The Relationship Effect

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The Relationship Effect

• John C. Norcross, PhDUniversity of Scranton

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Thought Experiments

• What accounts for the success of treatment for
  the addictions?
• 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, 90 of you will answer the
  relationship

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EBP 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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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 (what
  works in general)
• 2. identify effective methods to customize
  therapy to the individual patient (what works for
  particular patients)

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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 the collaborative
  relationship
• alliance ? relationship
• across 89 (adult) studies, the median r between
  the 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 (medium
  effect) but average d for psychotherapy vs. no
  treatment is .80

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Exemplars Addictions

• NIDA Collaborative Cocaine Treatment Study
• Alliance predicted outcome in all treatments
  (individual drug counseling, cognitive therapy,
  supportive-expressive)
• For patients with strong alliance, therapist
  adherence to a treatment model was essentially
  irrelevant to tx outcome
• For patients with weaker alliance, moderate level
  of therapist adherence was associated with best
  outcomes
• Alliance probably moderates outcome in
  counseling, psychotherapy, pharmacotherapy

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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 studies support positive relationship
  between cohesion (mostly member-to-member) and
  therapy outcome
• Increase cohesion conduct pre-group preparation,
  address early discomfort using structure,
  encourage member-to-member interaction, set norms
  (but not overly directive), develop emotional
  climate

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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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Exemplars Addictions

• Early Miller (1980s) studies on problem drinking
• In-therapy behavior of counselors rated on
  empathy
• Empathy ratings accounted for client outcomes at
  6 months (r .82), 12 months (r .71), and 2
  years (r .51)
• Therapist empathy strongly predicted client
  success
• Recent Moyers, Miller, Hendrickson study
• Therapist interpersonal skill predicts client
  involvement in MI
• Skills include empathy, acceptance,
  egalitarianism, warmth, and spirit

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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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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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Exemplars Addictions

• Karno Longabaugh (2002, 2005)
• Among high-reactant clients, increased therapist
  directiveness predicts worse tx outcomes and
  1-year posttx drinking
• Among low-reactant clients, therapist
  directiveness predicts better outcomes
• Increased therapist interpretations,
  confrontations, and introductions of new topics
  predict more frequent and larger quantities of
  drinking for medium and high reactant alcoholics

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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
  different 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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Discredited Relationships

• Progress by simultaneously using what works and
  avoiding what does not work
• Avoiding psychoquackery or voodoo txs requires
  professional consensus on discredited practices
• Series of literature reviews and 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 (r .33 between client and therapist
  alliance ratings)
• Therapist-centricity
• Ostrich behavior re early ruptures

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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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Frequent Questions Objections

• Are you saying that techniques or methods are
  immaterial to outcome?
• Isnt this just warmed over Carl Rogers?
• But isnt this all correlational research? Where
  are the RCTs?
• Yes, yes, the relationship is terribly important,
  but.

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A Sensible Question

• 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
  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

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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