Psychotherapy © 2013 American Psychological Association

2013, Vol. 50, No. 1, 52– 67 0033-3204/13/$12.00 DOI: 10.1037/a0030898

Psychotherapy Outcome: An Issue Worth Re-Revisiting 50 Years Later

Louis G. Castonguay
Penn State University

Responding to an invitation to celebrate the 50th anniversary of the journal Psychotherapy, the goal of
this article is to describe three general ways by which the impact of psychotherapy might be improved:
(a) clinically, by encouraging the assimilation of empirically based principles of change and psychopa-
thology research into day-to-day practice; (b) empirically, by fostering process and outcome research
focused on a wide range of common factors and basic findings; as well as (c) clinically and empirically,
by facilitating active collaboration of practitioners and researchers in various types of practice-oriented
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research. Reflected in these three potential avenues of growth are the assumptions that (a) we can
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improve our understanding and impact of psychotherapy by building on convergences and complemen-
tarities across different theoretical orientations, domains of research, and professional expertise, and that
(b) most of the clinical and research suggestions derived by such convergence and plurality may not
require drastic changes in the practice of many psychotherapists.

Keywords: psychotherapy process and outcome, evidence-based practice, practice-oriented research

With its first articles by Hans Strupp (1963, 1964) and Hans
Eysenck (1964) the journal Psychotherapy was born with a bang—
and plenty of acrimonious fireworks (how exiting, and sad at the
same time, it is to read two giants denounce the other’s view as
“erroneous and misleading” or “irrelevant, incompetent and im-
material”)! Fifty years later, the journal is still thriving, but it is
witnessing and contributing to a very different field. Much has
changed in half a century. Then, at least in comparison with what
we now know, there was no overwhelming empirical evidence that
psychotherapy (any kind of psychotherapy) works. As the first
issue of Psychotherapy offers us a glimpse of these, debates were
also raging between scholars of different orientations about the
conceptual and clinical merits of their preferred approaches (see
Castonguay & Goldfried, 1994).
Today, the efficacy and effectiveness of psychotherapy (at least
for the majority of clients who complete it) is no longer in question
(Lambert & Ogles, 2004), and the hostile debates between leaders
of divergent schools have substantially decreased. Yet, to use the
words of Strupp, I believe that we still have an “outcome prob-
lem.” As noted by Lambert and Ogles (2004), although “positive
statements about psychotherapy can be made with more confi-
dence than ever before, it is still important to point out that average
positive effects mask considerable variability in outcomes” (p.
181). In addition, it is clear that many clients terminate therapy
prematurely (Clarkin & Levy, 2004) and that a non-negligible
number of others deteriorate during treatment (Lambert & Ogles,
2004; Lilienfeld, 2007). Thus, although there is no more doubt that
This article is based in part on a keynote address presented at the Annual
meeting of L’Ordre des Psychologues du Québec, Québec (QC), October,
November 2010. The author is grateful for the feedback provided by James
Boswell and Mark Hilsenroth on an earlier version of this article.
Correspondence concerning this article should be addressed to Louis G.
Castonguay, PhD, Department of Psychology, Penn State University, Uni-
versity Park, PA 16802, USA. E-mail: lgc3@psu.edu
psychotherapy works, I would argue that its effect can be im-
proved—we can do more to retain some clients, help others further
benefit from it, and perhaps more importantly, decrease negative
effects. I would also suggest that one strategy to further enhance
(as well as better understand) psychotherapy is to foster rapproche-
ment (not only between theoretical orientations but also between
clinicians and researchers) and to encourage methodological and
epistemological plurality in our quest to reduce psychological
suffering. Answering an invitation to celebrate the 50th anniver-
sary of Psychotherapy, the aim of this article is to address the
current outcome problem by providing clinical and empirical sug-
gestions derived, in large part, on my work on process and out-
come studies (in controlled and naturalistic settings), psychother-
apy integration, psychopathology, practice-research networks, and
training.
How Can We Improve the Outcome of Therapy
Clinically?
One way to improve our effectiveness as practitioners is to use
and build upon the knowledge that ⬎60 years of psychotherapy
research has brought us. There are, in my view, different lines of
empirical evidence that can provide useful guidelines, if used
competently and flexibly, in our assessment, case formulation, as
well as treatment implementation.
Effective and Harmful Treatments
To begin with, let me make a suggestion that many will consider
“de rigeur” or imperative, whereas others will perceive it as
clinically naïve, if not misguided. If one is to discuss psychother-
apy outcome, however, it seems inescapable for him/her to take a
position about empirically supported treatments (ESTs). My posi-
tion is based on the assumption that it would be ill advised not to
pay attention to a large number of randomized clinical trials (RCT)
that have investigated the work of clinicians (most of them expe-
rienced, highly trained, and carefully supervised) treating real

52
 PSYCHOTHERAPY OUTCOME
clients suffering from debilitating conditions. I believe that, at the
minimum, these trials and the ESTs that were identified based on
them have provided us with first lines of attack (FLA) for the
treatment of many clients with specific clinical problems.
For some disorders (e.g., obsessive– compulsive disorder), the
EST outcome literature currently offers powerful, but limited, FLA
recommendations, whereas for others, especially depression, the
list of these recommendations is wider, including behavior ther-
apy, cognitive therapy, interpersonal therapy, brief dynamic and
process-experiential therapies (Follette & Greenberg, 2005). Con-
sidering the fact that depression is one of the most frequent
problems encountered in clinical practice, the list of ESTs is a clear
example of how outcome research can be viewed as an ally for
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clinicians. It demonstrates that if they identify themselves with one
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of three major theoretical orientations (cognitive– behavioral, psy-
chodynamic, and humanistic), practitioners will find in several
treatment manuals specific interventions that (a) are consistent
with their preferred view of human functioning and change and
that (b) can address problems experienced by a large percentage
of their clients (Castonguay, Schut, Constantino, & Halperin,
1999). The list of ESTs for depression also indicates that if they
chose to, the same therapists could expand their FLA repertoire for
depressed clients by receiving training in interpersonal therapy, a
well-supported treatment that does not fit neatly (and may, thus,
require additional training) into some of the most traditional par-
adigms of contemporary psychotherapy. As will be described
below, principles of change can be derived from such treatment
manuals and assimilated by therapists of different orientations.
The outcome literature has also provided us with a list of
potentially harmful treatments (PHT, Lilienfeld, 2007) for a num-
ber of clinical problems. Paying close and open-minded attention
to such a list can provide practitioners with indispensable guide-
lines regarding interventions that they should avoid using (or use
very carefully, see Castonguay, Boswell, Constantino, Hill, &
Goldfried, 2010).
In addition to the current benefits that clinicians can derive from
the outcome literature (in terms of interventions to consider using
and avoiding), I would like to suggest that some studies that have
been conducted within the EST movement could in the future
(assuming the correct political and social conditions) lead to one of
the most drastic changes in mental health practice— one that
would clearly benefit psychotherapists. Although we know that a
large number of depressed clients respond well to several type of
psychosocial and pharmacological treatments, we also know that
the relapse rates of successfully treated depressed individuals is
very substantial (see LeMoult, Castonguay, McAleavey, & Joor-
man, in press). Some RCTs have demonstrated that cognitive
therapy is not only equivalent in efficacy to medication for de-
pression, but that it is also associated with less relapse (see Hollon
& Dimidjian, 2009). Based on this empirical evidence, psycho-
therapy scholars, researchers, and clinicians could make a strong
case (to insurance companies, governmental agencies, and clients)
that the FLA for one of the most frequently treated clinical prob-
lems should not be medication but a well-established form of
psychotherapy. Sadly, although the percentage of depressed out-
patients treated with medication remained above 70% from 1998
to 2007, the percentage who received psychotherapy decreased
from 53.6% to 43.1% during the same period (Marcus & Olfson,
2010). I would also argue that the long-term advantage of psycho-
53
social interventions is not likely to be restricted to cognitive
therapy. In the context of current pressures for accountability,
psychodynamic, interpersonal, behavioral, and humanistic thera-
pists should push for the conduct of more RCTs comparing the
long-term impact of their preferred orientation to antidepressants,
as a politically and socially wise strategy to protect and enhance
their practice.
In line with the proposed strategy of building our efforts to
improve outcomes based on accumulated research, I would also
suggest that clinicians pay attention to non-EST empirical evi-
dence to (a) possibly improve the implementation and impact of
ESTs, (b) adapt ESTs for particular clients with specific disorders,
and/or to (c) find potentially useful intervention strategies in the
absence of ESTs for particular clients. Briefly described here are
clinical guidelines from two lines of non-EST research: Principles
of change and psychopathology.
Principles of Change
As an effort to move beyond false dichotomies that frequently
emerge in discourses about the process of change (i.e., the impact
of therapy is primarily due to techniques OR to relationship
variables OR to client factors), Larry Beutler and I created a task
force aimed at consolidating our current empirical findings about
what makes therapy work (Castonguay & Beutler, 2005b). Build-
ing on two previous task forces (Chambless & Ollendick, 2001;
Norcross, 2002), our initiative involved the pairing of influential
scholars from different theoretical orientations to review the evi-
dence of three specific domains (participant characteristics, rela-
tionship variables, and technical factors), within four types of
disorders frequently encountered by clinicians (dysphoric, anxiety,
personality, and substance use disorders). In addition, we asked
these scholars to derive from their review some principles of
change that could inform therapist assessment, case formulation,
and treatment plans.
From this collaborative effort emerged 61 empirically based
principles of change (common or unique to specific clinical prob-
lems) that could serve as guidelines of intervention for therapists
of most theoretical orientations. For example, examining the liter-
ature on client variables in the treatment for anxiety disorders,
Newman, Crits-Christoph, Connolly Gibbons, and Erickson
(2005) concluded that clients with higher levels of impairment (in
terms of severity, distress, Axis I comorbidity, interpersonal prob-
lems, and social support perceived as being critical), as well as
clients who perceived their relationship with their parents as neg-
ative, are less likely to benefit from psychotherapy. Among the
possible implications of these findings are: (a) despite the fact that
many cognitive-behavioral therapy (CBT) protocols have been
empirically validated for anxiety disorders, therapists should be
aware that some individuals suffering from these problems may
require a longer treatment than the number of sessions that are
typically prescribed in current EST manuals, and that (b) some of
anxious clients may benefit from an exploration and/or attempt to
resolve attachment issues (which are not a typical focus of tradi-
tional CBT for anxiety disorders).
As an example of a principle of change related to the treatment
of depression, Castonguay et al. (2005) concluded that therapist
self-disclosure is likely to be helpful in the treatment of depression,
but also suggest that therapists may consider using supportive and
 54 CASTONGUAY
reassuring self-disclosures rather than challenging ones. Another
relationship-based principle derived for the treatment of depres-
sion, as well as for the other three clinical problems targeted by the
Task Force, was that therapists should strive to establish and
maintain a good working alliance. Complementing this general
principle, it should be noted that a substantial empirical literature
has led to complementary knowledge about the alliance, including
the findings that it can be predicted by both client and therapist
characteristics and behaviors. Although the clinical implications of
these and other findings about the alliance have been described
elsewhere (Castonguay, Constantino, & Grosse-Holtforth, 2006),
it suffices to say that there is no evidence to support therapists
being disimissive or hostile toward their clients, or that they should
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ignore alliance ruptures as they emerge, as well as the variables
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that could foster, prevent, or repair them.
A number of principles of change related to techniques were
also derived by the Task Force. Using the treatment of depression
as an example, these include challenging clients’ cognitions, in-
creasing positive reinforcement, improving interpersonal function-
ing, improving marital, family, and social environments, and im-
proving emotional awareness, acceptance, and regulation (Follette
& Greenberg, 2005). These empirically based principles are suf-
ficiently specific to suggest a clear focus of interventions, yet they
are general enough to avoid restricting clinicians to a limited
number of interventions to achieve their intended tasks or goals.
For example, several techniques can be used to facilitate change in
clients’ beliefs, including interpretation, reformulation, and cogni-
tive restructuring. In line with a complementary (and theoretically
driven) list of principles of change described below, each of these
interventions can be used to foster the acquisition of a new per-
spective of self and others (Goldfried, 1980). Therapists, in other
words, do not necessarily have to abandon their preferred orien-
tations in order to be guided by empirically based principles of
change. In addition, these principles of change can help clinicians
to refine or expand their technical interventions to potentially
improve their effectiveness in treating clients with depression. For
instance, therapists who typically focus on intrapersonal change
(but focusing on insight or cognitive reappraisal) might consider
increasing their attention on interpersonal and social changes in
their clients’ life, not only to improve outcome at the end of
treatment, but also possibly reduce the risk of relapse after the
completion of therapy.
It should also be mentioned that many of the principles of
change related to client characteristics, relationship variables, and
technical interventions that have been identified by the Task Force
have also been presented as a source of knowledge to potentially
reduce harmful effects. Based in large part on these principles,
negative factors and toxic processes have indeed been delineated
to complement the PHT outcome literature in helping graduate
programs and supervisors to prevent or reduce deterioration that
has been observed in a non-negligible percentage of psychotherapy
clients (Castonguay, Boswell, Constantino, et al., 2010).
However, what has largely failed to emerge from the same Task
Force are principles of change related to therapist characteristics
(see Castonguay & Beutler, 2005a). This is particularly interesting
considering the fact that therapist characteristics were highlighted
by Strupp (1963) 50 years ago as factors to be investigated to
better address the outcome problem. Referring to therapists’ level
of expertise, personality, and attitude (as well as techniques that
are common and unique to different approaches), Strupp stated:
“These are staggering research problems, and the available re-
search evidence by and large is insufficient” (p. 2). As described
below, the current gap in empirical knowledge about therapist
characteristics reflects what could be viewed as a most deplorable
paradox in the current status of psychotherapy research—what this
also reflects, needless to say, is how ahead of his time Strupp was
when he wrote the first article ever published in Psychotherapy.
Psychopathology Research
Basic research is another source of empirical evidence that can
be used by clinicians to potentially improve treatment effective-
ness. Based on the belief that one way of increasing our under-
standing of complex phenomena is to foster connections between
different domains of knowledge, Tom Oltmanns and I have edited
a book aimed at weaving one type of basic research, that is,
psychopathology, into clinical practice (Castonguay & Oltmanns,
in press). In addition to providing the field with expert reviews of
research on the nature and etiology of psychological problems, we
set out to tackle the difficult, but exciting, challenge of deriving
clinical implications from research on typical symptoms, clinical
features, prevalence, course, comorbidity, onset, and risk factors
for the most commonly treated disorders in clinical practice. To-
ward these goals, we built teams of visible scholars, some of them
recognized for their expertise in psychopathology, others for their
research in psychotherapy, and many for their contributions to both
of these areas of knowledge. As an attempt to enrich and expand
upon current efforts toward evidence-based practice, each chapter
relies on rigorous and distinctive sources of knowledge to offer
assessment and treatment guidelines that should not be restricted to
any one theoretical orientation.
Again using depression as an example, here are some of the
clinical implications that have been derived from the basic re-
search on psychopathology (see LeMoult et al., in press, for more
comprehensive and detailed descriptions):
(a) Despite not being always emphasized in the psychological
literature, vegetative and somatic symptoms should be carefully
and systematically assessed; not only because of their relatively
low base rate, but also because they may be indicative of depres-
sion severity.
(b) Although not part of the diagnostic criteria, anger is fre-
quently associated with depression. Therapists should, thus, expect
the emergence of hostility in the therapeutic relationship and be
able to discern whether such emotion is a manifestation of depres-
sion and/or the consequence of alliance ruptures. Having meta-
communication skills (Safran & Muran, 2000) as part of their
technical repertoire may also help therapists to increase clients’
awareness (and decrease the negative impact) of their hostile
reactions to others—in the therapy room, as well as in their life.
(c) In light of the serious risk of suicide, basic research provides
invaluable knowledge to clinicians about the factors that should be
assessed when working with depressed clients (including panic
attacks, alcohol use, concentration, and insomnia).
(d) At the beginning of, during, and before terminating therapy,
clinicians would do well to assess clients’ work performance and
satisfaction, sexual functioning, health problems, and health care
behaviors. Frequently associated with depression, these issues
should be addressed (by extensive treatment, specific interven-
 PSYCHOTHERAPY OUTCOME
tions, and/or referral to other services) to increase the clients’
quality of life and possibly reduce the risk of relapse.
(e) When treating depression, therapists should expect that the
number of sessions typically prescribed in RCTs may not be
sufficient for clients with early onset, high levels of comorbidity,
and numerous previous episodes.
(f) The sharp increase in the prevalence of depression within the
Westernized contemporary culture suggests that an overinvolve-
ment in individualist pursuits (for personal accomplishment and/or
wealth) may reduce opportunities for social support during stress-
ful times. Clinically, this suggests that when working with depres-
sion, therapists should not only correct maladaptive thoughts,
foster awareness of unfinished business, and/or explore the past,
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but they should also help clients establish and deepen interpersonal
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and social relationships.
Interestingly, this suggestion perfectly fits with some of the
principles of change related to technical factors that, as mentioned
above, were derived from psychotherapy research on the treatment
of depression (i.e., improving interpersonal functioning, improving
marital, family, and social environment). As noted elsewhere,
“such convergence of findings across different communities of
knowledge may not be surprising considering the core aspects of
human functioning to which they appear to be linked. As argued by
MacLean (1985), communication and play are two of the evolu-
tionary developments that differentiate not only humans but all
mammals from reptiles. Denying or not attending to such ways of
being forces our clients and us to fight a losing evolutionary
battle!” (Castonguay, 2011, p. 132).
(g) Basic research on cognitive bias (attention, interpretation,
memory) and emotional regulation demonstrate that depressed
individuals have difficulties disengaging from negative cognitions
and sad affect. These findings suggest that interventions that can
help clients to become unstuck from maladaptive patterns of
automatic reaction may be helpful in the treatment of depression.
Interestingly, the results of basic research investigating the impact
of some strategies to foster adaptive emotional regulation (reap-
praisal of negative events as opposed to rumination; emotional
disclosure as opposed to emotional suppression) are consistent
with two of the principles of change derived from psychotherapy
research (i.e., challenging clients’ cognitions, and improving emo-
tional awareness, acceptance, and regulation). However, another
strategy found in experimental labs to be helpful in emotional
regulation, that is, distraction, does not appear to be featured
predominantly in most ESTs for depression. Though it may well be
inappropriate at times and in certain situations, the use of distrac-
tion can complement our traditional interventions. As I’ve self-
disclosed elsewhere, “one of the authors of this chapter has learned
that blasting Beethoven’s 9th symphony on his iPod in response to
pervasive and recurrent ruminations late at night, is not incompat-
ible with (and may actually be a powerful adjunct to) verbally
oriented forms of therapy. There are times to explore emotions and
examine maladaptive cognitions, but there are also times when we
should get our mind away from them” (in LeMoult et al., in press,
p. 47).
(h) Because basic biological and psychological research has dem-
onstrated the impact of stressful events on the onset and maintenance
of depression, psychotherapists would be well-advised to include in
their clinical repertoire a variety of stress-regulating strategies aimed
at, for example, increasing healthy patterns of sleeping, eating, and
55
exercising. Promising findings suggest that such strategies can be
added to traditional CBT for depression (Hayes, Beevers, Feldman,
Laurenceau, & Perlman, 2005), and it is likely that therapists from
other orientations might also be able to integrate them, flexibly and
appropriately, into their practice.
(i) Psychopathology research also shows that parental neglect and
abuse, as well as insecure parent– child attachment, are risk factors for
depression. In line with the argument stated above that findings on the
alliance do not provide any evidence for therapists to be dismissive or
hostile toward their clients, basic research suggests that the therapeu-
tic impact of an attentive, engaged, accepting, and affirming therapist
might be due in part to the corrective experiences that such relational
attitudes offer, in contrast with the inadequate forms of parenting
many depressed clients experienced. The influence of adverse inter-
personal experiences from the past also suggests that therapists, irre-
spective of their orientation, should be willing to ask about and
explore early relationship events and their potential effect on later
relationships in clients’ lives.
(j) Therapists should also be alerted that their clients’ depression
may be maintained by two tendencies observed in psychopathol-
ogy research: Depressed individuals excessively seek reassurance
and prefer to interact with others who confirm their negative view
of self. The use of strategies aimed at decreasing these specific
relational patterns may help depressed clients to create and main-
tain more meaningful and healthy interpersonal relationships. As
already mentioned, pursuing this therapeutic goal has been sug-
gested by different domains of research.
In concluding the first section of this article, I would like to
suggest that the clinical implications related to empirically based
principles of change and psychopathology research may not re-
quire drastic changes in the practice of many clinicians in order to
potentially improve their outcomes. Specifically, most therapists
would not have to change theoretical orientations in order to use
interventions that are consistent with the therapeutic guidelines
derived from these domains of research. I would also argue,
however, that empirical evidence, even when combining these two
lines of research with the findings of the EST and PHT outcome
literature, is not sufficient, at this stage in our field, to fully
improve our effectiveness. As argued elsewhere (Castonguay, Bo-
swell, Constantino, et al., 2010), this might especially be the case
with regard to the urgent need to address what may be our most
important outcome problem: Deterioration. To attend to our ethical
duty of “first, do no harm,” it may be wise to pay attention to
different sources of knowledge: Empirical (recognizing the rigor
and validity of diverse quantitative and qualitative methods), clin-
ical (recognizing the value of practitioner observations and inno-
vations as opposed to “letting the knowledge from practice drip
through the holes of a colander,” Kazdin, 2008), and conceptual
(recognizing that ideas and practices developed by major scholars
of theoretical traditions are not all captured in current textbooks
and manuals). Rather than being incompatible, these sources of
knowledge frequently complement each other and can provide us
with a plurality of information and perspectives to better under-
stand the complexity of psychotherapy (Castonguay, 2011). As
also previously argued (Castonguay, Boswell, Constantino, et al.,
2010), convergence among sources of knowledge (including be-
tween research domains highlighted several times above) can be a
safe way to build our confidence about what is assumed to facil-
itate or interfere with therapeutic change.
 56 CASTONGUAY
How Can We Improve the Outcome of Therapy
Empirically?
Let me begin this section, like the previous one, with a statement
that will be perceived by most as either imperative or naïve: Whereas
different lines of research have already provided guidelines for day-
to-day practice, further studies on the process and outcome of psy-
chotherapy are likely to help us improve the effectiveness of psycho-
social interventions. Although this may well sound like a truism, we
would be ill advised to take for granted that in the current hegemony
of neurological and biological sciences, large numbers of psychother-
apy studies will be readably supported. It might be wise for psycho-
therapy researchers, clinicians, and mental health administrators to
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collaborate in advocating for the increase of public and private fund-
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ing toward improving what have been shown to be powerful tools to
attenuate debilitating problems. I would also suggest that a particu-
larly fruitful way to advance current research (let alone convince
governmental and other agencies that it deserves to be further sup-
ported) is to build on our strong foundations. We already have
empirical evidence supporting major treatments (in terms of some of
their mechanisms of change and their impact for a majority of clients).
And although we should refine these traditional models, we should go
beyond theoretical boundaries to further improve what psychotherapy
has to offer to mental health. This could be done at both process and
outcome levels.
Process Research
In order for us to improve outcomes, it seems important to better
understand how therapy works, as well as what accounts for when
it fails to work. In line with the plea made by Strupp (1963) half
a century ago, this requires research to examine the process of
therapy. An important line of process research involves the inves-
tigation of interventions and mechanisms of change that are at the
core of specific forms of therapy. At this point in time, empirical
support has been found for several components assumed to be
responsible for change in particular approaches. For example,
consistent with a CBT model, the use of specific techniques such
as self-monitoring (DeRubeis & Feeley, 1990; Feeley, DeRubeis,
& Gelfand, 1999), homework (Burns & Nolen-Hoeksema, 1991),
and exposure (Foa, Huppert, & Cahill, 2006) have been positively
linked with outcome in this orientation. In addition, clients’ cog-
nitive change and acquisition of compensatory skills, both hypoth-
esized to mediate change in CBT treatments, have been shown to
be predictive of improvement in this form of therapy (Barber &
DeRubeis, 2001; Garratt, Ingram, Rand, & Sawalani, 2007; Hof-
mann et al., 2007; Strunk, DeRubeis, Chiu, & Alvarez, 2007).
Several studies investigating the process of change in psychody-
namic therapy have also found a significant relationship between
the use of theoretically consistent techniques (such as interventions
aimed at fostering emotional experience, addressing defenses, ex-
ploring the past, or drawing connections between different rela-
tionships in client’s life, including with his or her therapist) and
therapeutic change (e.g., Ablon & Jones, 1998; Connolly Gibbons
et al., 2012; Gaston, Thompson, Gallagher, Cournoyer, & Gagon,
1998; Hillsenroth, Ackerman, Blagys, Baity, & Mooney, 2003;
Ulvenes et al., 2012). Similarly, some of the core processes em-
phasized in humanistic and experiential treatments (such the ther-
apist’s empathy, as well as the client’s deepening and processing
of emotion) have been associated with positive outcome in these
approaches (see Elliott, Greenberg, & Lietaer [2004] and Green-
berg & Pascual-Leone [2006] for reviews).
Interestingly, however, a recent meta-analysis failed to find a
significant relationship between therapists’ adherence and compe-
tence to theoretically prescribed interventions in different forms of
treatment (Webb, DeRubeis, & Barber, 2010). Moreover, some of
studies have found core components of both CBT and psychody-
namic therapies to be negatively related to improvement (e.g.,
Castonguay, Goldfried, Wiser, Raue, & Hayes, 1996; Hayes, Cas-
tonguay, & Goldfried, 1996; Schut et al., 2005). Rather than
indicating that central interventions of particular orientations are
powerless or detrimental, these findings are more likely suggesting
that prescribed techniques, as well as the theoretical models that
they are built upon, may not be sufficient to explain change.
Current and future research could be particularly helpful here by
providing us with findings that could expand our understanding of
change, which, in turn, could lead to improvements in outcome.
Building on our conceptual and empirical foundations, we need
to look at the relationship between different variables (related to
technique, relationship, and participants’ characteristics) in facili-
tating and/or interfering with the process of change. Fortunately,
some studies have begun to do this. For example, both descriptive
(e.g., Castonguay et al., 1996; Piper et al., 1999) and quantitative
studies (e.g., Owen & Hilsenroth, 2011; Owen, Hilsenroth, &
Rodolfa, in press; Ryum, Stiles, Svartberg, & McCullough, 2010)
have suggested that a consideration of the therapeutic relationship
(such as the quality of the alliance), within which prescribed
interventions are used, is critical in order to understand their
potential impact on outcome. Furthermore, other studies have
suggested that the frequent use of specific interventions (such as
interpretation) may be particularly effective for some clients and
potentially detrimental for others (Crits-Christoph & Connolly
Gibbons, 2002). Going one step further, a recent study investigat-
ing the interaction between treatment, client, and relationship
variables revealed unexpected findings. Specifically, Høglend et
al. (2011) found that the “impact of transference interpretation on
psychodynamic functioning was more positive within the context
of a weak therapeutic alliance for patients with low quality of
object relations. For patients with more mature object relations and
high alliance, the authors observed a negative effect of transfer-
ence work.” As further noted by the authors, “[t] he specific effects
of transference work was influenced by the interaction of object
relations and alliance, but in the direct opposite direction of what
is generally maintained in mainstream clinical theory.” (p. 697).
Although this study does not provide definite answers about what
facilitate or interfere with change in psychodynamic treatment
(Ryum et al. [2010], e.g., found that higher focus on transference
work within the context of weaker alliance was associated with
less therapeutic change), it is noteworthy in its attempt to capture
the complexity of psychotherapy. Interestingly it also fits the final
recommendation suggested by the Task Force described above. As
we argued, “[p]articipant, relationship, and technique principles do
not operate in isolation . . .. Perhaps the most difficult and exciting
challenge in psychotherapy research resides in the fact that prin-
ciples that are related to these three domains are in a constant flux
of interaction and interdependence. While some research has be-
gun to delineate such complex relationships, much more needs to
be done before we achieve an adequate understanding of how these
 PSYCHOTHERAPY OUTCOME
factors work with, against, and within one another to enhance
change” (Castonguay & Beutler, 2005b, p. 368). Ultimately, such
studies are likely to offer a new lens to observe and participate in
the therapeutic process, as well as innovative and discriminative
(what to use, when, and with whom) guidelines to improve our
effectiveness.
Another way to go beyond our current theoretical models of change
(without repudiating them as inadequate foundations) is to fully
recognize the role and extent of factors that are common to many
approaches (as noted early in this article, Strupp [1963] emphasized
the need for more research on unique and common factors in psy-
chotherapy). A considerable amount of evidence has been collected to
support relationship factors (such as the alliance, empathy) that are
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present in different forms of therapy (Norcross, 2002). What has also
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been argued elsewhere (Castonguay, 1993), however, is that common
factors are not restricted to relationship variables. For example, Gold-
fried (1980; Goldfried & Padawer, 1982) identified five principles of
change that cut across different orientations. Theoretically derived,
these principles of change are complementary to the empirically
derived principles described above, and whereas some of these prin-
ciples focus on relationship variables (expectancies and alliance),
others focus on strategies of intervention.
Interestingly, two of the principles of change identified by
Goldfried, the acquisition of a new perspective of self (or insight)
and the facilitation of corrective experiences have been the focus
of long-standing collaborations between highly influential scholars
and researchers from different theoretical orientations and research
expertise (quantitative, qualitative, randomized clinical trials, nat-
uralistic investigations, and cases studies). This collaboration has
taken place within the context of the Penn State Conferences on
the process of change that my colleague Clara Hill and I have been
organizing since 2001.
These collaborative efforts have led to a conceptual clarification
of these principles of change from various traditions (CBT, psy-
chodynamic, humanistic, systemic), as well as to consensus about
their respective natures, the factors that facilitate them, and their
consequences. Equally important, one of the missions of the Penn
State conferences is to stimulate research by having several par-
ticipants conduct quantitative and qualitative studies. In one of
these investigations, Hayes, Feldman, and Goldfried (2005) found
that insight (exploration of issues leading to a new connection,
meaning, or shift in perspective) was associated with affective
arousal and hope, the expression of positive and negative views of
self, as well as improvement. Reflecting convergence across do-
mains of research, this study also found that rumination was
related to worse outcome—such a result is indeed consistent with
one of the basic findings related to strategies of emotional regu-
lation described above.
Other studies presented in the two books that have emerged
from the first two series of conferences (Castonguay & Hill, 2005,
2012) have investigated how client narrative expression facilitates
(and is fostered by) clients’ new perspective of self (Angus &
Hardtke, 2005), how such a new perspective (or insight) can
develop when working with dreams (Hill et al., 2005), how clients
view corrective experiences (Heatherington, Constantino, Fried-
lander, Angus, & Messer, 2012; Knox, Hess, Hill, Crook-Lyon, &
Burkhard, 2012), and how these experiences take place in various
forms of therapy and in supervision (Anderson, Ogles, Heckman,
& MacFarlane, 2012; Berman et al., 2012; Castonguay et al., 2012;
57
Holtforth & Flückiger, 2012; Ladany et al., 2012). In addition,
each of the two series of conferences has led to a list of recom-
mendations for future research that has begun to stimulate new
studies. For example, McAleavey and Castonguay (2012) have
recently explored the important question of what interventions
(common or unique to specific orientations) might facilitate in-
sight. Surprisingly, they found that the use of psychodynamic
techniques was negatively related to the acquisition of new per-
spectives about self and others. This is yet another example of how
research can challenge the field to modify and/or expand both our
models and practice to better understand change—and ultimately
improve our outcomes.
In a similarly surprising and challenging way, another set of com-
mon factors that reflects the complexity of the process of change has
been referred to elsewhere as “faux unique” (Castonguay, 2011). As
for the general strategies aimed at facilitating new perspectives and
corrective experiences, these “faux unique” components are not re-
stricted to relationship variables— challenging yet another false di-
chotomy that technical interventions are unique to specific approaches
and that common (or what is sometimes called, misleadingly in my
view, “nonspecific”) factors are interpersonal variables that are aux-
iliary to techniques (see Castonguay, 1993).
As reviewed by Blagys and Hilsenroth (2000), and consistent
with its underlying model, process studies have demonstrated that
in CBT there is less focus on affect, past experience, interpersonal
relationships (including with the therapist), and avoidance or hin-
dering of treatment progress than in psychodynamic therapy. In-
terestingly, however, process-outcome research also suggests that
CBT therapists do focus on these issues (even in RCTs) and that
they should emphasize them more than they already do. This is
because what has been linked with outcome in CBT are “heretic”
interventions such as: fostering emotional experiencing and ex-
pression (Castonguay et al., 1996; Castonguay et al., 1998; Watson
& Bedard, 2006), exploring attachment relationships with early
significant others (Hayes et al., 1996), and a set of psychodynamic
techniques that include the exploration of the therapeutic relation-
ship and defensive maneuvers (Ablon & Jones, 1998; Jones &
Pulos, 1993). Although not all interventions consistent with psy-
chodynamic theory have been found to predict outcome in CBT
(e.g, Ulvenes et al., 2012), these findings can shed new light on
how CBT works.
The surprising and challenging input that faux unique variables
can provide toward expanding our conceptualization of the process
of change is not restricted to CBT. As mentioned above, for
example, the acquisition of compensatory skills has been hypoth-
esized as a specific mechanism to mediate change in CBT and, as
predicted, has been related to outcome in this treatment. However,
a recent study has also found it to be predictive of change in
psychodynamic therapy (Connolly Gibbons et al., 2009).
Basic research can also enrich our understanding of the therapy
process, in part by providing unexpected (at least within the
context of our current theories of psychotherapies) directions for
improving treatment process and outcome. For example, consistent
with one of the clinical guidelines derived from psychopathology
research described above, therapists may need to pay keen atten-
tion to clients’ self-needs. In one study, greater similarity between
client-perceived therapist behavior and client self-directed behav-
ior (even when negative in nature) was associated with better
client-rated alliance early in CBT (Constantino et al., 2005). This
 58 CASTONGUAY
finding has important conceptual and clinical implications, as it
alerts therapists that a premature emphasis on challenging negative
self-conceptions may counteract an optimal balance of the client’s
self-verification and self-enhancement needs (Constantino & Wes-
tra, 2012). As yet another fruitful contribution of the Penn State
Conferences, suggestions for better understanding and improving
the process of change have also been derived from developmental
(Bowman & Safran, 2005; Constantino & Westra, 2012) and social
psychology (Haverkamp & Tashior, 2005), as well as cognitive
and neural sciences (Caspar & Berger, 2005, 2012). Furthermore,
as a unique example of an insightful integration of scientific
domains, Adele Hayes and her colleagues used dynamic systems
and chaos theory to successfully predict that emotional and cog-
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nitive destabilization would be linked with improvement in cog-
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nitive therapy for depression (Hayes & Strauss, 1998).
To reiterate, these findings (as well as new directions from a
diversity of scientific domains discussed above) do not suggest that
our current theories about psychotherapy are fundamentally flawed.
What they suggest is that our current models of change are not
sufficient and that process research that is not tied to the constructs of
a single psychotherapy model (or to psychotherapy at all) can help us
to expand and build upon such models. Although it is crucial to
recognize the importance of, and continue to pursue, studies on factors
that are assumed to be at the core of particular forms of therapy, we
also need to think outside the theoretical boxes that have traditionally
guided our treatments. As illustrated next, the knowledge that we can
derive from such an “outside” perspective may also fuel our efforts to
improve treatment outcome.
Outcome Research
In his article for the first issue of Psychotherapy, Eysenck
(1964) revealed some of the earliest roots of RCTs. In his own
words, it “is to be hoped that in the near future American psychol-
ogists and psychiatrists will follow the example of their British and
Commonwealth brethren and set up clinical trials to evaluate the
adequacy of these two methods of therapy [psychotherapy and
behavior therapy] against each other.” (p. 99). Although it seems
that the field has, in large part, ignored what in hindsight appears
to be have been a crucial recommendation of Strupp (conducting
more research examining the contribution of therapist characteris-
tics on outcome), a large segment of psychotherapy research has
followed Eysenck’s wishes for more RCTs (despite having differ-
ent impacts with respect to their specific recommendations, both
men were clearly ahead of their time!).
There is no doubt in my mind that RCTs have given scientific
credence to some forms of psychotherapy in the field of mental
health—a field that may constantly be at risk of being overshadowed
by the medical model and medications. I am also convinced that
RCTs (in controlled contexts and, as described below, in naturalistic
settings) should continue to be conducted. However, what I think
should receive less attention (and, thus, less funding) are RCTs
comparing two forms of well-established therapies, especially for
disorders for which we already have ESTs. As argued by Borkovec
(Borkovec, 1994; Borkovec & Castonguay, 1998), this is because
these specific comparative trials cannot provide a valid answer to the
ultimate scientific task that they are aimed at addressing, that is,
demonstrating a cause and effect relationship. Scientific studies in-
vestigate cause and effect relationships by comparing two conditions
that are identical, with the exception of one aspect (which is predicted
to cause the expected difference between the two comparison condi-
tions). Borkovec has argued that these specific comparative trials are
unable to meet this scientific requirement because, fundamentally,
they are not comparing treatments that are equivalent in all-but-one
factor (i.e., the specific techniques prescribed by the treatment man-
uals). At the core of this argument is the fact that it is impossible to
determine whether therapists have provided the prescribed treatments
with the same level of competence and attunement to the clients’
needs, simply because the skills that are involved to achieve these
levels of competence and attunement are different in each treatment.
Even if a researcher was to find that, for example, CBT and
psychodynamic-interpersonal (PI) therapists evidence the same aver-
age on adherence and competence scales, it would be misleading to
assume that these therapists were equally “pure” and competent in
implementing the treatment investigated. Because these scales would
by definition be assessing different interventions, there is no reason to
believe that a score of say “4 out of 5” on a measure of CBT
competence is equivalent to the same score on a measure assessing PI.
These scales are measuring apples and oranges.
Nevertheless, there are a number of situations where compara-
tive RCTs are relevant tools to address important issues related to
psychotherapy outcome. One of these issues is scientific and
political credibility. In the current state of our field, for example,
few will have more than tentative faith in a psychotherapy ap-
proach for obsessive– compulsive disorder until it is compared
with an established CBT protocol. In my opinion, a recent RCT
has increased the credibility of psychodynamic therapy for depres-
sion by showing its equivalence to medication (as well as the
humbling lack of difference between these two forms of ESTs to
a placebo condition; Barber, Barrett, Gallop, Rynn, & Rickels,
2012). Furthermore, RCTs can be informative, research and
clinical-wise, by showing that a treatment similar to what is
frequently used in day-to-day practice can be as impactful, if not
superior, to theoretically and technically sophisticated therapies
designed by expert researchers. For example, Crits-Christoph et al.
(2009) found that carefully conducted drug counseling was more
effective than cognitive and dynamic therapies in the treatment of
cocaine addiction. (For other merits of RCTs, see Barber, 2009).
However, I believe that to maximize the clinical impact of
outcome trials, including RCTs, the field should invest more
energy into increasing the efficacy and effectiveness of treatments
that we know to be effective, rather than comparing them (and, as
described below, some of the studies aimed at this goal can
actually get closer to establishing cause– effect relationships). This
strategy is line with the main theme of this article: building on our
foundations. Also in line with this theme and consistent with the
research evidence described above, I would suggest that one of the
ways (by no means the only way) to improve our effective treat-
ments is to modify and/or expand on them based on process
(common and faux-unique) and basic research.
One example of such an attempt is a research program aimed at
expanding cognitive therapy for the treatment of depression. As
mentioned earlier, my colleagues and I found that therapists’
emphasis on the CT model and techniques was negatively related
to outcome (Castonguay et al., 1996). Descriptive analyses sug-
gested, however, that what was problematic was not the prescribed
interventions per se, but the context within which they were used.
Our analyses revealed that when confronted with alliance ruptures,
 PSYCHOTHERAPY OUTCOME
therapists tended to increase their focus on aspects of (or interven-
tions prescribed by) the CT model that the clients were reluctant to
accept or engage in. This strategy (also observed in psychody-
namic therapy to address a similar problem; see Piper et al., 1999)
did not appear to repair the alliance ruptures, and may even have
exacerbated them. Based on these findings, we developed an
integrative cognitive therapy (ICT) where therapists use the tradi-
tional CT model and interventions, except when confronted with
an alliance rupture. In these circumstances, therapists follow
guidelines specified by both Burns (see Burns & Auerbach, 1996)
and Safran (see Safran & Segal, 1990), and use interventions
consistent with humanistic, psychodynamic, and interpersonal
models (e.g., exploration of the therapist’s contribution to the
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relationship difficulties). Once the rupture is repaired, the therapist
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then returns to the CT protocol, using the same techniques in a way
that is experienced less negatively by the client or by using another
intervention prescribed by CT that is more attuned to the client’s
needs. Although preliminary, two studies have been conducted so
far indicating that the integration of non-CBT interventions to deal
with alliance ruptures in CT for depression is not only possible, but
may lead to incremental efficacy (Castonguay et al., 2004; Con-
stantino et al., 2008). There is, of course, no reason to believe that
strategies to repair alliance ruptures would be irreconcilable with
or irrelevant to the practice of other forms of therapy.
Additional efforts aimed at expanding CBT have also led to
promising results. These include the integration of techniques to
increase clients’ outcome expectations (a process variable that has
received empirical support and has been identified by Goldfried
[1980] as general principle of change) in the treatment of depres-
sion (Constantino, Klein, Smith-Hansen, & Greenberg, 2009); the
addition of motivational interviewing interventions (which are
based substantially on client-centered constructs that have also
received empirical support) in the treatment of generalized anxiety
disorder (GAD) (Westra, Arkowitz, & Dozois, 2009); as well as
the integration of interventions aimed at fostering functional sta-
bility (guided, in part, by basic research on the role of healthy sleep
and exercise) and emotional processing (based on the process
research mentioned above on affective and cognitive destabiliza-
tion) in the treatment of depression (Grosse Holtforth et al., 2011;
Hayes et al., 2007). Such efforts to expand effective treatments
should by no means be restricted to CBT. Although preliminary,
Nelson and Castonguay (2012) conducted a study that showed that
it is both possible (in terms of process) and promising (in terms of
outcome) for PI therapists to systematically integrate homework (a
therapeutic activity that, as mentioned above, has been associated
with and found to be predictive of change in CBT) into their
treatment of depression.
As with the evidence related to principles of change and psy-
chopathology mentioned above, the use of these new treatments
would not require drastic change in the practice of many therapists.
In line with facets of the current integration movement in psycho-
therapy, the above findings suggest that one way of improving our
outcome is not to force a choice between different treatments (or
to invent new ones) but to assimilate (Messer, 2001) within exist-
ing therapies constructs and techniques associated with other ori-
entations (and/or scientific domains). However, such assimilative
treatments are unlikely to be a panacea and may turn out to be only
a step in our continual quest to increase our therapeutic impact.
This is a sobering conclusion that I have derived from a long and
59
time-consuming research effort that my colleagues and I at Penn
State University have conducted, with the goal of improving the
efficacy of CBT for GAD (see Newman, Castonguay, Borkovec, &
Molnar, 2004). Although CBT was (and is still) the only EST for
GAD, an analysis of research trials (including a number of studies
conducted by Borkovec at Penn State) suggested that only 50% of
the clients fully responded to this treatment (Borkovec & Wish-
man, 1996). Findings also collected at Penn State further indicated
that clients who experienced interpersonal problems at the end of
CBT showed a higher probability of relapse (Borkovec, Newman,
Pincus, & Lytle, 2002). Rather than creating a new treatment for
GAD, my colleagues and I embarked on the task of improving the
efficacy and therapeutic reach of CBT by building on two distinct,
but complementary, scientific traditions: basic research (e.g., psy-
chopathology findings that individuals with GAD have had past
and current interpersonal problems, as well as difficulty with
experiencing emotions; see Newman et al., 2004) and process
research (e.g., that the exploration of interpersonal, developmental,
and emotional issues have been found to be infrequent, yet pre-
dictive of outcome in CBT).
Influenced by the work of Safran and Segal (1990), we created
an integrative treatment where a number of interpersonal (e.g.,
exploration of the therapeutic relationship), psychodynamic (e.g.,
exploration of attachment issues with early significant others), and
humanistic (e.g., experiential techniques to facilitate acceptance
and deepening of emotion) interventions were added to CBT. In
our first study, we found that the addition of these techniques
(within a treatment manual called interpersonal/emotional process-
ing [I/EP]) to a CBT protocol led to higher effect sizes than the
average found in previous trials on traditional CBT (Newman,
Castonguay, Borkovec, Fisher, & Nordberg, 2008). Based on these
preliminary, but promising, results, we conducted an RCT com-
paring (via an additive design) two treatments: our integrative
therapy (involving 14 2-hr sessions sequentially combining a 50-
min segment of CBT and a 50-min segment of I/EP) and a control
condition (involving a 50-min segment of CBT and a 50-min
segment of supportive listening, aimed at controlling for common
factors such as time and therapist attention).1
Contrary to our prediction, however, the two conditions failed to
be statistically different (Newman et al., 2011). Although these
disappointing results could be accounted for by a lack of power to
detect real differences, I believe that they likely also reflect the
impact of moderators. Put in a larger context, the most important
question, scientifically and clinically speaking, is not whether
integrative treatments (this one, as well as the innovative therapies
described earlier in this section) are more effective than traditional
ones, but for whom these integrative approaches are a better
option. Considering the fact that previous studies indicate that 50%
1
In line with the arguments stated above, we used this additive design
for scientific purposes—i.e., to investigate a cause and effect relationship.
In contrast with traditional comparative-outcome studies, we included the two
conditions tested in our second study with the aim of having them be equiv-
alent in all respects, with the exception of the addition of specific non-CBT
techniques. Accordingly, if we were to find the predicted difference between
these two conditions, this finding would have suggested not only that CBT can
be improved but, more importantly from a scientific perspective, that the cause
of this improvement (above and beyond common factors, such as time and
therapist attention) was the addition of interpersonal, psychodynamic, and
humanistic interventions to the CBT protocol.
 60 CASTONGUAY
of GAD clients benefit from CBT, for example, outcome research
would be most helpful if it was to identify the clients who are most
likely to benefit from an already established EST, and those who
are most likely to need more than our current FLA to fully recover.
Based on findings that negatively perceived parenting has been
associated with negative outcome in the treatment of anxiety
disorders, it may be that clients with attachment problems could
further benefit from the exploration of past and current relation-
ships than those without such difficulties. In line with this hypoth-
esis, a recent qualitative analysis conducted on the treatment of a
client who responded positively in this RCT suggested that while
CBT brought significant change in handling stressful situations
and reducing somatic symptoms, I/EP facilitated complementary
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(and apparently synergistic) improvement (Castonguay et al.,
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2012). The client’s exploration of emotional conflicts (in terms of
wishes and fears) toward others (including therapist, spouse, and
children), some of the traumatic and developmental sources of
these conflicts, as well as his maladaptive patterns of relationship
(as manifested in repeated alliance ruptures) appear to have helped
him better identify his interpersonal needs and change his way of
relating with others (and himself). But although this specific client
might have benefitted from I/EP, the exploration of emotions and
interpersonal issues might not be necessary, or may even interfere
with the impact of CBT for other clients with GAD. In fact, an
accurate assessment of the complexity of therapy may require us to
recognize that “pure” and straightforward treatments are some-
times as good, if not better, than combined and more complicated
ones.
How Can We Improve the Outcome of Therapy
Clinically and Empirically?
For the most part, many of the clinical and empirical suggestions
presented above reflect an integration of different sources of
knowledge, and several of them emerge from active collaborations
between researchers of different worldviews (such as the Task
Force on principles of change, the book on psychopathology, and
the Penn State conferences). To a large extent, however, these
integrative efforts reflect what has been described elsewhere as
empirical imperialism (Castonguay, Boswell, Zack, et al., 2010).
Like most current avenues of evidence-based practice, they repre-
sent unidirectional attempts in building bridges between science
and clinical work, with individuals (like me) who see few clients
informing individuals who see many more clients about what
should be investigated (and how it should be investigated) in order
for the field to better understand and improve psychotherapy.
These efforts are no doubt worthy of consideration, but I would
like to suggest that they should be complemented by another form
of collaboration, one between clinicians and researchers. Referred
to as “Practice-Oriented Research” (POR, Castonguay, Barkham,
Lutz, & McAleavey, in press), this type of collaborative partner-
ship has already led to a very large number of studies that have the
potential to provide innovative contributions toward the current
outcome problem. Rather than being irreconcilable, practice-
oriented research and evidence-based research can be viewed as
equipoise and complementary strategies in building a robust
knowledge base and improving clinical practice (Barkham & Mar-
gison, 2007; Barkham, Stiles, Lambert, & Mellor-Clark, 2010).
Although they address a wide array of topics and involve a
diversity of research methods, POR studies share two important
features: They are conducted in naturalistic settings and they are
based on standardized measurement systems used as part of rou-
tine clinical practice. In addition, POR studies, as a whole, are
guided by the unifying goals of providing opportunities for clini-
cians to (a) be active participants in research, (b) use data collected
in their setting to inform their own practice, (c) examine questions
that they see as clinically relevant, and (d) contribute to advance-
ment of scientific knowledge. Recently reviewed under three ma-
jor approaches (practice-based research, patient-focused research,
and practice-research networks, Castonguay et al., in press), a few
examples of POR are described here.
Perhaps the most well-known patient-focused, if not POR, stud-
ies have focused on feedback. Propelled by the seminal work of
Michael Lambert, this research is particularly noteworthy, as it can
help us meet what I referred to earlier as our most important
clinical responsibility of “first, do no harm.” Although the field has
long been alerted that a significant number of clients deteriorate
during therapy (Bergin, 1966), Lambert’s research has demon-
strated that clinicians tend to underestimate the number of their
own clients who will deteriorate during treatment and have diffi-
culty predicting, at the beginning of therapy, the clients who will
do so. Research has also shown, however, that the use of feedback
informing therapists about who is not progressing as expected can
help reduce deterioration. Moreover, by providing clinical tools,
including information based on research on alliance rupture and
repair, therapists can further decrease negative effects (see Lam-
bert, 2010 for review). An obvious clinical implication of such a
combination of process and outcome findings is that, irrespective
of their theoretical orientation, therapists should seriously consider
using alliance (and outcome) measures and attempt improve the
alliance when indicated and/or adjust their interventions based on
the quality and solidity of the therapeutic relationship. Regarding
the issue of the therapeutic relationship, it is interesting how
empirical evidence and clinical observations can provide conver-
gent and complementary knowledge that can help us reduce harm-
ful effects, and, thereby, improve our outcomes. In 1913, way
before any research was ever conducted on the alliance, Freud
addressed the important question of when therapists should use
interpretation in psychoanalysis. He argued that this should not be
done before a good rapport has been established with the client. He
then stated that this is especially the case for accurate interpreta-
tions, adding that “usually the therapeutic effect at the moment is
nothing; the resulting horror of analysis, however, is ineradicable.”
(p. 187).
In terms of practice-based research, what appears to have
retained most attention in the field are studies on the therapist
effect. Reflecting, in no small way, Bruce Wampold’s major
contribution (e.g., Wampold, 2001), we have clear evidence sup-
porting what most trainers and supervisors (let alone practitioners)
believe: Some therapists are better than others. As noted by Lam-
bert and Ogles (2004), the “therapist factor, as a contributor to
outcome, looms large in the assessment of outcome. Some thera-
pists appear to be unusually effective, while others may not even
help the majority of patient who seek their services” (p. 181).
Interestingly, the findings of a recent study suggest that the ther-
apist effect may be quite specific. Based on a sample of 696
therapists and 6,960 clients, Kraus, Castonguay, Boswell, and
 PSYCHOTHERAPY OUTCOME
Nordberg (2011) found that when their clients’ outcomes were
assessed with an instrument that measured several clinical prob-
lems and dimensions of functioning, only one therapist was found
to be effective across all areas (interestingly, very few therapists
were found to be ineffective on all of problem areas measured).
This study suggested that, on average, therapists are effective at
treating five or six clinical problem areas. The findings also revealed
that therapist effectiveness did not correlate highly between the dif-
ferent problems measured. In contrast with the notion that a few
therapists are better than most for all clients, these findings suggest
that the majority of therapists are effective (96% of the therapists were
shown to be effective in treating at least one clinical domain), but the
competencies of individual practitioners may be specific to particular
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problem areas. Based on clinicians’ problem with predicting deterio-
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ration, I would venture to guess that most therapists would have
difficulty identifying all, or even most of the clinical problems that
they are particularly good (or bad) at treating. Especially if these
results are replicated, the use of such feedback would not require
drastic changes from most clinicians but could provide them specific
feedback (positive and constructive) that could confirm, as well as
challenge, their perception of their expertise, which, in turn, could
lead them to seek referrals, provide supervision, and/or receive addi-
tional specific training.2
POR conducted within the context of practice-research net-
works (PRNs) may well represent the optimal antidote for empir-
ical imperialism. When conducted under ideal conditions, such
research involves the active collaboration of practitioners and
researchers in all aspects of the investigation—from the choice of
the topic to study, the design and implementation of the research
protocol, and the analysis and dissemination of the results. As
noted in Castonguay et al. (in press), this “collaboration aims to
foster a sense of equality, shared ownership, and mutual respect
between researchers and clinicians, and promoting diversity of
scholarship (i.e., different ways of understanding and investigating
complex phenomena). It also capitalizes on the complementary
expertise, knowledge, and experiences of each stakeholder to pro-
vide unique opportunities for two-way learning to conduct studies
that are both clinically relevant and scientifically rigorous.”
A relatively large number of PRNs have been developed within
the context of several professional organizations, to address spe-
cific clinical problems, or to conduct scientifically rigorous and
clinically meaningful research in a variety of treatment settings.
For example, as part of a series of studies conducted within the
Pennsylvannia Psychological Association Practice Research Net-
work (PPA PRN), experienced therapists designed and imple-
mented, with their own private clients, a study aimed at identifying
what clients found most helpful and hindering during every session
of their therapy (Castonguay, Boswell, Zack, et al., 2010). As
described in Castonguay, Nelson, Boutselis, et al., (2010),
therapist-investigators used the study protocol to collect data that
seamlessly and simultaneously served empirical and clinical pur-
poses, thereby allowing them to confound science and practice. In
another study focused on the treatment of disruptive behavioral
problems (DBP) in children, clinicians and researchers built a
research program aimed at assessing the use of principles of
change underlying ESTs for DBP in clinical practice, as well as the
link between these evidence-based (and practitioner-based) inter-
ventions and treatment outcome (Garland, Hurlburt, & Hawley,
2006). Within a different PRN infrastructure involving ⬎150
61
university counseling centers, another study was conducted to
determine whether clients’ utilization of previous mental health
services (and its link with symptom change) could provide useful
information to clinicians in terms of their case formulation and
treatment planning (Boswell, McAleavey, Castonguay, Hayes, &
Locke, 2012).
A number of studies have also been conducted at a PRN that has
been developed in the training clinic at Penn State University.
Conducted by and for students, such studies have the potential to
optimize the scientific-practitioner model by combining (actually
confounding) its three main facets: research, clinical, and training
(as argued elsewhere, “simultaneous, seamless, and repeated inte-
gration of science and practice activities as early as possible in a
psychotherapist’s career might create an intellectual and emotional
[hopefully secure] attachment to principles and merits of the
Boulder model” [Castonguay, 2011, p. 135]). In one of these
studies, Boswell, Castonguay, and Wasserman (2010) showed that
when used by particular therapists and with particular clients,
cognitive– behavioral interventions can be associated with worse
impact. This is yet another example of how POR research could
help us address the crucial issue of harmful effects.
In addition to reviewing past and current studies conducted
within the POR paradigm, my colleagues and I have offered
recommendations to foster future clinician–researcher collabora-
tions aimed at improving our understanding and the impact of
therapy (Castonguay et al., in press). Among them is to “ask and
tell.” This can be done by inviting clinicians to present what they
consider, based on their practice, to be the issues about process and
outcome that have been largely ignored by researchers (e.g., Cas-
tonguay, Adam-Term, Cavanagh, et al., 2010) and by surveying
practitioners about the factors that limit the effectiveness of ESTs,
as they have implemented them in their day-to-day work (Gold-
fried, et al., 2012).
Another recommendation is for the field to move beyond efforts
to create “bridges” between science and practice. For many, the
growth pathway of the scientific-practitioner model typically in-
volves separate, and more or less distinct steps: Scholars (clini-
cians and/or researchers) formulate ideas and interventions, re-
searchers test these constructs and procedures (frequently in
controlled situations), and efforts are then made to “translate” the
scientific results in naturalistic settings. Although this traditional
pathway has provided, at least in my view, multiple contributions
to field, it may also explain in part the slow and limited “up-take”
of published research by clinicians. One way to facilitate more
efficient and widespread use of research findings in day-to-day
psychotherapy is to melt down the distinction between scientific
and practice activities. This can be achieved, to a lesser or greater
extent, by designing “clinically syntonic” studies; studies involv-
ing tasks that are intrinsically and immediately relevant to clinical
2
Interestingly, being able to identify therapists who are particularly
effective at treating particular clinical problems does not tell us why they
are effective. This still leaves us confronted with what could be viewed as
one of the most intriguing conceptual, clinical, and research paradoxes in
psychotherapy today: We know that there is a therapist effect, but we do
not know what makes some therapists more effective than others, in
general and for specific problems. Following the exploration of insight and
corrective experiences, the goal of the current series of Penn State Con-
ferences on the process of change is to address this knowledge gap.
 62 CASTONGUAY
work (Castonguay, Nelson, Boutselis, et al., 2010). I believe that
clinicians will be particularly interested in participating and using
research if they are not able to differentiate between the scientific
and clinical aspects of the study protocol. This is what happened,
for example, in the PPA PRN study described above, when clini-
cians were reading their clients’ descriptions of helpful and hin-
dering events that took place during the session that just ended—at
that precise moment, clinicians were unable to say whether they
were collecting data or preparing themselves for the next session.
They were, of course, doing both. As stated from a more global
perspective, “rather than trying to connect science and practice, as
if they stand on different river banks, we should strive to confound
the two activities in order to create a new, unified landscape of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
knowledge and action” (Castonguay et al., in press).
This document is copyrighted by the American Psychological Association or one of its allied publishers.
Conclusion
Even though 50 years have passed since the first articles were
published in Psychotherapy, most therapists and clinicians would
agree that we still have an outcome problem—and that it is worth
revisiting it. Clinically and empirically, we know that a substantial
number of clients do not begin, complete, or benefit (fully or at all)
from the psychosocial treatments they are offered. Few would also
disagree that considerable work can be done to increase our
understanding of the process of change, as well as to improve,
match, and deliver current treatments in ways that are more attuned
to our clients’ needs. Considering the complexity and importance
of these challenges, I strongly believe that we should build on our
empirical, conceptual, and clinical foundations, and that we can
and should do so by establishing connections between different
domains of knowledge and practice. As highlighted above, efforts
toward such integration and collaboration can be based on several
convergences of findings and observations, as well as on comple-
mentary sources of expertise and knowledge.
The assumption that building on plurality and convergences can
improve psychotherapy outcome is based on two obvious prem-
ises: That this type of rapprochement can widen the scope of our
understanding and the repertoire of our practice, as well as increase
our confidence in interventions or constructs that are supported by
different perspectives of knowledge. The same assumption, how-
ever, comes with an unpleasant cost, at least for me: The loss of a
secret (and no doubt grandiose) dream that I (and the incalculable
number of more qualified researchers and practitioners) could,
with all the resources and time in the world, eventually design and
conduct the “perfect” psychotherapy study—a conceptually ap-
pealing, methodologically flawless, statistically impeccable, and
clinically relevant investigation that might shape the thinking,
practice, training, and research in the field. Of course, I do envi-
sion (and hope to conduct) a few studies that I would consider
optimal (“best that I can do”) within my own research philosophy
and program. As one that could be deduced from the pages above,
at the top of this list would be an RCT that would be (a) designed,
implemented, and disseminated in collaboration with clinicians, as
well as researchers with a wide range of methodological/episte-
mological and conceptual expertise; (b) based on an additive
design with the goal of testing the causal impact of training
therapists to use specific interventions in their day-to-day practice;
(c) focused on interventions that would be derived from previous
research (psychotherapy and/or basic), could be assimilated within
the clinical repertoire of therapists of different theoretical orienta-
tions, and could help them address problems and impasses that
they are confronted with when treating a wide varieties of clinical
problems; and (d) that would plan for both quantitative (including
the investigation of moderators and mediators) and qualitative
analyses to examine the role of client, therapist, technical, and
relationship variables (as well as their interaction) in facilitating
and interfering with immediate, short-term, and long-term impact
of the targeted interventions. However, I also hope to conduct a
similar study within a controlled environment by investigating the
addition of specific interventions to improve treatments already
shown to be effective (EST). In my view, both types of studies are
important because they reflect distinct research paradigms
(practice-oriented and evidence-based) that have their respective
strengths and limitations (in terms of internal and external validity)
and, as mentioned above, they should be viewed as equivalent and
complementary in building an empirically based knowledge to
guide our practice (Barkham et al., 2010; Castonguay et al., in
press). Examining the same interventions in naturalistic and con-
trolled environments would not only inform our level of confi-
dence in their impact and mechanisms, but would also shed greater
light on their complexity, for example, under which conditions or
context, with whom, and used in what ways might particular
interventions improve psychotherapy outcome. Replication of re-
sults within a specific paradigm is also crucial. Each study has its
own idiosyncrasies (in terms of participants, design, treatment
protocols, etc.) and imperfections. When similar results are ob-
tained despite variations of methodologies and experimental mis-
takes we can have more confidence in the reliability and validity of
the effects obtained. As an insightful researcher and clinician once
said, “we cannot put much faith into one single study!” (Slodz,
personal communication, November 2003).
Although I can easily live with the fact that no one study is
perfect, it is much more unsettling for me to accept that research
is frequently perceived as irrelevant and intrusive by clinicians
(Castonguay, Hayes, & Locke, 2011). With the hope of raising
a contrasting picture, I have attempted to describe how research
can actually serve many important functions. It can provide us
with a list of treatments that could be viewed as FLA, a list of
treatments to avoid (or to be used very carefully), and a large
number of principles of change that can complement these two
lists. Research can also provide us with lessons of humility by
revealing, for example, that a serious percentage of our clients
deteriorate and that we are largely unable to predict who will be
harmed during or as a result of therapy. On this basis alone, we
can use research as an ally to improve ourselves—the same way
that, once we have established a good alliance, we tend to
encourage our clients to replace maladaptive patterns of living
with more healthy ones.
Perhaps parallel to the delicate balance of challenge and
acceptance (as eloquently stated by Linehan, 1993) that we
strive to achieve with our clients, research also provides us with
many sources of support. For instance, it has increased our
confidence in the assertions of several theoreticians (including
Freud, and, of course, Rogers) and the observations of many
practitioners that the relationship matters. Furthermore, re-
search can surprise us by suggesting, for example, that the
exploration of the past and emotion might be beneficial in CBT,
which could, in turn, offer us potential directions for how to
 PSYCHOTHERAPY OUTCOME
expand our clinical repertoire—at least with some clients.
Moreover, research provides us with much needed political and
social “munitions” to survive and potentially strive in the heart
of the current pressures for accountability; not only by demon-
strating that psychotherapy is effective for a large number of
clinical problems but it may also offer the first line of attack for
the leading cause of disability in the world— depression (see
LeMoult, Castonguay, McAleavey, & Joorman, in press). As
potential tools to address our current outcome problem, I have
also argued that most of the research-based guidelines high-
lighted in this article could be implemented without necessarily
imposing drastic changes on the practice of clinicians, irrespec-
tive of their theoretical orientations. This can also be the case
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
for numerous findings that have emerged from other psycho-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
therapy (e.g., Castonguay, Muran, Angus, Hayes, Ladany, &
Anderson, 2010; Straus, Baber, & Castonguay, in press) and
basic research programs (e.g., Constantino & Castonguay,
2003).
Despite what research can offer to day-to-day practice, it is
clear that it has yet to substantially guide the work of many
clinicians. Interestingly, however, a survey of both clinicians
and researchers found that practitioners give more importance
to research than researchers give to clinical literature (Beutler,
Williams, Wakefield, & Entwistle, 1995). It is perhaps, there-
fore, not surprising that some clinicians “feel disenfranchised
by researchers, believing that research often disregards their
realities and invalidates their experience as professionals” (Gar-
land et al., 2006, p. 32). Similar to Kazdin’s (2008) denounce-
ment of the costly loss of clinical knowledge (through a drip-
ping colander), Beutler et al. (1995) warned that “scientists may
be missing important avenues for identifying critical areas of
research. They may do a better scientific job if they were more
attentive to the writings and ideas of their clinical colleagues”
(pp. 989 –990). I am convinced that I and many of my col-
leagues have become better researchers by asking clinicians
what they need to know to avoid and better resolve the impasses
they struggle with, what they think might be ways to improve
our treatments (including ESTs), and by collaborating with
them in the design, implementation, and dissemination of clin-
ically relevant and scientifically rigorous research.
Many books attest that the collaboration between researchers
from different theoretical orientations and scientific domains
can lead to fresh and innovative contributions of knowledge,
but so can a full partnership between researchers and clinicians.
Needless to say, such an alliance might be more difficult to
build because the potential partners live in different
worlds—we face different pressures, are engaged in different
tasks, and are motivated, to a large extent, by different incen-
tives. However, as many beautiful songs, great novels and, if we
are lucky enough, personal experiences remind us, improbable
unions can also lead to beautiful and deeply gratifying relation-
ships. Such unions are worth establishing, enhancing, and, like
the outcome problem, revisiting. It is with this in mind that I
would like to reconnect with my own ancestral French culture,
paraphrase Jacques Brel, and end this article by telling clini-
cians and researchers “ne nous quittons pas”—let’s stay to-
gether.
63
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 PSYCHOTHERAPY OUTCOME 67

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Received October 13, 2012
Accepted October 15, 2012 䡲

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