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Farber B,A., Doolin E.M.
Psychotherapy: 2011, 48(1), p. 58–64.
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This meta-analytic review commissioned by the American Psychological Association finds outcomes improve the more therapists are consistently warm and show high regard for clients. Given the stigma and low regard attached to addiction and addicts, these findings have important implications for promoting recovery.
Summary Editor's note: Though not specific to patients with drug and alcohol problems, many of the studies in the analyses described below will have included such patients, and the principles are likely to be applicable to these disorders among others, not least because substance use problems generally form part of a complex of broader psychosocial problems.
This review is one of several in a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships. It reports on a research synthesis of the links between outcomes of therapy and the degree to which therapists are consistently warm and show high regard for their clients – sometimes termed 'therapist affirmation,' 'non-possessive warmth,' or, as in this review, 'positive regard'. As in practice measured by the client's (non)agreement with statements like, "I feel appreciated by her;," "How much he likes or dislikes me is not altered by anything that I tell him about myself," "He seems to like me no matter what I say to him," or "He appreciates me”. This was one of a trio of interpersonal qualities posited in 1957 in a classic paper by Carl Rogers. The other two, often termed congruence or genuineness and empathy, are reviewed in other papers in this special issue. Rogers' paper fostered the view that the therapist-client relationship per se was the critical determinant of therapeutic success, rather than the therapist's technical expertise in, for example, choice and timing of interventions.
The featured review incorporated meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesising results from relevant studies to provide estimates of the overall strength of the link between outcomes and positive regard, and to be able to probe for influences on the strength of those links. Strength is expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. By convention, in the behavioural sciences an effect size of the type used in the featured analyses is considered a small effect at 0.10, a medium effect at 0.30, and a large effect at 0.50. using the 'r' metric, which can be squared to calculate how much of the difference in outcomes can be attributed to differences in the therapy dimension being investigated. The assumption was made that there is no single, true strength of the link between outcomes and regard which appears to vary only because of methodological differences, but that instead strength really might vary across the studies included in the analysis.
The analysis included studies of individual adult or adolescent therapy which measured both patient progress and positive regard, and reported on their relationships in a way which enabled results to be aggregated with those from other studies.
Across the resulting 18 studies, the strength of the link between positive regard and therapy outcomes equated to a small to medium effect size of 0.27, a statistically significant link which accounted for 7% of the variance in outcomes, indicating that better outcomes can be expected when the therapist affirms and conveys unconditional warmth and liking for their client.
However, the strength of this relationship varied across the studies more than would be expected by chance. Several factors appeared to influence this. Most notably, the apparent impact of positive regard tended to be higher in psychoanalytic or psychodynamic therapies, perhaps because such sentiments are unexpected and relatively rarely expressed, so when they occur are disproportionately powerful.
Although in the analysis no patient characteristics emerged as significant influences, some are likely to affect the therapist's provision of positive regard and the extent to which this promotes therapeutic success. Some patients (such as those who themselves are warm and empathic) are more easily liked and therefore elicit more affirmation than others. The reverse will also probably be the case, suggesting that patients with borderline or narcissistic disorders are far less likely to consistently evoke positive regard. Patients who are more highly motivated to do therapeutic work, who appear courageous or risk-taking, seem more likely to evoke their therapist's positive regard.
The psychotherapist's ability to provide positive regard is significantly associated with therapeutic success. However, the meta-analysis indicates a moderate relationship, suggestive of the fact that, like many other relational factors, it is a significant but not exhaustive part of the process-outcome equation. Extrapolating from the data suggests the following recommendations for clinical practice.
Therapists' provision of positive regard is strongly indicated in practice. At a minimum, it 'sets the stage' for other effective interventions and, at least in some cases, may be sufficient to effect positive change.
There is virtually no research-driven reason to withhold positive regard. Either it has no apparent influence on outcomes or this is positive.
Positive regard is valuable across the major forms of psychotherapy. From a psychodynamic perspective, it strengthens the client's sense of self or agency and belief in their capacity to be engaged in an effective relationship; from a behavioural perspective, it functions as a reinforcing reward for engagement in therapy, including difficult self-disclosures; and from a humanistic perspective, it facilitates the client's natural tendency to grow and fulfil his or her capacity as a human being. Since nearly all schools of therapy now explicitly or implicitly promote the value of this basic attitude to patients, the results of these studies have implications not only for person-centred therapists, but for virtually all psychotherapists.
At least in the US context, positive regard may be particularly important when a therapist from the racial majority is working with a minority client.
Therapists cannot be content with feeling good about their patients, but should ensure they communicate a caring, respectful, positive attitude that serves to affirm a client's basic sense of worth. This does not mean a stream of compliments or a gushing of positive sentiment which may overwhelm or even terrify some clients. To many, if not most clients, the conviction that 'My therapist really cares about me' is likely to be critical, especially in times of stress.
Therapists need to monitor their positive regard and adjust it as a function of the needs of particular patients and specific clinical situations. Therapists vary in the extent to which they are able to convey positive regard and clients vary in the extent to which they need, elicit, and/or benefit from this. It seems likely that the inevitable ruptures in the therapeutic alliance (reviewed elsewhere in this special issue) during therapy are the result not only of a therapist's technical errors, but also their occasional inability to demonstrate minimally facilitative levels of positive regard and support.
commentary This article was in a special issue of the journal Psychotherapy devoted to effective therapist-client relationships. For other Findings entries from this issue see:
Evidence-based psychotherapy relationships: Psychotherapy relationships that work II
Evidence-based psychotherapy relationships: Alliance in individual psychotherapy
Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy
Evidence-based psychotherapy relationships: Alliance in couple and family therapy
Evidence-based psychotherapy relationships: Cohesion in group therapy
Evidence-based psychotherapy relationships: Empathy
Evidence-based psychotherapy relationships: Goal consensus and collaboration
Evidence-based psychotherapy relationships: Congruence/genuineness
Evidence-based psychotherapy relationships: Collecting client feedback
Evidence-based psychotherapy relationships: Repairing alliance ruptures
Evidence-based psychotherapy relationships: Managing countertransference
Evidence-based psychotherapy relationships: Research conclusions and clinical practices
The special issue which contained the article featured above was the second from the task force. The first was a special issue of the Journal of Clinical Psychology. While the second aimed to identify elements of effective therapist-client relationships ('What works in general'), the first aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). For Findings entries from this first special issue see this bulletin. Both bodies of work have also been summarised in this freely available document from the US government's registry of evidence-based mental health and substance abuse interventions.
Last revised 29 May 2011
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