Norcross J.C., Lambert M.J.
Psychotherapy: 2018, 55(4), p. 303–315.
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Research findings amalgamated in 16 reviews for an American Psychological Association task force led them to authoritatively assess many dimensions of the client–psychotherapist relationship as important determinants of patients’ progress. “The relationship can heal,” is the overall conclusion – one likely to be highly relevant to recovery from addiction.
Summary [Though not specific to clients with drug and alcohol problems, the principles derived from this overview of reviews of psychotherapy studies are likely to be applicable, partly because severe substance use problems generally form part of a broader complex of psychosocial problems. Addictions work may not necessarily best be conceptualised as psychotherapy, but there is a therapeutic element to it which makes these findings relevant to keyworkers and counsellors. This review updates an earlier version from the same lead author.]
The featured overview set the context for and interpreted the findings of 16 reviews conducted for a task force of the American Psychological Association, each devoted to different aspects of effective therapist–client relationships in psychotherapy.
The strength of the links between outcomes and aspects of the therapy relationship was often stronger than that found to distinguish the effectiveness of a treatment compared to no treatment or an alternative treatment.
Due to the nature of the original studies, usually a causal effect on outcomes could not be established. Nevertheless, the safest stance is to presume that good relationships are an important determinant of treatment success, and that nurturing, maintaining, and as needed, re-establishing such relationships, are core therapeutic tasks.
The featured overview set the context for and interpreted the findings of 16 reviews ( list at the end of this analysis) conducted for a task force of the American Psychological Association, each devoted to different aspects of what makes for effective therapist–client relationships in psychotherapy – the ‘how’ of relating to clients in ways which improve outcomes. The featured overview and the constituent reviews were published in a special issue of the journal Psychotherapy.
Each review explained and defined these different aspects and amalgamated findings on their associations with the outcomes of psychotherapy, offering what the overview saw as “the best available research and clinical practices on numerous facets of the therapy relationship”. The latter was broadly defined as “the feelings and attitudes that the therapist and the client have toward one another, and the manner in which these are expressed” – dimensions increasingly seen as the core of effective psychosocial treatment panel below. However, relationship aspects of therapy do not stand alone. The overview argued that the dichotomy between treatment methods and techniques (what is done by the therapist) and the therapy relationship (how therapists and clients behave towards each other) is a false one – that the relationship does not exist apart from what the therapist does in terms of method, and that it is not possible to imagine any methods which would not have some relational impact. Treatment methods are relational acts; what one does and how one does it are complementary and inseparable.
The relationship aspects reviewed for the task force were chosen partly on the basis of their theoretical significance, but also on whether sufficient research had been done, meaning some potentially important aspects were omitted. The chosen aspects are not all practically or theoretically independent; they overlap and may depend on each other for their impacts. Relatively neglected was the contribution of the client, despite the fact that several of the constituent reviews found the patient’s perspective on the therapy relationship more closely related to outcomes than that of the therapist.
In the passages below the featured overview stressed the importance of relationships in psychotherapy and contrasted this with their relative neglect in research and practice guidelines.
“Most [guidelines] depict interchangeable providers performing treatment procedures. This stands in marked contrast to the clinician’s and the client’s experience of psychotherapy as an intensely interpersonal and deeply emotional experience. Although efficacy research has gone to considerable lengths to eliminate the individual therapist as a variable that might account for patient improvement, the inescapable fact of the matter is that it is simply not possible to mask the person and the contribution of the therapist.”
“Ask patients what they find most helpful in their psychotherapy. Ask practitioners which component of psychotherapy ensures the highest probability of success. Ask researchers what the evidence favors in predicting effective psychological treatment. Ask psychotherapists what they are most eager to learn about. Ask proponents of diverse psychotherapy systems on what point they can find commonality. The probable answer, for all these questions, is the psychotherapy relationship, the healing alliance between the client and the clinician.”
“Both clinical experience and research findings underscore that the therapy relationship accounts for as much, and probably more, of the outcome variance as particular treatment methods [yet] treatment guidelines give short shrift – some would say lip service – to the person of the therapist and the emergent therapeutic relationship.”
The overview also traced the work of the task force of the American Psychological Association which commissioned it and the constituent reviews. First aim of the task force was to identify elements of generally effective therapy relationships (‘What works in general’). These reviews were published in the special journal issue which included the overview, and also in book form. Second aim was to identify effective methods of adapting or tailoring treatment to the individual (‘What works in particular’). These reviews have so far been published only in book form and have not been analysed for the Effectiveness Bank. However, the task force took their implications into account in formulating the conclusions and recommendations reported below.
Generally the 16 constituent reviews had conducted meta-analyses amalgamating research findings to provide estimates of the overall strength of the link between post-therapy outcomes and an aspect of the therapeutic relationship, and explored possible influences on the strengths of these links. Strength was calculated as a correlation coefficient, an expression of the degree to which outcomes co-varied with the relationship aspect. The chosen metric ranged from -1 (perfect negative co-variation, meaning that as one side of the link gets larger the other diminishes to the same degree) to +1 (perfect positive co-variation, meaning that as one side of the link gets larger so does the other, and to the same degree). Correlation coefficients were also converted to effect sizes. Effectively these metrics indicate how influential that relationship aspect had been if causally linked to outcomes.
For the overview each member of the task force’s 10-person steering committee rated the evidentiary strength of each relationship aspect analysed by the constituent reviews. Their ratings were based on: the number of studies; the consistency of their results; how independent the studies were; the strength of the association between the relationship aspect and outcomes; evidence that this was due to a causal link between the two; and how applicable the research was to normal practice. Using these criteria, the 10 experts independently judged the strength of the research evidence as “demonstrably effective”, “probably effective”, “promising but insufficient research to judge”, “important but not yet investigated” or “not effective”. These ratings were then aggregated, with the results in the table below.
Relationship aspects in generalEntries linked to relevant review
Tailoring therapy to the client’s characteristics
Reactance (degree to which client reacts against authority or being led)
Stage of change (from not yet thinking about it to maintaining change)
Promising, but insufficient research
Important but not yet investigated
The links between outcomes and aspects of the therapy relationships were often stronger than that found to distinguish the effectiveness of a treatment compared to no treatment or an alternative treatment. Across thousands of individual studies and hundreds of meta-analytic reviews, the typical impact of psychotherapy versus no psychotherapy equates to an effect size averaging 0.80 to 0.85. In the reviews on which the overview was based, effect sizes ranged from about 0.24 to 0.80. For example, at an effect size of 0.57, the quality of the therapist–client alliance in individual psychotherapy emerged as one of the strongest and most robust predictors of successful psychotherapy. However, some of the analyses of relationship aspects found these less strongly related to outcomes for patients being treated for certain disorders, usually substance use, severe anxiety, or eating disorders.
With just two exceptions, the constituent reviews found no randomised trials capable of demonstrating a causal link between the focal relationship aspect and outcomes, a key limitation of the research. Like many of the reviewed aspects, on ethical grounds some of the most precious features of interpersonal relationships in life are incapable of random assignment or being manipulated by researchers; parental love is an exemplar. However, dozens of studies suggest that the therapy relationship does casually contribute to outcomes.
Indeed, in reality relationship aspects are probably more influential than effect sizes aggregated across individual patients and studies suggest. Because they are differentially effective in different situations and for different clients, practitioners flexibly adjust the intensity and timing of relational behaviours to fit the singular context. For example, for some patients in some situations, less rather than more overt empathy may be called for, diluting the overall association between empathy and outcomes across all patients.
However, presenting each aspect as if it had its own effects is misleading. While these relationship aspects ‘work’, they work together and interdependently. For example, alliance in individual therapy and cohesion in group therapy never act in isolation from other relationship behaviours, such as empathy and support. Nor does it seem humanly possible to cultivate a strong relationship with a patient without ascertaining their feedback on the therapeutic process, and the therapist understanding their ‘countertransference’ emotional reactions to the client. All the relationship elements interconnect as the therapist tries to tailor therapy to the unique, complex individual.
There is arguably also a hierarchical relationship between the different aspects. Global ways of being in therapy are described by super-ordinate, high-level constructs such as alliance, cohesion, and empathy. Below that level are strategies for managing the therapy relationship such as positive regard, self-disclosure, managing emotional expression, promoting credibility, formally collecting feedback, managing countertransference, and resolving ruptures in the therapist–client relationship. Then – more about the person than a strategy or skill – there are therapist qualities such as flexibility, congruence, and reactivity in responding to countertransference. Finally, there is the client’s contribution – their attachment style, preferences, expectations, coping styles, culture, reactance level, and diagnosis, all of which may serve as reliable signs for adapting therapy to the individual.
On the basis of the constituent reviews the task force made recommendations, of which those relating to practice, training and policy are listed below. These were not intended to be practice or treatment standards but to represent current scientific knowledge to be understood and applied in the context of the clinical evidence available in each case. To aid psychotherapy practitioners, students, educators and trainers in implementing these evidence-based aspects of the therapy relationship, the US Society for the Advancement of Psychotherapy has compiled interviews with experts.
Practitioners are encouraged to make the creation and cultivation of the therapy relationship a primary aim of treatment
Practitioners are encouraged to:
• make creation and cultivation of the therapy relationship a primary aim of treatment, especially relationship elements found demonstrably or probably effective;
• benchmark relational behaviours such as alliance, empathy, and cohesion against cut-off scores on popular clinical measures in ways that lead to more positive outcomes;
• adapt or tailor psychotherapy to specific client characteristics in ways found to be demonstrably or probably effective. In particular, success rates will be improved by regularly assessing and responsively attuning psychotherapy to clients’ cultural identities (broadly defined);
• routinely monitor patients’ satisfaction with the therapy relationship, comfort with efforts to adapt therapy to them, and response to treatment. Such monitoring leads to increased opportunities to re-establish collaboration, improve the relationship, modify technical strategies, and investigate factors external to therapy that may be hindering its effects;
• concurrently use evidence-based relationships and evidence-based treatments adapted to the whole patient.
• Mental health training and continuing education programmes are encouraged to provide competency-based training in the demonstrably or probably effective aspects of the therapy relationship, and in adapting psychotherapy to the individual patient in ways that demonstrably or probably enhance treatment success.
• Psychotherapy educators and supervisors are encouraged to train students in assessing and honouring clients’ cultural heritages, values and beliefs in ways that enhance the therapeutic relationship and inform treatment adaptations.
• Mental health training accreditation and certification bodies are encouraged to develop criteria for assessing the adequacy of training in evidence-based therapy relationships and responsiveness to the individual patient.
• Professional bodies for psychotherapy and counselling are encouraged to educate their members on the benefits of evidence-based therapy relationships and responsiveness to the individual patient.
• As they frequently now do about evidence-based treatments, mental health organisations as a whole are encouraged to educate their members about the improved outcomes associated with therapists offering higher levels of evidence-based therapy relationships.
• Professional bodies and other mental health organisations are encouraged to advocate for the research-substantiated benefits of a nurturing and responsive human relationships in psychotherapy.
• Mental health service administrators are encouraged to attend to and invest in relational features and adaptations of their services which transcend patient diagnoses. Attempts to improve the quality of care should account for therapy relationships and responsiveness to individuals, not only the implementation of evidence-based treatments for specific disorders.
Reversing the effective behaviours identified above helps identify some ineffective qualities of the therapy relationship predictive of treatment drop-out and failure. These include poor alliances in adult, adolescent, child, couple, and family psychotherapy, low levels of cohesion in group therapy, and paucity of collaboration, consensus, empathy, or positive regard. The ineffective practitioner will not seek or be receptive to formal methods to feedback to the client on their progress and on the therapy relationship, will ignore alliance ruptures, and will be unaware of countertransference issues. Incongruent (or inauthentic) therapists, non-credible treatments and emotion-less sessions, detract from patient success.
Research offers another means of identifying ineffective qualities of the relationship. In 2011 a review of that literature recommended that practitioners avoid confrontation, negative processes, assumptions, therapist-centricity, and rigidity. To that list can be added cultural arrogance. Psychotherapy is inescapably bound to the cultures in which it is practiced by clinicians and experienced by clients. 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.
Relationships in psychotherapy make substantial and consistent contributions to patient outcomes independent of the specific type of psychological treatment. Relationship behaviours are robustly effective predictors of patient success. We need to proclaim publicly what decades of research has discovered and what hundreds of thousands of practitioners have witnessed: the relationship can heal.
The therapy relationship accounts for client improvement (or the lack of it) as much as, and probably more than, the particular treatment method. Practice and treatment guidelines should explicitly address therapist behaviours and qualities that promote a facilitative therapy relationship. Efforts to promulgate best practices and evidence-based treatments without including the relationship and responsiveness to the individual are seriously incomplete and potentially misleading. Adapting psychological treatment (‘responsiveness’) to client characteristics which cut across diagnostic categories contributes to successful outcomes at least as much as, and probably more than, adapting to the client’s diagnosis. The therapy relationship acts in concert with treatment methods, patient characteristics, and other practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and how they work together to generate benefits for the client.
commentary This impressively wise overview based on what the authors see as the best available scientific evidence also amounts to a ‘call to arms’ to forefront the therapy relationship in policy, training and practice, and to redress its relegation to a ‘nuisance’ factor to be eliminated in research focused on whether one type of therapy (such as cognitive-behavioural or psychoanalytic approaches) is better than nothing, or better than another. Cutting across all these schools of therapy are, it is argued, therapy relationships, a set of ‘common factors’ which lie at the heart of any effective psychosocial treatment, and which also influence other forms of treatment. Despite the questions raised below, the safest stance for trainers, supervisors, therapists, counsellors, patients and clients, is to presume that a good relationship is an important determinant of treatment success, and that nurturing, maintaining, and as needed, re-establishing such relationships, are core tasks not just in psychosocial therapies, but in treatment generally.
UK addiction treatment guidelines from the National Institute for Health and Care Excellence (NICE) date from 2007 and have yet to catch up on trends in psychosocial treatment for mental health problems to recognise the salience of the relationship. The relevant text acknowledges the need to “establish and sustain a respectful and supportive relationship with the service user” but offers no guidance on what such a relationship consists or how to establish it, instead focusing on the ‘what to do’ elements of particular psychosocial treatment modalities. Some services in the UK are going further, seeking to reduce drop-out by matching clients’ personalities with a suitable therapist to give a head start to the formation of a therapeutic alliance.
Persuasive as the evidence and arguments are, there is an Achilles’ heel to the resulting recommendations in the featured overview and nearly all the constituent reviews. The recommendations are almost always based on the assumption that the association between a relationship factor and outcomes arises from a causal link between the two. If it does, then this link can be leveraged by the therapist to improve outcomes, who can (for example) augment patient progress by developing greater empathy, being more collaborative, or encouraging the client to be more emotionally expressive. There is, however, nearly always an alternative explanation which studies of the kind included in the reviews cannot eliminate – that these relationship qualities blossom during therapy which is in any event going well, or with patients or therapists who are in any event going to do well. In other words, that high-quality relationships are by-products of a therapy that is working, not a driving force in it working.
For example, patients who are going to do well in any event may be more likely to cooperate with and feel positive about their therapists, and therapists more capable of generating these feelings may also be more competent in other ways. As causality theorists have explained, “Thunder correlates with power outages, but thunder does not cause power outages. To distinguish causal from noncausal correlations, it is important to control for alternative causes.” Without effectively random allocation of patients to therapies designed to exemplify poor as well as good relationship qualities, these “alternative causes” cannot completely be eliminated. However, taking such risks with vulnerable individuals seeking help is ethically unacceptable, and in practice, devising the therapies, ensuring they do not differ in any other ways, and ethically attracting a representative sample of patients to them, seems near, if not actually, impossible.
On the other hand, for nearly all the relationship aspects investigated for the task force, there are strong countervailing reasons for accepting causality (of a complex and multi-faceted kind) as an interpretation of the findings. First is the consistency of the positive associations between relationship qualities and outcomes. Though sometimes small and non-significant, very few studies have found these associations to be negative. Second is the plausibility of the proposition that establishing good working and person-to-person relationships, in which therapists can and do take care to know what is happening and respond to it, will help keep patients in therapy and more productively working with the therapist towards agreed therapeutic goals.
Additionally, there seems little or nothing to lose, and possibly much to gain, from establishing these relationship with clients, nothing to gain and possibly much to lose from failing to do so, and ethical considerations demand such qualities in the response to troubled individuals who have come to you for help. As the featured review did, flipping these qualities on their heads seems to reveal the absurdity of denying they have any influence on therapy. “Seems to”, because it is not unknown for randomised trials to expose what ‘seems’ an obvious common-sense truth to be nothing of the kind. A relevant example might be the assumption that regular counselling is essential to the effectiveness of some prescribing-based treatments.
The Effectiveness Bank offers other key reading on relationships in treatment. In 2004 to 2006 Drug and Alcohol Findings devoted the five-part Manners Matter series to relationships at client–service and client–practitioner levels, and later constructed collections bringing together all Effectiveness Bank entries on common factors in general and therapy relationships in particular. The five cells in the “Practitioners” columns (columns B) of the Effectiveness Bank’s alcohol and drug treatment matrices list and comment on the most important UK-relevant research and guidance relating to practitioner–patient relationships. Agreeing with the featured reviewers, an Effectiveness Bank hot topic, Treatment staff matter, has argued that “addiction treatment research generally dismisses the impact of the therapist as ‘noise in the system’ to be eliminated in order to focus on the therapy. In the light of what we now know – and have done for many years – they are eliminating what matters in order to focus on what generally does not, an investigative gaze misdirected not just in substance use but also across psychosocial therapies for mental health problems.” Like the Manners Matter series and the collections referred to above, it set out to redress this balance.
The 16 constituent reviews on which the featured overview was based are listed below.
The ‘real’, person-to-person relationship
Alliance in couple and family therapy
Alliance in child and adolescent therapy
Cohesion in group therapy
Goal consensus and collaboration
Therapist self-disclosure and ‘immediacy’
Therapist and client emotional expression
Repairing ruptured alliances between therapists and clients
Treatment outcome expectations
Feeding back client progress data therapists
Thanks for their comments on this entry in draft to Bruce E. Wampold of the University of Wisconsin in the USA and Asna Ahmed, counselling psychologist with special interest in addiction, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 09 April 2019. First uploaded 20 March 2019
REVIEW 2018 Congruence/genuineness: a meta-analysis