Clinical Impact Statement: This article describes future directions in psychotherapy research. It first reviews current problems and gaps in the field. It then discusses recent research advances and how they might help propel psychotherapy research to the next level.
While an impressive amount of knowledge has been gathered so far from psychotherapy process and outcome research (see Lambert, 2013), there are still many unanswered questions and areas of needed additional attention. Some of these remaining questions focus on clarifying currently unanswered debates in the field; others represent ways to improve current outcomes; and some focus on the use of new technologies to enhance the understanding of how and why psychotherapy works.
Some of the Current Questions in the Field
One of the most important areas of study for psychotherapy researchers is identifying what causes change in psychotherapy. Theoretical orientations have long provided suggestions on the causes and mechanisms of change, but the existing psychotherapy research has yet to identify a universal explanation. This is despite the fact that many of the long-standing debates in the field focus on this issue. For example, whether specific factors or common factors are more important for change in psychotherapy and whether or not psychotherapy orientations and even specific interventions are equally effective in their outcomes (Wampold & Imel, 2015). In addition, thousands of studies have been conducted seeking to identify effective therapy ingredients (Norcross & Lambert, 2018), but much of this research has only provided suggestions on variables that correlate with psychotherapy outcomes (such as the therapeutic alliance) and no clear evidence about which variables are necessary and sufficient to bring change about.
Another important area for future psychotherapy research is to continue the trend toward conducting research in practice settings. As noted by Campbell & Stanley (1963), while previous emphasis on randomized control trials (RCTs) has focused on the internal validity of psychotherapy research (the degree that the outcomes could be attributed to the intervention), focus is now being turned to examine the external validity of psychotherapy research (the degree that the results generalize to conditions outside of psychotherapy research labs). There is the overall question if information from RCTs generalize to real world practice, as there are a number of differences between RCTs and practice (such as the types of clients seen and the degree that a specific treatment protocol is followed). Because of the limitations with RCTs, some have indicated that “the dissemination of transportability of efficacious treatments may be one of the most fertile areas of study for the next decade” (Lambert, 2013, p. 193), and, given the rising costs of healthcare, ways to improve the cost-effectiveness of psychotherapy are also likely to be explored (Wampold, Hollon, & Hill, 2011).
Another research area that needs more attention is the study of why some clients get worse in therapy. Some research has suggested that approximately one-third to one-half of all adult psychotherapy clients either do not improve or get reliably worse while in psychotherapy (Hansen, Lambert, & Forman, 2002). And some studies suggest that the deterioration rates in children and adolescents in psychotherapy might be even higher (Warren, Nelson, Mondragon, Baldwin, & Burlingame, 2010). There are various reasons patients might not respond to treatment, including factors specific to the client (low motivation, lack of social support), therapist (poorly delivers treatment), and treatment (inadequate conceptualization, wrong treatment for specific problem). Various research studies have examined how to adapt treatment for non-responders (Cooper & Fairburn, 2011; McCauley, Schloredt, Gudmundsen, Martell, & Dimidjian, 2011); however, much more information is needed regarding why specific people do not respond to treatment and how to improve treatment for them (Lambert, 2013).
In recent years, there has been increased attention given to the complexities of the dyad in psychotherapy. Not only are researchers now more fully studying therapist effects and predictors of therapist effectiveness (Baldwin & Imel, 2013), they are more closely examining the reciprocal and dynamic nature of the client and therapist relationship. These include studies about tailoring approaches to individual clients (Norcross & Lambert, 2018) as well as investigations of the immediate influence of the client on the therapist and the therapist on the client (Zilcha-Mano, 2017).
Recent Advancements in Psychotherapy Research
There are a variety of recent advancements in the field of psychotherapy research that will allow for a more in-depth study of the research questions discussed above. A few of these advances include the use of meta-analytic techniques, the proliferation of practice-research networks, micro-process research, the use of natural language processing, and the use of online data collection.
While meta-analysis, or “the analysis of analyses” (Glass, 1976, p. 3), has been utilized in psychotherapy research since the late 1970s (Smith & Glass, 1977), its use has skyrocketed over the past decade. For example, over 100 articles in six psychotherapy journals from 2011 to 2013 were identified as having a reference to meta-analysis in the title or abstract (Baldwin & Del Re, 2016). The rise in popularity of this technique is likely linked to its robust power. Inthout, Ioannidis, and Borm (2012) have found that even a meta-analysis with only a few studies that lack full statistical power still had lower error rates than one well-powered clinical trial. Given this, Baldwin and Del Re (2016) have emphasized that meta-analysis is “arguably one of the most important methodological innovations in the history of psychotherapy research” (p. 249). Meta-analyses will likely continue to be used to help statistically summarize psychotherapy research on a variety of topics in the future.
Another more recent development in psychotherapy research involves the use of practice-research networks, which were introduced into the field in the mid-1990s (McMillen, Lenze, Hawley, & Osborne, 2009). These networks were originally developed in an attempt to address several problems with previous psychotherapy research, including the fact that psychotherapists are not always influenced by research when doing clinical work and researchers sometimes pay little attention to the questions that clinicians who do full time clinical work have (Beutler, Williams, Wakefield, & Entwistle, 1995; Cohen, Sargent, & Sechrest, 1986). These problems can create a divide between science and practice in psychology, and negatively impact the scientist-practitioner model. Thus, there is a growing movement to include practitioners in the research process by having practice-research networks in which clinicians are involved in determining research questions and developing designs that work in their real-world clinical settings (Castonguay, Barkham, Lutz, & McAleavey, 2013). This line of research has four main goals: (1) to have practitioners be active participants in the scientific studies, (2) to have practitioners use the data collected in the studies to inform their clinical work, (3) to have practitioners and researchers examine questions that are relevant to practice, and (4) to have practitioners contribute to the development of scientific knowledge. While this approach has some challenges (such as limited funding and the extra time needed to collaborate to design the study and to collect the data) this model can lead to research that answers a number of questions about psychotherapy in real-world contexts (Castonguay et al., 2013; McMillen et al., 2009).
A third more recent development in psychotherapy research is to focus in more detail on the micro-processes of psychotherapy. Much of the existing process research that has thus far been done focuses only on examining process variables at a session or a treatment episode level. However, it is possible that many process variables change within the course of a single session. Micro-process research aims at gaining a deeper understanding of how and why change happens in psychotherapy by focusing on the moment-to-moment experiences in session. Although this line of research has existed in the past, researchers are now beginning to expand into this micro-process domain in much more detail (Altenstein, Krieger, & Holtforth, 2013; Flückiger, Zinbarg, Znoj, & Ackert, 2014; Pace et al., 2016). For example, in a recent study, Altenstein and colleagues (2013) had trained coders watch a middle session of psychotherapy for depression in order to code both the clients’ and therapists’ dominant and affiliative behaviors each moment using a joystick rater. In another study, Flückiger and colleagues (2014) focused on minute-by-minute rating of the fifth session of 20 different psychotherapy clients’ sessions in order to examine which in-session factors were linked with treatment outcomes. The raters coded for factors such as experience of negative emotions, personal and interpersonal strengths, goals, and positive reinterpretation of problems. As this research area grows, the field will likely learn much more detail about the changes that can occur during the course of a single psychotherapy session and how to train psychotherapists to be as effective as possible in promoting client growth.
New technologies are also now available that can help researchers focus more on the linguistic processes that occur in treatment. Natural language processing is a subfield of computer science that is beginning to be used in psychotherapy research. The goal of Natural Language Processing is to “learn, understand, and produce human language content” (Hirschberg & Manning, 2015, p. 261). This field can be useful to study the conversations that occur in the course of psychotherapy using computer science. It was previously difficult to study the language that was used in psychotherapy because of the manual labor of human coding of transcripts. With the recent growth in this technology, researchers have been able to do complex analyses such as identifying depression in people based on information in their Twitter feeds (Mowery, Way, Bryan, & Conway, 2015). By using this technology to help analyze conversations during the course of psychotherapy, much more detailed information can be gleaned about the psychotherapy process. Pace et al. (2016) outline a number of ways that natural language processing can be used in psychotherapy research, such as testing relational processes, examining fidelity to treatment protocols, and providing automated feedback to providers based on their session audio tapes.
In addition to these advances in data coding and analysis, another important development in psychotherapy research is the development of additional ways to collect data from clients in the first place. With the advances in technology that resulted in the development of the internet, researchers quickly started to examine the potential of the internet for collecting survey data (McGlade, Milot & Scales, 1996; Mehta & Sivadas, 1995; Stanton, 1998). Using the internet, psychotherapy research data can now be collected via a variety of methods, such as through social media or online survey distributors (King, O’Rourke, & DeLongis, 2014; Kosinski, Matz, Gosling, Popov, & Stillwell, 2015). Horton, Rand, and Zeckhauser (2011) suggest that “online experiments can be an appropriate tool for exploring human behavior, and merit a place in the experimentalist’s toolkit alongside traditional offline methods” (p. 406). Given the proliferation of social scientists collecting data online, this development has the strong potential to contribute to our understanding of psychotherapy. However, research is needed to first test whether online recruitment methods, such as Amazon’s Mechanical Turk, are indeed reliable and valid methods for conducting psychotherapy research. Further, ethical issues such as fair pay and ensuring confidentiality should be considered.
Psychotherapy researchers have the monumental task of working to improve the effectiveness of the interventions that we offer to clients who seek out treatment. Several important questions about treatment efficacy, causes of change, external application of research, and the dynamic nature of psychotherapy remain. Fortunately, psychotherapy researchers now have a number of important technological, methodological, and statistical advances that can help them in answering these unresolved questions. We have come a long way through our scientific studies as a field and it will be exciting to see where the next age of psychotherapy research will bring us.
Cite This Article
Tompkins, K. & Swift, J. K. (2019). The future of psychotherapy research: Where are we going and how can we get there? Psychotherapy Bulletin, 54(1), 38-43.
Altenstein, D., Krieger, T., & Holtforth, M. G. (2013). Interpersonal microprocesses predict cognitive-emotional processing and the therapeutic alliance in psychotherapy for depression. Journal of Counseling Psychology, 60, 445-452. doi:10.1037/a0032800
Baldwin, S. A., & Del Re, A. C. (2016). Open access meta-analysis for psychotherapy research. Journal of Counseling Psychology, 63, 249-260. doi:10.1037/cou0000091
Baldwin, S., & Imel, Z. E. (2013). Therapist effects. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 258-297). Hoboken, NJ: Wiley.
Beutler, L. E., Williams, R. E., Wakefield, P. J., & Entwistle, S. R. (1995). Bridging scientist and practitioner perspectives in clinical psychology. American Psychologist, 50, 984-994.
Campbell, D. T., & Stanley, J. C. (1963). Experimental and quasi-experimental designs for research and teaching. Chicago, IL: Rand McNally.
Castonguay, L., Barkham, M., Lutz, W., & McAleavey, A. (2013). Practice-oriented research. In J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 85-133). Hoboken, NJ: Wiley.
Cohen, L. H., Sargent, M. M., & Sechrest, L. B. (1986). Use of psychotherapy research by professional psychologists. American Psychologist, Special Issue: Psychotherapy Research, 41, 198-206.
Cooper, Z., & Fairburn, C. G. (2011). The evolution of “enhanced” cognitive behavioral therapy for eating disorders: Learning from treatment nonresponse. Cognitive and Behavioral Practice, 18, 394-402.
Flückiger, C., Zinbarg, R. E., Znoj, H., & Ackert, M. (2014). Resource activation in generalized anxiety – An observer-based microprocess analysis of patients’ in-session outcomes. Psychotherapy, 51, 535-545. doi:10.1037/a0034119
Glass, G. V. (1976). Primary, secondary, and meta-analysis of research. Educational Researcher, 5, 3-8. doi:10.3102/0013189X005010003
Hansen, N., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response effect and its implication for treatment delivery services. Clinical Psychology: Science and Practice, 9, 329-343.
Hirschberg J., & Manning, C. D. (2015). Advances in natural language processing. Science, 349(6245), 261-266. doi:10.1126/science.aaa8685
Horton, J. J., Rand, D. G., & Zeckhauser, R. J. (2011). The online laboratory. Experimental Economics, 14, 399-425. doi:10.1007/s10683-011-9273-9
Inthout, J., Ioannidis, J. P., & Borm, G. F. (2012). Obtaining evidence by a single well-powered trial or several modestly powered trials. Statistical Methods in Medical Research, 25, 538-552. doi: 10.1177/0962280212461098
King, D. B., O’Rourke, N., & DeLongis, A. (2014). Social media recruitment and online data collection: A beginner’s guide and best practices for accessing low-prevalence and hard-to-reach populations. Canadian Psychology/Psychologie Canadienne, 55, 240-249. doi:10.1037/a0038087
Kosinski, M., Matz, S. C., Gosling, S. D., Popov, V., & Stillwell, D. (2015). Facebook as a research tool for the social sciences: Opportunities, challenges, ethical considerations, and practical guidelines. American Psychologist, 70, 543-556. doi:10.1037/a0039210
Lambert, M. J. (2013). The efficacy and effectiveness of psychotherapy. In M. J. Lambert (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed., pp. 169-218). Hoboken, NJ: Wiley.
McCauley, E., Schloredt, K., Gudmundsen, G., Martell, C., & Dimidjian, S. (2011). Expanding behavioral activation to depressed adolescents: Lessons learning in treatment development. Cognitive and Behavioral Practice, 18, 371-383.
McGlade, L. T., Milot, B. A., & Scales, J. (1996). The World Wide Web: A new research and writing tool. The American Journal of Clinical Nutrition, 63, 981-982.
McMillen, J. C., Lenze, S. L., Hawley, K. M., & Osborne, V. A. (2009). Revisiting practice-based research networks as a platform for mental health services research. Administration and Policy in Mental Health and Mental Health Services Research, 36, 208-321. doi:10.1007/s10488-009-0222-2
Mehta R., & Sivadas E. (1995). Comparing response rates and response content in mail versus electronic mail surveys. Journal of the Market Research Society, 37, 429-439.
Mowery, D. L., Way, W., Bryan, C., & Conway, M. (2015). Towards developing an annotation scheme for depressive disorder symptoms: A preliminary study using twitter data, NAACL-CLPsych, 89-98.
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55, 303-315. doi:10.1037/pst0000193
Pace, B. T., Xiao, B., Dembe, A., Steyvers, M., Narayanan, S., Atkins, D. C., & Imel, Z. E. (2016). What about the words? Natural language processing in psychotherapy. Psychotherapy Bulletin, 51, 14-18. Retrieved from http://societyforpsychotherapy.org /wp-content/uploads/2014/11/Bulletin51-1_Online.pdf
Smith, M. L., & Glass, G. V. (1977). Meta-analysis of psychotherapy outcome studies. American Psychologist, 32, 752-760. doi:10.1037/0003-066X.32.9.752
Stanton, J. M. (1998). An empirical assessment of data collection using the Internet. Personnel Psychology, 51, 709-725.
Wampold, B. E., Hollon, S. D., & Hill, C. E. (2011). Unresolved questions and future directions in psychotherapy research. In J. C. Norcross, G. R. VandenBos, & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (2nd ed., pp. 333-356). Washington, DC: American Psychological Association.
Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). New York, NY; Routledge.
Warren, J. S., Nelson, P. L., Mondragon, S. A., Baldwin, S. A., & Burlingame, G. M. (2010). Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings. Journal of Consulting and Clinical Psychology, 78, 144-155. doi: 10.1037/a0018544
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72, 311-325. doi:10.1037/a0040435