Daryl Mahon (Outcomes Matter, Ireland)

Evidence Based Counselling & Psychotherapy for the 21st Century Practitioner

ISBN: 978-1-80455-733-4, eISBN: 978-1-80455-732-7

Publication date: 9 February 2023


Mahon, D. (2023), "Prelims", Evidence Based Counselling & Psychotherapy for the 21st Century Practitioner, Emerald Publishing Limited, Leeds, pp. i-xvi.



Emerald Publishing Limited

Copyright © 2023 Daryl Mahon

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Evidence Based Counselling & Psychotherapy for the 21st Century Practitioner

Title Page

Evidence Based Counselling & Psychotherapy for the 21st Century Practitioner



Outcomes Matter, Ireland

United Kingdom – North America – Japan – India – Malaysia – China

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Emerald Publishing Limited

Howard House, Wagon Lane, Bingley BD16 1WA, UK

First edition 2023

Copyright © 2023 Daryl Mahon, Chapters 9, 10 and 12 © 2023 the respective authors.

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ISBN: 978-1-80455-733-4 (Print)

ISBN: 978-1-80455-732-7 (Online)

ISBN: 978-1-80455-734-1 (Epub)


List of Figures and Tables vii
Biographies ix
Acknowledgements xi
Introduction xiii
Part 1. Setting the Scene for Evidence Based Practice
Chapter 1: Empirically Supported Treatments: A Brief History
Daryl Mahon 3
Chapter 2: Evidence Based Practice: An Overview
Daryl Mahon 15
Chapter 3: The Common Factors in Therapy
Daryl Mahon 27
Part 2. Evidence Based Relationships & Responsiveness
Chapter 4: Evidence Based Relationships 1: Therapeutic Alliance, Goals and Collaboration, Alliance Rupture–Repair, and Feedback-informed Care
Daryl Mahon 39
Chapter 5: Evidence Based Relationships 2: Treatment Credibility and Outcome Expectancy
Daryl Mahon 53
Chapter 6: Evidence Based Relationships 3: Emotional Expression, Counter-transference, Self-disclosure, and Immediacy
Daryl Mahon 61
Chapter 7: Evidence Based Relationships 4: Empathy, Congruence, Unconditional Positive Regard, and Real Relationship
Daryl Mahon 71
Chapter 8: Evidence Based Responsiveness 1: Client Factors
Daryl Mahon 85
Chapter 9: Evidence Based Responsiveness 2: Multicultural Considerations
Ravind Jeawon and Daryl Mahon 99
Part 3. Innovations for 21st Century Psychotherapy: Practice, Supervision & Training
Chapter 10: Information Technology and Behavioural Healthcare in the 21st Century
Jeb Brown, Ashley Simon and Justin Turner 117
Chapter 11: Deliberate Practice for Enhancing Skill Development in 21st Century Psychotherapy
Daryl Mahon 135
Chapter 12: Enhancing Supervision Through the Use of Data
Daryl Mahon and Jeb Brown 147
Chapter 13: Simulated Psychotherapy Case Study for the 21st Century Practitioner and Supervisor
Daryl Mahon 159
Index 175

List of Figures and Tables


Fig. 1. EBP in Psychology. 17
Fig. 2. Contextual Deliberate Practice Model. 173


Table 1. Areas of Concern and Some Solutions. 11
Table 2. Guidelines from APA. 16
Table 3. Types of Research Used to Establish Effectiveness of Psychological Therapies. 18
Table 4. Types of Alliance Ruptures. 44
Table 5. Five Levels of Empathy. 74
Table 6. Stages of Change Description. 87
Table 7. MCO Framework. 108



Daryl Mahon, is a psychotherapist, lecturer and researcher. Prior to taking up his current role in research, he worked across the social inclusion sector, working with individuals and communities facing marginalisation. Much of his work has centred on substance use with people also involved in the criminal justice system, mental health difficulties and homelessness. More recently, he has been working as an Action Researcher with a European non-profit organisation based in Dublin working in complex systems change to support social services to solve complex problems and scale social innovations and evidence based practices.

He also lectures in Health and Social Care and delivers training to national and international practitioners and organisations. He has published in various peer reviewed areas related to psychotherapy processes and outcomes, trauma and leadership. His recently published best-selling book on Amazon, Trauma Responsive Organisations: The Trauma Ecology Model provides an in-depth exploration into trauma responsive organisations. He used the period during Covid to transition from psychotherapy practice to focus exclusively on research, training and lecturing.


Jeb Brown completed his PhD in Counselling Psychology from Duke University in 1978. During the next two decades, he worked in a series of jobs where he was both a clinician and an administrator/supervisor, Including as Executive Director for The Center for Family Development, Executive Director of United Healthcare’s Behavioural Health Systems in Utah and Director of Clinical Programmes for Aetna Health Plans. In 1998, he founded a consulting firm, the Center for Clinical Informatics, and began work on the ALERT Clinical Information System for PacifiCare Behavioural Health.

The ALERT system survived PacifiCare’s acquisition by United Health Care and collaborative work with various academic researchers who were granted access to data within ALERT clinical information system resulted in a stream of peer reviewed articles advancing the methodology for benchmarking treatment outcomes. In 2007, he and Takuya Minami, PhD, founded the ACORN Collaboration and began work on a next generation clinical information system with a goal of greatly expanding the capabilities of older platforms. The Center for Clinical Informatics maintains the servers and programmes the system. The ACORN platform continues to build off lessons learned over 20 years of research and development, and regular use of the platform by practitioners has been demonstrated to measurably, clinically and meaningfully improve treatment outcomes from one year to the next. Until recently, he continues to maintain a part-time psychotherapy practice.

Ravind Jeawon, MIACP, is a licenced, Dublin-based psychotherapist and Founder of Talk Therapy Dublin, a service which aims to provide inclusive counselling supports to clients experiencing distress. His clinical experience began supporting community counselling services in Dublin providing psychotherapy and psychosocial support to communities affected by socioeconomic inequality, organised crime and homelessness. Having spent over three years in this area, he moved into private practice and noticed further demand by minoritised clients looking for responsive counselling linked to issues around ethnicity, race and the experience of migration. This encouraged an increasing interest in multiculturally responsive counselling, prompting him to pursue further training in the area at the Nafsiyat Intercultural Centre in London.

He has expanded his work to include training and the mentoring of students and newly qualified therapists from diverse backgrounds and provides counselling services to the International Organization for Migration in Ireland linked to their voluntary return programme. As a therapist, he continues to advocate for more inclusivity within mental health practice, particularly linked to core trainings and an improvement in multicultural responsiveness from caring professions when providing services to minoritised communities.

Ashley Simon, is a Co-owner of ACORN, a mental health analytics platform that tracks client progress and clinician effectiveness. Over her 10 years at ACORN, Ashley has worked as the head of Risk Assessment, QA, has co-authored on the collaboration’s psychometric research, and now directs ACORN’s content and training initiative. She holds a Master’s degree in Middle East Studies and Linguistics, and a Bachelor’s degree in Psychology.

Justin Turner, is a a Co-owner of ACORN. With over a decade of experience at ACORN as the operational manager, Justin oversees a wide array of daily functions. These functions include customer support, employee management and training, database management, form creation, and the creation of informational videos that help to inform clinicians of best practices for improving their clients’ outcomes.


This is the second time in a 12-month period that I have sat down to write the acknowledgements part of a fully completed academic book. My reason for invoking this is not one of pride, although proud I am. The reason I bring this to the attention of the reader is to express my gratitude to my family, especially my wife. You don’t write one, let alone two academic books during a 12-month period without the support of your family. To the unwavering support of my wife Jessica who puts up with my antics and long hours behind the computer screen, I love you. My children Zianna and Zayne, who never fail to enquire into my progress with my books. My hope is that I will be enquiring into the progress of both of your books in the future.

To my valued colleagues who contributed to chapters. Ravind Jeawon has come on board for the second time and brings his passion for making therapy more multiculturally responsive, thank you. To Dr Jeb Brown, who will be surprised to know that he helped plant the seed for this book, long before we ever met. Your contributions have greatly enriched this book and your life’s work is truly impressive. It has been my absolute pleasure getting to know you during our online conversations and writing articles together.


In the second year of my undergrad training in psychotherapy, two things happened that are relevant to the writing of this book. Firstly, I came across research on the common factors, and I read an article that was written by my now colleague, co-author and chapter contributor to this book, Dr Jeb Brown. Perhaps, I was put off by the response that the lecturer gave me when I brought the common factors up for discussion, or perhaps like the lecturer and many other practitioners, I didn’t fully appreciate the relevance and significance of the common factors in therapy. Thus, my focus went elsewhere in the therapy literature. In psychotherapy, this generally means getting caught up in the next modality of therapy that is being marketed as the next great pill to solve a range of psychological issues. Unfortunately, much of psychotherapy research and practice likes to treat therapy like a medicine. That is, certain therapies work like a pill and act as remedial interventions for specific disorders or issues. Thankfully, it was not long before I was back on track and exploring the therapeutic factors that provide for effective psychotherapy, and it is these factors that make up a large part of this book. I seek to move the debate on by exploring what we know about the various factors (non-modalities) that contribute to the change process, and how we as a field can build on this knowledge through innovative deliberate practice training methods, and data-informed supervision.

I have always been curious as to how things work, no more so than with psychotherapy. So, as I delved back into the research on common factors and other aspects of psychotherapy processes and outcomes I was shocked to find that many of the criteria that we place huge value on have are generally not predictive of client outcomes. Years practicing, level of qualification, modality delivered, supervision, personal therapy, licencing body and continuing professional development do not tend to improve the effectiveness of the practitioner. I was both shocked and excited, and began to investigate these areas eagerly, publishing some papers. After spending many years practicing, researching and providing training in psychotherapy processes and outcomes, it makes sense to support this with an academic book. Whether you are a novice psychotherapy trainee, or a seasoned practitioner or supervisor, you will find this book a helpful evidence based resource. Over three sections, the chapters discuss evidence based practice in its various forms, including an analysis of research used, the debate around the effectiveness of specific therapies, commonalities across therapies and the many evidence based relationship variables that are said to contribute to effective psychotherapy. In addition, client factors are also discussed before moving onto exploring the use of technology, deliberate practice, supervision, and a simulated client case that will illustrate the application of some of the methods and ideas that we have outlined. As such, the book is structured across the following three sections, which describe what it is that an effective twenty-first century practitioner needs to know, do and reflect on to improve the effectiveness of their psychotherapeutic work and client outcomes.

Part 1

The first part of this book explores three key aspects of psychotherapy research and practice. In Chapter 1, I examine the evolution of empirically supported treatments (EST). Not without their criticism, I provide a historical perspective on EST and discuss how ESTs are often positioned as psychologies answer to medicine. That is, ESTs are treatments that are designed to reduce symptomology in the same way medicine provides a pill to treat a sick person. The role of the American Psychological Association in developing these therapies is outlined along with a critique of the role of the randomised control trial as a way to assess effectiveness of treatments.

In Chapter 2, I provide an overview of Evidence based practice (EBP) as defined and operationalised by the American Psychological Association. Crucially, in comparison to EST, EBP is positioned as a verb, as opposed to the noun like use of treatment modalities. The three components of EBP are discussed, namely:

  1. The best available evidence; in conjunction with

  2. Individual clinical expertise; that is consistent with

  3. Client culture, values and preferences.

‘Everyone has won, and all must have prizes’. This is the premise of the debate offered by the common factors proponents discussed in Chapter 3. The common factor debate rests on the idea that in general all treatment modalities will tend to be about equally effective because of non-specific treatment element that are common across diverse treatment approaches. It was Saul Rosenzweig in 1936 who first put forward the idea of commonalities among therapies. Since then, other researchers have built on these ideas, and this chapter tracks the trajectory of this research and the models proposed. The chapter finishes with some ideas regarding common and specific factors in therapy, ultimately, whether therapy gains its effectiveness from specific or common factors is perhaps a misleading dichotomy.

Part 2

The second section in this book deals with the substantive variables that have shown to impact on the outcome of psychotherapy. Altogether, I discuss 22 different factors that practitioners must consider under the heading of evidence based relationships, and evidence based responsiveness. In order to achieve this within the publishing guidelines, yet also provide the necessary information, a structured approach that provides a brief overview of each construct, along with the most up-to-date research, and the impact of the variable on psychotherapy outcomes is summarised. As such, the purpose is not to delve deep into each construct in detail, but rather, to provide a basic description to help the practitioner understand the variable being discussed, its empirical foundations and several top tips. The substantial bibliographies in each chapter will provide areas for further reading. Considering the breadth of constructs across this text, and given my aim to have this book act as a practical evidence based resource for the average practitioner to dip in and out of, having bite size chunks that practitioners can draw on is the best way to achieve this.

The first four chapters in Part 2 explore the research pertaining to evidence based relationships. Chapter 4 discusses the big impactful variables of the therapeutic alliance, goals and collaboration, alliance rupture–repair, and feedback-informed treatment. Chapter 5 explores how the idea of expectancy is conceptualised in psychotherapy, through treatment credibility and outcome expectancy, two key common factors that do not get discussed enough in the literature. Internal experiences can be considered to be the theme of Chapter 6, the relationship aspects of emotional expression, counter-transference, self-disclosure and immediacy are examined.

Finally, in Chapter 7, the big impactful variables of empathy, genuineness, unconditional positive regard and the real relationship are considered. Like previous chapters in this section, the research basis, impact and top tips are provided.

The second section of Part 2 focuses on evidence based responsiveness. While practitioners must be responsive to clients in various different ways, this part of the book provides an examination of responsiveness based on what we can consider to be client characteristics. In Chapter 8 and using the same format as in evidence based relationships, I set out the relevant research and impact of, attachment style, coping style, reactant level and stage of readiness for change Furthermore, the process of adapting treatment based on client preferences is considered. Multicultural responsiveness is dealt with in Chapter 9, Ravind Jeawon and I felt it necessary to have a whole chapter dedicated to this important area of psychotherapy practice. Ravind joins me once again to author a multicultural chapter, after co-authoring a chapter in my previous book on trauma responsive organisations.

Part 3

Part 3 of this book is where the idea of the twenty-first century practitioner really comes into its own. The final section of the book has four exciting chapters that will outline various innovative practices in the training and supervision of practitioners, in addition to the use of technology in therapy, and a simulated client case study demonstrating the application of many of the processes and practices discussed. I am grateful to have Dr Jeb Brown contribute Chapter 10 on the use of technology in psychotherapy. Anyone with an interest in the use of ‘big data’ for the purpose of psychotherapy will enjoy both the historic perspective, and the current innovations. Jeb also co-authored with me, a chapter on the use of data in supervision for the purpose of providing more effective care, and to inform deliberate practice.

Deliberate practice is a concept still in its infancy as applied to the initial training and ongoing continuous development of seasoned practitioners. Chapter 11 provides a rationale for the use of deliberate practice in the acquisition of psychotherapy skills and expertise. The processes and principles involved in this training regime are discussed, and I link it to the big impact variables outlined in the previous chapters as an initial method for skills acquisition. The use of routine outcome data in supervision is described in Chapter 12. Dr Jeb Brown and I provide the reader with picture of what the supervisory relationship in the twenty-first century can look like by using data to inform supervision and a deliberate practice training regime. Finally, Chapter 13 provides a simulated client case study for the twenty-first century practitioner and supervisor. A narrative commentary of a client–practitioner session illustrates the application of many of the variables discussed in this book, in addition to a practitioner–supervisor session focussed on using data and clinical information to inform supervision and deliberate practice to improve the acquisition of skills, and to enhance expertise and improve outcomes.