What specifically is effective in the powerful psychotherapy relationship? Not my question, but the one posed in the introductory paper to a recent milestone edition of the journal Psychotherapy which distils the key evidence for critical aspects of the therapeutic relationship and offers important pointers to how we may incorporate the findings from research into our practice. Who knew there was so much to the relationship?
Anyone looking for authoritative evidence for the impact of the relationship on therapy outcomes need look no further than Psychotherapy Relationships That Work: Evidence-Based Responsiveness. It’s a collection of papers written by some of the most eminent researchers in the field, first published in 2002, with a second edition in 2011.
The first edition resulted from work by a task force commissioned by the American Psychological Association (APA) Division of Psychotherapy to “identify, operationalize, and disseminate information on empirically supported therapy relationships.” Each edition began as a series of papers which were subsequently published in book form. The 2011 edition is one of my key ‘go to’ resources for evidence on the power of the therapy relationship.
The relationship refreshed
This important work has been revised and published in the form of a series of 16 papers contained in a recent edition of the journal Psychotherapy. Topics include the alliance, the role of empathy, congruence and positive regard, therapist self-disclosure, client perceptions of treatment credibility, counter-transference management and alliance rupture repair. Doubtless it will be published in printed form in due course but the papers are available online now. Only the first two are open access at this stage, sadly, but abstracts and impact statements are available to view for each paper from the summary page.
This edition of the journal is introduced by John Norcross and Mike Lambert in a paper which gives shape to what follows. They introduce the aims of the latest work as well as its findings. They highlight that as a result of this work, the expert consensus of the task force was that nine of the relationship factors under scrutiny were demonstrably effective, seven were probably effective, and one was promising but had insufficient evidence for a definitive judgement (further details below).
Summing up the abstract Norcross and Lambert state:
The authors conclude that decades of research evidence and clinical experience converge: The psychotherapy relationship makes substantial and consistent contributions to outcome independent of the type of treatment.
What’s inside and how are the papers are structured?
There are 16 papers in all not including the introduction, covering various aspects of the relationship generally and more specifically, within particular settings. They are:
1. The alliance in adult psychotherapy: A meta-analytic synthesis. (Open access)
2. Meta-analysis of the prospective relation between alliance and outcome in child and adolescent psychotherapy
3. Meta-analysis of the alliance–outcome relation in couple and family therapy
4. Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome
5. Cohesion in group therapy: A meta-analysis
6. Therapist empathy and client outcome: An updated meta-analysis
7. Positive regard and psychotherapy outcome: A meta-analytic review
8. Congruence/genuineness: A meta-analysis
9. The real relationship and its role in psychotherapy outcome: A meta-analysis
10. Therapist self-disclosure and immediacy: A qualitative meta-analysis
11. Therapist and client emotional expression and psychotherapy outcomes: A meta-analysis
12. A meta-analysis of the association between patients’ early treatment outcome expectation and their posttreatment outcomes
13. A meta-analysis of the association between patients’ early perception of treatment credibility and their posttreatment outcomes
14. Countertransference management and effective psychotherapy: Meta-analytic findings
15. Alliance rupture repair: A meta-analysis
16. Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring
Each paper follows a common format:
Introduction : Definitions and Measures : Clinical Examples [i] : Results of Previous Reviews : Meta-Analytic Review : Mediators and Moderators [ii] : Patient Contributions [iii] : Limitations of the Research : Diversity Considerations [iv] : Therapeutic Practices
The last sections, therapeutic practices, offer valuable pointers for practitioners as to how they might best translate the research findings into their own therapeutic model and practice.
What were the conclusions on the task force?
As mentioned above the task force were able to conclude, from the strength of the available evidence, those relationship elements which were demonstrably effective, which probably effective, and the single element (therapist self-disclosure and immediacy) lacked evidence to reach a conclusion. The findings are shown in the table below.
What does not work?
Within their introductory paper Norcross and Lambert identify what will be ineffective relationship practices by highlighting the reverse of effective behaviours:
Thus, what does not work are poor alliances in adult, adolescent, child, couple, and family psychotherapy, as well as low levels of cohesion in group therapy. Paucity of collaboration, consensus, empathy, and positive regard predict treatment drop out and failure. The ineffective practitioner will not seek or be receptive to formal methods of providing client feedback on progress and relationship, will ignore alliance ruptures, and will not be aware of his or her countertransference. Incongruent therapists, discreditable treatments, and emotional-less sessions detract from patient success.
In their review of the literature that resulted in the 2011 collection of papers, Norcross and Lambert [v] recommended that practitioners avoid a range of unhelpful behaviours: confrontations, negative processes, assumptions, therapist–centricity, and rigidity. To this list they now add cultural arrogance: the “Arrogant impositions of therapists’ cultural beliefs in terms of gender, race/ethnicity, sexual orientation, and other intersecting dimensions of identity are culturally insensitive and demonstrably less effective.” That works for me.
Accessing the full range of 15 papers in this collection which are not open access will set you back a tidy $179.25. Annoying, but it’s how academic publishers make a living. As soon as I hear that the collection is available in a rather less expensive book form, I’ll be sure to let you know!
In the meantime I’d be delighed to hear your thoughts on this topic.
References
[i] Concrete examples of the relationship behaviour under consideration.
[ii] The results of the potential mediators and moderators of the association between the relationship element and treatment outcome
[iii] The patient’s contribution to that relationship and the distinctive perspective he or she brings to the interaction
[iv] How diversity (e.g., gender,race/ethnicity, sexual orientation, and socioeconomic status)fares in the research studies and the meta-analytic results.
[v] 2011. Norcross J C & Lambert M J. Evidence-Based Therapy Relationships. http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199737208.001.0001/acprof-9780199737208-chapter-1
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Very interesting thanks Barry.
I agree that the relationship is absolutely key in all the forms of therapy which I practice Individuals, couples, family and psycho-sexual. I note with interest that what doesn’t work are “emotionless sessions” I totally agree and remember Gendlins research which demonstrated (following hours of listening to taped client sessions) that the clients who progressed, were those who paused to connect with emotion and sometimes struggled to find the right words. Focusing is an excellent way of helping clients connect to their emotion, as is Glenda Freedman’s systemic approach of co-constructing emotion, checking in with clients if their “sad” is the same as ours, seeing if other words also describe that emotion and exploring how the clients family might have demonstrated their “sadness”.
As you say its a shame these academic papers are so expensive to access ( I regularly find myself not being able to view 30 + year old papers, put off by the cost of f£30 per day !). But hopefully this will be published at some point and more reasonably priced.
Many thanks Graeme
Graeme, thanks once again for your post. Focusing – such a simple idea and yet so powerful! I actually bought Eugene Gendlin’s Focusing-Oriented Therapy after reading of his death last year. What a loss to our field his death was.
Maybe I should focus a blog on getting past the research paywall without paying?
Thanks again! Barry