The Most Important Skill Set in Mental Health

Steven C. Hayes

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Aug 13, 2022

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What We Found After Analyzing Nearly 55.000 Studies

Credit: Nicole Avagliano

Why does psychotherapy work? Until relatively recently, many scientists studying methods of improving mental and behavioral health have delayed answering that question. Instead, they argued, it’s better first to ask if a method works, and when we know that it does, then we can ask why.

It’s not an irrational strategy, but as the decades went by thousands upon thousands of studies poured out an ever expanding list of interventions, many of which might look different but actually work by the same processes or mechanisms. The lists of “evidence-based therapies” maintained by scientific bodies or governmental agencies did not require any knowledge of processes of change, so methods proliferated. Sometimes quite outlandish theories were put forward by therapy advocates and as long as the bottom line outcomes were better than a control condition, the methods went on those lists — emboldening advocates to claim their theories were correct.

Maybe. Maybe not. Outcomes alone can’t tell you. You have to answer the “why” question.

Gradually statistical methods that identify important pathways of change — that answer the why question — became more common in psychotherapy research. The best known and most widely used method is called “mediational analysis”. Mediation applies when a) a treatment changes a near term process more so than a control condition, b) that process relates to outcomes in both groups, and pulling out that “a to b” pathway significantly reduces the impact of treatment on outcome. It’s not a perfect method but it’s a place to start and the body of studies in that area are now large enough to do a comprehensive tally. About five years ago, my colleagues (Stefan Hofmann then at Boston University; Joe Ciarrochi at Australian Catholic University; and our associates Baljinder Sahdra and Fred Chin) and I decided to look at all successful mediational studies ever done on any psychosocial intervention in a randomized controlled trial targeting a mental health outcome.

We had no idea what we were in for.

It turned out to be a huge effort that took the work of nearly 50 people over the next four years to complete. We…