What are a few of the key characteristics of truly effective therapy? This question goes beyond the typical “evidence-based” argument commonly employed by researchers and clinicians to tout the superiority of one therapeutic approach over another, and is often considered by clients or patients when choosing a psychotherapist.

The reality is that the kind of efficacy I am referring to here transcends any particular type of therapy, be it CBT, DBT, REBT, ACT, Adlerian, positive psychology, person-centered, psychodynamic, psychoanalytic, Jungian, humanistic, existential, gestalt therapy, coherence therapy, narrative therapy, solution-focused therapy, etc., because there is variance of efficacy even within these various orientations to therapy. For instance, some courses of psychoanalytic or cognitive-behavioral therapy are more or less successful than others, and the same may be said of all the other therapy types.

How can we account for these significant differences in efficacy within these specific therapeutic approaches? And, more generally, what makes some courses of psychotherapy successful from the patient’s perspective and others not so successful? (See, for example, my previous PT posting about author Daphne Merkin’s deeply frustrating experience with therapy here.)

For some time now, researchers (2024) have been telling us that seasoned psychotherapists not only do not generally attain better outcomes in treatment, but, on average, they actually become somewhat less effective the more experience they accrue. How can that be?

Certainly, this is deeply discouraging news for the senior practitioner, who likes to think of him or herself as improving with age like a fine wine or cheese. If—and this is something difficult for some of us to do—we are to accept this counterintuitive phenomenon noted in scientific studies, including earlier ones that found no difference in therapeutic outcomes between treatment provided by neophyte and clinically experienced providers, how are we to make sense of it? And what are the implications and impact on the self-esteem and professional persona of the seasoned clinician? Not to mention, for the public, who traditionally tend to look for someone with more rather than less clinical experience when seeking a psychotherapist.

If we were to visualize a graph of the evolution, efficacy, and professional development of a psychotherapist, I would, for most, imagine it peaking at some point well into their career when sufficient clinical and life experience has been accrued. If so, what then could possibly explain the studies suggesting that there is, for some, an inverse correlation between experience and efficacy? And why might it decline rather than continuing to evolve and develop at some point?

In most professions, whether plumbing, carpentry, auto repair, acting, writing, medicine, physics, movie-making, sculpture, architecture, etc., experience matters. Certain skills must be mastered, and the neophyte needs to work hard and long, typically under the watchful eye and tutelage of a more experienced mentor or supervisor, in order to attain and hone these essential skills. Thus, the first question we must ask ourselves has to do with the basic skills needed to conduct psychotherapy: What are they? For if the effective practice of psychotherapy requires certain specific skills, it stands to reason that the trainee who has not yet mastered these skills would be less (not more or equally) effective than those who have. If this is not the case, as some of these studies suggest, what makes psychotherapy effective apart from acquiring these fundamental skills?

One key question regarding such research findings has to do with how psychotherapy efficacy was measured and defined. For example, psychoanalysis or depth psychology has its own notions of what a successful psychotherapy outcome looks like, existential therapy another, and cognitive-behavioral therapy still another. Moreover, therapy goals and outcomes may be different for younger and older patients or clients, with younger patients possibly seeking younger therapists than older ones.

As celebrated existential therapist Irvin Yalom might respond to this query: “It’s the relationship, stupid.” Existential psychotherapists like Rollo May, J.F.T. Bugental, and Yalom have long emphasized and touted the profound therapeutic power of the clinical relationship itself. Indeed, many existential therapists would argue that the preoccupation with skills and technique ultimately diminishes the healing power of the psychotherapy relationship. So, if, as existential therapists have long held, the success of psychotherapy hinges primarily on the nature and quality of the relationship between clinician and client or patient, one could conclude that, to the extent this capacity to create such an essential interpersonal relationship is present in the student as much as the seasoned therapist, practice and experience are unnecessary.

Indeed, following this line of logic, it could be argued that the more education, technical training, and clinical experience a psychotherapist receives, the less able they are to promote and maintain a healing therapeutic alliance. But that, in my view, is a specious argument at best. Clinical training and experience are at least as important as the natural capacity to be curious, care, and create supportive, nurturing relationships, though the latter quality is undeniably central and something that cannot fully be taught.

In this sense, the fundamental ability to compassionately relate to and empathize with others in psychotherapy is, as with innate talent in music, art, medicine, or other pursuits, something someone either has or does not have. It is a gift and, in some cases, stems from the psychotherapist’s personal experience of being a “wounded healer.” It can be cultivated and improved upon, but not merely manufactured by attending graduate or medical school. Psychotherapy trainees who already possess this natural talent for relating deeply to others start out with a distinct advantage over those in their cohort who lack this ability.

Indeed, it may be that those psychotherapists who do not possess this innate talent initially learn and benefit from their technical education and training, but later peak in their capacity to relate deeply to their patients. Interestingly, their intrinsic psychological typology (Jung, 1971) plays some part: While at first blush we might believe that more extraverted types hold an advantage in creating and maintaining this all-important transformative therapeutic alliance, we may be mistaken when speaking specifically of psychotherapy, which traditionally attracted more introverted than extraverted practitioners. While extraverted types can be educated and trained to be more attentive and receptive to the inner life of both themselves and their patients, such introversion for them remains, as Jung recognized, their “inferior function,” which, over time, may reach its farthest limitations.

Therapist “burnout” is yet another possible explanation for the diminishing returns over time: Lack of self-care on the part of the psychotherapist inevitably takes its toll on the quality of the therapeutic relationship and efficacy of treatment. This underscores the vital importance for psychotherapists to take exceptionally good care of themselves, both emotionally and physically, and to seek psychotherapy for themselves as needed.

At any event, people seeking psychotherapy would do well to consider not only the relevant factors of education, training, clinical experience, and particular therapeutic approach when choosing a therapist but other, sometimes less tangible, factors such as the “fit” between therapist and patient, the style, the “feel,” etc. For, in the end, as various studies have shown (see, for example, Wampold, 2001 ), it is the quality of the therapeutic relationship, what we call the “working alliance”—in conjunction with factors like the clinician’s theoretical orientation, training, personality, psychological type, and world-view—that contributes to the success or failure of psychotherapy.