Psychotherapy Relationships

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Psychotherapy Relationships Evidence-Based
Practices

• John C. Norcross, Ph.D.University of Scranton

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International Juggernaut of EBP

• ? Effort to base clinical practice on robust,
  primarily research, evidence
• ? IOM definition Evidence-based practice is the
  integration of best research evidence with
  clinical expertise and patient values.
• ? Response to clarion calls for accountability
• ? Demands for EBPs are here to stay and will
  escalate in future

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APA Definition of EBPs

• Evidence-based practice in psychology is the
  integration of the best available research with
  clinical expertise in the context of patient
  characteristics, culture, and preferences.
• www.apa.org/practice/ebp.html or May 2006
  American Psychologist

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Words are Magic

• ? EBPs have profound implications for practice,
  training, research, and policy
• ? No one is arguing for the converse
  (non-evidence based practices)
• ? What is privileged as evidence-based will
  determine, in large part, what treatment is
  conducted, what is taught, what is funded
• ? EBPs are noble in intent, but ripe for misuse
  and abuse

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Fundamental Questions

• ? EBPs are wrapped in clinical, methodological,
  and epistemological issues that cannot be ignored
  
• ? A truly evidence-based approach demands that we
  examine and follow the evidence, even if it is
  critical of certain EBP iniatives
• ? Does EBP map well onto psychotherapy?

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Unresolved Questions re EBPsNorcross, Beutler,
Levant (2005)

• 1. What Qualifies as Evidence of Effective
  Practice?
• Clinical expertise, scientific research, patient
  values
• 2. What Qualifies as Research for Effective
  Practice?
• Case studies, single-participant, qualitative,
  change process, effectiveness, RCTs
• 3. What Tx Outcomes Should Establish EBPs?
• Self-report, objective behavioral indices,
  therapist judgment, external/society decisions
• 4. Does Manualization Improve Therapy Outcomes?
• 5. Are Research Patients Clinical Trials
  Represent-ative of Practice?

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Unresolved Questions IINorcross, Beutler,
Levant (2005)

• 6. What Should be Validated?
• Tx method, therapist, therapy relationship,
  patient, principles of change
• 7. What Materially Influences What is Published
  as Evidence?
• Theoretical allegiance, funding source
• 8. Do ESTs Produce Outcomes Superior to Non-ESTs?
  
• 9. How Well Do EBPs Address of Diversity?
• Ethnicity, gender, sexual orientation,
  disability status
• 10. Are Efficacious Laboratory-Validated
  Treatments Readily Transportable to Clinical
  Practice?

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APA book edited by Norcross. Beutler, Levant
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Thought Experiments

• What accounts for the success of psychotherapy
  (psychosocial tx)?
• What accounts for the success of your personal
  therapy?

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Your Probable Answer

• Many things account for success
• Including the patient, the therapist, their
  relationship, the treatment method, and the
  context
• But when pressed, approx 90 of you will answer
  the relationship

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Whats Missing from EBPs?

• The person of the therapist
• The therapy relationship
• The patients (nondiagnostic) characteristics
• Do treatments cure disorders,
• or do relationships heal people?

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Henry (1998) concludes the panel

• would find the answer obvious, and empirically
  validated. As a general trend across studies, the
  largest chunk of outcome variance not
  attributable to preexisting patient
  characteristics involves individual therapist
  differences and the emergent therapeutic
  relationship between patient and therapist,
  regardless of technique or school of therapy.
  This is the main thrust of three decades of
  empirical research.

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Dual Aims of ESRs

• 1. identify elements of effective therapy
  relationships
• 2. identify effective methods to customize
  therapy to the individual patient

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Steering Committee

• Steven Ackerman (student)
• Lorna S. Benjamin (U of Utah)
• Larry Beutler (U of California)
• Charles Gelso (U of Maryland)
• Marvin Goldfried (SUNY-Stony Brook)
• Clara Hill (U of Maryland)
• Michael Lambert (BYU)
• John C. Norcross (chairperson)
• David Orlinsky (U of Chicago)
• Jackson Rainer (Publication Board)

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Oxford Univ Press book edited by Norcross
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Evaluation Criteria

• Number of empirical studies
• Consistency of empirical results
• Independence of supportive studies
• Magnitude of association between the relationship
  element and outcome
• Evidence for direct causal link between
  relationship element and outcome
• Ecological or external validity of the research

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Conclusions

• The therapy relationship makes substantial and
  consistent contributions to psychotherapy outcome
  independent of the type of tx.
• Practice and treatment guidelines should address
  therapist behaviors and qualities that promote
  the therapy relationship.
• Efforts to promulgate practice guidelines or EBPs
  without including the therapy relationship are
  seriously incomplete and potentially misleading.

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Conclusions II

• The therapy relationship acts in concert with
  discrete interventions, patient characteristics,
  and clinician qualities in determining treatment
  effectiveness.
• Adapting or tailoring the therapy relationship to
  patient characteristics (in addition to
  diagnosis) enhances the effectiveness of
  treatment.
• These conclusions do not constitute practice
  standards

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Demonstrably Effective Elements of Therapy
Relationship

• ? The Alliance
• ? Cohesion in Group Therapy
• ? Empathy
• ? Goal Consensus Collaboration

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The Alliance

• quality strength of collaborative relation
• alliance ? relationship
• typically measured as agreement on therapeutic
  goals, consensus on treatment tasks, and a
  relational bond.
• across 89 (adult) studies, the median r between
  alliance and tx outcome was .21, a modest but
  very robust association
• similar r for children, adols, adults
• r of .21 translates into a d of .45 but average
  d for psychotherapy vs. no treatment is .80

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Cohesion in Group Therapy

• parallel of alliance in individual therapy
• refers to the forces that cause members to remain
  in the group, a sticking-togetherness
• 80 of the studies support positive relationships
  between cohesion (mostly member-to-member) and
  therapy outcome

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Empathy

• Therapists sensitive ability to understand the
  clients thoughts, feelings, and struggles from
  clients view
• Meta-analysis of 47 studies (190 tests of
  empathy-outcome association) median r of .32
• Highest effect size in the relationship
• Use the clients perspective (not clinicians
  perspective or external ratings)

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Probably Effective Elements of Therapy
Relationship

• Positive Regard
• Congruence/Genuineness
• Feedback
• Repair of Alliance Ruptures
• Self-Disclosure
• Countertransference Management
• Quality of Relational Interpretations

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Collecting Real-Time Feedback

• ? Inquire directly about clients impressions
• ? Compare those data to some benchmark
• ? Provide feedback immediately to therapist
• ? Address explicitly with client in-session
• (1) How are you doing?
• - Progress/improvement/change
• (2) How is the psychotherapy going?
• - Satisfaction with treatment methods
• (3) How are we (the relationship) doing?
• - Satisfaction with the therapy relationship

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Repairing Ruptures

• a tension or breakdown in collaboration
• most clients have some negative feelings about tx
  or relationship which they are reluctant to
  broach
• most clients do not tell us about ruptures unless
  asked
• repairs of ruptures facilitated by (1) therapist
  responding nondefensively, (2) attending directly
  to relationship, (3) adjusting behavior, and (4)
  collecting feedback

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Lethality of One Size Fits All
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Customizing the Relationship

• What works for specific patients different
  strokes for different folks
• Call it responsiveness, attunement, tailoring,
  matchmaking, prescriptive
• Create a new therapy for each patient
• Tailor the relationship to particulars of the
  patient according to general research evidence

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Demonstrably Effective Means of Customizing the
Relationship

• Resistance
• Functional Impairment

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Resistance Level

• Refers to being easily provoked responding
  oppositionally to external demands
• Matching therapist directiveness to client
  resistance improves tx outcome (80 of studies).
• High-resistance patients benefit more from
  self-control methods, minimal therapist
  directiveness, and paradoxical interventions
• Low-resistance clients benefit more from
  therapist directiveness and explicit guidance

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Probably Effective Means of Customizing the
Relationship

• Coping Style
• Stages of Change
• Anaclitic Introjective Dimensions
• Expectations
• Assimilation of Problematic Experiences

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Stages of Change

• Precontemplation, contemplation, preparation,
  action, maintenance
• Meta-analysis of 47 studies found ESs of .70 and
  .80 for the use of different change processes in
  the stages
• Therapist optimal stance also varies with stage
  of change nurturing parent, a Socratic teacher,
  experienced coach, a consultant

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Insufficient Research to Judge

• Attachment Style
• Gender Matching
• Ethnicity Matching
• Preferences
• Religion and Spirituality
• Personality Disorders

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Patient Preferences

• Tx method, relationship style, therapist
  characteristics, tx length, etc.
• inquire what client desires and what despises
• multiple benefits of asking collaboration,
  empowerment, diagnostic, accommodation, modeling
• Relationship style
• - Tepid - Warm
• - Passive - Active
• - Formal Informal

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Limitations

• Omissions (e.g., family therapy, discrete
  techniques)
• Content overlap (e.g., goal consensus and
  alliance)
• Patients contribution to the relationship
• Disorder-specific nature of the therapy
  relationship

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Discredited Relationships

• Progress by simultaneously using what works and
  avoiding what does not work
• Avoiding psychoquackery or voodoo psychology
  requires consensus on discredited practices
• Series of Delphi polls of experts in mental
  health and the addictions

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Probably Discredited Relationship Behaviors in
Psychotherapy

• Confrontations
• Frequent interpretations
• Negative processes (e.g., hostile, pejorative,
  rejecting, blaming)
• Assumptions
• Therapist-centricity
• Ostrich behavior re early ruptures

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"Warning -- misuse of the Orgone Accumulator may
lead to symptoms of orgone overdose. Leave the
vicinity of the accumulator and call the 'Doctor'
immediately!" - Wilhelm Reich
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Practice Recommendations

• Make the creation and cultivation of a therapy
  relationship a primary aim.
• Adapt the therapy relationship to specific
  patient characteristics in the ways shown to
  enhance outcome.
• Routinely monitor patients responses to the
  therapy relationship and ongoing tx.
• Concurrent use of ESRs and ESTs tailored to the
  patient is likely to generate the best outcomes.

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Training Recommendations

• Training programs are encouraged to provide
  explicit and competency-based training in the
  effective elements of the therapy relationship.
• Accreditation certification bodies are
  encouraged to develop criteria for assessing
  training in ESRs in their evaluation process.
• Graduate training is encouraged to offer ESR
  modules on systematically adapting the therapy
  rel. to the individual patient.

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Frequently Asked Questions

• Are you saying that techniques or methods are
  immaterial to outcome?
• But arent you exaggerating the impact of
  relationship factors and minimizing treatment
  effects?
• Isnt this just warmed over Carl Rogers?

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Frequently Asked Questions II

• Wont these results contribute further to
  deprofessionalizing psychotherapy?
• Are psychotherapists able to adapt their
  relational style to patients proclivities and
  personalities?
• But isnt this all correlational research?

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Frequently Asked Questions III

• So, are you saying that the therapy relationship
  (in addition to method) is crucial, that it can
  be improved by certain therapist contributions,
  and that it can be effectively tailored to the
  individual patient?

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Be a Scientist-Practitioner Look at All of the
Evidence

• ? Cultivate the therapy relationship
• ? Customize the relationship (and tx) to
  individual patient context
• ? Simultaneously use (inclusively defined) EBPs
  and avoid (consensually identified) discredited
  practices