Using Evidence-Based Practices
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Evidence-basedtherapyrelationships-Researchconclusionsandclinicalpractices.pdf
Evidence-Based Therapy Relationships: Research Conclusions and Clinical Practices
John C. Norcross University of Scranton
Bruce E. Wampold University of Wisconsin, Madison
In this closing article of the special issue, we present the conclusions and recommendations of the interdivi- sional task force on evidence-based therapy relationships. The work was based on a series of meta-analyses conducted on the effectiveness of various relationship elements and methods of treatment adaptation. A panel of experts concluded that several relationship elements were demonstrably effective (alliance in individual psychotherapy, alliance in youth psychotherapy, alliance in family therapy, cohesion in group therapy, empathy, collecting client feedback) while others were probably effective (goal consensus, collaboration, positive regard). Three other relationship elements (congruence/genuineness, repairing alliance ruptures, and managing countertransference) were deemed promising but had insufficient evidence to conclude that they were effective. Multiple recommendations for practice, training, research, and policy are advanced.
Keywords: psychotherapy relationship, treatment outcome, meta-analysis, alliance, evidence-based practice
We shall not cease from exploration
And the end of all our exploring
Will be to arrive where we started
And know the place for the first time.
—T. S. Eliot (Little Gidding in Four Quartets)
Having traversed more than a dozen meta-analyses and arrived at the end of this special issue, we have a final opportunity to present the interdivisional task force conclusions and to reflect on its work. Like the tireless traveler in Eliot’s poem, we have rediscovered the therapy relationship and know it, again, for the first time.
This closing article presents the conclusions and recommendations of the second Task Force on Evidence-Based Therapy Relationships. These statements reaffirm and, in several instances, update those of the earlier task force (Norcross, 2001, 2002). We then offer some final thoughts on what works, what does not work, and clinical practice.
Conclusions of the Task Force
} The therapy relationship makes substantial and consistent contributions to psychotherapy outcome independent of the spe- cific 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 ther- apist behaviors and qualities that promote a facilitative therapy rela- tionship.
} Efforts to promulgate best practices or evidence-based prac- tices (EBPs) without including the relationship are seriously in- complete and potentially misleading.
} Adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis) enhances the ef- fectiveness of treatment.
} The therapy relationship acts in concert with treatment meth- ods, patient characteristics, and practitioner qualities in determin- ing effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations.
} Table 1 summarizes the task force conclusions regarding the evidentiary strength of (a) elements of the therapy relation- ship primarily provided by the psychotherapist and (b) methods of adapting psychotherapy to particular patient characteristics.
} The conclusions do not by 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.
Recommendations of the Task Force
General Recommendations
1. We recommend that the results and conclusions of this second task force be widely disseminated in order to enhance awareness and use of what “works” in the therapy relationship.
John C. Norcross, Department of Psychology, University of Scranton; Bruce E. Wampold, Department of Counseling Psychology, University of Wisconsin, Madison.
Portions of this article are adapted, by special permission of Oxford University Press, from a chapter of the same title by the same authors in J. C. Norcross (Ed.), 2011, Psychotherapy relationships that work (2nd ed.). New York, NY: Oxford University Press. The book project was cosponsored by the APA Division of Psychotherapy.
Correspondence regarding this article should be addressed to John C. Norcross, PhD, Department of Psychology, University of Scranton, Scran- ton, PA 18510-4596. E-mail: [email protected]
Psychotherapy © 2011 American Psychological Association 2011, Vol. 48, No. 1, 98 –102 0033-3204/11/$12.00 DOI: 10.1037/a0022161
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2. Readers are encouraged to interpret these findings in the context of the acknowledged limitations of the task force’s work.
3. We recommend that future task forces be estab- lished periodically to review these findings, in- clude new elements of the relationship, incorpo- rate the results of non-English language publications (where practical), and update these conclusions.
Practice Recommendations
4. Practitioners are encouraged to make the creation and cultivation of a therapy relationship, charac- terized by the elements found to be demonstrably and probably effective, a primary aim in the treat- ment of patients.
5. Practitioners are encouraged to adapt or tailor psychotherapy to those specific patient character- istics in ways found to be demonstrably and prob- ably effective.
6. Practitioners are encouraged to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to in- creased opportunities to reestablish collaboration, improve the relationship, modify technical strat- egies, and avoid premature termination.
7. Concurrent use of evidence-based therapy rela- tionships and evidence-based treatments adapted to the patient is likely to generate the best out- comes.
Training Recommendations
8. Training and continuing education programs are encouraged to provide competency-based training
in the demonstrably and probably effective ele- ments of the therapy relationship.
9. Training and continuing education programs are encouraged to provide competency-based training in adapting psychotherapy to the individual pa- tient in ways that demonstrably and probably en- hance treatment success.
10. Accreditation and certification bodies for mental health training programs should develop criteria for assessing the adequacy of training in evidence-based therapy relationships.
Research Recommendations
11. Researchers are encouraged to progress beyond correlational designs that associate the frequency of relationship behaviors with patient outcomes to methodologies capable of examining the complex associations among patient qualities, clinician be- haviors, and treatment outcome. Of particular im- portance is disentangling the patient contributions and the therapist contributions to relationship el- ements and, ultimately, outcome.
12. Researchers are encouraged to examine the spe- cific mediators and moderators of the links be- tween the relationship elements and treatment outcome.
13. Researchers are encouraged to address the obser- vational perspective (i.e., therapist, patient, or ex- ternal rater) in future studies and reviews of “what works” in the therapy relationship. Agreement among observational perspectives provides a solid sense of established fact; divergence among perspectives holds important implications for practice.
Table 1 Task Force Conclusions
Elements of the relationship Methods of adapting
Demonstrably effective Alliance in individual psychotherapy Reactance/resistance level Alliance in youth psychotherapy Preferences Alliance in family therapy Culture Cohesion in group therapy Religion and spirituality Empathy Collecting client feedback
Probably effective Goal consensus Stages of change Collaboration Coping style Positive regard
Promising but insufficient Congruence/genuineness Expectations Research to judge Repairing alliance ruptures Attachment style
Managing countertransference
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Policy Recommendations
14. APA’s Division of Psychotherapy, Division of Clinical Psychology, and other practice divisions are encouraged to educate its members in the benefits of evidence-based therapy relationships.
15. Mental health organizations as a whole are en- couraged to educate their members about the im- proved outcomes associated with using evidence- based therapy relationships, as they frequently now do about evidence-based treatments.
16. We recommend that the American Psychological Association and other mental health organizations advocate for the research-substantiated benefits of a nurturing and responsive human relationship in psychotherapy.
17. Finally, administrators of mental health services are encouraged to attend to the relational features of those services. Attempts to improve the quality of care should account for treatment relationships and adaptations.
What Works
The process by which the preceding conclusions on which relationship elements are demonstrably and probably effective require some elaboration, as these tend to be the most cited and controversial findings of the task force. These conclusions repre- sent the consensus of expert panels composed of five judges who independently reviewed and rated the empirical evidence. They evaluated, for each relationship element, the previous research summary and the new meta-analysis according to the following criteria: number of empirical studies; consistency of empirical results; independence of supportive studies; magnitude of associ- ation between the relationship element and outcome; evidence for causal link between relationship element and outcome; and the ecological or external validity of research. Their respective ratings of demonstrably effective, probably effective, or promising but insufficient research to judge were then combined to render a consensus. In this way, we added a modicum of rigor and consen- sus to the process, which was admittedly less so in the first task force.
The consensus deemed six of the relationship elements as de- monstrably effective, three as probably effective, and three as promising but insufficient research to judge. As members of that consensus panel, we were impressed by the skepticism and preci- sion of the raters (as scientists ought to be). At the same time, were also impressed by the disparate and perhaps elevated standards against which these relationship elements were evaluated.
Consider the evidentiary strength required for psychological treatments to be considered demonstrably efficacious in two influ- ential compilations of evidence-based practices. The Division of Clinical Psychology’s Subcommittee on Research-Supported Treatments (www.div12.org/PsychologicalTreatments/index.html) requires two between-groups design experiments demonstrating
that a psychological treatment is either (a) statistically superior to pill or psychological placebo or to another treatment or (b) equiv- alent to an already established treatment in experiments with adequate sample sizes. The studies must have been conducted with treatment manuals and conducted by at least two different inves- tigators. The typical effect size of those studies was often smaller than the effects for the relationship elements reported in this special issue. For listing in SAMHSA’s National Registry of Evidence-based Programs and Practices (www.nrepp.samhsa.gov), only evidence of statistically significant behavioral outcomes dem- onstrated in at least one study, using an experimental or quasi- experimental design, that has been published in a peer-reviewed journal or comprehensive evaluation report is needed. The inter- vention must be accompanied by implementation materials, train- ing, and support resources that are ready to use by the public. By these standards, practically all of the dozen relationship elements in this journal issue would be considered demonstrably effective, if not for the requirement of a randomized clinical trial, which is neither clinically nor ethically feasible for the vast majority of these elements (as explicated in the introductory article in this issue).
In important ways, the criteria for relationship elements are more rigorous. Whereas the criteria for designating treatments as evidence-based relies on only one or two studies, the evidence for relationship elements discussed here are based on comprehensive meta-analyses of many studies (in excess of 50 in several cases), spanning various treatments and research groups. The studies used to establish evidence-based treatments are, however, clinical trials, which are often designated as the “gold standard” for establishing evidence. Nevertheless, these studies are often plagued by con- founds, such as researcher allegiance and bogus comparisons. The point here is not to denigrate the criteria used to establish evidence-based treatments but to underscore the robust scientific standards by which the relationship elements have been evaluated.
A further research complication, but a clinical strength, con- cerns responsiveness. Research on the effectiveness of the psycho- therapy relationship is constrained by therapist responsiveness— the ebb and flow of clinical interaction. Responsiveness refers to therapist behavior that is affected by emerging context and occurs on many levels, including choice of a treatment method, case formulation, strategic use of the self, and then adjusting those to meet the emerging, evolving needs of the client at any given moment (Stiles, Honos-Webb, & Surko, 1998). Effective psycho- therapists 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 moments. Successful responsiveness can confound attempts to find naturalistically ob- served linear relations of outcome with therapist behaviors (e.g., cohesion, positive regard). Because of such problems, the statisti- cal relations between the relationship and outcome cannot always be trusted. By being clinically attuned and flexible, psychothera- pists make it more difficult in research studies to discern what works.
What Does Not Work
Translational research is both prescriptive and proscriptive—it tells us what works and what does not. In the following section, we
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highlight those therapist relational behaviors that are ineffective, perhaps even hurtful, in psychotherapy.
One means of identifying ineffective qualities of the therapeutic relationship is to simply reverse the effective behaviors. 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 countertransfer- ence.
Another means of identifying ineffective qualities of the rela- tionship is to scour the research literature and conduct polls of experts. Here are six behaviors to avoid according to that research (Duncan, Miller, Wampold, & Hubble, 2010) and a Delphi poll (Norcross, Koocher, & Garofalo, 2006):
} Confrontations. Controlled research trials, particularly in the addictions field, consistently find a confrontational style to be ineffective. In one review (Miller, Wilbourne, & Hettema, 2003), confrontation was ineffective in all 12 identified trials. By contrast, expressing empathy, rolling with resistance, developing discrep- ancy, and supporting self-efficacy, characteristic of motivational interviewing, have demonstrated large effects with a small number of sessions (Lundahl & Burke, 2009).
} Negative processes. Client reports and research studies con- verge in warning therapists to avoid comments or behaviors that are hostile, pejorative, critical, rejecting, or blaming (Binder & Strupp, 1997; Lambert & Barley, 2002). Therapists who attack a client’s dysfunctional thoughts or relational patterns need, repeat- edly, to distinguish between attacking the person versus her be- havior.
} Assumptions. Psychotherapists who assume or intuit their client’s perceptions of relationship satisfaction and treatment suc- cess are frequently inaccurate. By contrast, therapists who specif- ically and respectfully inquire about their client’s perceptions frequently enhance the alliance and prevent premature termination (Lambert & Shimokawa, pp. 72–79, this issue).
} Therapist-centricity. A recurrent lesson from process- outcome research is that the client’s observational perspective on the therapy relationship best predicts outcome (Orlinsky, Ron- nestad, & Willutzki, 2004). Psychotherapy practice that relies on the therapist’s observational perspective, while valuable, does not predict outcome as well. Therefore, privileging the client’s expe- riences 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 and mistakenly assume she has not contributed to that breach. Dogmatic reliance on particular relational or therapy meth- ods, incompatible with the client, imperils treatment (Ackerman & Hilsenroth, 2001).
} Procrustean bed. As the field of psychotherapy has matured, using an identical therapy relationship (and treatment method) for all clients is now recognized as inappropriate and, in select cases, even unethical. The efficacy and applicability of psychotherapy will be enhanced by tailoring it to the unique needs of the client, not by imposing a Procrustean bed onto unwitting consumers of psychological services. We should all avoid the crimes of Pro-
crustes, the legendary Greek giant who would cut the long limbs of clients or stretch short limbs to fit his one-size bed.
We can optimize therapy relationships by simultaneously using what works and studiously avoiding what does not work.
Concluding Thoughts
In the culture wars of psychotherapy that pit the therapy relationship against the treatment method (Norcross & Lambert, pp. 4 – 8, this issue), it is easy to chose sides, ignore discon- firming research, and lose sight of our superordinate commit- ment to patient benefit. Instead, let us conclude, like T. S. Eliot, by “arriving where we started” and underscoring three incon- trovertible but oft-neglected truths about psychotherapy rela- tionships.
First, the interdivisional taskforce was commissioned in order to augment patient benefit. We continue to explore what works in the therapy relationship and what works when we adapt that relation- ship to (nondiagnostic) patient characteristics. That remains our collective aim: improving patient success, however measured and manifested in a given case.
Second, psychotherapy is at root a human relationship. Even when “delivered” via distance or on a computer, psychotherapy is an irreducibly human encounter. Both parties bring themselves— their origins, culture, personalities, psychopathology, expectations, biases, defenses, and strengths—to the human relationship. Some will judge that relationship a precondition of change and others a process of change, but all agree that it is a relational enterprise.
Third, how we create and cultivate that powerful human rela- tionship can be guided by the fruits of research. As Carl Rogers (1980) compellingly demonstrated, 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 behavior, or, yes, a therapy relationship.
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Received October 19, 2010 Revision received October 28, 2010
Accepted October 28, 2010 �
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