatment protocols showed weak effect sizes. The core task of psychotherapy appears to be developing a strong therapeutic relationship through engagement, understanding, affirmation, genuineness, and collaboration.

1. Expertise and Psychotherapy:
Core Tasks
Scott D. Miller, Ph.D.
International Center for Clinical Excellence

2. The Evolution of Psychotherapy:
So, what’s happened?
•Since the 1960’s:
•Number of treatment
approaches grown from 60 to
400+;
•10,000+ “how to” books
published on psychotherapy;
•145 manualized treatments for
51 of the 297 possible diagnostic
groups in DSM.
Duncan, B., Miller, S., Wampold, B., & Hubble, M. (eds.) (2009). The Heart and Soul of Change: Delivering What Works.
Washington, D.C.: APA
Miller, S.D., Hubble, M.A., Chow, D.L., & Seidel, J.A. (2013). The outcome of psychotherapy: yesterday, today, and
tomorrow. Psychotherapy, 50, 88-97.
Wampold, B.L. (2001). The great psychotherapy debate. Mahwah, NJ: LEAPress.

3. The Evolution of Psychotherapy:
Progress
•In most studies of treatment conducted over the
last 40 years, the average treated person is better
off than 80% of the untreated sample.
•No difference in outcome between treatment
approaches;
•Taken together, comparative, component
(dismantling), mediating variable, & aptitude-bytreatment studies all show that specific ingredients
are NOT needed to achieve a good outcome.
Duncan, B., Miller, S., Wampold, B., & Hubble, M. (eds.) (2009). The Heart and Soul of Change: Delivering
What Works. Washington, D.C.: APA Press.

4. The Evolution of Psychotherapy:
Progress ?
“Decades of psychotherapy
research have failed to find
a scintilla of evidence that
any specific ingredient is
necessary for therapeutic
change.”
Ahn, H., & Wampold, B. (2001). Where oh where are the specific ingredients: A meta-analysis of
component studies in counseling and psychotherapy. Journal of Counseling Psychology, 48(3), 251-257.
Duncan, B., Miller, S.D., Wampold, B., & Hubble, M. (2009). The Heart and Soul of Change: Delivering
What Works in Therapy. APA: Washington, D.C.
Wampold, B. (2001). The Great Psychotherapy Debate. Mahwah, N.J.: LEA, 204.

5. The Evolution of Psychotherapy:
Factor
# Studies
# Patients
Effect Size d
% of variability in
outcomes
Common Factors
Alliancea
190
2630
.57
.075
Empathya
59
3599
.63
.090
Goal Consensus/collaborationa
15
1302
.72
.115
Positive Regard/Affirmationa
18
1067
.56
.073
Congruence/Genuinessa
16
863
.49
.057
Specific Ingredients
Differences between treatmentsb
>5900
<.20
<.010
Adherence to protocolc
28
1334
.04
<.001
Rated competence in delivering
particular treatment
aNorcross,
295
18
633
.14
.005
J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy,
48(1), 4-8. doi: 10.1037/a0022180
bWampold, B. E. (2001b). The great psychotherapy debate: Model, methods, and findings.
Mahwah, NJ: Lawrence Erlbaum Associates.
cWebb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S.
(2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom
change. Journal of Consulting and Clinical Psychology, 79(3), 279-283. doi: 10.1037/a0023252

6. The Evolution of Psychotherapy:
What Does Make a Difference ?
Factor
# Studies
# Patients
Effect Size d
% of variability in
outcomes
Common Factors
Alliancea
190
2630
.57
.075
Empathya
59
3599
.63
.090
Goal Consensus/collaborationa
15
1302
.72
.115
Positive Regard/Affirmationa
18
1067
.56
.073
Congruence/Genuinessa
16
863
.49
.057
Specific Ingredients
Differences between treatmentsb
>5900
<.20
<.010
Adherence to protocolc
28
1334
.04
<.001
Rated competence in delivering
particular treatment
aNorcross,
295
18
633
.14
.005
J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy,
48(1), 4-8. doi: 10.1037/a0022180
bWampold, B. E. (2001b). The great psychotherapy debate: Model, methods, and findings.
Mahwah, NJ: Lawrence Erlbaum Associates.
cWebb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S.
(2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom
change. Journal of Consulting and Clinical Psychology, 79(3), 279-283. doi: 10.1037/a0023252

7. The Evolution of Psychotherapy:
What Does Make a Difference ?
Factor
# Studies
# Patients
Effect Size d
% of variability in
outcomes
Common Factors
Alliancea
190
2630
.57
.075
Empathya
59
3599
.63
.090
Goal Consensus/collaborationa
15
1302
.72
.115
Positive Regard/Affirmationa
18
1067
.56
.073
Congruence/Genuinessa
16
863
.49
.057
Specific Ingredients
Differences between treatmentsb
>5900
<.20
<.010
Adherence to protocolc
28
1334
.04
<.001
Rated competence in delivering
particular treatment
aNorcross,
295
18
633
.14
.005
J. C., & Lambert, M. J. (2011). Psychotherapy relationships that work II. Psychotherapy,
48(1), 4-8. doi: 10.1037/a0022180
bWampold, B. E. (2001b). The great psychotherapy debate: Model, methods, and findings.
Mahwah, NJ: Lawrence Erlbaum Associates.
cWebb, C. A., DeRubeis, R. J., Amsterdam, J. D., Shelton, R. C., Hollon, S. D., & Dimidjian, S.
(2011). Two aspects of the therapeutic alliance: Differential relations with depressive symptom
change. Journal of Consulting and Clinical Psychology, 79(3), 279-283. doi: 10.1037/a0023252

8. The Evolution of Psychotherapy:
•Baldwin et al. (2007):
•Study of 331 consumers, 81
clinicians.
•Therapist variability in the
alliance predicted outcome.
•Consumer variability in the
alliance unrelated to
outcome.
Baldwin, S., Wampold, B., & Imel, Z. (2007). Untangling the AllianceOutcome Correlation. Journal of Consulting and Clinical Psychology, 75(6),
842-852.

9. The Evolution of Psychotherapy:
•Despite the evidence:
•Training continues to emphasize
model and technique;
•Therapists firmly believe that the
expertness of their techniques leads
to successful outcomes;
•The field as a whole is continuing
to embrace the medical model.
•Emphasis on so-called, “empirically
supported treatments” or “evidence
based practice.”
•Embracing the notion of diagnostic
groups, treatment specificity.
Eugster, S.L. & Wampold, B. (1996). Systematic effects of participants role on
the evaluation of the psychotherapy session. Journal of Consulting and Clinical
Psychology, 64, 1020-1028.

10. The Evolution of Psychotherapy:
What are the “Core Tasks” of Therapy?

11. The Evolution of Psychotherapy:
A New Question and Focus
•What is the core task
of psychotherapists?
Engagement
“…the most important
determinant of
outcome…[this] can
be considered fact
established by 40plus years of research
on psychotherapy.”
Miller, S.D., Hubble, M.A., Chow, D.L., & Seidel, J.A. (2013). The outcome of psychotherapy: yesterday, today, and
tomorrow. Psychotherapy, 50, 88-97.
Orlinsky et al. (2005). Process and outcome in psychotherapy. In M.J. Lambert (ed). The Handbook of Psychotherapy
and Behavior Change (5th ed.). New York: Wiley.

12. Engagement
Understand,
Affirm,
Be Congruent, Genuine, &
Collaborative,
Seek Consensus