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This entry is our analysis of a review or synthesis of research findings added to the Effectiveness Bank. The original review was not published by Findings; click Title to order a copy. Free reprints may be available from the authors – click prepared e-mail. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text Unfold supplementary text The Summary conveys the findings and views expressed in the review. Below is a commentary from Drug and Alcohol Findings.

Title and link for copying Comment/query to editor

Evidence-based psychotherapy relationships: Goal consensus and collaboration.

Tryon G.S., Winograd G.
Psychotherapy: 2011, 48(1), p. 50–57.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Tryon at gtryon@gc.cuny.edu. You could also try this alternative source.

This meta-analytic review commissioned by the American Psychological Association finds that outcomes improve the more clients and therapists agree on goals and methods and form collaborative working relationships to implement those agreements. The findings support deep patient involvement in deciding treatment goals and methods.

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 and clients agree on objectives and ways of working ('goal consensus'), Defined by the authors as:
• patient-therapist agreement on goals;
• the extent to which a therapist explains the nature and expectations of therapy, and the patient's understanding of this information;
• the extent to which goals are discussed, and the patient's belief that goals are clearly specified;
• patient commitment to goals; and
• patient-therapist congruence on the origin of the patient's problem, and congruence on who or what is responsible for problem solution.
and the degree to which they function as a team, working together to achieve those goals ('collaboration'). Collaboration is largely defined by the instruments devised to assess it. These assess:
• mutual involvement of patient and therapist in a helping relationship;
• patient cooperation; and
• role involvement.
Another indicator of, but not a measure of, collaboration is:
• patient completion of assigned homework.
These concepts represent important dimensions of the patient's contribution to therapy as well as that of the therapist. Patients often downplay their role, but to a greater degree than in many medical treatments, psychotherapy requires their active involvement. The verbal interchanges involved in establishing goal consensus reflect a negotiation in which patients and therapists together refine the goals and tasks of therapy. The patient's collaborative contribution to therapy takes the form of offering information, insights, self-reflections, elaborations and explorations of important themes, and working actively with the therapist's comments.

Agreeing goals and collaborative working are also important components of the working alliance between therapist and client, dealt with in general in other articles in this special issue in respect of adults in individual therapy, children and adolescents, couples and families, and group therapy.

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 goal consensus and collaboration, 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 analyses included English-language studies of adult psychotherapy published in a journal between 2000 and 2009 which measured both patient progress and the relevant concepts, and reported on their relationships in a way which enabled results to be aggregated with those from other studies. The resulting 28 studies included 15 documenting goal consensus links with therapeutic progress and 19 collaboration. Progress was variously measured by (among other indicators) retention in treatment, symptom reduction, adaptive functioning, patient experience of and satisfaction with therapy, their sense of wellbeing and of having improved, and readiness to change.

Main findings

Goal consensus Across the relevant 15 studies with 1302 clients, and after correcting for sample sizes and the unreliability of the measures in each study, the strength of the link between goal consensus and therapy outcomes equated to a medium effect size of 0.34. This statistically significant link accounted for nearly 12% of the variance in outcomes – for psychosocial studies, a substantial relationship indicating that better outcomes can be expected when patient and therapist agree on therapeutic goals and processes to achieve these goals.

After correcting for the unreliability of their measures and different sample sizes, the individual studies varied little in their assessments of the strength of the link, so there was no scope for assessing what might influence the closeness of this relationship.

Collaboration Across the relevant 19 studies with 2260 clients, and after correcting for sample sizes and the unreliability of the measures in each study, the strength of the link between collaboration and therapy outcomes equated to a medium effect size of 0.33. This statistically significant link accounted for nearly 11% of the variance in outcomes – for psychosocial studies, a substantial relationship, indicating that patient experience and wellbeing appear considerably enhanced by a better quality collaborative relationship between patient and therapist.

After correcting for the unreliability of their measures and different sample sizes, the individual studies varied little in their assessments of the strength of the link, so there was no scope for assessing what might influence the closeness of this relationship.

Relationship between goal consensus and collaboration Since therapist and patient have to collaborate to reach agreement on the goals and tasks of therapy, one might expect that measurements of goal consensus and collaboration would co-vary. Across the four studies of 340 patients which provided usable data on this issue, and after correcting for sample sizes and the unreliability of the measures in each study, the strength of the link between goal consensus and collaboration equated to a statistically significant small to medium effect size of 0.19. This means that, as expected, when one is good or bad, the other tends to be the same, but the parallel is far from perfect; often there will be good consensus but poor collaborative implementation of that consensus and vice versa. However, with so few studies this findings cannot be relied on.

After correcting for the unreliability of their measures and different sample sizes, the four studies agreed in their assessments of the strength of the link, so there was no scope for assessing what might influence the closeness of this relationship.

Practice recommendations

The results of the primary meta-analyses indicate strong links between patient-therapist goal consensus or collaboration and positive therapy outcomes. The results point to a number of practices that psychotherapists can profitably employ.

Begin work on the client's problems only after you both agree on treatment goals and the ways together you will go about reaching them.

Rarely push your own agenda. Listen to what your patients tell you and formulate interventions with their input and understanding.

Encourage patients' contributions throughout psychotherapy by asking for their feedback, insights, reflections, and elaborations. Regularly seek information from patients about their current functioning, motivation to change, and social support, and provide feedback about their progress.

Educate patients about the importance of their collaborative contribution to the success of therapy, for example, by sharing with patients the results of research – such as the studies reviewed in this article – that link their collaborative contribution to successful outcomes.

To enhance homework completion, encourage patient collaboration in formulating assignments, assign homework that relates to treatment goals, begin with small, easily accomplished assignments and build up, define homework tasks clearly and in writing, provide written reminders, and encourage and incorporate patient feedback on homework.

Be 'on the same page' with patients. Check frequently with patients to make sure you understand each other and are working toward the same ends.

If ethically and clinically appropriate, modify your treatment methods and relational stance, in response to patient feedback.


Findings logo 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: 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 29 May 2011. First uploaded

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