Treatment Overview

Logan Durant; Aidan Stevenson; Dr. Laura Lambe

7 Treatment Overview

Logan Durant; Aidan Stevenson; and Dr. Laura Lambe

Donna, a first-generation university student, struggled with the transition from high school to university. Her grades were less than ideal, and she had difficulty making new friends. She is now having trouble sleeping, which has added to the stress about her future and continues to cause her grades to suffer. She eventually decided to talk to one of her professors about her situation, and he asked if she had ever considered talking to a professional, something she had never thought of doing. After a conversation with her parents, Donna agreed to set up a consultation with a local clinical psychologist.

Learning Objectives

By the end of this chapter, you will be able to:

Define psychotherapy and understand how it is delivered.
Compare and contrast different theoretical approaches to psychotherapy.
Describe the ethical considerations related to psychological interventions (e.g., confidentiality and informed consent).
Understand the dodo bird effect and whether therapy is effective.

What is therapy, and how is it delivered?

The American Psychological Association (APA) defines psychotherapy as “any psychological service provided by a trained professional that primarily uses forms of communication and interaction to assess, diagnose, and treat dysfunctional emotional reactions, ways of thinking, and behaviour patterns.” (APA Dictionary of Psychology, 2023).

People can seek therapy for many different reasons, such as stress from a job or the passing of a loved one, as well as unexplained symptoms like loss of appetite or changes in sleep. Some people seek therapy for a diagnosed mental health condition (e.g., an anxiety disorder, major depressive disorder), but this is not always necessary. When seeking therapy, there are a variety of professionals who may be suitable for the presenting problem, including clinical psychologists, social workers, or counselling therapists (see Chapter 1 for a comparison of these professionals). When seeking therapy, there are several options available depending on the nature of the presenting concern.

In individual therapy, the client meets with the therapist to discuss their symptoms or problems and the goals they have for their therapy (McCann & Pieter, 2006). Then, depending on the theoretical approach the therapist practices, treatment will involve different methods to alleviate symptoms and achieve goals. Each session in this form of therapy typically last around 45-50 minutes, and the frequency of sessions and overall duration of therapy depends on the needs of the client (McCann & Pieter, 2006).

Group therapy, as its name implies, involves therapy conducted with multiple clients at the same time, often in an inpatient setting like a hospital or clinic (Pappas, 2023). In group therapy, a therapist (or sometimes two therapists) works with the clients to address problems and improve symptoms, while also promoting group cohesion to strengthen the alliance between client and therapist, as well as with fellow group members. Group therapy can provide a sense of solidarity between members, as they are often experiencing similar problems, with some of the most common being anxiety, depression and post-traumatic stress disorder (Pappas, 2023). Groups typically consist of 7-10 individuals, which ensures that every member can be included, while also maintaining a sense of cohesion (Malhotra et al., 2024). The makeup of a group can be more heterogeneous or homogeneous. Homogeneity helps group members identify with other members, while heterogeneity provides a diversity component that is more representative of the real world. The duration of group therapy can also differ, with some treatments lasting a finite number of sessions, whereas others are more open-ended and their termination is subject to the decision of the therapist (Malhotra et al., 2024). The sessions themselves usually last around 90-120 minutes.

Family therapy deals with issues occurring within a family, and takes a more relational approach to therapy, looking at how members of the family interact with each other (McCann & Pieter, 2006). Within family therapy, different approaches are employed to improve client outcomes. For less severe issues, for instance, psychoeducation may be used, where the family is taught about the issue their family member is going through and how to supportively interact with them (Varghese et al., 2020). More in-depth therapies can be used in more severe cases, such as for individuals with chronic health issues or personality disorders. Some of the main goals within family therapy are improving communication and problem-solving in the home, as this will foster a better environment for the family member whose presenting concern is a primary focus.

Three side-by-side illustrations on a black background showing therapy formats: a laptop for online/teletherapy, a small circle of five people talking for group therapy, and one therapist speaking with one client for individual therapy. — **Figure 1:** Examples of therapy modalities

All of these types of therapy can also be delivered in-person or in a virtual format. In the last decade, online therapy (sometimes referred to as “teletherapy” or “telepsychology”) has become increasingly popular (Aafjes-van Doorn et al., 2024b). Using online conferencing software similar to Zoom, clinicians can connect with clients more easily than ever. Online therapy sessions are generally run in the exact same way as in-person sessions. As long as clients have access to an internet connection and a device with a camera, they can receive real-time access to a mental health professional. While online therapy existed before the COVID-19 pandemic, it was rapidly adopted during this time (Aafjes-van Doorn et al., 2024b). Some clinicians choose to only offer in-person sessions, only offer online sessions, or operate from a hybrid model and provide both types of care.

As you might imagine, there are pros and cons for in-person vs virtually delivered services. The potential benefits of virtual care include improved access for some clients —especially when they are located rurally or need therapy during odd hours (College of Alberta Psychologists, 2024) and getting to see how clients interact in the comfort of their own homes (Aafjes-van Doorn et al., 2024b). However, some clients report reduced feelings of connection during online therapy compared to in-person (Aafjes-van Doorn et al., 2024a), and not all clients have a private space with a strong internet connection that is necessary for virtual care. Thankfully, the decision of whether or not to choose virtual care can largely be left to individual preferences, as online therapy has been shown to have similar efficacy to in-person therapy (Giovanetti et al., 2022; Lin et al., 2022).

Think about it

Given the rise of AI-driven mental health tools (e.g., chatbots, virtual therapists), do you think traditional therapy could eventually be replaced—or should technology only supplement human therapists?

What types of therapy do clinical psychologists practice?

Clinical psychologists generally follow a theoretical approach that shapes how they go about assessment, case formulation, diagnosis, and treatment. These theoretical approaches are systems that help to explain, understand, change human behaviour, and improve individuals’ mental well-being. Clinicians often choose their clinical orientation as a result of their clinical experience, values, graduate training, as well as empirical research on the orientation. There are numerous theoretical orientations a psychologist may have; all of which have their own strengths and limitations. In Canada, most clinical psychologists identify with a cognitive-behavioural orientation (Ionita & Fitzpatrick, 2014), likely because most Canadian graduate schools focus on this type of training and because CBT has a strong evidence base (Hofmann et al., 2012). Some psychologists also describe themselves as “atheoretical”, “eclectic”, or say they take an “integrated” approach—meaning they combine elements of various theoretical schools of psychotherapy. An exhaustive list of theoretical approaches to psychotherapy and their details could (and does) take up whole textbooks. As such a brief and limited description of some of the more popular approaches is given here:

Psychodynamic Therapies

Psychodynamic therapies are contemporary adaptations of Sigmund Freud’s original psychoanalytic theories. While they retain many foundational elements of Freud’s work, proponents have sought to modernize them by grounding the approach in empirical research, emphasizing scientific rigour, and implementing time-limited treatment models. These therapies continue to draw heavily from psychoanalytic concepts, including Freud’s structural theory of the mind—comprising the id, ego, and superego—as well as ego psychology, developed by Anna Freud, which explores how the ego evolves and functions, particularly through childhood experiences. A central goal of psychodynamic therapy is to help clients gain insight into unconscious processes that influence their thoughts, behaviours, and relationships. This involves uncovering intrapsychic conflicts, unconscious thought patterns, and defence mechanisms that may be contributing to psychological distress. Unlike traditional psychoanalysis, which could span years or even a lifetime, modern psychodynamic therapies are typically brief and aim to facilitate meaningful change within a defined period, often lasting only a few months. Psychodynamic therapy is non-directive; instead of planning what to talk about, clinicians allow clients to freely associate and talk about what naturally comes to mind for them. While they may guide the client to thoughts they view as therapeutically important, the client is in control.

Symmetrical black inkblot (Rorschach-style) centered on a white background—abstract, mirror-imaged shapes resembling wings or a mask. — **Figure 2:** An example of an inkblot test. Do you see anything in the shape?

Psychodynamic therapists use projective tests such as the Rorschach Inkblot Test or the Thematic Apperception Test (TAT) to assess clients. These tests have limited evidence for their validity and reliability and have slowly fallen out of favour within North American clinical psychology (McGrath & Carroll, 2012). Another assessment used by psychodynamic therapists is free association. Free association refers to the practice of asking a client to say whatever comes to mind. The clinician then interprets what the client is saying and encourages them to keep speaking without consciously controlling their flow of thoughts.

Psychodynamic therapies have limited evidence for their efficacy (e.g., check out this website from the Society for Clinical Psychology for evidence-based psychological treatments). However, due to their more flexible and client-directed nature, psychodynamic therapies can be challenging to evaluate compared to behavioural or cognitive behavioural therapies.

Think about it

Proponents of behavioural therapies often point to effectiveness research showing how well it works relative to other kinds of therapy. Critics say this isn’t a fair comparison since certain kinds of therapy are easier to research than others. What do you think?

Experiential-humanistic Therapies

Experiential-humanistic therapies (EHTs) are characterized by their emphasis on an empathetic and understanding relationship between clinician and client—the therapeutic relationship (Elliott et al., 2013; Greenberg, 2010). Within EHTs, the therapeutic relationship is itself seen as a factor that promotes healing and progress within clients. As the name suggests, EHTs focus on the human experiences of clients and encourage them to get in touch with their present-moment selves and emotions. Broadly, EHTs are person-centred therapies which require the clinician to have genuine care and respect for each and every client they see and use such care and respect as a tool to help improve clients’ condition (Elliott et al., 2013; Greenberg, 2010).

One kind of EHT is existential therapy, developed by American psychiatrist Irving Yalom (1931-Present). Existential therapy recognizes the absurd, irrational, and strange nature of being a human in a confusing and ambiguous world. Instead of attempting to resolve this conflict through grasping at ideas such as God, nations, authority, history, and tradition—existentialism pushes for individuals to accept that the world and self are confusing, conflicting, and anxiety inducing (Solomon, 2005). Irving Yalom gives the definition, “Existential psychotherapy is a dynamic approach to therapy which focuses on concerns that are rooted in the individual’s existence.” The focus of existential therapy is to develop an interpersonal relationship between clinician and client that creates therapeutic change. Clinicians use techniques (Yalom, 1980; Elliott et al., 2013) such as:

Empathic mirroring, where the clinician mirrors back to the client what they are seeing, feeling, hearing, and experiencing within sessions.
Invoking the actual, where the clinician encourages the client to feel the full expansive range of their emotions. For example, encouraging them to recognize and experience the feelings of anger and abandonment that are underlying their feelings of inadequacy.
Feedback, where the clinician gives information to the client about what they are seeing and hearing in sessions. The client is treated as an equal who has less knowledge about therapy/psychology.
Confrontation, where the clinician points out and discusses the client’s inconsistencies and discrepancies. This is done gently and gradually.

One of the most popular EHTs is emotion-focused therapy (EFT). EFT is an evidence-based therapy for depression, anxiety, and couples’ issues (Kramer et al., 2025)—with some limited evidence for use in trauma and eating disorders (Glisenti et al., 2021, Paivio et al, 2010). EFT was developed through the work of Canadian psychologist Leslie Greenberg (1945-Present) and colleagues. The basic principle of EFT is that people’s emotions are a fundamental part of their self and self-organization. Clinicians using EFT view emotions as a key part of how people determine and act on their goals, needs, wants, and concerns. Further, emotions are deeply tied to memories—EFT states that when a person has a strong emotion tied to a memory or event, it becomes an emotional scheme. These emotional schemes are then automatically applied to other events and scenarios. EFT attempts to target maladaptive emotional schemes that resulted from negative experiences such as betrayal, pain, or abandonment. Clients are taught to differentiate between primary and secondary emotions. For example, primary emotions are a person’s fundamental reactions to life events around them (i.e., feeling angry when someone cuts you off in traffic). In contrast, secondary emotions are a person’s response to their own thoughts or feelings about an event rather than the actual primary emotions from the event (i.e., feeling guilty over being angry when you see the “new driver” bumper sticker on the car that cut you off). EFT therapists help clients to understand whether the emotions they are experiencing are adaptive or maladaptive. In sum, EFT is a directive therapy where clinicians act as a guide for clients to explore their emotional states, identify adaptive emotions, and reduce maladaptive emotions.

Cognitive Behavioural Therapies

Modern-day Cognitive Behavioural Therapy (CBT) is a widely practiced and empirically supported form of psychotherapy that blends both behavioural and cognitive approaches. It integrates the behavioural focus on learned responses—such as classical and operant conditioning—with cognitive psychology’s emphasis on thought patterns and beliefs. CBT’s roots lie in behavioural psychotherapy, which emerged as a scientific alternative to psychoanalytic methods, viewing mental health issues as conditioned responses that could be changed through relearning. Pioneers like Joseph Wolpe (1915-1997), influenced by figures such as Ivan Pavlov (1849-1936), Mary Cover Jones (1897-1987), and John Watson (1878-1958), developed techniques like systematic desensitization to treat anxiety disorders. Aaron Beck (1921-2021), who also originally trained in a psychoanalytic framework, began to reject many of Freud’s ideas as he started to notice how many of his clients with depression had the same maladaptive thinking patterns. Beck eventually developed his ideas into cognitive therapy, proposing that psychological distress stemmed from maladaptive beliefs and faulty cognitive processes. Beck’s approach involved helping clients identify and restructure negative automatic thoughts and cognitive distortions. By combining these cognitive strategies with behavioural techniques, CBT emerged as a comprehensive, flexible, and effective treatment for a wide range of psychological disorders (Thoma et al., 2015).

Case Study

Student in a yellow shirt sits at a desk with hands on head, looking stressed over an open notebook; another student in the background writes, out of focus. — **Figure 3:** Homework for CBT looks different from the homework we are used to doing for school!

Think back to Donna’s case. In an initial CBT session, she might work with her therapist to identify goals related to her mood and anxiety. Her goals might include 1) learning new coping strategies for managing anxiety, 2) establishing some social connections, and 3) improving her sleep. Can you think of any other goals she might have?

Cognitive Behavioural Therapy (CBT) is currently the most widely practiced form of psychotherapy in North America (Jamies et al., 2015; Norcross & Karpiak, 2012), known for its structured, evidence-based, and integrative approach. It combines behavioural techniques, focused on modifying learned responses, with cognitive strategies that address maladaptive thought patterns. CBT is typically time-limited, aiming to resolve specific issues within a set number of sessions, often between 5 and 20, scheduled weekly or bi-weekly. The therapy is present-focused, concentrating on current symptoms and practical solutions, while acknowledging the influence of past experiences (Hofmann et al., 2012). Clinicians often spend the first session(s) teaching the client about CBT (e.g., connections between thoughts, feelings, and behaviours) and working together to establish treatment goals. The clinician will work with the client to make a treatment plan for the course of therapy and regularly monitor progress. The general goal of CBT is a reduction in presenting problems and an increase in functioning and quality of life—if this is not happening, then the treatment strategy needs to change. CBT also frequently has clients complete “homework”. Homework in CBT tends to be short, actionable tasks for clients to complete in their own time. The purpose of homework is to empower clients to be more active participants in their treatment and help prevent relapse by providing skills they can use independently (Kazantzis et al., 2005). Importantly, CBT is grounded in scientific research, with new methods and techniques only adopted when supported by strong empirical evidence. The overall evidence base for CBT is very strong and generally has more evidence supporting its efficacy than any other form of therapy (David et al., 2018). You will learn more about CBT in Chapter 9!

Currently, psychology is in the “third-wave” of CBT. The two most popular third-wave cognitive-behavioural therapies are acceptance and commitment therapy (ACT) and dialectical behaviour therapy (DBT). Third-wave CBTs build upon previous practice with an increased focus on mindfulness and acceptance. These therapies are briefly described below; however, you will learn more in Chapter 10!

Dialectical Behaviour Therapy (DBT)

DBT was developed by Marsha Linehan as a treatment for borderline personality disorder (BPD) and has proven effective in reducing suicidal and self-injurious behaviours (Linehan, 1993). The term “dialectical” reflects the philosophical and Buddhist roots of DBT, emphasizing the coexistence of opposing truths. DBT teaches that contradictory thoughts and feelings, such as believing life is both meaningful and meaningless, can simultaneously be valid. This reconciliation of opposites, known as a dialectic, helps clients accept the complexity and fluidity of their experiences. Through this lens, DBT encourages both clients and clinicians to embrace change, contradiction, and acceptance, fostering a therapeutic environment where individuals are supported as they are.

Acceptance and Commitment Therapy (ACT)

ACT is based on and was built from relational frame theory (RFT), RFT implies that cognition is a learned behaviour. RFT implies that mental health issues are based within the same cognitive processes as verbal problem solving and reasoning, and thus cannot be eliminated. Within this framework, the goal of ACT is NOT necessarily to reduce symptoms, but to learn to increase psychological flexibility. By being more “psychologically flexible,” clients learn how to detach from tricky thoughts and feelings and to engage in a more values-driven life. Through mindfulness, acceptance, and committed action, clients learn to be present, accept internal experiences without resistance, and pursue meaningful goals, thereby reducing the impact of psychological distress even if the underlying thoughts persist. ACT is an emerging therapy, with evidence supporting this approach for the treatment of chronic health conditions (Hayes, 2006).

Eclectic/Integrative Practice

Eclectic (or integrative) approaches to psychotherapy take a “keep what works, leave what doesn’t” approach to therapy. Many psychologists categorize themselves as taking an eclectic/integrative approach to psychotherapy (Heinonen & Orlinsky, 2013). The ultimate goal of an integrative approach is to increase the efficacy, effectiveness, and suitability of psychotherapy for any given client. While integration/eclecticism may seem like a shockingly obvious solution to theoretical disagreements, it is not quite so simple. Efficacy and effectiveness research is typically conducted on manualized therapies, so the more a clinician deviates from this standardized approach, the less evidence they have that their treatments will work. Further, clinicians must ensure they are not practicing outside of their scope of expertise. If a clinician has only received training in CBT and sees a research article on the potential benefits of existential-style confrontation, they must not choose to suddenly include confrontation in their repertoire. Instead, they need to seek professional training and guidance on any new techniques or therapies they wish to integrate. Clinical psychologists have an ethical, professional, and societal responsibility to give the best care possible for their clients.

Test yourself!

Common Factors

Despite the wide variety of treatment approaches, there are some aspects of the therapeutic process that are remarkably consistent. These common factors include aspects such as a supportive relationship and the expectation that things will get better.

Simple line illustration of one person standing on a slope and reaching down to pull another person up—symbolizing help, support, and guidance. — **Figure 4:** Common factors in therapy include a supportive relationship and expectations of improvement

The Therapeutic Alliance

The relationship or therapeutic alliance between therapist and client is extremely important to the success of therapy. Typically, this relationship aims to be collaborative, with the patient and therapist working together to accomplish the goals of the therapy while ensuring the patient’s ongoing needs are met (Opland & Torrico, 2024). The therapeutic alliance begins the first time a potential patient meets their therapist (or even before, based on impressions made when booking the appointment), where the patient assesses how trustworthy and capable the therapist is. This initial meeting is crucial to the decision of the patient to continue therapy, and in fact, the most common time for patients to terminate therapy is after the first session (Connel et al., 2006). After the first session of therapy, the alliance operates continuously over the course of treatment. It is important for a therapist to evaluate the relationship with their client by inquiring about their satisfaction with the treatment so far and discussing any potential concerns they may have (Stubbe, 2018). This consistent communication helps keep clients engaged, and in turn lowers the chance that they will drop out of treatment prematurely. Several other ways of strengthening the alliance have been shown to be effective, including agreement on goals of the therapy between therapist and client, as well as commitment of the client to the therapy (Bachelor, 2013). Further, evidence has shown a strong correlation between the therapeutic relationship and positive therapeutic outcomes, making it an integral part of the treatment process (Flückiger et al., 2018)

Consider:

How could Donna’s therapist attempt to strengthen the therapeutic alliance with her?

What could cause strain on the therapeutic relationship?

The Ethics of Therapy

Remember that therapy (and the therapeutic relationship) also must uphold standards of ethical practice. In Canada, the primary ethical doctrine for therapists is the Canadian Psychological Association’s (CPA) Canadian Code of Ethics for Psychologists, which outlines rules for practicing therapy in the country. (see Chapter 2 for a review). Let’s consider how some of these ethical principles relate to psychotherapy:

Informed Consent

One of the most important facets of ethical practice in therapy is that of informed consent, which falls under Pillar 1: Respect for the dignity of persons and peoples (CPA, 2017). Informed consent, at the most basic level, is the idea that individuals engaging in therapy should be able to make a collaborative decision with the therapist about the treatment they will receive (Berg et al., 2001). This also involves passing knowledge from therapist to patient about therapy options, enabling them to make the most informed choice possible while ensuring that patient autonomy is preserved. Informed consent has been shown to improve health outcomes, reduce malpractice claims, and increase patient satisfaction overall (Cordasco, 2013). In modern therapy, there are two primary models of informed consent: the event model and the process model (Baptista et al., 2022). The event model looks at informed consent as one instance that occurs at the beginning of therapy, where the proposed treatment is discussed, a decision on the type of treatment is made, and a form is usually signed by the patient. In contrast, the process model, as its name suggests, views informed consent as an ongoing process, where informed consent is obtained repeatedly as new decisions about the direction of therapy are made over the course of treatment (Baptista et al., 2022). Below are the seven aspects common in informed consent (Braddock et al., 1997; Cordasco, 2013):

Discussing the patient’s role in the decision-making process.
Describing the clinical issue and suggested treatment.
Discussing alternatives to the suggested treatment (including the option of no treatment).
Discussing risks and benefits of the suggested treatment (and comparing them to the risks and benefits of alternatives).
Discussing related uncertainties.
Assessing the patient’s understanding of the information provided.
Eliciting the patient’s preference (and thereby consent).

Example:

Example: Donna’s therapist recommends that they use a cognitive-behavioural approach to her treatment, which her therapist explains is the most evidence-based approach for emotional difficulties like anxiety and low mood. Her therapist explains that by talking about tricky thoughts and feelings and learning new strategies to cope, this approach will hopefully help her start feeling better in a few weeks. They also talk about how CBT does not work for everyone, and how Donna could also consider other treatment approaches, such as medication or emotion-focused therapy.

Confidentiality

As therapists typically learn a lot of sensitive information from their clients, it is important to discuss confidentiality, the guarantee that this information will be kept between therapist and client (albeit with some exceptions). This ethical principle also falls under Pillar 1 of the CPA code of ethics (CPA, 2017). Some of the most common times confidentiality needs to be broken are if the patient presents a danger to themselves or others, or if evidence of child or elder abuse should be reported (Darby & Weinstock, 2018).

Example:

Donna is a university student in a small, rural community. Her therapist lives and works in the same small community. Consider the following ethical dilemmas related to confidentiality, what ethical principles apply, and how you might navigate them:

Imagine that you are Donna’s therapist. You head out to the grocery store and unexpectedly run into Donna and a group of what looks to be her friends. Do you say hi? Why or why not?

Imagine that you know Donna’s parents quite well, and they ask you to see her for therapy. You are initially hesitant given your friendship with her family but also know there are essentially no other care providers available in your rural area. Would you take Donna on as a client? Why or why not?

Competence and Self-Knowledge

Competence and self-knowledge are important ethical principles captured under Pillar 2, Responsible Caring (CPA, 2017). It is crucially important that psychologists accurately represent their training and practice within the bounds of their competence (Abramowitz et al., 2023). This means clinicians should never suggest or perform a treatment that they are not trained in or do not know well. They should also only refer clients to trained and competent treatment providers. Psychologists should also continually engage in self-reflection and consider how their morals, values, and biases influence their practice (Canadian Psychological Association, 2017). Moreover, they should also be sensitive to the personal attributes of their clients (i.e., culture).  Furthermore, clinical psychology is a constantly evolving field. New research is continuously published, and new treatments, techniques, and technologies are emerging. It is a psychologist’s ethical duty to keep up to date with literature involving the methods and treatments they specialize in.

Airplane oxygen masks hanging down from the overhead compartment inside a passenger aircraft. The yellow masks with attached clear plastic bags and tubing have deployed, ready for use.

Have you ever been on a plane watching the flight attendant do a safety demonstration, and they say, “In the event of an emergency, make sure to secure your own oxygen mask before assisting someone else”? The same idea applies to clinical psychologists when it comes to prioritizing self-care. Given the caring nature of the profession, clinical psychologists can suffer from compassion fatigue, vicarious trauma, and burnout. A study conducted by the American Psychological Association among clinical psychologists found that more than one-third of psychologists reported experiencing burnout (Abramowitz et al., 2023). Vivolo et al., (2024) discuss psychologists’ experiences with burnout and report negative effects on their ability to perform their job effectively. To protect themselves and their clients, psychologists have an ethical duty to engage in self-care.

Avoid Conflict of Interest

Dual relationships refer to situations in which multiple roles exist between a clinician and client (Zur, 2007). For example, should a clinician take their hairdresser on as a client? What about an ex-romantic partner? While dual relationships may not always be unethical, they should be avoided whenever possible; however, this is not always feasible (Canadian Psychological Association, 2017). There is a significant power imbalance between a clinician and client, and it is imperative that a psychologist should never exploit this relationship to further their personal, political, or business interests. This may occur in many ways, some obviously wrong, and others more inconspicuous. All dual relationships, real or potential conflicts of interest, should be resolved in a manner which prioritizes Respect for the Dignity of Persons and Peoples (Principle 1) and Responsible Caring (Principle 2) (Canadian Psychological Association, 2017).

Does Therapy Work?

Now that we’ve discussed some of the major concepts present in general therapy, it is important to talk about how successful therapy is at treating psychological problems. First, however, it is necessary to distinguish between two major categories of success: effectiveness and efficacy. Efficacy is the extent to which something works in a lab setting, such as in a clinical trial for a new drug (Gartlehner et al., 2006). These settings are often highly controlled and standardized to minimize any potential variance. Effectiveness, on the other hand, is how well something works in the “real world”. Effectiveness studies allow for more heterogeneous samples, resulting in the potential for variance, and aim to replicate more realistic environments (Singal et al., 2014). If a treatment is higher in effectiveness, it is more generalizable across populations and so can be considered more practical to implement.

Relative to no treatment, many types of therapy have been shown to be effective, with some arguing that this is because of the commonalities across all forms of therapy. This phenomenon is sometimes referred to as the Dodo Bird effect, meaning that any therapy is better than no therapy, and that all therapies are approximately equal. Prominently discussed by Wampold in a 1997 meta-analysis, which found no difference in outcomes of bona fide therapies, the idea of the dodo bird effect still lingers in therapy today. Support for the dodo bird effect is closely tied to the idea of common factors of therapy, with proponents of the idea attributing positive therapeutic outcomes to said factors (therapeutic alliance, empathy, unconditional positive regard). (Budd & Hughes, 2009).

There is more research, however, that documents the benefits of specific factors. In other words, the specific “ingredients” of certain forms of therapy matter. The specific factors model is often supported by practitioners of CBT and posits that certain factors within treatment modalities work particularly well for certain psychological disorders (Budd & Hughes, 2009; Westra, 2022). For example, research consistently documents that exposure is the key active ingredient in CBT for anxiety, underscoring the importance of this specific treatment approach for this specific disorder (Mulder et al., 2017).

Looking at these contrasting perspectives can be a difficult task, especially with the wide variety of disorders and therapy options to treat them. This brings us to the idea of evidence-based practice, which uses published findings in the literature to inform treatment strategies (Cook et al., 2017). Often, this evidence is taken from meta-analyses, randomized control trials and effectiveness studies, and is combined with clinical expertise to produce the most optimal outcomes. Today, CBT is the primary model of therapy used in evidence-based practice, with its theory-based model of treatment and clear guidelines for clinicians allowing for easy standardization (Mulder et al., 2017). You can learn more about which treatments are considered evidence-based practice on the Society for Clinical Psychology’s website.

Summary

Throughout this chapter, you have learned about various aspects of psychological intervention. We have discussed the various delivery models of therapy (individual, family, online etc.) as well as the different theoretical frameworks practiced by therapists (CBT, ACT, Eclectic Therapy etc.). You have also learned about the importance of ethical practice and some ways ethical standards are upheld. Finally, we have gone over the debate of therapy effectiveness, comparing the specific versus common factor schools of thought, as well as the concept of the dodo bird effect.

Check your understanding questions:

Why is it important to distinguish between efficacy and effectiveness when evaluating therapy outcomes?
Existential therapy focuses on concepts like freedom, meaninglessness, and isolation. How might these ideas help a client like Donna better understand her challenges? See if you can compare and contrast this with other treatment approaches.
Imagine that Donna has the option to choose either in-person or virtual therapy. What factors should she consider when making this decision?
Which theoretical approach to treatment is most common among Canadian psychologists and why?