Psychoanalysis Unit


Predicting Negative and Null Clinical Outcomes in Adult Psychotherapy

A Mixed-Methods, Naturalistic Study of Implicated Interpersonal Variables


It has consistently been estimated that one-third to two-thirds of adults who attend psychological therapies experience negative (harmful) or null (insignificant) treatment outcomes (NNCOs) (Lambert, 2010). This situation presents serious ethical concerns in relation to unmet patient needs, therapist training and the allocation of resources. The current researchers are focusing on the problem of NNCOs in individual adult psychological therapy. They wish to explore the possibility that NNCOs might be predicted in advance, providing opportunities for preventative action to be taken. They have considered theories and research from 3 notable sources: psychoanalysis/psychodynamic psychotherapy (Lane, Monaco & Gregson, 1997), epistemic trust theory (Fonagy, Luyten and Allison, 2015) and p factor theory (Caspi, Houts, Belsky, Goldman-Mellor, Harrington, Israel, & Moffitt, 2014). Each of these perspectives propose that particular variables are implicated in NNCOs. The team have devised a naturalistic, mixed-methods research design to investigate the predictive value of these variables in relation to NNCOs.


In the quantitative leg of the study the research team aim to:

  1. Investigate the preliminary reliability and validity of a new measure of epistemic trust.
  2. Establish whether psychoanalytic/psychodynamic NTR variables, epistemic trust and the p factor are observable to a significantly greater extent in NNCO cases than in non-NNCO cases.
  3. Test the theory that there is a relationship between NTR variables, epistemic trust and the p factor, and that epistemic trust supersedes NTR variables and the p factor as a predictor of NNCOs.

In the qualitative leg of the study the research team aim to:

  1. Establish if interpersonal therapeutic events associated with NNCO variables can be reliably identified in therapy sessions.
  2. Establish the extent to which therapists are aware of the emergence of these variables in therapy sessions.
  3. Explore the nature of such interactions and their relationship to epistemic trust, social learning and therapeutic progress in NNCO and non-NNCO cases from participants’ and expert non-participants’ perspectives.


Current stage of project

The research team are working on the development of the Epistemic Trust Questionnaire, along with other research teams in UCL. They have recruited 3 psychological treatment providers in Dublin, Ireland (where the data collection will be conducted) to participate in the study. They have been granted funding by the American Psychoanalytic Association. They have obtained ethical approval from UCL and are in the final stages of the ethics application process in Ireland.


Research team and affiliations

Professor Patrick Luyten is Director of the PhD in Psychoanalysis programme and Course Director of the PhD programme in Evidence-Based Child and Adolescent Mental Health at University College London. He is a member of Research Advisory Board and the Conceptual and Empirical Research Committee of the International Psychoanalytical Association. Professor Luyten is also Associate Professor at the Faculty of Psychology and Educational Sciences, University of Leuven, Belgium

Professor Peter Fonagy OBE is the Head of the Research Department of Clinical, Educational and Health Psychology, and Professor of Contemporary Psychoanalysis and Developmental Science at University College, London.  He is CEO of the Anna Freud Centre, London, and is currently serving as Senior Investigator, British National Institute for Health Research. He is also Visiting Clinical Professor at Harvard University, and Clinical Professor of Psychiatry at Yale University.

Claire O’Dowda is researching this subject as part of a PhD in Psychoanalysis that she is completing under the supervision of Professor Patrick Luyten and Professor Fonagy in University College London. Claire is a Chartered Counselling Psychologist, a qualified Clinical Supervisor and an Adjunct Teaching Fellow in Trinity College Dublin.


Publications and related reading

Bo, S., Sharp, C., Fonagy, P., & Kongerslev, M. (2017). Hypermentalizing, attachment, and epistemic trust in adolescent BPD: Clinical illustrations. Personality Disorders: Theory, Research, and Treatment8(2), 172.

Fonagy, P., & Allison, E. (2014). The role of mentalizing and epistemic trust in the therapeutic relationship. Psychotherapy, 51(3), 372–380. https://doi.org/10.1037/a0036505

Fonagy, P., & Campbell, C. (2017). Mentalizing, attachment and epistemic trust: how psychotherapy can promote resilience. Psychiatria Hungarica32(3), 283-287.

Fonagy, P., Campbell, C., & Bateman, A. (2017). Mentalizing, attachment, and epistemic trust in group therapy. International Journal of Group Psychotherapy67(2), 176-201.

Fonagy, P., Luyten, P., & Allison, E. (2015). Epistemic petrification and the restoration of epistemic trust: A new conceptualization of borderline personality disorder and its psychosocial treatment. Journal of personality disorders29(5), 575-609.

Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed our minds about: Part 1. Borderline personality disorder as a limitation of resilience. Borderline Personality Disorder and Emotion Dysregulation, 4(1), 11. https://doi.org/10.1186/s40479-017-0061-9

Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2017). What we have changed our minds about: Part 2. Borderline personality disorder, epistemic trust and the developmental significance of social communication. Borderline Personality Disorder and Emotion Dysregulation, 4(1), 9. https://doi.org/10.1186/s40479-017-0062-8

Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathology52(2), 94-103.

Fonagy, P., Luyten, P., Campbell, C., & Allison, L. (2014). Epistemic trust, psychopathology and the great psychotherapy debate. Online Artikel, Zugriff unter: http://www.societyforpsychotherapy.org/epistemic-trust-psychopathology-a...

Luyten, P., Campbell, C., & Fonagy, P. (2019). Reflections on the contributions of Sidney J. Blatt: The dialectical needs for autonomy, relatedness, and the emergence of epistemic trust. Psychoanalytic Psychology36(4), 328.


Caspi, A., Houts, R., Belsky, D., Goldman-Mellor, S., Harrington, H., Israel, S., & Moffitt, T. (2014). The p factor: One general psychopathology factor in the structure of psychiatric disorders? Clinical Psychological Science, 2(2), 119–137.

Fonagy, P., Luyten, P., & Allison, L. (2015). Epistemic petrification and the restoration of epistemic trust: A new conceptualization of borderline disorder and its psychosocial treatment. Journal of Personality Disorders. 29(5). 575-609.

Lambert, M., (2010). Predicting negative treatment outcome: methods and estimates of accuracy. In Prevention of treatment failure: the use of measuring, monitoring, and feedback in clinical practice (pp.83-105). American Psychological Association: America.

Lane, R., Monaco, M., & Gregson, K. (1997). The negative therapeutic reaction (NTR): A review and synthesis for practitioners. Journal of Contemporary Psychotherapy, 27(2), 131–116.