Watch any video demonstrating the power of a therapeutic treatment. You will see the therapist appear first. They will speak to their personal clinical experience and the experience of other clinicians using the approach. If it is an evidence-based treatment (EBT), they will speak to the research demonstrating the efficacy of their findings in randomized, controlled trials. The therapist will then discuss the interventions, reflections, and interpretations they use. They will introduce their theory of change, how they navigate stages of treatment, the techniques they employ, and who is best served by their approach. They will then introduce the client, who is heretofore unknown and who is the recipient of these interpretations, reflections, and interventions. It is here that we meet the only person who is either capable of or tasked with therapeutic change. When the video ends, you will again see the therapist. They will discuss their view of the session and whether it was a good demonstration of their approach. You will not get to see the next 167 hours of the client’s life, where they will spend the remaining 99.4% of their week trying to implement any and all therapeutic change.

When clients spend the vast majority of their lives outside of the therapy office, it is perhaps no surprise that whichever EBT a clinician uses actually matters very little to their outcomes, and that client factors are the greatest contributors to change. In my own research, client characteristics explained between 80-97% of changes in cohesion, an important contributor to group therapy outcomes. At the same time, everything the counselors did (or didn’t do) explained between 1-9% of change. In others’ wide-ranging findings, client factors explain 86% of change in important outcomes as compared to the roughly 1% explained by the specific EBT used.

So why does something that only accounts for 1% of what matters in therapy account for 100% of what we discuss as clinicians? Why does it continue to be so important to us therapists, and why do we spend so much money, time, and energy on trainings in EBTs when there is good evidence that such training does little if anything to improve client outcomes?

It is my belief that we are so drawn to EBTs as clinicians not because clients need them per say, but because we need them. My hypothesis here is that evidence-based treatments primarily serve an important coping function for therapists, not a directly curative function for clients. Now, to the extent that an EBT may help a clinician cope in adaptive ways with the complexity of psychotherapy, it may be beneficial to their patients. On the other hand, if an EBT emphasizes potentially detrimental coping strategies, it may certainly interfere with important curative processes in a therapy session. Thus, it is my belief that we are studying the wrong set of outcomes when we look at EBTs from the perspective of client outcomes. Instead, we should be comparing EBTs by what they offer the clinician!

While it is beyond the scope of this blog post to examine the evidence on whether EBTs contribute to outcomes only through their impact on therapist coping (though we might start by checking out Beidas & Kendall, 2010), we can certainly hypothesize some ways in which EBTs might either help or hinder counselor coping.

EBTs as Adaptive Coping for Counselors

1). Counselor Tolerance of Ambiguity: One way an EBT may help a clinician to adaptively cope in a therapy session is by offering them an internally consistent narrative. This is extremely important for counselors who are themselves at least as stressed and anxious as their clients, as it provides a sense of direction in the midst of ambiguity. Having a cohesive theory, goals, and set of interventions gives us something to “turn to” in moments of confusion. In this way an EBT is an internal resource that may support emotional softening in response to perceived threats. This would allow a clinician to better tolerate the ambiguity inherent in changing something fundamentally outside of their control (client behaviors) and reduce interpersonal distancing. This would also help them manage anxiety, stay present, and prevent them from detaching, disengaging, or numbing. Such distancing behaviors have indeed been found to negatively predict client outcomes (Shamoon, Lappan, & Blow, 2016).

2). Counselor Emotional Safety: In addition to helping manage negative emotion, having an evidence-based treatment can also support counselor positive emotion by providing containment and emotional acceptance. Having an EBT to turn to during difficult moments can help us manage a finite list of interventions and behaviors. For example, knowing that the goal for a session is simply to help clients identify and label three major automatic negative thoughts can help clinicians breathe a sigh of relief. Indeed, most therapists report that treatment manuals for EBTs help them feel they are staying on track during therapy (Addis & Krasnow, 2000). Together, containment and emotional safety could improve client outcomes by supporting clinician emotional well-being, which is thought to be a major characteristic of the “Master Therapists” (Jennings & Skovholt, 1999).

3). Counselor Experience of Mastery: Evidence-based treatments were initially proposed and studied as a way of legitimizing the profession of psychotherapy in the eyes of the medical community, which itself went through a revolution of “Evidence-Based Medicine” beginning in the 1960s. EBTs can help clinicians feel more legitimate in their role, as well as in the eyes of the medical community and society at large. When we feel that what we have to offer is important and meaningful, we often experience greater self-efficacy and believe we can help our clients. Such self-perceptions have been found to be positively associated with client outcomes by promoting therapeutic alliance and increasing client adherence to treatment (Bartle-Haring, Bryant, & Whiting, 2022).

EBTs as Maladaptive Coping for Counselors

1). Counselor Avoidance: While EBTs may support important positive coping practices, it is also quite possible they may unintentionally reinforce maladaptive counselor behaviors. For example, EBTs may encourage therapists to avoid exploring content that falls outside of prescribed protocols or are seen as overly difficult or distracting from prescribed treatment goals. In an effort to clarify therapy, EBTs may actually hinder a therapist’s capacity to stay with complex or challenging issues that arise. Oftentimes, clients have idiosyncratic goals, values, or theories about how they could change that simply cannot be captured by CBT, EFT, IPT, or any other T. By trying to maintain a specific focus, an EBT may unintentionally suggest that client experiences are unimportant or not valuable to outcomes. This may dissuade clients from meaningful participation in their own therapy, which, because clients are the major change agents, is an incredible loss for outcomes (Holdsworth, Bown, Brown, & Howat, 2014).

2). Counselor Misattunement: It may also be the case that EBTs could interfere with therapist authenticity and present-focused attention, which is core to empathic expression (Macaulay, Toukmanian, & Gordon, 2007). An EBT may unintentionally reinforce over-intellectualizing, emotional numbing, or avoidance of situations which are upsetting to the therapist. This may undermine an empathic, holding presence in the face of distressing emotion, which itself is an important factor in psychological health (see Leyro, Zvolensky, & Bernstein, 2010). Rigid adherence to an EBT may lead therapists to prioritize adherence to treatment protocols over attuning to the experiences of their clients in the here-and-now. This misattunement could potentially result in a lack of responsiveness to clients' changing circumstances or emotional states, ultimately undermining the therapeutic alliance and impeding progress in therapy.

3). Counselor Negative Feedback Loops: In some cases, EBTs may inadvertently promote a dynamic of mutually escalating negative interactions within the therapeutic relationship. Such a negative feedback loop could develop when a therapist becomes overly attached to the EBT as the most important aspect of treatment. As such, a therapist may covertly or overtly exert pressure on a client to conform to an EBT agenda. This may unintentionally create resistance in the client by pushing too hard or insisting on their own perspective. This resistance from the client can then trigger further efforts by the therapist to assert control over the therapeutic process, leading to a cycle of escalating tension and resistance. In this way, instead of fostering collaboration and trust, an EBT may contribute to feelings of frustration, defensiveness, or disengagement on the part of the client.

We therapists need supportive coping practices as much as anyone, and it may just be the case that EBTs say much more about us as counselors than our clients. While that’s not to say that EBTs have no place in therapy (indeed, we at Center for Couples & Self have been trained in many evidence-based treatments), we may need to look again at exactly how they contribute to outcomes. EBTs can potentially offer therapists structure, emotional/cognitive coherence, and a sense of legitimacy, they can also inadvertently perpetuate avoidance of difficult content, misattunement with our clients, and ensnare us in negative feedback loops. It’s likely time that counselors and researchers point our EBT fingers in the right direction and reexamine our own, complex relationship with evidence-based treatments.