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Norcross J.C., Wampold B.E.
Psychotherapy: 2011, 48(1), p. 98–102.
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Draws conclusions and makes recommendations based on research syntheses commissioned by the American Psychological Association on effective therapeutic relationships and how to match therapeutic style to different patients. Though not specific to substance use, this work will be critical to the recovery agenda for addiction treatment.
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 closing article presents the conclusions and recommendations of the second Task Force on Evidence-Based Therapy Relationships convened by the American Psychological Association. The task force defined the therapy relationship as: "The feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed". Their conclusions about this relationship were 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. and reviews reproduced in two journal special issues. The first set were in a special issue of the Journal of Clinical Psychology, and aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). The second set were in a special issue of the journal Psychotherapy, and were devoted to evidence-based, effective therapist-client relationships ('What works in general'). Conclusions from both sets are presented in this article.
On the basis of these analyses and earlier reviews commissioned by the task force, expert panels came to a consensus on the strength of the evidence for each element of the relationship and each possible way of matching therapeutic style to different types of patients. They classified these as "demonstrably effective", "probably effective", or "promising but insufficient research to judge", taking in to account: the number of empirical studies; the consistency of their findings; the independence of supportive studies; the magnitude of the association between the relationship element and outcome; evidence for a causal link between the relationship element and outcomes; and the ecological or external validity of research – the degree to which its findings can be expected to be replicated in routine practice.
The following relationship elements were judged demonstrably effective in affecting and improving outcomes for clients. Each is linked to the Findings entry for the review which analysed them.
Alliance in individual psychotherapy
Alliance in youth psychotherapy
Evidence-based psychotherapy relationships: Alliance in family therapy
Cohesion in group therapy
Collecting client feedback
The following relationship elements were judged probably effective in affecting and improving outcomes for clients. Each is linked to the Findings entry for the review which analysed them.
Adapting therapeutic approaches to the following characteristics of patients (other than their diagnoses) was judged demonstrably effective in affecting and improving outcomes for clients. Each is linked to the Findings entry for the review which analysed them.
Religion and spirituality
The therapy relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment.
The therapy relationship accounts for why clients improve (or fail to improve) at least as much as 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 or evidence-based practices without including the relationship are seriously incomplete and potentially misleading.
Adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis) enhances the effectiveness of treatment.
The therapy relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations.
These conclusions and the judgements made about effectiveness do not in themselves constitute a set of practice standards but represent current scientific knowledge to be understood and applied in the context of all the clinical evidence available in each case.
This concluding article does not call for uniform or slavish adoption of the relationship elements it found effective, observing that good psychotherapists are responsive to the different needs of their clients, providing varying levels of relationship elements in different cases and within the same case at different times. Responsiveness clouds research attempts to attribute client improvement to any particular relationship element or matching strategy yet constitutes good clinical practice which is difficult to encapsulate and evaluate in a highly controlled research study. By being clinically attuned and flexible, psychotherapists make it more difficult for research studies to discern what works.
Practitioners are encouraged to make the creation and cultivation of a therapy relationship, characterised by the elements found to be demonstrably and probably effective, a primary aim in the treatment of patients.
Practitioners are encouraged to adapt or tailor psychotherapy to the specific patient characteristics identified in the reviews in ways found to be demonstrably and probably effective.
Practitioners are encouraged to routinely monitor patients' responses to the therapy relationship and ongoing treatment. Such monitoring provides opportunities to re-establish collaboration, improve the relationship, modify technical strategies, and avoid premature termination.
Concurrent use of evidence-based therapy relationships and evidence-based treatments adapted to the patient is likely to generate the best outcomes.
Though the task force was concerned to find effective practices, its work and other research and expert opinion has also helped identify what therapists should avoid as ineffective or potentially harmful.
One means of identifying ineffective qualities of the therapeutic relationship is to simply reverse the effective behaviours. Thus, what does not work includes a low quality alliance in individual psychotherapy, lack of cohesion in group therapy, and discordance in couple and family therapy. Paucity of empathy, collaboration, consensus, and positive regard predict treatment drop out and failure. The ineffective practitioner will resist client feedback, ignore alliance ruptures, and discount his or her countertransference. Other risky practices to look out for are:
Confrontations Particularly in the addictions field, a confrontational style has been found consistently ineffective. In contrast, expressing empathy, rolling with resistance, developing discrepancy, and supporting self-efficacy – characteristic of motivational interviewing – have large effects in relatively few therapy sessions.
Negative processes Client reports and research studies converge in warning therapists to avoid hostile, pejorative, critical, rejecting, or blaming comments or behaviour. Therapists who attack a client's dysfunctional thoughts or relational patterns need – repeatedly – to distinguish between attacking the person versus their behaviour.
Assumptions Psychotherapists who assume or intuit their client's perceptions of relationship satisfaction and treatment success are frequently inaccurate. By contrast, therapists who specifically and respectfully inquire about their client's perceptions frequently enhance the alliance and prevent premature termination.
Therapist-centricity A recurrent lesson from process-outcome research is that the client's perspective on the therapy relationship best predicts outcome. Psychotherapy practice that relies on the therapist's perspective, while valuable, does not as accurately predict outcome. Privileging the client's experiences is central.
Rigidity By inflexibly and excessively structuring treatment, the therapist risks empathic failures and inattentiveness to clients' experiences. Such a therapist is likely to overlook a breach in the relationship or mistakenly assume they have not contributed to that breach. If incompatible with the client, dogmatic reliance on particular relational or therapy methods imperils treatment.
Procrustean bed Using an identical therapy relationship (or treatment method) for all clients is now recognised as inappropriate and sometimes unethical. The efficacy and applicability of psychotherapy will be enhanced by tailoring it to the unique needs of the client.
Psychotherapy is at root a human relationship. Even when 'delivered' via distance or on a computer, it is an irreducibly human encounter. Both parties bring themselves – their origins, cultures, personalities, psychopathologies, expectations, biases, defences, and strengths – to the human relationship. Some will judge that relationship a precondition of change, others a process of change, but all agree that it is a relational enterprise. How we create and cultivate that powerful human relationship can be guided by the fruits of research. There is no inherent tension between a relational approach and a scientific one. Science can, and should, inform us about what works in psychotherapy, be it a treatment method, an assessment measure, a patient behaviour, or, yes, a therapy relationship.
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: 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
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 02 June 2011. First uploaded
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