A new meta-analysis published in The Lancet Psychiatry offers compelling evidence that what clients value most from psychotherapy often goes unmeasured by traditional outcome tools.
Led by Michaela Ladmanová of Masaryk University, the study analyzed data from 177 qualitative studies spanning eight decades and 24 countries. The findings show that clients report a range of meaningful benefits from therapy that extend far beyond a reduction in mental health symptoms.
The researchers consisted of a group of individuals from universities across Europe, led by Michaela Ladmanová of Masaryk University in the Czech Republic.
“The meta-analysis showed that clients value outcome dimensions beyond symptom reduction, such as deeper self-understanding, enhanced self-agency, and greater social engagement,” the authors write. “By examining psychotherapy outcomes across various diagnoses and therapeutic approaches, we highlight limitations in traditional outcome measures, showing the need for more comprehensive, client-centred assessment tools and the value of incorporating qualitative methods into understanding dimensions of change.”
All eight researchers involved in the study have also been psychotherapy clients themselves. Their approach aimed to better capture the nuanced, lived experiences of people in therapy—something that is often lost in standard clinical metrics.
The authors argue that symptom-focused assessments fail to reflect the complexity of what clients hope to achieve and actually experience in therapy. These outcomes, they suggest, require broader, qualitative tools that can account for personal growth, emotional processing, and changes in how people relate to themselves and others.
Rather than treating mental distress as a problem to be fixed through measurable symptom reduction, the findings highlight the importance of meaning, relationship, agency, and narrative in processes of healing. It points to a broader view of psychological life, understanding therapy as a space where people seek coherence, dignity, and transformation within the context of their lived realities. In doing so, the research invites us to reconsider what constitutes evidence, what counts as change, and whose experiences are considered legitimate in defining the aims of care.
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These outcome measurement tools exist. Clinicians generally don’t care to use them.
However, if goal of psychotherapy research is to demonstrate to health insurance companies and national health services of health outcomes of therapy, the ones mentioned in the article aren’t particularly convincing for securing payment.
Clinicians, you have to pick a lane. If you want psychotherapy to be treated like a healthcare intervention and be considered healthcare professionals, you need to conceptualize your work through a lens of psychopathology, symptoms, diagnoses, etc. we know that this just isn’t the case for people’s wellbeing. Mental illnesses are not illnesses in a meaningful sense.
If you want to use psychotherapy as a relational service to sell individuals a sense of greater meaning, agency, and engagement, then recognize that if you want to make a decent living that justifies your years of education, you are not doing healthcare. Likely you will only be working with already wealthy people who who can afford this excersie and you will not be helping anyone who is actually in a rough place.
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It is important to realize that a focus on “symptom reduction” was pushed by the APA in order to justify the medicalization of “mental health treatment” and specifically to justify the use of drugs to “treat” such “symptoms.” It is easy to underestimate how reframing mental/emotional distress as “symptoms” plays into the hands of the current “thought leaders” and pushers of a drug-based “treatment” paradigm. Focusing on other “outcomes,” particularly on learning from CLIENTS what they regard as positive results, is essential if we want to overcome the current destructive model of thinking about “mental health!”
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What is the relationship between what clients want and psychotherapy offerings?
What people want from therapy is to feel better or less bad, and they are told that therapy is basically the only place you can go to do that.
Unintended outcomes identified after the fact like in this study is nice, but unless a clients goal was more meaning or social engagement or whatever, what does it matter that they got it from therapy?
And what do therapists do when faced with a myriad of potential desired outcomes? Pretend that therapy can help engender all of them? Therapy is supposed to have a theory of action to support intended change. If just chasing patient satisfaction (which should not be considered a meaningful outcome), therapy is just a self-reinforcing trap of a catchall relationship creates to meet the deficiencies of a shitty society that just replicates the deficiencies of that shitty society by existing.
Surely if we put on equal footing other ways to deepen meaning, self understanding, and social engagement psychotherapy would be seen as an expensive, wasteful, and isolating process. That it requires so much resources as an institution as is makes it likely part of the problem in people not experiencing those above options. Unless you will invoke the tally fallacy that only in psychotherapy these outcomes can be had?
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I don’t disagree. There are so many ways for people to achieve those “outcomes” that don’t involve the expense and risk of psychotherapy, and there’s really no way to properly train psychotherapists to be competent in accomplishing these outcomes. I am certainly never one to assume or believe that psychotherapy is the only or best way to accomplish the goals mentioned. I’m trying to point out that the focus on “symptom control” exists to medicalize “mental health” and make it easier to justify prescribing drugs for the “symptoms.” Whether therapy can accomplish any of the outcomes you mention is a very legitimate question. My point is only that those should be the standard, rather than making a person “feel less depressed.” The latter tends to result in the actual outcome of “feeling less.” Not something most people are seeking!
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I don’t therapy as is can function to meet needs of regular people in need without private insurance or state funding.
Psychotherapy can’t get health insurance reimbursements unless it pretends to be healthcare –and the entire apparatus of nonsense built around it (especially the codifying of mental health parity laws).
Perhaps countries with national health services or more interested in the welfare of the people could still find a way to justify paying therapists from state funds without being healthcare, noting that social engagement and self understanding are good for a free population broadly. But this doesn’t seem likely.
So as is in America–therapy as is can never function honestly AND serve a meaningful percentage of people in distress AND pay therapists for their time/skillsets (whatever those are).
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Good idea for a study.
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Are you familiar with Foucault’s concept of the psy-complex dispositif ?? It is the disciplinary mechanism that has taken over the psy disciplines and controls what most professionals do. It consists of the policies of institutions such as clinics and hospitals (which usually have a medical model focus), the professional examinations to get a license to practice, and the disciplinary procedures of the licensing boards (which usually have a panopticonian processs (examine yourself) and get on-going education to bring yourself up to speed), and so forth. Woe betide any practitioner who steps outside of these requirements. The late Milton Erickson, who was or is considered the greatest psychotherapist of all time, once commented that “Too many psychotherapists try to plan what thinking they will do, instead of waiting to see what the stimulus they receive is, and then letting their unconscious mind respond to the stimulus”. But try telling a policy maker or a licensing board that you are going to sit comfortably in a liminal zone with your client and await for unforeseen and unforeseeable new becomings to emerge. Or that you are not convinced that a comprehensive assessment is necessary in most cases; let alone a risk assessment.
As the Ladmanová article makes clear, outcome monitoring tools are a way of addressing this – but most licensing boards and policy makers won’t take much notice of them.
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I don’t know if I necessarily agree with this. I think back to the past when I was struggling big-time with depression: I wanted symptom reduction. I wanted the depression gone. And the research shows that psychotherapy isn’t all that good at giving results. Here are some quotes from a psychologist admitting this:
‘Let me draw your attention to one of these, a classic study which examined the results of a number of other studies. In a review of therapy factors that account for significant client progress, Lambert calculated the per cent of improvement that could be attributed to each of several variables… He found that “spontaneous remission” (improvement of the problem by itself without any treatment) accounted for 40%, an additional 15% of the change resulted from placebo effects (which he referred to as “expectancy controls”, that is that the patient expected to get better no matter what was done,) while a further 30% improved as the result of common factors in the relationship such as trust, empathy, insight and warmth. Only 15% of the overall improvement could be attributed to any specific psychological intervention or technique. Based on these findings one could conclude that 85% of clients would improve with the help of a good friend and 40% without even that.’
– Dineen, T. (1998). Psychotherapy: snake oil of the 90’s. Skeptic Magazine 6(3
“[T]here have been very few studies which have evaluated the effectiveness of treatment in real-world settings, and when these are analyzed, they show an average effect size very close to zero… In another major study designed to seek out such evidence, Bickman’s colleague, Bhar Weiss, carefully examined the effect of two years of traditional child psychotherapy as it is typically delivered in out-patient settings. What he found was not the expected benefits but rather no effect at all.”
– Dineen, T. (1998). Psychotherapy: snake oil of the 90’s. Skeptic Magazine 6(3
Quotes taken from here: https://totalmentalhealth.info/how-well-does-psychotherapy-work-mental-health-workers-tell-the-truth/
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Those are good quotes. They are likely quite accurate.
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Of course, some people want “symptom reduction.” Others don’t. The point is that the client is the one who should be able to decide what “success” looks like for them.
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There is a phenomenon called “ethics creep” which plagues researchers – which is the ever increasing ethical requirements stipulated by ethics boards to do research – there is a parallel “ethics creep” in the practice of psychotherapy – an expansion of moral surveillance and bureaucratic oversight – accompanied by an ever increasing number of complaints by fellow professionals and clients (often at the urging of other professionals). This results in psychotherapists practicing more by the book – which is the stipulations of the “psy dispositif” – even though many clinicians know (courtesy of Bruce Wampold’s writings) that a DSM diagnosis and an empirically validated treatment is not the way to go for best outcomes – if a clinician wants best outcomes they will use outcome monitoring tools – but at the risk of getting into trouble with their employer (if they work for an agency) or the licensing board for not following so-called “best practice guidelines”. This is the main reason that psychotherapy results are not giving clients what they want.
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