Research: The friendly facts
Therapy Today, March 2026.

I don’t remember the exact moment of agreeing with Nancy Rowland, former Head of Research for BACP and a dear mentor, that I would write a review of research findings in the counselling and psychotherapy field. I do remember, though, a ‘ride the rapids’ jet boating trip, after the 2005 Society for Psychotherapy Research Conference in Montreal, when we talked about the idea. Perhaps it was the exhilaration of the trip that made me feel like it would be an exciting thing to do: cutting and thrusting through the waves of research findings. In fact, the next year or so was more like rowing across the Atlantic in a storm-force headwind: driving my way through hundreds, maybe even thousands, of research papers – all of which are still neatly stored in arch files on my office floor (and bookshelves and wardrobes).  

Friendly facts 2008

I was very proud of the end result though: Essential Research Findings in Counselling and Psychotherapy: the facts are friendly published by Sage in 2008. I felt like, for the first time, someone had pulled together an accessible, succinct and relatively engaging summary of the latest counselling and psychotherapy research; and one that, unlike National Institute for Health and Care Excellence (NICE) and other medical model guidelines, did not privilege randomised controlled trials (RCTs) and manualised treatment guidelines. Rather, reflecting my own humanistic, existential and personcentred leanings, the book also considered, in depth, the role of the relationship, therapist and client factors in determining change. What I also felt proud of was that in the book I had put to one side my own passion for research methodologies – such as phenomenological, collaborative and self-reflective approaches – and produced a book that turned attention to the findings, per se.

Reviewing all the evidence to 2008, the conclusion I came to was that it was client factors – such as the client’s level of motivation and involvement in therapy – that were the principal determinants of change. ‘As the old joke goes,’ I wrote in the conclusion, ‘How many therapists does it take to change a lightbulb? One, but the lightbulb has really got to want to change.’ Another key conclusion was that most therapeutic orientations were about equivalent in effectiveness. This is the well-known ‘Dodo bird verdict’, named after the Dodo bird in Alice in Wonderland, who exclaims, after the Caucus-race, ‘Everybody has won, and all must have prizes.’ All therapies, the research seemed to show, were better than no therapy, but no orientation of therapy was better (or worse) than the others. 

Ironically, although my book has probably been cited more times for saying ‘It’s the relationship that counts’ than anything else, I actually came away from the research, here, more cautious than I had gone in. Yes, the quality of the relationship was clearly the strongest predictor of outcomes after client factors, but correlation could not be taken as evidence of causation: it might be, for instance, that clients who do better in therapy liked their therapists more. I was surprised, too, by the lack of evidence for therapist factors. While the evidence clearly showed that a proportion of client improvement was due to the person of the therapist, it was unclear why that was the case. Training, supervision, life experience, even personal therapy – none of these factors seemed to show much association with the amount that clients improved. 

Unfortunately research findings do not age well. When Nancy and I first talked about the book she warned me off writing it as a single-authored text. ‘There’s so much new evidence coming out all the time,’ she said, ‘you don’t want to be reviewing it all, yourself, a few years down the line.’ As with so many other things Nancy was right: for years the thought of rowing into that headwind again felt unbearable. So, only after 16 years of procrastinating, balking and evasion did I finally force myself to make a start on the second edition. Probably what helped most was a confluence of new editions of the ‘bibles’ of psychotherapy research that I could draw on, including Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change, Psychotherapy Relationships That Work (Wiley) and the more recent Psychotherapy Skills and Methods That Work (OUP USA). Also, every morning while I was writing, I would post multiple-choice questions on what I had been learning on Facebook, with answers in the evening. That was a great way of remembering that what I was researching had relevance beyond my own particular bubble of desk, computer screen and psychopathic cat. Here’s just one example of the questions I put out there: ‘Recent research has suggested that the greatest degree of client improvement tends to come about when the therapist:  

A. Loves themselves as a person and loves themselves as a therapist
B. Loves themselves as a person but doubts themselves as a therapist
C. Doubts themselves as a person but loves themselves as a therapist
D. Doubts themselves as a person and doubts themselves as a therapist. 

Answer to follow.’ (It’s answer B.) 

So what’s new? What does the research evidence tell us that was not evident in 2008? To some extent, while there are thousands of new research studies out there, the findings are not radically different from 2008. We still know, for instance, that client factors are the principal determinants of change, and we still haven’t found much of a link between the therapist’s own therapy and client outcomes. But at the same time, as I worked through the research for the second edition, I came to see several important developments or shifts in what the evidence was telling us. The following five are ones that, for me, feel particularly significant, striking or unexpected. 

1. Process of change 

In recent years there has been an exciting growth of qualitative research examining in depth how clients actually change in therapy. A key innovation here has been the development of qualitative metaanalysis techniques, which allow researchers to draw together findings from multiple qualitative studies into a coherent whole.¹ What, for instance, do clients see as the impacts of helpful events in psychotherapy? A recent qualitative meta-analysis, drawing on data from 17 studies across a range of orientations, found that the seven most commonly reported impacts (in approximate descending order) were: gaining a new perspective on the self; experiencing relief; feeling heard, understood and accepted; developing new skills/coping strategies; becoming more in touch with your emotions; feeling empowered; and having a sense of reassurance/feeling supported/having a sense of hope.² 

As can be seen here, gaining insight has been found to be the most commonly described outcome of therapy by clients, leading to the potential for new behaviours, choices and ways of relating to self and others, as well as greater mental clarity, confidence and control. For instance, one client in psychodynamic therapy said: ‘I was completely stuck when I started therapy, I shed a lot of tears in therapy. I’m less stuck now, things became more disentangled.’³ Consistent with this, a recent qualitative meta-analysis of clients’ experiences of psychotherapy, drawing on data from more than 100 studies, articulated the core category of change in psychotherapy as follows: ‘Being known and cared for supports clients’ ability to agentically recognise obstructive experiential patterns and address unmet vulnerable needs.’⁴

2. Therapist personality 

Today best estimates are still that therapist characteristics contribute a small but significant amount, around 7% on average, to client change. However, in recent years we have started to get clearer and more compelling evidence on what therapist characteristics make the difference. In part, this is due to developments in digital technology and the increased use of routine outcome monitoring, so that it is possible for researchers to analyse ‘big data’ from hundreds of therapists and tens of thousands of clients. New statistical methods have also helped researchers to separate out differences in outcomes across therapists from differences in outcomes across clients. 

As in 2008 there is very little evidence that therapist demographic characteristics such as age, gender identity or ethnicity make much difference to outcomes. However, if we look at therapist psychological characteristics there is growing evidence that therapists with a more secure attachment style and a more affiliative interpersonal nature tend to have better outcomes overall.^5,6 This may particularly be the case where clients have more severe levels of distress, where greater attachment security may help therapists be more flexible in their responding. There is also now more evidence that greater therapist wellbeing (as measured, for instance, by degrees of self-affiliation) is associated with improved outcomes.⁷ New research is also showing strong links between client outcomes and therapists’ levels of reflexivity, mindfulness and emotional intelligence.⁸ This seems to be particularly important for therapists with marked areas of vulnerability (for example, attachment anxiety, neuroticism). Here, low reflexivity can be particularly problematic; but a combination of high reflexivity and high therapist vulnerability is associated with some of the best client outcomes. 

In terms of therapists’ professional characteristics there is still limited evidence that training leads to substantial improvements in client outcomes. However, at the very least, training has been shown to help therapists improve their skills (for example, empathy).⁹ This has been shown to be particularly the case for deliberate practice, a new approach to therapy training that has become popularised in recent years.¹⁰ Deliberate practice involves a highly effortful focus on the development of specific skills (for example, effective use of silence), with cycles of feedback (for example, through listening to session recordings in supervision), practice and repetition to achieve successive upskilling. Supervision itself also now has more evidence of positive effects, though it seems that it is the quality of the supervision rather than its quantity that matters most.¹¹ This, then, raises the question of what makes a highly effective supervisor, with recent evidence suggesting that it is a mix of collegiality, professionalism, skilfulness and the capacity to create safety. In addition, fascinating new research suggests that clients do better when therapists have higher levels of professional humility: that is, therapists are willing to engage in benign and constructive self-critical evaluation.¹² Answer B to the earlier multiple-choice quiz question seems to be right: we do best, on average, when we value ourselves as a person but are open to questioning the effectiveness of our work. 

3. Therapeutic relationship 

A third area in which there have been significant developments in research findings – again partly driven by advances in statistical methods, and partly by the greater ubiquity of regular outcome monitoring – has been an understanding of the association between the quality of the therapeutic relationship and outcomes. Here, new methods have assessed these variables not just at one time point but at multiple times over therapy. That way it becomes possible to see whether clients’ experiences of positive therapeutic relating directly precede improvements in outcomes. And indeed they do.^13-15 Such studies still cannot prove causality, but they are about as close as we can get through quantitative designs (barring randomising clients to good and poor-quality therapeutic relationships, which may not go down well with an ethics committee!). In addition, an ever-increasing body of qualitative research shows that clients experience the therapeutic relationship as a key factor in determining outcomes – and this is as true for the more techniqueoriented therapies (for example, CBT) as it is for the more relationship-oriented ones (for example, person-centred therapy).¹⁶

4. Dodo or do don’t? 

So does that mean that, according to the latest research, relationship-focused therapies are actually more helpful than technique-focused ones? Unfortunately (for us advocates of relational therapies) not. For a start, the quality of the relationship only explains a moderate amount of variance in outcomes, around 15%.¹⁷ So Yalom’s much-loved professional rosary, ‘It’s the relationship that heals, the relationship that heals, the relationship that heals’, still isn’t borne out by the empirical research.¹⁸ Second, and perhaps more importantly, there’s no evidence that clients rate the therapeutic relationship in relationship-oriented therapies as any better than in techniqueoriented ones. Indeed, when asked about events that led to the formation and strengthening of the alliance, one study found that clients were most likely to cite technical activities such as being taught grounding techniques or listing goals.¹⁹ 

In fact, based on the contemporary evidence, any challenges to the Dodo bird verdict are more likely to come the other way around. In 2008 the conclusion of equivalence across therapeutic orientations seemed pretty compelling to me. Yes, there were studies that showed CBT had better outcomes than personcentred therapy (PCT), but when you dug into them a lot of the findings could be explained by allegiance effects: that is, the biases of the researchers. Not only were such researchers almost always advocates of CBT, but the straw man PCTs they set up were often designed by CBT researchers, and sometimes even supervised and delivered by them – no wonder CBT did better! 

Then in 2021 we had the results of the PRaCTICED trial.²⁰ What was different about this pragmatic RCT of CBT vs PCT (both up to 20 weekly sessions, delivered in real-world NHS settings) was that it was delivered by a team with balanced allegiances; led by a researcher of impeccable methodological rigour and equipoise; and funded by an organisation (BACP) which, if anything, was hoping to show that PCT was not inferior to CBT. It was also one of the largest psychotherapy trials yet conducted, with more than 500 participants. And what did the study find? On the primary outcome, at six months, the clients in the PCT were doing, on average, as well as those in CBT. But at 12 months, on symptoms of depression, those in the CBT conditions were doing somewhat better, on average, than those who had had PCT. 

Of course, one study, however well conducted, is never definitive. But the finding of the PRaCTICED trial triangulates with a number of other lines of research evidence: all suggesting that a ‘classical’, relationship-focused PCT may be somewhat less effective, on average, than a more structured, therapist-directed approach (such as CBT or interpersonal therapy) in reducing symptoms of psychological distress, particularly depression. First, a recent highly rigorous and comprehensive metaanalysis (ie, statistical review) of different psychotherapies for depression found that, ‘The effects of the therapies did not differ significantly from each other, except for non-directive supportive counselling that was less effective than all the other types of therapy.’²¹ Second, within the humanistic therapies themselves, reviews have consistently concluded that more process-directive approaches (such as emotion-focused therapy) tend to show larger effects than less process-directive ones.²² Both these sets of findings could be dismissed as a result of allegiance effects but, third, there is a growing body of qualitative evidence showing that while relational qualities are among the most valued by clients, therapist-led techniques, exercises and guidance are often experienced by clients as being of additive benefit. For instance, clients with primary cancers, when asked what they had found helpful in psychological therapy, described many relationship factors but also pointed to a range of therapist-led techniques, such as engaging with problem-solving activities, and the psychologist sharing their knowledge of the process of adjustment following diagnosis.²³ Recent research has also shown that clients tend to want more, rather than less, therapist direction.²⁴ There is also good evidence to show that assessing and accommodating client preferences are associated with reduced dropout and small improvements to outcomes.²⁵  

In questioning the extension of the Dodo bird verdict to a relationshipfocused PCT there are several important caveats. Among them, nearly all this research uses symptom reduction as the principal outcome. It is quite possible (though not proven) that with different outcome indicators PCT would prove as effective – or even more effective – than other orientations. In addition, these differences are averages, such that some clients will still do much better in PCT than in more therapist-directed approaches. Nevertheless, the evidence today suggests that the Dodo bird verdict may be better considered a ‘Dodo bird tendency’: that, on average, most therapies tend to do about as well as each other most of the time, but there are also important nuances and complexities to consider. 

5. Tailoring therapy 

That leads on, then, to a fifth major area of development for psychotherapy research: understanding how clients’ individual characteristics – such as their problem type, demographic characteristics or personality traits – influence the kind of therapy that may be most helpful for them. Here, developments in the curation of big data, along with machine learning, make it possible to analyse associations between client characteristics and outcomes across hundreds of thousands of clients, and to develop algorithms for matching clients to therapies to optimise benefit. And although in their infancy such approaches seem to work, with small but significant overall advantages for tailored interventions.^26,27 

In terms of what kind of tailoring individual clients may need, recent years have seen a substantial increase in research on culturally adapted therapies. These are interventions in which the language, culture and context of the therapy are systematically modified in ways that are compatible with the client’s cultural patterns, meanings and values. For instance, a culturally adapted CBT for Chinese Americans with depression – developed in collaboration with the Chinese American community – involved integrating Chinese cultural metaphors and symbols, using Chinese cultural and philosophical teachings and addressing issues of salience to the Chinese community.²⁸ Meta-analyses indicate that such adapted therapies can lead to significant gains over treatment as usual.²⁹ Similar effects have been found for therapies that are tailored to clients’ particular religious or spiritual beliefs.³⁰ Qualitative research indicates that clients from other marginalised groups, such as disabled and neurodivergent clients, also value therapeutic practices that are sensitive to their particular contexts and concerns. For instance, one CBT client said, ‘The worst experience I had within therapy was when they completely disregarded my disability and told me to try things [like going to community clubs]. They gave me “advice” to go do things that my disability disallows me.’³¹ Along with professional humility, then, there is evidence to suggest that therapies work best when offered from a standpoint of cultural humility, ‘characterised by respect and lack of superiority toward an individual’s cultural background and experience’.³² 

There is also increased evidence that, on two personality characteristics, particular kinds of clients tend to do better in particular therapies. The first relates to the question of the effectiveness of PCT: clients who are more reactant (for example, don’t like being told what to do) tend to do better in less directive therapies, while clients who are more compliant tend to do better in more directive therapies.³³ Second, clients who have more internalised coping styles tend to do better in insight-oriented therapies (like psychodynamic approaches), while clients who have more externalised coping styles tend to do better in symptom-oriented therapies (like CBT).³⁴ In addition, as we saw earlier, a series of recent metaanalyses are indicating that clients seem to do better, and stay in therapy longer, when it is aligned to their particular preferences.³⁵ 

Meaning-making 

A few months ago, posting some of our recently published research on a therapists’ Facebook group, I was somewhat taken aback by the blunt response, ‘I find these studies to be fantastically boring and completely meaningless.’ This respondent went on to say, ‘What [research] cannot do, no matter the methodology or researcher, is anything meaningful to improve the so-called “outcomes” of therapy.’*

I suspect this view is not uncommon across the counselling and psychotherapy community, but is it right? No doubt I have my own allegiances here, having driven into the headwinds of research evidence twice over, but I think not. Of course, research evidence does not give us all the answers – it is inevitably biased and it can never capture the full complexity of the therapeutic encounter. However, to conclude that it is therefore ‘unnecessary’ and ‘in vain’ would seem a false dichotomisation. Research tells us some things, just as supervision does, and theory, and personal experience; and what it does particularly well, in my view, is to help us see things from a client’s eye view. Research at its best represents the cumulative experiences, perspectives and outcomes of service users, and that can challenge us, as therapists, out of our own, often self-reinforcing theories and assumptions about what works. An orientation, for instance, may teach a therapist that clients change by learning new skills but, as we have seen, that is only one of the benefits that clients can get out of therapy. So maybe that therapist will be challenged to think about how they can also support change through other mechanisms – for instance, helping clients feel empowered, hopeful and reassured. 

In addition, even if we do think that research findings in counselling and psychotherapy are completely meaningless, the reality is the wider world does not. Tell a prospective client who feels depressed that ‘therapy A’ is, on average, more helpful in reducing their depression than ‘therapy B’, and most people, I imagine, would opt for the former. And why shouldn’t they? If I go to a physiotherapist or a dietician I would also like to know that what they do tends to work. As a counterpoint it might be argued that what we do as therapists is more complex and ineffable, with undefinable outcomes. But how many professionals would say that their practice is simple, basic and easily operationalised? Moreover, if we want to be commissioned for practice in public health settings it does not seem unreasonable to me that we are expected to show that in some way our work contributes to improvements in (mental) health. Certainly that is how commissioners, funders and politicians now tend to see things, and I think that is unlikely to reverse. It is no longer enough to say to them, ‘I think that what I do works.’ They want to see the research to back that up. So if we want to see our practices available within the public domain, we need to be familiar with the evidence, and the language of evidence, and develop the kind of research findings that will be persuasive at that level.

In the second edition of Essential Research Findings in Counselling and Psychotherapy, published this spring, there are a multitude of new research findings that I hope will inform and stimulate therapists and help them review their practices. Many of those findings will be reassuring but some, as above, will be challenging, and I think it is important to recognise that engaging with research evidence is not just a cognitive process: it is also a deeply emotional one. Most of us care whether our research practices are supported by the evidence, and the tendency to dismiss, ignore or minimise those findings that challenge it are strong. Personally, for instance, I was gutted when I learnt the outcomes of the PRaCTICED trial – I would have loved to see PCT wiping the floor with CBT – but I also wanted to find the resilience and courage within me to bear that reality and adapt so that I could look at ways of being ever more helpful to my clients. As ethical therapists we are called to be open, inquisitive and embracing of what the evidence out there might mean: to put our clients’ realities before our own needs and wants. This is the spirit that Rogers expresses when he talks about his own research and the facts being friendly: ‘In our early investigations,’ he writes, ‘I can well remember the anxiety of waiting to see how the findings came out. Suppose our hypotheses were disproved! Suppose we were mistaken in our views! Suppose our opinions were not justified!’ 

However, he goes on to state: ‘At such times, as I look back, it seems to me that I disregarded the facts as potential enemies, as possible bearers of disaster. I have perhaps been slow in coming to realise that the facts are always friendly. Every bit of evidence one can acquire, in any area, leads one that much closer to what is true. And being closer to the truth can never be a harmful or dangerous or unsatisfying thing. So while I still hate to readjust my thinking, still hate to give up old ways of perceiving and conceptualising, at some deeper level I have, to a considerable degree, come to realise that these painful reorganisations are what is known as learning, and that, though painful, they always lead to a more satisfying, somewhat more accurate way of seeing life.’³⁶ 

*Consent was given to publish these quotes 

• Mick Cooper’s Essential Research Findings in Counselling and Psychotherapy: the facts are friendly (2nd ed) is co-published by BACP and Sage. Get 35% off your copy with code UKBACP22 at Sage Pub. Offer valid for orders on Sage Pub for shipping to UK (free delivery), Europe, Middle East, Africa and Asia, and orders on Ebooks.

• Mick Cooper’s book launch and workshop ‘On what really works: research that supports your practice’ will take place on 11 April, 10am-1pm. For more information please visit: Online Events.