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Knowledge is power. A key aspect of the Primacy of Therapy Project is to find and publicize knowledge about how therapy is often superior to medications for treating most mental disorders.

Yet there is so much we still need to learn to understand how good we are now, and how great therapy can become. One of the most important topics of research in psychotherapy is monitoring outcomes and alliance, as a way to improve the quality of therapy. Dr. David Burns, in his TEAM approach, strongly advocates measuring client outcomes, and therapeutic alliance in each session. Dr. Burn’s intuition about the value of measuring has been borne out by the research. Jeff Reese’s work showed that when therapists measured outcomes and alliance in individual therapy, that clients improved twice as much, compared to when the therapist did not measure. Ankers, and Duncan ran the largest randomized clinical trial to date in couples therapy. Each therapist measured outcomes and alliance with half their caseload, and did not measure the other half. They found that the effectiveness of therapy was doubled, tripled, or even quadrupled, among the dependent variables. For example, couples in the feedback condition were twice as likely to stay together 6 months after therapy ended, three times as likely for both to be happy at that time, and four times as likely for both to be happy right at the end of therapy, compared to couples who did not give objective feedback to their therapist. Reese found similar results in his marriage therapy study, that when the therapist measured outcomes and alliance, that couples were three times as likely to report clinically significant improvement, compared to when the therapist did not measure.

Clearly, measuring each session dramatically improves the quality of therapy. But so much still needs to be learned. One of the most important areas of research is in mood disorders, such as depression. Many research studies have shown that psychotherapy alone is as effective, or more effective, than medications in treating depression. However, these studies have not delivered therapy where there has been routine measurement of client outcomes, and alliance with the therapist. Client outcomes were usually measured at the end of therapy, and therapeutic alliance was not measured in each session. Thus, the therapist did not know, session by session, if the client was actually improving, and what the client’s sense of teamwork with the therapist was like. The therapist did not know the data if their interventions were helping or not.

This is a major gap in our knowledge. I would encourage any researcher to start a study where people with depression are randomly assigned to treatment either with meds, or with psychotherapy. A crucial feature is that in the therapy condition, outcomes and alliance are measured each session. This would answer the question of how effective therapy is, compared to meds, when therapy has routine measurement incorporated.


Reese, R.J., Norsworthy, L., & Rowlands, S. (2009). Does a continuous feedback model improve psychotherapy outcomes? Psychotherapy: Theory, Research and Practice. 46, 418-431

Anker, M.G., Duncan, B.L., & Sparks, J. A. (2009). Using client feedback to improve couple therapy outcomes: A randomized clinical trial in a naturalistic setting. Journal of Consulting and Clinical Psychology,77, 693-704.

Reese, RJ, Norsworthy, LA., Toland, MD., Slone, NC. (2010). Effect of client feedback on couple psychotherapy outcomes. Psychotherapy: Theory, Research, Practice and Training. 47. 616-630.