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Norcross J.C., Lambert M.J.
Psychotherapy: 2011, 48(1), p. 4–8.
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Based on new meta-analytic reviews, a US task force has authoritatively assessed what makes for an effective therapeutic relationship. Though not specific to substance use, this work will be critical to the recovery agenda for addiction treatment.
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 article introduces a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships, and traces the work of the interdivisional task force of the American Psychological Association that supported it. The dual aims of the task force are to identify elements of effective therapy relationships ('What works in general' – the subject of the current special issue) and to identify effective methods of adapting or tailoring treatment to the individual patient ('What works in particular' – the subject of another special issue). The therapy relationship was defined as: "The feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed".
The immediate purpose of this special issue is to summarise the best available research and clinical practices relating to elements of the therapy relationship and to show that research clearly demonstrates the healing qualities of this relationship, without at the same time belittling the simultaneous contributions of treatment methods, therapists, and, above all, the patients, by far the most influential. The underlying purpose is to repair some of the damage incurred by the 'culture wars' in psychotherapy which have dramatically pit the treatment method (eg, cognitive-behavioural therapy or psychoanalysis) against the therapy relationship, based on the false dichotomy expressed in the question, 'Do treatments cure disorders, or do relationships heal people?' Instead the task force argued that the relationship does not exist apart from what the therapist does in terms of method, and we cannot imagine any treatment methods that would not have some relational impact. Put differently, treatment methods are relational acts, and the value of a treatment method is inextricably bound to the relational context in which it is applied.
The constituent reviews all had to be based on 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 links between outcomes and dimensions of the therapy relationship. These also enabled the analysts to probe for influences on the strength of those links. Each calculated 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. Given the many factors contributing to outcomes and the inherent complexity of psychotherapy, the task force did not expect to find large, overpowering effects from any single facet of the complex therapy relationship. Instead, it expected to and did find that several facets were associated with beneficial, small to medium-sized improvements in retention or outcomes.
On the basis of these analyses, expert panels came to a consensus on the strength of the evidence for each dimension, classifying each as "demonstrably effective", "probably effective", or "promising but insufficient research to judge". A prominent limitation was the difficulty of establishing causal connections between the relationship and the treatment outcome. It was usually impossible to be sure whether the relationship caused improvement, or simply reflected it, or whether both reflected some other variable. What has been possible is to show that therapy relationship factors precede outcomes, a necessary requirement for causality, and multiple studies with different methodologies suggest these factors probably do causally contribute to outcomes. It is also the case that some of the most precious behaviours in life are incapable on ethical grounds of being subject to studies which can establish causality such as random assignment and experimental manipulation – parental love is a prime example.
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: 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: Positive regard
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 26 May 2011
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