Have you ever felt like you’re paying a therapist to simply listen, only to wonder when the real work begins?
In youth psychotherapy, clinicians often choose from a wide menu of techniques, but it’s often unclear which ones are truly effective or just filling time.
New research sought to find out what specific “treatment elements” within therapy sessions are most powerfully linked to children and adolescents feeling better.
This large-scale investigation combined data from six previous clinical trials of Modular Approach to Therapy for Children (MATCH).
The study followed 490 youths aged 6 to 15 across 5,403 treatment sessions.
Researchers used sophisticated statistical models to track weekly changes in symptoms, comparing them against the specific treatment principles used in the immediately preceding session.
This technique allowed them to separate week-to-week changes (within-person effects) from overall differences between clients (between-person effects), offering a clearer look at what truly drives change.
Key Takeaways
- Action is Power: Therapeutic principles focused on building skills—specifically “increasing motivation” (like rewards/praise) and “trying the opposite” (like exposure)—were linked to significantly better, immediate symptom outcomes.
- The Future is Now: The “future planning” principle, which involves reviewing skills and planning post-therapy use, also predicted especially good outcomes. Greater overall use of future planning throughout treatment was linked to better long-term outcomes for some symptoms.
- Engagement Comes at a Cost: “Engagement/psychoeducation,” which includes rapport-building activities, was associated with worse immediate symptom outcomes.
- Skills Over Small Talk: The negative link to engagement was mainly driven by “getting to know you” activities, which were highly correlated with less time spent on skills-building modules.
- Some Skills Showed No Link: Three common skill principles—”feeling calm,” “repairing thoughts,” and “solving problems”—did not show a significant short-term association with symptom change in this study.
The study organized 33 individual therapy modules into seven overarching treatment principles. The core finding reveals a stark split in effectiveness.
The High-Impact Skill Builders
Three principles were strongly associated with immediate positive changes in symptoms: “increasing motivation,” “trying the opposite,” and “future planning”.
- Increasing Motivation: This principle uses behavioral methods like contingency management (rewards) to encourage desirable behaviors. Its use was linked to better symptom scores on caregiver-reported measures of internalizing, externalizing, and total symptoms. Within this principle, specific modules like praise and active ignoring showed the strongest beneficial effects.
- Trying the Opposite: This is essentially practicing the positive opposite of unhelpful behaviors, with classic examples being exposure for anxiety or behavioral activation for depression. Its use was linked to better youth-rated outcomes for externalizing and idiographic top problems. The exposure module (practicing) was especially promising.
- Future Planning: Generally used later in therapy, this involves planning how to maintain and use skills after treatment ends. Both the total amount of this principle used across treatment (between-person effect) and its use in any given week (within-person effect) were linked to better outcomes. This suggests that both finishing a full, planned course of therapy and practicing post-therapy skills are important for symptom scores.
The Engagement Paradox
The single most frequently used principle, “engagement/psychoeducation,” was surprisingly linked to worse subsequent symptom scores across six different measures.
This principle includes activities like “getting acquainted,” building rapport, general conversation, and social support.
The researchers stress that this doesn’t mean the therapeutic relationship is bad.
However, their sub-analysis found the negative effect was primarily driven by “getting to know you” activities and engaging parents.
Why the unexpected link to poorer outcomes?
The data showed that when therapists spent more time on engagement, they spent significantly less time on skills-based principles.
The study suggests that when building a relationship and building skills compete for time, the benefit of treatment may be reduced.
The Behavioral Edge
Interestingly, the most effective principles—increasing motivation and trying the opposite—are both relatively behavioral in nature.
The three more cognitively or physiologically focused principles—”feeling calm,” “repairing thoughts,” and “solving problems”—did not show significant short-term effects.
This aligns with some past research suggesting that behavioral approaches may be especially effective for youth.
Why It Matters: Prioritizing Action in Therapy
For a parent or guardian, these findings offer a vital perspective on what to look for in youth therapy.
If a child’s therapy seems focused session after session on only talking about feelings or vague problem identification, the science suggests the treatment may not be optimally effective.
This research supports a model of therapy where action and skill acquisition are prioritized.
Think of therapy not as a place to just talk, but as a mental gymnasium where practical, difficult skills are taught and practiced, like exposure (trying the opposite) or using a reward chart (increasing motivation).
For clinicians, these results offer data to help select and prioritize treatment elements, especially when uncertainty arises.
The takeaway is clear:
While a good relationship is important, the core work of youth psychotherapy seems to lie in the consistent, session-by-session application of specific, behavioral, and future-oriented skills.
These findings may ultimately help refine youth psychotherapy protocols to emphasize these high-impact methods, moving us closer to a truly personalized and efficient mental health care system.
Reference
Girard, J. M., Yermol, D. A., Bylsma, L. M., Cohn, J. F., Fournier, J. C., Morency, L.-P., & Swartz, H. A. (2025). Dynamic and dyadic relationships between facial behavior, working alliance, and treatment outcomes during depression therapy. Journal of Consulting and Clinical Psychology, 93(11), 749–760. https://doi.org/10.1037/ccp0000980
