Open research questions in Psychotherapy Techniques and Applications

What the literature leaves open

• Further research attention is needed to understand the factors that might help or hinder each facet of the engagement process, - Systematic enquiry into patients' therapy experiences is needed so these voices can be heard and engagement topics can be explored directly

  A model of engagement in psychological therapy · 2026 · DOI

• Investigate the long-term effects of psychotherapy experiences, - Examine the relationship between psychotherapy experiences and treatment outcome in different populations, - Explore the impact of psychotherapy experiences on patient engagement and adherence

  No pain, no gain revisited: the impact of positive and negative psychotherapy experiences on treatment outcome · 2024 · DOI

• There is little agreement on how to define and conceptualise engagement. Few studies focus primarily on engagement, relying mainly on single behavioural indicators. The process of engagement is not well understood, particularly from the patient's perspective.

  A model of engagement in psychological therapy · 2026 · DOI

• Evidence is inconclusive partially because it is rarely assessed which interventions are actually employed in naturalistic outpatient settings.

  What works for whom in outpatient cognitive-behavioral therapy? Integration of techniques from different therapeutic orientations and their interactions as predictors of treatment outcome in different diagnostic groups. · 2026 · DOI

• OBJECTIVE: The mechanisms underlying psychotherapy's effects remain debated, with some emphasizing theory-specific therapeutic techniques and others highlighting common factors like therapeutic alliance.

  What works for whom in outpatient cognitive-behavioral therapy? Integration of techniques from different therapeutic orientations and their interactions as predictors of treatment outcome in different diagnostic groups. · 2026 · DOI

• However, little is known about why some cases are not-on-track and what strategies can help to improve their treatment response.

  Why are some cases not on track? An investigation of common obstacles and solutions during feedback-informed psychological therapy. · 2026 · DOI

• Future research should explore treatment mechanisms, cost-effectiveness, and implications for health policy.

  The long-term effectiveness of psychodynamic and analytical psychotherapy in routine care: Results from a naturalistic study over 6 years. · 2025 · DOI

• OBJECTIVES: Therapists vary widely in their use of feedback, which may reflect differences in how they incorporate feedback into their clinical judgment-especially when their evaluations diverge from their patients'.

  The impact of routine outcome monitoring and feedback integration on treatment outcome: A therapist-specific indicator of belief updating processes? · 2025 · DOI

• OBJECTIVE: Most youth psychotherapies contain multiple treatment elements; little is known about their relative effectiveness.

  Between- and within-person relations between treatment modules and symptom improvements across six randomized controlled trials. · 2025 · DOI

• Analytic process is a poorly understood concept often thought to have an agreed upon meaning despite evidence to the contrary.

  Defining analytic process: An overdue update of an essential analytic concept · 2025 · DOI

• So long as it remains ill-defined, its value as a metric of both candidate progression and whether a presented case demonstrates said process is dubious.

  Defining analytic process: An overdue update of an essential analytic concept · 2025 · DOI

• Representative data examining the effectiveness of psychotherapy under real-world conditions in Austria is lacking.

  Process and outcome of outpatient psychotherapies under clinically representative conditions in Austria: protocol and feasibility of an ongoing study · 2024 · DOI

• Further research on the emotional and relational quality of psychotherapeutic relationships in PD treatments is needed.

  Countertransference, alliance, and outcome in the treatment of patients with personality disorder: a longitudinal naturalistic study · 2024 · DOI

• Interviews with children such as Sam have provided rich data about the psycholinguistic capacities of 4- to 6-year-old oedipal phase children, and particularly their ability to use language for diverse purposes-reporting past experiences, predicting and projecting about future events, exploring beyond the reality with which they are familiar, making jokes to experiment with possibilities, and creating various types of imaginative play. One can see in such sessions elaborate conversational skills and abili ties to take the listener's perspective. At this stage, the child is able to use many levels simultaneously, selecting vocabulary, structures, and appropriate paralinguistic markers, such as into nation, stress, and eye contact, in order successfully to engage with others and follow his own ideas (Chomsky, 1969; Bates, 1976; Bloom and Lahey, 1978; de Villiers and de Villiers, 1978; Olson, 1980). One might hypothesize that these psycholinguistic capacities are necessary preconditions for social development beyond a DonaldJ. Cohen et al. certain point, or for entry into the oedipal phase. This hypoth esis would find support from studies of children with severe language disorders (developmental aphasia) whose social devel opment remains profoundly impaired (Caparulo and Cohen, 1983; Paul and Cohen, 1984; Cantwell and Baker, 1987). Ex ploring the linguistic issues in general and their implications for psychopathology is beyond the scope of this paper. However, it is useful to relate these linguistic capacities to some of the critical elements of the oedipal configuration, for example, the child's interest in comparative power and his suspension of disbelief, and what these entail in relation to aggressive and sexual urges and coping with reality. The comparisons to, and assumption of, attributes of the same-sex parent are highly invested by the oedipal child, who is convinced that his or her fantasies of displacing the rival can and will be realized if only the object of the longings recognizes his superior worth. How the child defines this worth will differ among children and between the sexes and may be represented in terms of physical power, intellect, abilities at manipulating, seductiveness, cooking skills, friendliness, physical charm, among others. That the conquest of the beloved object's ex clusive affection is also predicated on the elimination of the rival proves fertile ground for the child's aggressive fantasies and fears of retaliation. Above all else, the oedipal child is under the pressure of in stinctual drives which cannot and will not find immediate grati fication in reality. In order to sustain his or her quest, the oedipal child must be capable of suspending disbelief-to deny that he or she is small and cannot enjoy the privileges and pleasures of the grownups (Freud, 1920). However, the child is harassed in his quest by anxieties and real deficiencies which must be denied, lessened, or worked through if his invincibility is to be main tained (Peller, 1954). The little girl must find ways to explain why she does not win an exclusive position in father's life in spite of her attempts to woo him (by baking "special treats" just for daddy, wearing mother's lipstick, sitting on his lap), and his admiring responses. The boy at some level needs to confront his exclusion from the parents' special relationship, even though his mother acknowledges how big, strong, and smart he is. Oedipal children must turn from a passive role in which they might fall

  Analytic Discussions with Oedipal Children · 1987 · DOI

• What one recollected about childhood is instead a worked-over version of the memory traces laid at the time, which remain unknown in their original form.

  Freud's Seduction Theory · 1987 · DOI

• There is a lack of understanding of the therapeutic effect of transference interventions in psychodynamic psychotherapy. There is a need for more research on the use of TIs in short-term psychoanalytic psychotherapy with adolescents diagnosed with depression.

  Transference interventions in psychodynamic psychotherapy for adolescent depression: a qualitative study · 2026 · DOI

• Future research could further explore the role of the uncanny in creating fear in literature. Future research could also analyze the use of the uncanny in other genres, such as film or television.

  Blindness and the Unseen: A Psychoanalytic Reading of Fear in Bird Box · 2026 · DOI

• The paper identifies a gap in the analysis of psychological horror and the construction of fear in literature. The paper notes that prior work in Gothic literature has often focused on the breakdown of reason, but has not fully explored the role of the uncanny in creating fear.

  Blindness and the Unseen: A Psychoanalytic Reading of Fear in Bird Box · 2026 · DOI

• The findings of this study highlight the central role of the clinician–patient therapeutic alliance in improving treatment outcomes among patients with depression in Benue State. Accordingly, clinicians should deliberately prioritise early and sustained alliance-building as part of routine care. This can be achieved by clearly discussing treatment goals, agreeing on tasks, and actively involving patients in decision-making from the first few sessions. Also, healthcare facilities should also introduce routine assessment of therapeutic alliance using brief standardised tools to identify and address weak alliances early. Given that stronger therapeutic alliances lead to better outcomes, there is a need to improve the quality of clinician–patient interactions within the healthcare system. Administrators should implement caseload management strategies to reduce clinician burnout and allow adequate time for meaningful engagement with patients. Mental health services should adopt collaborative care approaches (Onah, 2024), ensuring that patients are active participants in treatment decisions, which enhances adherence and satisfaction. Furthermore, supervision systems should incorporate relational competence, enabling senior clinicians to mentor others on effective alliance-building. The integration 16 medRxiv preprint doi: https://doi.org/10.64898/2026.05.19.26353601 ; this version posted May 22, 2026. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license . of patient feedback mechanisms can also help monitor and improve the quality of therapeutic relationships. The significant role of relational factors such as trust, empathy, and communication underscores the importance of structured and intentional interpersonal engagement in clinical practice. Thus, clinicians should adopt effective communication techniques, including open-ended questioning, reflective listening, and clear summarisation, to strengthen trust and understanding. Ensuring continuity of care, where patients consistently see the same clinician, is critical for maintaining relational stability. Additionally, integrating psychoeducation for patients and families can reduce stigma, improve understanding of depression, and enhance trust in treatment. Community-based awareness initiatives should also be encouraged to promote positive attitudes toward mental health care. Finally, culturally responsive and context-sensitive strategies are essential for sustaining therapeutic relationships in Benue State. Clinicians should be trained to engage respectfully with local beliefs and cultural interpretations of depression, using appropriate language and communication styles, including local dialects where necessary. Low-cost innovations such as follow-up phone calls or SMS reminders can help maintain contact between visits and reinforce adherence. At the policy level, therapeutic alliance should be recognised as a key indicator of quality care, while training institutions should embed relational competence as a core component of clinical education. Overall, strengthening the therapeutic relationship represents a practical, scalable, and cost-effective approach to improving depression outcomes in resource-limited settings. 17 medRxiv preprint doi: https://doi.org/10.64898/2026.05.19.26353601 ; this version posted May 22, 2026. The copyright holder for this preprint (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY 4.0 International license .

  Therapeutic Alliance and Treatment Outcomes Among Patients with Depression in Benue State · 2026 · DOI

• Several limitations should be considered when interpreting the findings of this study. First, the cross- sectional design precludes causal inference and limits the ability to establish temporal relationships among therapeutic alliance, relational factors, and treatment outcomes. Second, all variables were assessed using patient self-report measures, raising the possibility of common method bias and inflated associations. Third, the sampling strategy, which involved purposive selection of facilities, may restrict the generalisability of the findings to other settings, particularly underserved populations with limited access to care. Fourth, the absence of clinician-rated alliance measures and objective indicators of treatment adherence limits the comprehensiveness of the assessment. Finally, unmeasured confounding variables, such as clinician experience, treatment modality differences, and severity of depression at baseline, may have influenced the observed relationships. In addition, clinician-related characteristics such as professional discipline, years of clinical experience, and formal psychotherapy training were not comprehensively examined as independent predictors within the structural model. These factors may influence alliance formation and treatment outcomes and should therefore be incorporated into future research. However, beyond its empirical contributions, this study highlights the importance of situating therapeutic processes within their socio-cultural context. In settings characterised by limited resources, high stigma, and variability in mental health literacy, the therapeutic alliance may function not only as a clinical construct but also as a culturally embedded relational process. Future research should therefore move beyond universal models of alliance to develop contextually grounded frameworks that reflect the lived realities of patients in sub-Saharan Africa.

  Therapeutic Alliance and Treatment Outcomes Among Patients with Depression in Benue State · 2026 · DOI

• Traditional literary analysis frequently prioritizes manifest content, overlooking the unconscious. The unconscious is an active and dynamic system that fundamentally shapes human experience and expression. A truly comprehensive understanding of narrative agency necessitates a delve into the unconscious.

  Architectures of the Unconscious: Reimagining Narrative Agency through a Synthesis of Freudian Drive, Jungian Shadow, and Lacanian Real · 2026 · DOI

• The paper suggests that empirical validation of the proposed framework is needed. Future research can build on this framework to develop therapeutic approaches tailored to individual patients' needs.

  Epistemic Object Relations: Character Organisation and the Reception of Information · 2026 · DOI

• The systematic mapping between specific character organisations and specific epistemic stances has not been articulated. The paper identifies a need for a framework that integrates the Psychodynamic Diagnostic Manual (PDM-3) and epistemic trust frameworks.

  Epistemic Object Relations: Character Organisation and the Reception of Information · 2026 · DOI

• It is unclear what therapist-level characteristics predict variation in therapist effectiveness. There is a need for further research into the factors that influence patient outcomes.

  Multimodal Assessments of Therapist Characteristics Are Largely Unrelated to Patient Outcomes: A Preregistered Analysis · 2026 · DOI

• The high heterogeneity of psychopathological phenomena and individual differences in the course of mental problems. The need to consider inter-individual differences and adapt therapy to cultural contexts. The complexity of identifying relatively homogeneous subgroups of patients characterized by distinct profiles of psychological functioning.

  The Need for a Person-Oriented Approach in Research and Therapy: Treatment Personalization in Clinical Psychology and Psychotherapy · 2026 · DOI

Most-cited papers in Psychotherapy Techniques and Applications

• Clinical significance: A statistical approach to defining meaningful change in psychotherapy research. · Journal of Consulting and Clinical Psychology · 1991 · 7,943 citations
• The social constructionist movement in modern psychology. · American Psychologist · 1985 · 2,144 citations
• Relation between working alliance and outcome in psychotherapy: A meta-analysis. · Journal of Counseling Psychology · 1991 · 1,578 citations
• Meta-analysis of psychotherapy outcome studies. · American Psychologist · 1977 · 1,388 citations
• Vicarious traumatization: A framework for understanding the psychological effects of working with victims · Journal of Traumatic Stress · 1990 · 1,372 citations
• The effects of psychotherapy: an evaluation. · Journal of Consulting Psychology · 1952 · 1,146 citations
• The efficacy of psychodynamic psychotherapy. · American Psychologist · 2010 · 1,046 citations
• Comparative Studies of Psychotherapies · Archives of General Psychiatry · 1975 · 1,046 citations
• Toward a unified treatment for emotional disorders · Behavior Therapy · 2004 · 1,044 citations
• Toward an Interactional Description of Depression · Psychiatry · 1976 · 994 citations

Most recent work

• Does baseline severity interact with the effects of psychotherapy for depression? A meta-analytic review · Journal of Affective Disorders · 2026
• PAD-S/CSA as a candidate shared representation layer for computational psychotherapy: minimal architecture and a staged validation roadmap · Frontiers in Psychiatry · 2026
• Psychotherapy treatment manuals for adult populations (1950–2025): A scoping review · Clinical Psychology Review · 2026
• The Essence of Ericksonian Psychotherapy: Toward a Manualized Resource · International Journal of Clinical and Experimental Hypnosis · 2026
• Why are some cases not on track? An investigation of common obstacles and solutions during feedback-informed psychological therapy. · Journal of Consulting and Clinical Psychology · 2026
• Between actionality and meaning: Group therapy as a site of liberation madness · Group Analysis · 2026
• How to define psychological therapy and psychotherapy? – An interdisciplinary proposal · Clinical Psychology in Europe · 2026
• Hypnotically Informed Psychotherapy: Erickson and Beyond · International Journal of Clinical and Experimental Hypnosis · 2026
• From Maverick to Mainstream: Four Key Contributions of Milton H. Erickson to Hypnosis and Psychotherapy · International Journal of Clinical and Experimental Hypnosis · 2026
• Ericksonian Hypnotherapy and Psychotherapy: Special Issue · International Journal of Clinical and Experimental Hypnosis · 2026

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