What I Wish My Clients Knew Before Starting Therapy

By Dr Sarah Fischer, Principal Psychologist, Behavioural Edge Psychology

In short, the research suggests that the name of the therapy predicts less of the outcome than five other things. The quality of the therapeutic relationship, the skill and empathy of the individual psychologist, your own engagement and hope, whether progress is measured along the way, and whether strains between you are noticed and repaired. Each is explained below, with the evidence behind it for clients starting therapy.

Most people arrive at a first session with a version of the same question. Have I picked the right kind of therapy? It is a reasonable question, and the wellness industry encourages it, because brands of therapy are easy to market. The research tells a more interesting story. Decades of psychotherapy outcome studies suggest that the label on the therapy matters less than a handful of other ingredients, several of which sit at least partly in your hands. Here are five of them, along with what the evidence actually says.

A caveat before we start. The research on common factors in psychotherapy is contested at its margins, and reasonable scientists still argue about how much specific techniques contribute. What follows is a synthesis of the mainstream evidence, with the strongest findings first, rather than a settled verdict.

1. The relationship does a large share of the work

The connection between the quality of the therapeutic relationship and the outcome of therapy is the most consistently replicated finding in psychotherapy research. A meta-analysis by Flückiger, Del Re, Wampold and Horvath (2018), covering 295 studies and more than 30,000 clients, found a correlation of r = .278 between the alliance and outcome, and this held across different types of therapy.

The word ‘alliance’ means more than liking your therapist. Bordin (1979) defined it as three things working together. An emotional bond, agreement on the goals of therapy, and agreement on the tasks, meaning what you will actually do in and between sessions. Agreement on goals and tasks matters as much as the bond itself. So, if you are three sessions in and you are not sure what you are both working towards, that is worth raising. Clarifying it is not an interruption to therapy. It is therapy.

2. Who delivers the therapy matters as much as which therapy is delivered

Some therapists reliably get better results than others, even when everyone is following the same treatment manual. Wampold and Imel documented this pattern in The Great Psychotherapy Debate (2015), and it is a consistent theme across the American Psychological Association task force reviews collected in Norcross and Lambert (2019). One of the clearest individual ingredients is empathy. A meta-analysis of 82 samples and more than 6,000 clients found therapist empathy correlated with outcome at r = .28 (Elliott, Bohart, Watson and Murphy, 2018), which is about the same size as the alliance effect.

The practical implication is that fit is a legitimate selection criterion. Feeling understood by your psychologist is an active ingredient of treatment, with an effect about the size of anything in the manual. If after a fair trial you do not feel understood, it is reasonable to say so, and reasonable to change.

3. You are the most important ingredient

It is easy to imagine therapy as something done to you, like physiotherapy for the mind. The outcome research points the other way. In most common factors models, the largest share of the variance in outcomes is attributed to client factors. Your motivation, your readiness, your resources, your relationships outside the room, and your hope that things can change. Lambert (1992) famously estimated that extratherapeutic client factors accounted for around 40 per cent of outcome, and while that figure is approximate and methodologically dated, the broad conclusion has held up. What you bring, and what you do between sessions, carries real weight.

Expectancy belongs here too. Believing that the approach makes sense and can plausibly help counts as an active ingredient in its own right. The research literature treats a credible rationale and positive expectancy as part of what makes therapy work. This is one reason a good psychologist will spend time explaining why an approach fits your situation rather than simply administering it.

4. Measuring progress changes progress

Therapists, like everyone else, are imperfect judges of how their own work is going. Routine outcome monitoring, meaning brief standardised measures completed regularly and reviewed together, corrects for this. Lambert and colleagues showed across a series of studies with the OQ-45 that giving therapists feedback on client progress reduces deterioration and improves outcomes, with the largest gains for clients who are not on track (Shimokawa, Lambert and Smart, 2010). Miller and Duncan built a similar approach into feedback-informed treatment.

This is one of the few findings a practice can implement immediately. It is why clients at Behavioural Edge Psychology in Melbourne complete short outcome measures across an episode of care. The questionnaires work as an early warning system, and you are allowed to ask what yours are showing.

5. If something feels off between you and your therapist, say so

Strains and misunderstandings in the therapy relationship, which researchers call ruptures, are normal. What matters is whether they are noticed and repaired. A meta-analysis of 11 studies by Eubanks, Muran and Safran (2018) found that repairing ruptures was associated with better outcomes, at r = .29.

The willingness to notice strain, name it without defensiveness and renegotiate is arguably one of the skills that separates highly effective therapists from the rest. But the client holds half of this. If you leave a session feeling dismissed, misread or pushed, the single most therapeutic thing you can do is bring it back into the room. A good psychologist will welcome it.

The honest footnote

None of this means technique is irrelevant. ‘Less than the field once assumed’ still leaves a good deal. The match between the method, your preferences and your presenting problem still moderates outcomes, and the debate between the common factors camp and the empirically supported treatments camp remains unresolved. Exposure work for OCD, for example, has specific effects that a warm conversation will not replicate. The point is narrower and more useful. The relationship, the fit, your own engagement, honest measurement and the courage to repair strain are not the soft extras of therapy. They are load-bearing.

Frequently asked questions

Does the type of therapy I choose matter?

It matters less than most people expect and more than zero. Head-to-head comparisons between established, credible therapies tend to find small differences, which is why researchers focus on the common factors described above. The type of therapy matters most where a specific problem has a specific well-evidenced treatment, such as exposure and response prevention for OCD. For many presentations, the quality of the relationship and your own engagement predict more of the outcome than the brand of therapy.

How do I know whether therapy is working?

Ask to track it. Standardised outcome measures completed every few sessions give you and your psychologist an objective read on progress, and the research shows that monitoring progress in this way improves outcomes, particularly when things are drifting off track. Subjectively, useful early signs include feeling understood, having a shared sense of what you are working on, and small changes in how you respond to situations between sessions.

What should I do if I do not click with my psychologist?

Say so, first. Strain in the relationship is common, and the evidence shows that naming and repairing it predicts better outcomes. If after raising it directly the fit still is not there, changing psychologists is legitimate and sensible. Therapist fit is an active ingredient of treatment.

How much of the outcome depends on me?

A substantial share. Client factors such as motivation, hope, resources and what you practise between sessions account for the largest slice of outcome variance in most common factors models. Therapy tends to work best when it is treated as something you do, with skilled support, rather than something done to you.

When starting therapy, how many sessions will I need?

It depends on what you are working on and how you respond. Many people notice change within the first few sessions. Structured treatments for specific problems, such as PTSD or OCD, commonly run between eight and twenty sessions, with the length adjusted to progress rather than fixed in advance. Under a Medicare Mental Health Treatment Plan, up to ten individual sessions are subsidised each calendar year. A sensible approach is to agree an initial number of sessions with your psychologist, measure progress along the way, and review together before deciding what comes next.

References

• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260.

• Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175

• Eubanks, C. F., Muran, J. C., & Safran, J. D. (2018). Alliance rupture repair: A meta-analysis. Psychotherapy, 55(4), 508–519. https://doi.org/10.1037/pst0000185

• Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172

• Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. In J. C. Norcross & M. R. Goldfried (Eds.), Handbook of psychotherapy integration. Basic Books.

• Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work (3rd ed., Vols 1–2). Oxford University Press.

• Shimokawa, K., Lambert, M. J., & Smart, D. W. (2010). Enhancing treatment outcome of patients at risk of treatment failure: Meta-analytic and mega-analytic review of a psychotherapy quality assurance system. Journal of Consulting and Clinical Psychology, 78(3), 298–311. https://doi.org/10.1037/a0019247

• Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge.

Dr Sarah Fischer is the Principal Psychologist at Behavioural Edge Psychology, an adults-only practice consulting in Caulfield South and St Kilda, Victoria, with telehealth across Australia. This article is general information, not individual advice. If you are considering therapy, you can book an appointment at www.behaviouraledgepsychology.com or phone 03 8771 4315.