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References

Farber, B. A., Suzuki, J. Y., & Lynch, D. A. (2018). Positive regard and psychotherapy outcome: A meta-analytic

review. Psychotherapy, 55(4), 411–423. https://doi-org.library.capella.edu/10.1037/pst0000171

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Positive Regard and Psychotherapy Outcome: A Meta-Analytic Review

By: Barry A. Farber

Department of Counseling and Clinical Psychology, Teachers College, Columbia University;

Jessica Y. Suzuki

Department of Counseling and Clinical Psychology, Teachers College, Columbia University

David A. Lynch

Department of Counseling and Clinical Psychology, Teachers College, Columbia University

Acknowledgement: We gratefully acknowledge the research assistance provided by Jenna Cohen, Stephanie

Fritz, Devlin Jackson, Tao Lin, Amar Mandavia, and Rebecca Shulevitz.

This article is adapted, by special permission of Oxford University Press, by the same authors in J. C. Norcross

& M. J. Lambert (Eds.). (2018), Psychotherapy relationships that work (3rd ed.). New York, NY: Oxford

University Press. The Interdivisional APA Task Force on Evidence-Based Psychotherapy Relationships and

Responsiveness was cosponsored by the APA Division of Psychotherapy/Society for the Advancement of

Psychotherapy.

The deepest principle in human nature is the craving to be appreciated.—William James, 1890/1981, p. 313

Over 60 years ago, in what is now considered a classic article, Carl Rogers (1957) posited that

psychotherapists’ provision of positive regard, congruence (genuineness), and empathy were the necessary

and sufficient conditions for therapeutic change. Rogers had been developing these views for many years,

some of which were expressed as early as Rogers 1942 in his seminal work, Counseling and Psychotherapy.

Still, the publication of the 1957 article catalyzed a shift in the way that many thought about the putative

mechanisms of psychotherapeutic change. The prevailing view at the time—and still an enormously influential

one though currently cast in somewhat different (e.g., more evidence-based) terms—was that technical

expertise on the part of the therapist, especially in terms of choice and timing of interventions, was the

discriminating element between effective and noneffective therapy. Under the sway of Rogers’ burgeoning

influence in the late 1950s and throughout the 1960s, the notion that the relationship was the critical factor in

determining therapeutic success took hold (Farber, 2007; Farber, Brink, & Raskin, 1996).

Psychotherapists of varying persuasions, including those from theoretical camps that had traditionally

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emphasized more technical factors, have increasingly acknowledged the importance of the relationship.

Behaviorists and cognitive behaviorists now suggest that a good relationship may facilitate the provision of their

psychological interventions (Beck, 1995; Leahy, 2008; Linehan, 1993), and many psychoanalytic therapists

have shifted their clinical perspective to emphasize “relational” factors (Mitchell & Aron, 1999; Wachtel, 2008).

But even before these relatively recent developments, there is evidence to suggest that Freud’s psychoanalytic

cases were only successful when he was supportive and positively regarding. As Breger (2009) noted,

When Freud followed these [psychoanalytic] rules his patients did not make progress. His well-known

published cases are failures . . . in contrast are patients like Kardiner and others—cases he never wrote or

publicly spoke about—all of whom found their analyses very helpful. With these patients, what was curative

was not neutrality, abstinence, or interpretations of resistance, but a more open and supportive relationship,

interpretations that fit their unique experiences, empathy, praise, and the feelings that they were liked by their

analyst. (p. 105)

This observation suggests that along with whatever positive effects accrue as a result of accurate

interpretations, psychoanalytic success has arguably always been based substantially on the undervalued

ability of the analyst to be empathic and, even more to the point of this chapter, to be supportive and positively

regarding of his or her patients.

In this article, we review positive regard and discuss how the use of multiple terms (including affirmation,

respect, nonpossessive warmth, support, validation, and prizing) has led to conceptual confusion and empirical

difficulties in determining its link to treatment outcome. We consider research measures and clinical examples

involving positive regard and affirmation. We then summarize the results of our meta-analysis on the

association between therapist positive regard and treatment outcome in psychotherapy. The article concludes

with research limitations, diversity consideration, and therapeutic practices reflective of positive regard and

affirmation.

Definitions and Measures

To the extent that the therapist finds himself experiencing a warm acceptance of each aspect of the client’s

experience as being a part of that client, he is experiencing unconditional positive regard. . . . It means there

are no conditions of acceptance. . . . It means a “prizing” of the person . . . it means a caring for the client as a

separate person. (Rogers, 1957, p. 101)

From the beginning of his efforts to explicate the essential elements of client-centered (later termed person-

centered) therapy, Rogers focused on positive regard and warmth: “Do we tend to treat individuals as persons

of worth, or do we subtly devaluate them by our attitudes and behavior? Is our philosophy one in which respect

for the individual is uppermost?” (Rogers, 1951, p. 20). Some of his prominent followers (Bozarth & Wilkins,

2001) have asserted that positive regard is the curative factor in person-centered therapy.

To this day, agreeing on a single phrase to refer to this positive attitude remains problematic. It is most often

termed positive regard but early studies and theoretical writings preferred the phrase nonpossessive warmth; in

addition, some work distinguished unconditionality (valuing the person “irrespective of the differential values

which one might place on his specific behaviors,” Rogers, 1959, p. 208) from positive regard (“attitudes such as

warmth, liking, respect sympathy, acceptance”; Rogers, 1959, p. 208). In his famous filmed work with Gloria

(Shostrom, 1965), Rogers struggled to find a single phrase to illuminate the concept: It is, he said, “real

spontaneous praising; you can call that quality acceptance, you can call it caring, you can call it a non-

possessive love. Any of those terms tend to describe it.” Some reviews of the research on “acceptance,

nonpossessive warmth, or positive regard” (Orlinsky, Grawe, & Parks, 1994, p. 326) grouped them under the

category of therapist affirmation. We will use the phrase positive regard to refer to the general constellation of

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behaviors encompassed by this and similar phrases.

Further confusing the definition, Rogers’ focus on accepting and affirming that the client has, from the outset,

been conflated with his other facilitative conditions for therapeutic change—empathy and genuineness. The

therapist’s attempt to “provide deep understanding and acceptance of the attitudes consciously held at the

moment by the client” could only be accomplished by the therapist’s “struggle to achieve the client’s internal

frame of reference, to gain the center of his own perceptual field” (Rogers, 1951, pp. 30–31). In a similar vein,

Rogers suggested that the therapist’s genuineness or congruence was a prerequisite for his or her experience

of positive regard and empathy (Rogers & Truax, 1967). In fact, most research focusing on the effects of

therapist positive regard have used measures that include items reflecting overlapping relational elements.

The best validated and most commonly used measure of the facilitative conditions, the Barrett-Lennard

Relationship Inventory (BLRI; Barrett-Lennard, 1964, 1978, 1986) contains two subscales to assess the

positive regard construct: Level of Regard, “the overall level or tendency of one person’s affective response to

another” (Barrett-Lennard, 1986, p. 440), and Unconditionality of Regard, the extent to which “regard. . .is

stable” (p. 443). Research has found, however, that the Unconditionality of Regard subscale is less reliable and

valid than the other subscales (Barrett-Lennard, 1964; Cramer, 1986). As a result, the Unconditionality

subscale has increasingly been excluded in studies using the BLRI. In general, clinical and research

conceptualizations in recent decades have tended to focus more on the “positive regard” strand than the

“unconditionality” strand.

The BLRI consists of 64 items across four domains (Level of Regard, Empathic Understanding,

Unconditionality of Regard, and Congruence). Eight items are worded positively, and eight negatively, in each

domain; each item is answered on a +3 (yes, strongly felt agreement) to −3 (no, strongly felt disagreement)

response format. This instrument can be used by a client, a therapist, or an external observer. Level of Regard,

according to Barrett-Lennard (1986, pp. 440–441), “is concerned in various ways with warmth, liking/caring,

and ‘being drawn toward’.” Positive items include “she respects me as a person,” “I feel appreciated by her,”

and “She is friendly and warm toward me.” Representative negative items include “I feel that she disapproves

of me,” “She is impatient with me,” and “At times she feels contempt for me.”

Truax, a colleague of Rogers, developed two instruments to measure Rogers’ facilitative conditions. One was a

set of scales to be used by raters in their assessment of these conditions as manifest in either live observations

or through tape recordings of sessions. There are five stages on the scale that measures nonpossessive

warmth. At Stage 1, the therapist is “actively offering advice or giving clear negative regard” (Truax & Carkhuff,

1967, p. 60), whereas at Stage 5, the therapist “communicates warmth without restriction. There is a deep

respect for the patient’s worth as a person and his rights as a free individual” (p. 66).

The second instrument developed by Truax, the Relationship Questionnaire (Truax & Carkhuff, 1967), was to

be used by clients. This measure consists of 141 items marked “true” or “false” by the client. Of these items, 73

are keyed to the concept of nonpossessive warmth; however, many of these items are also keyed to the other

two facilitative conditions (genuineness and empathy). That is, a “true” response on one item may count toward

a higher score on more than one subscale. Representative items on the Nonpossessive Warmth scale are as

follows: “He seems to like me no matter what I say to him” (this item is also on the Genuineness scale); “He

almost always seems very concerned about me”; “He appreciates me”; and “Even if I were to criticize him, he

would still like me.”

In addition to these scales, therapist positive regard has been assessed via instruments designed primarily to

measure the strength of the alliance. In particular, the Vanderbilt Psychotherapy Process Scale (O’Malley, Suh,

& Strupp, 1983; Suh, Strupp, & O’Malley, 1986) has been used in this manner. Each of 80 items is rated by

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clinical observers on a 5-point Likert-type scale either from the actual therapy sessions or from video- or

audiotapes of therapy. Factor analyses of these items have yielded eight subscales, one of which, Therapist

Warmth and Friendliness, closely approximates positive regard. The specific therapist attributes rated in this

subscale include “involvement” (the therapist’s engagement in the patient’s experience), “acceptance” (the

therapist’s ability to help the patient feel accepted), “warmth and friendliness,” and “supportiveness” (the

therapist’s ability to bolster the patient’s self-esteem, confidence, and hope). Therapist positive regard can also

be measured through the Structural Analysis of Social Behavior (Benjamin, 1984), using scores for the

Affirming and Understanding cluster. Consistent with Rogers’ theorizing about positive regard, this cluster

combines elements of warmth and empathy.

A new 43-item measure of positive regard (Psychotherapist Expressions of Positive Regard; Suzuki & Farber,

2016) has also been developed. Its factor structure strongly suggests three distinctive components:

Supportive/Caring Statements (e.g., “I’m glad you shared that with me.”), Unique Responsiveness (e.g., “My

therapist remembers the name or details of something or someone I have spoken of in the past.”), and

Intimacy/Disclosure (e.g., “My therapist has tears in his/her eyes as I relate a sad story.”).

Clinical Examples

Arguably, the most cited, if somewhat controversial (Daniels, 2014), example of positive regard comes from

Rogers’ filmed work with Gloria (Shostrom, 1965). Gloria stated that she wished that her own father would talk

to her like Rogers was doing at that moment and then remarked, “Gee, I’d like you for my father.” Rogers

responded to her, “You look to me like a pretty good daughter.” It is a moving moment, one that has been used

to illustrate not only positive regard but also corrective emotional experience (Farber, Bohart, & Stiles, 2012).

The other examples that follow have been drawn from disparate theoretical orientations and include various

means of providing positive regard to patients. Although the explicit therapeutic value of positive regard was

first proposed by Rogers, the provision of this condition occurs in the work of practitioners of multiple clinical

traditions. Furthermore, according to clients, positive regard is not solely reflected in explicit statements of the

therapist’s valuing of or caring for the client. In a study investigating client perceptions of positive regard

(Suzuki & Farber, 2016), the therapist behaviors that respondents experienced as most affirming included: “My

therapist offers me a new way of understanding a part of myself that I usually view as a weakness”; “My

therapist shows she or he is listening through her or his body language”; “My therapist maintains eye contact

with me”; “My therapist encourages me to take pride in the things I do well”; and “My therapist speaks to me in

a gentle tone of voice.” A clinical case in which multiple aspects of positive regard are exhibited by the therapist

can be found in the study by Farber and Suzuki (2018).

Given these considerations, some of the following examples are not prototypical affirming statements but rather

therapist words or behavior that convey an overall attitude of positive regard. The first example is a fictitious

clinical amalgam; the second and third are taken from previously published case material (in which patient

information has been de-identified).

Case Example 1

ClientI’m just feeling so worn-out and sad.

Therapist(nodding, attentive, maintaining eye contact, and then, after a moment’s silence, in a very gentle

voice): Tell me more, please. I’d like to really understand what you’re going through.

This brief example illustrates the way in which a therapist’s body language and the paralinguistic elements of

his or her speech can contribute significantly to whatever verbal message is offered to the client. This client

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feels held and cared about even before the therapist’s gentle invitation to share more about his or her situation.

Case Example 2

ClientIt really hurts when I think about the fact that it is over.TherapistYes, of course it hurts. It hurts because

you loved him and it did not work out. It shows, I think, your capacity to love and to care. But it also hurts to

have that ability.ClientI do not think I’ll ever feel that way.TherapistRight now it may be important for you to

protect yourself with that feeling. Perhaps we can look at what you have learned about yourself and your needs

and the kind of man who would be right for you.ClientWhat do you mean?TherapistI mean that you have a

great ability to love. But what can you learn about what you need in a man that [Tom] lacked?ClientI guess I

learned not to get involved with a married man.TherapistWhat do you think led you to think you’d be able to

handle being involved with a married man?ClientWell, after my marriage ended, I guess I didn’t want to get too

attached. So I thought that being involved with someone who is married would keep me from being

hurt.TherapistPerhaps you’ve learned that you have such a strong ability to love that you cannot

compartmentalize your feelings that way (Leahy, 2001, p. 82).

In this example, Leahy, a cognitive therapist, is consistently empathic (“of course it hurts”) and attempts to

teach his patient something about herself and her needs and choices by making a connection between her

current behavior and past actions. Moreover, his interventions are provided in a supportive, caring way,

emphasizing his patient’s “strong ability to love.”

Case Example 3

You’re reading me entirely wrong. I don’t have any of those feelings. I’ve been pleased with our work. You’ve

shown a lot of courage, you work hard, you’ve never missed a session, you’ve never been late, you’ve taken

chances by sharing so many intimate things with me. In every way here, you do your job. But I do notice that

whenever you venture a guess about how I feel about you, it often does not jibe with my inner experience, and

the error is always in the same direction: You read me as caring for you much less than I do. (Yalom, 2002, p.

24)

In this example, Yalom, an existential therapist, offers assumedly accurate feedback to his patient on her

interpersonal tendencies (much like a psychoanalytic therapist might do). In doing so, he explicitly conveys the

fact that he cares for this patient far more than she imagines to be the case.

Results of Previous Reviews and Meta-Analyses

As part of a comprehensive review of the process and outcome in psychotherapy, Orlinsky and colleagues

(1994) studied this general phenomenon under the rubric of therapist affirmation, explained by the authors as a

variable that includes aspects of acceptance, nonpossessive warmth, and positive regard. They found that 56%

of the 154 results reviewed were positive, and that the findings based on patients’ perspective (the patient’s

rating of the therapist’s positive regard) yielded even a higher rate of positive therapeutic outcomes, 65%.

“Overall,” Orlinsky et al. concluded, “nearly 90 findings indicate that therapist affirmation is a significant factor,

but considerable variation in ES [effect size] suggests that the contribution of this factor to outcome differs

according to specific conditions” (p. 326).

In their review of positive regard for the first edition of Psychotherapy Relationships that Work (Norcross, 2002),

Farber and Lane (2002) highlighted several patterns. First, no post-1990 study reported a negative relationship

between positive regard and outcome. Second, the results of the 16 studies analyzed were essentially evenly

split between positive and nonsignificant effects. That is, 49% (27/55) of all reported associations were

significantly positive, and 51% (28/55) were nonsignificant. However, the authors noted that the majority of

nonsignificant findings occurred when an objective rater (rather than the therapist or patient) evaluated

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therapeutic outcome. Third, confirming the pattern noted by previous reviewers, Farber and Lane found that

when the patient rated both the therapist’s positive regard and treatment outcome, a positive association

between these variables was especially likely. Lastly, the effect sizes for the significant results tended to be

modest, with the larger effect sizes occurring when positive regard was assessed in terms of its association

with the length of stay in therapy rather than outcome per se.

Finally, in the previous (second) edition of Psychotherapy Relationships that Work (Norcross, 2011), Farber and

Doolin (2011) analyzed 18 studies. Using a random effects model, they reported an aggregate effect size of r =

.27 (p < .000, N = 1,067), indicating that positive regard has a moderate association with psychotherapy

outcomes; only two of the studies yielded negative effect sizes. Univariate categorical moderator analyses

indicated that the following moderators were significant: publication outlet (i.e., journal article vs. dissertation),

rater perspective, origin of sample (random vs. convenience sample), measure used to assess positive regard,

time in treatment when positive regard was measured, and type (theoretical orientation) of treatment. Notably,

they found that the overall effect of positive regard on outcome tended to be higher when the treatment was

psychoanalytic/psychodynamic.

Meta-Analytic Review

Literature Search and Study Selection

To find studies that documented a relation between positive regard and outcome in psychotherapy, we used the

PsycINFO database. Main root terms searched in the title or the abstract were positive regard, warmth,

nonpossessive warmth, therapist affirmation, unconditional positive regard, acceptance, validation, and

unconditional regard. All these terms were crossed with psychotherapy, psychotherapist, and

psychotherapeutic. Additional studies were located by running a search with the root term “Barrett-Lennard”

because this is the most widely used instrument to assess positive regard. Furthermore, all meta-analyses and

review articles yielded by these searches were combed for eligible empirical studies. We generally excluded

non-English articles from consideration, with the exception of a few articles that were translated (by a colleague

of ours) from German.

The specific inclusion criteria were as follows: (a) the study identified positive regard as unconditional regard,

positive regard, warmth, nonpossessive warmth, affirmation, acceptance, or validation; (b) positive regard (in

any of these forms) was a predictor of outcome in the study; (c) the study reported quantitative outcome data

and relevant statistics (e.g., correlations between positive regard ratings and treatment outcome or mean

outcome comparisons between groups with differential positive regard ratings) that could be used to calculate

effect sizes; and (d) treatment was individual, family, or group psychotherapy.

We broadened the inclusion criteria compared with those used in the previous meta-analysis, which identified

only 18 eligible studies. Rather than restricting our focus to individual adult psychotherapy, we included 13

studies on family or group treatment and 13 studies that included participants younger than age 18 years. In

this iteration, we coded for additional treatment variables to investigate whether they had a moderating impact

on the relation between positive regard and outcome.

Furthermore, in contrast to the previous edition, we did not immediately exclude studies we encountered

through the search parameters described earlier that looked at positive regard as part of a “composite” factor

—typically as part of the constellation of Rogerian facilitative conditions. We obtained disaggregated raw data

through correspondence with the authors of three studies, but in most cases, this did not prove possible.

Because investigating the facilitative conditions in aggregate is a relatively common practice in both early and

more recent studies—a practice justified by the strong intercorrelations among positive regard, empathy, and

congruence/genuineness—we included these composite variables with the goal of testing for a moderating

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effect when positive regard is assessed singly versus in an aggregate form.

A total of 24 studies using composite scores (typically from the Truax rating scales or BLRI) were included in

the meta-analysis. Only those studies in which the composite predictor (typically, the three facilitative

conditions) was coherently defined with an overall clear relation to positive regard were included, whereas

studies that aggregated positive regard with an excessively large or unwieldy group of variables were excluded.

Finally, we excluded studies that explicitly reported that participants in the low and high facilitative conditions

groups did not have significantly different ratings of positive regard.

In addition, we consulted the 2011 chapter to determine which of those 18 studies met our current criteria. One

article (Quintana & Meara, 1990) was excluded because it did not explicitly examine the relation between

positive regard and therapeutic outcomes. After scanning the literature with these criteria in mind, more than

100 studies were selected for review, of which 64 were found to be entirely consistent with these criteria and

thus were included in the meta-analysis (Table 1).

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Studies (K = 64) and Effect Sizes Used in the Meta-Analysis Investigating the Effects of Positive Regard on

Treatment Outcome

The characteristics of the studies included in the meta-analysis are summarized in Table 2. The study

(measurement) characteristics we rated were as follows: positive regard measure, whether positive regard was

assessed alone or as part of a composite, time of predictor and outcome measurement (early treatment,

midtreatment, late/termination, follow-up, or multiple measurements averaged), rater perspective for predictor

and outcome variables (client, therapist, external rater, or combination of the aforementioned), and total

number of participants.

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Characteristics of Studies (k = 64) Included in the Meta-Analysis

Characteristics of the sample/treatment that were coded were as follows: mean age, percentage of men,

percentage of racial/ethnic minorities, nationality (U.S. vs. other), predominant diagnosis (mood/anxiety

disorder, severe mental illness, or other), outpatient versus inpatient setting, child versus adult participants,

group versus family treatment, and therapy modality (psychodynamic, cognitive-behavioral, or mixed/other).

The therapist factors coded for this meta-analysis were as follows: mean age, percentage of men, and

experience level of therapists (trainees vs. nontrainees).

Effect Size Coding

Because the purpose of this meta-analysis was to examine the relation between therapist positive regard and

treatment outcome, effect sizes were collected for each analysis that included positive regard and an outcome

variable. Because each study reported effects using different types of effect sizes, we converted all effect sizes

to Hedges’ g (per Cooper, Hedges, & Valentine, 2009). When computing Hedges’ g, each effect size accounts

for the sample size of each study-based analysis; thus, Hedges’ g offers an unbiased estimator of d because

the effect size estimate d tends to have a small overestimation bias that can be removed using a correction

formula.

Results

A total of 369 effect sizes within 64 studies, comprising 3,528 participants, were included in the overall analysis.

Using a random effects model, the aggregate effect size was g = .28, indicating that positive regard has a small

association with psychotherapy outcomes. Additionally, the 95% confidence interval did not include zero

(confidence interval = 0.25, 0.31), indicating that the effect of positive regard on outcome is significantly

different from zero.

To assess whether there was variability among these 64 studies above and beyond what would be expected by

chance, a homogeneity test was conducted. Using the homogeneity statistics, Q and I (Hedges, 1982), the

assumption that the studies selected were sampled from the same population (i.e., were homogenous) was

rejected, Q (df = 368) = 1132.56, p < .0001; I = 67.51%. This indicated that there is a large amount of

heterogeneity of effects among these studies, suggesting that study factors may be moderating the omnibus

effects.

To assess for publication bias or the “file drawer problem,” we conducted an Orwin’s fail-safe N analysis. The

analysis found that a total of 2,049 studies that are not significant at the .05 level would be needed to negate

the strength of the aggregated effect. However, the funnel plot of included studies (Figure 1) suggests the

possibility of publication bias—the substantial asymmetry around the mean may be evidence that included

studies disproportionally report elevated effect sizes. The studies that had effect sizes of g > 1.0 tended to be

published before 1995 and had an n of less than 50, with the exception of Murphy and Cramer (2010) and

Cordaro, Tubman, Wagner, and Morris (2012).

2

2

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Figure 1. Funnel plot of studies included in meta-analysis of the effects of Positive Regard.

Because 369 effect sizes were nested within 64 studies, the assumption of independence was managed via

stipulating a correlation between outcome measures of .50 (Wampold et al., 1997). To account for this issue

statistically, we used a multilevel random effects meta-analysis in which effect sizes were nested within

individual study samples (Konstantopoulos, 2011). This analysis accounted for the fact that some studies

utilized the same data set to report multiple correlations of positive regard and outcome. Controlling for nesting

within samples, the multilevel analysis yielded a larger effect than the random effects model, with an aggregate

effect size of g = .36 (confidence interval = 0.28, 0.44) and the same heterogeneity, Q (df = 368) = 1132.56, p <

.001.

Comparison to Previous Meta-Analyses

As noted, the current meta-analysis included a far greater number of studies (k = 64) than either the 2002 or

2011 analyses of the association between positive regard and treatment outcome (k = 16 and 18, respectively).

In contrast to these earlier meta-analyses, the current meta-analysis incorporated studies of positive regard

with broader inclusion criteria that investigated child, family, and group psychotherapy, as well as studies that

investigated the collective effects of Rogers’ three facilitative conditions on therapeutic outcome. Perhaps as a

result of these differences, the current study yielded a small effect size. Adopting a random effects model, the

most recent previous (2011) meta-analysis reported an aggregate effect size of r = .27, whereas in this current

meta-analysis, g was calculated as .28, a figure that corresponds to nearly double that of r at these lower

levels.

The variability within studies contributed to the modest (small) overall effect size of the current meta-analysis.

When accounting for the heterogeneity of study data sets, the aggregate effect size increased to g = 0.36. This

could be indicative of study-level random and systematic error that differentially impact sample characteristics.

Moderators

To account for the heterogeneity present in the included studies, we first conducted several univariate

categorical moderator analyses. All covariate analyses utilized a restricted maximum-likelihood estimator to

generate unbiased estimates of the variance of covariance parameters. To be considered a significant

moderator, the factor needed to be both statistically significant in the test for residual heterogeneity (QE) and

the test of moderators (QM). As Table 3 indicates, the following moderators explained statistically significant

heterogeneity of the aggregate effect sizes: therapy format, therapeutic setting, therapist experience level,

client diagnosis, and the type of outcome measure used. When factors were considered individually (rather

than in a multilevel model, see the following text), positive regard tends to have a more powerful association

with psychotherapy outcome in individual therapy, in an outpatient setting, when therapy is performed by

trainees, with clients presenting with mood or anxiety disorders (as opposed to severe mental illness), and

when outcome is assessed via measures of global or overall symptomatology (as opposed to specific indices of

depression or anxiety).

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Statistically Significant Univariate Moderators

Following the univariate moderator analyses, all significant moderators were combined into a multilevel

metaregression model (Table 4). This controlled for the correlations between moderator variables. The overall

test of moderators, QM (df = 10) = 36.48, p < .0001, indicated that the moderators significantly explained some

of the heterogeneity across studies; however, the test of residual heterogeneity suggested that, as a model, the

heterogeneity across studies remains high after accounting for the moderators in the model (QE (df = 288) =

707.33, p < .0001). Because many of the predictor variables were significantly correlated, the model-building

approach corrects for the inflated alpha associated with multiple univariate analyses. When all significant

covariates were included in a metaregression model, only the model’s intercept was significant.

Multi-Level Meta-Regression Model With All Significant Univariate Covariates

Patient Contributions

The patient’s experience of therapist positive regard is the ultimate criterion of its presence. Affirmation

succeeds only if it is received as intended, and the client is obviously the primary determinant of that. There is

no positive regard without a client, to borrow an analogy from Winnicott. In fact, Rogers (1957) believed that it

is only the client’s perspective that matters—it is the client’s experience of positive regard (or genuineness or

empathy) that “counts,” and the therapist’s belief as to whether he or she has been positively regarding is

essentially moot in regard to outcome.

Patient demographics did not emerge as significant moderators in our analyses. In fact, when factors were

considered individually (rather than in a multilevel model), only one patient-related characteristic emerged as

significant: Positive regard was shown to have a more powerful association with psychotherapy outcome with

clients presenting with mood or anxiety disorders rather than severe mental illness. This may represent an

unfortunate clinical reality—that therapists’ provision of positive regard to clients with severe psychopathology

does not “work” as well as with clients with mood or anxiety disorders. Rogers (1957) would not have been

surprised by this finding; in his work with schizophrenic patients as part of the Wisconsin Project, he theorized

that these patients often perceived positive regard as “indifference” and that a more “conditional, demanding

attitude,” at least in the early stages of therapy, might prove more effective in establishing a good therapeutic

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relationship (Rogers, 1966, p. 186). In addition, the possibility that positive regard is especially potent in

working with less severely impaired clients is contrary to the perceptions of therapists who were interviewed

regarding their perceptions of the nature and value of positive regard (Traynor, Elliott, & Cooper, 2011).

Importantly, though, what must be kept in mind is that this finding of a significant contribution of patient severity

to the effects of positive regard on outcome no longer emerged when a multilevel model of study characteristics

was generated.

Limitations of the Research

Our database was restricted to 64 studies, a relatively small basis for conclusions about a variable that has

been part of psychotherapeutic lore for more than 60 years. Although this is a larger number of studies

compared with the previous meta-analysis (18 studies), some of the studies we deemed eligible for inclusion

included null results for a subset of the hypotheses tested without reporting adequate information to calculate

effect sizes for these tests. As a result, these null results could not be incorporated into the meta-analysis and

represent a bias toward significance in our meta-analysis. Moreover, there have been few studies of positive

regard within the past 20 years. We believe that the concept of positive regard has not so much gone away in

recent years as it has been folded into other constructs, including the therapeutic alliance, the “real

relationship,” and the therapist’s provision of empathy.

Another possible limitation is as follows: Positive regard may interact with a specific uninvestigated aspect of

therapy and that its effects are better understood as a complex product of multiple processes or therapeutic

conditions. For example, positive regard might be significantly associated with outcome only when therapist

directiveness is low (Orlinsky & Howard, 1978) or, conversely, when therapists frequently assign homework or

are typically challenging or confrontational. The point is that there are too few investigations of the ways in

which positive regard may be confounded with other therapist attitudes and behaviors. In a somewhat similar

vein, the multiple forms that many “brand name” therapies take (e.g., the many strands and “waves” of CBT)

suggest that aggregating multiple varieties of therapeutic approaches under a single variable may result in data

loss or misleading results.

Finally, the extant research, including our own meta-analysis, has not addressed the question of whether

positive regard has different effects on the reduction of symptoms (either diagnostic-specific or overall

symptoms) in comparison, say, to various, global indices of patient well-being, social adjustment, or happiness.

Neither have studies investigated the extent to which any beneficial effect of a therapist’s provision of positive

regard endures beyond the end of treatment.

Diversity Considerations

Due to the inconsistent reporting of patient demographics in our studies, we selected only a small number of

demographic variables to include in our meta-analysis—gender composition of clients and therapists and

percentage of ethnic minorities among clients. Unfortunately, the older studies that comprise the majority of our

data set rarely addressed these matters. The majority—White composition of psychotherapy practitioners and

clients—both in the included studies and in the population as a whole—limited our ability to identify genuine

effects for race and ethnicity in which they might exist. Only one study included in this meta-analysis sampled a

mostly non-White population (Cordaro et al., 2012). A critical mass of studies specifically investigating the

consequence of positive regard with a more diverse sample of clients will be needed to elucidate this issue.

That said, participant diversity—including client and therapist identities (e.g., age, race, ethnicity, gender,

religion, and sexual orientation) and their interaction—likely impacts the provision and effects of positive regard

in a multitude of ways. For example, it has been suggested that therapist expressions of positive regard may be

particularly potent when working with stigmatized or marginalized populations, such as sexual minority youth

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(Lemoire & Chen, 2005). A recent qualitative study (Suzuki, 2018) found that clients who related easily to their

therapists as a result of demographic similarities felt that this rapport facilitated their experience of positive

regard. In this regard, practitioners working across differences that reinforce a felt differential in power or

privilege may need to be especially conscious of the need for and the manner in which they convey positive

regard to their clients. Positive regard may be particularly salient in treatment outcome when nonminority

therapists work with minority clients. In such cases, the possibility of client mistrust compels greater therapist

awareness of the clinical value of consistent provision of positive regard (Sue & Sue, 1999).

Therapeutic Practices

The psychotherapist’s provision of positive regard or affirmation significantly predicts and relates to therapeutic

success. It is a small but important part of the process–outcome equation. Extrapolating from the meta-

analysis, we offer the following recommendations for clinical practice:

Provide positive regard in practice. At a minimum, it “sets the stage” for other mutative interventions and, at

least in some cases, may prove sufficient to effect positive change.

In fact, there is virtually no research-driven reason to withhold positive regard. We are reminded of the oft-

heard sentiment in contemporary psychoanalytic circles that one of Kohut’s major contributions was to provide

a theoretical justification for being kind to one’s patients.

Keep in mind that affirming patients may serve many valuable functions. Positive regard may strengthen

the client’s sense of self or agency and belief in his or her capacity to be engaged in an effective relationship. A

therapist’s positive regard may also function as a positive reinforcer for clients’ engagement in the therapeutic

process, including difficult self-disclosures, and facilitates growth and resilience.

Avoid the tendency to be content with feeling good about patients; instead, allow yourself to express

positive feelings to clients. The therapist’s conveyance of positive regard does not have to translate to a

stream of compliments that may overwhelm or even terrify some clients; rather, it speaks to therapists

communicating a caring, respectful, positive attitude that affirms a client’s sense of worth. To many, if not most,

clients, the conviction that “My therapist really cares about me” likely serves a critical function, especially in

times of stress.

Convey regard through multiple channels. These entail, inter alia, offering reassuring, caring words,

creating positive narratives, active listening, flexibility in scheduling, speaking in a gentle tone of voice,

establishing responsive eye contact, and maintaining positive body language.

Monitor your positive regard and adjust it as a function of particular patients and specific situations.

Therapists vary in the extent to which they convey positive regard to their patients, and clients vary in the

extent to which they need, elicit, and benefit from it. We suspect that the inevitable ruptures in the therapeutic

alliance result not only from a therapist’s technical errors but also from the therapist’s occasional inability to

demonstrate minimal levels of positive regard.

Make positive regard a topic of supervision. Provide supervision that includes investigations of the specific

ways in which supervisees’ acceptance, liking, and caring for their clients have been conveyed (or not) in

sessions and what the clinical consequences of these actions have been.

References

An asterisk (*) indicates studies included in the meta-analysis.

*Alexander, J. F., Barton, C., Schiavo, R. S., & Parsons, B. V. (1976). Systems-behavioral intervention with

families of delinquents: Therapist characteristics, family behavior, and outcome. Journal of Consulting and

Clinical Psychology, 44, 656–664. 10.1037/0022-006X.44.4.656

Arts, W., Hoogduin, C. A. L., Keijsers, G., Severeijns, R., & Schaap, C. (1994). A quasi-experimental study into

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

13 of 22 2/23/2019, 4:33 PM

the effect of enhancing the quality of the patient-therapist relationship in the outpatient treatment of obsessive-

compulsive neurosis. The patient-therapist relationship: Its many dimensions. Rome, Italy: Consiglio Nazionale

delle Ricerche.

Athay, A. L. (1974). The relationship between counselor self concept, empathy, warmth, and genuineness, and

client rated improvement(Doctoral dissertation). University of Utah, Salt Lake City, Utah. Retrieved from

ProQuest Digital Dissertations.

*Bachelor, A. (1991). Comparison and relationship to outcome of diverse dimensions of the helping alliance as

seen by client and therapist. Psychotherapy, 28, 534–549. 10.1037/0033-3204.28.4.534

*Barnicot, K., Wampold, B., & Priebe, S. (2014). The effect of core clinician interpersonal behaviours on

depression. Journal of Affective Disorders, 167, 112–117. 10.1016/j.jad.2014.05.064

Barrett-Lennard, G. T. (1964). The Relationship Inventory. Form OS-M-64 and OS-F-64 Form MO-M-64 and

MO-F-64. Armidale, New South Wales, Australia: University of New England.

Barrett-Lennard, G. T. (1978). The Relationship Inventory: Later development and applications. Catalog of

selected documents in psychology, 8, 68.

Barrett-Lennard, G. (1986). The relationship inventory now: Issues and advances in theory, method and use. In

L. S.Greenberg & W. M.Pinsof (Eds.), The psychotherapeutic process: A research handbook (pp. 439–476).

New York, NY: Guilford Press.

Beck, J. S. (1995). Cognitive therapy: Basics and beyond. New York, NY: Guilford Press.

*Beckham, E. E. (1989). Improvement after evaluation in psychotherapy of depression: Evidence of a placebo

effect?Journal of Clinical Psychology, 45, 945–950. 10.1002/1097-4679(198911)45:6<945::AID-

JCLP2270450620>3.0.CO;2-2

*Beckham, E. E. (1992). Predicting patient dropout in psychotherapy. Psychotherapy, 29, 177–182.

10.1037/0033-3204.29.2.177

Bedics, J. D., Atkins, D. C., Comtois, K. A., & Linehan, M. M. (2012). Treatment differences in the therapeutic

relationship and introject during a 2-year randomized controlled trial of dialectical behavior therapy versus non-

behavioral psychotherapy experts for borderline personality disorder. Journal of Consulting and Clinical

Psychology, 80, 66–77.

*Bell, H., Hagedorn, W. B., & Robinson, E. H. (2016). An exploration of supervisory and therapeutic

relationships and client outcomes. Counselor Education and Supervision, 55, 182–197. 10.1002/ceas.12044

Benjamin, L. (1984). Principles of prediction using Social Analysis of Structural Behavior (SASB). In R.

A.Zucker, J.Aronoff, & A. J.Rabin (Eds.), Personality and the prediction of behavior (pp. 121–173). New York,

NY: Academic Press.

*Bennun, I., & Schindler, L. (1988). Therapist and patient factors in the behavioural treatment of phobic

patients. British Journal of Clinical Psychology, 27, 145–151. 10.1111/j.2044-8260.1988.tb00762.x

Beutler, L. E., Machado, P. P. P., & Neufeldt, S. A. (1994). Therapist variables. In S. L.Garfield & A. E.Bergin

(Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 229–269). New York, NY: Wiley.

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

14 of 22 2/23/2019, 4:33 PM

*Blaauw, E., & Emmelkamp, P. M. (1994). The therapeutic relationship: A study on the value of the Therapist

Client Rating Scale. Behavioural and Cognitive Psychotherapy, 22, 25–35. 10.1017/S1352465800011784

*Blatt, S. J., Quinlan, D. M., Zuroff, D. C., & Pilkonis, P. A. (1996). Interpersonal factors in brief treatment of

depression: Further analyses of the national institute of mental health treatment of depression collaborative

research program. Journal of Consulting and Clinical Psychology, 64, 162–171. 10.1037/0022-006X.64.1.162

Bozarth, J. D., & Wilkins, P. (2001). Rogers’ therapeutic conditions: Evolution, theory and practice

(Unconditional positive regard, Vol. 3). Herefordshire, United Kingdom: PCCS Books.

BregerL.. (2009). A dream of undying fame: How Freud betrayed his mentor and invented psychoanalysis. New

York, NY: Basic Books.

*Brouzos, A., Vassilopoulos, S. P., & Baourda, V. C. (2015). Members’ perceptions of person-centered

facilitative conditions and their role in outcome in a psychoeducational group for childhood social anxiety.

Person-Centered and Experiential Psychotherapies, 14, 32–46. 10.1080/14779757.2014.965843

*Brouzos, A., Vassilopoulos, S., Katsiou, P., & Baourda, V. (2017, May). The group processes in a

psychoeducational program for anger management in elementary school students. Paper presented at 16th

Panhellenic Congress of Psychological Research, Hellenic Psychological Society and Department of

Psychology of the Aristotle University of Thessaloniki, Thessaloniki, Greece.

Cain, D. J. (1973). The therapist’s and client’s perceptions of therapeutic conditions in relation to perceived

interview outcome (Doctoral dissertation). University of Wyoming, Laramie, WY. Retrieved from ProQuest

Digital Dissertations.

Canterbury-Counts, D. (1989). The impact of the therapeutic relationship on weight loss in a behavioral weight

management program(Doctoral dissertation). Retrieved from ProQuest Digital Dissertations.

*Chisholm, S. M. (1998). A comparison of the therapeutic alliances of premature terminators versus therapy

completers (Unpublished doctoral dissertation). Kent State University, Kent, OH.

*Coady, N. F. (1991). The association between client and therapist interpersonal processes and outcomes in

psychodynamic psychotherapy. Research on Social Work Practice, 1, 122–138. 10.1177/104973159100100202

*Conte, H. R., Ratto, R., Clutz, K., & Karasu, T. B. (1995). Determinants of outpatients’ satisfaction with

therapists: Relation to outcome. Journal of Psychotherapy Practice and Research, 4, 43–51.

Cooper, H., Hedges, L. V., & Valentine, J. C. (Eds.). (2009). The handbook of research synthesis and meta-

analysis (2nd ed.). New York, NY: Russell Sage Foundation.

*Cordaro, M., Tubman, J. G., Wagner, E. F., & Morris, S. L. (2012). Treatment process predictors of program

completion or dropout among minority adolescents enrolled in a brief motivational substance abuse

intervention. Journal of Child and Adolescent Substance Abuse, 21, 51–68. 10.1080/1067828X.2012.636697

Cramer, D. (1986). An item factor analysis of the revised Barrett-Lennard Relationship Inventory. British Journal

of Guidance and Counselling, 14, 314–325. 10.1080/03069888608253521

*Cramer, D., & Takens, R. J. (1992). Therapeutic relationship and progress in the first six sessions of individual

psychotherapy: A panel analysis. Counselling Psychology Quarterly, 5, 25–36. 10.1080/09515079208254447

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

15 of 22 2/23/2019, 4:33 PM

Daniels, D. (2014). “Permanently cheated”–Part I. Contemporary Psychotherapy. Retrieved from

www.contemporarypsychotherapy.org/volume-6-no-1-summer-2014/permanently-cheated/

*de Beurs, E. (1993). The assessment and treatment of panic disorder and agoraphobia. Amsterdam, the

Netherland: Thesis Publishers.

*Eckert, P. A., Abeles, N., & Graham, R. N. (1988). Symptom severity, psychotherapy process, and outcome.

Professional Psychology: Research and Practice, 19, 560–564. 10.1037/0735-7028.19.5.560

Farber, B. A. (2007). On the enduring and substantial influence of Carl Rogers’ not-quite essential nor

necessary conditions. Psychotherapy, 44, 289–294. 10.1037/0033-3204.44.3.289

Farber, B. A., Bohart, A. C., & Stiles, W. B. (2012). Corrective (emotional) experience in person-centered

therapy: Carl Rogers and Gloria Redux. In C.Hill & L. G.Castonguay (Eds.), Transformation in psychotherapy:

Corrective experiences across cognitive behavioral, humanistic, and psychodynamic approaches (pp.

103–119). Washington, DC: APA Books. 10.1037/13747-007

Farber, B. A., Brink, D. C., & Raskin, P. M. (1996). The psychotherapy of Carl Roger: Cases and commentary.

New York, NY: Guilford Press.

Farber, B. A., & Doolin, E. M. (2011). Positive regard. In J. Norcross (Eds.), Psychotherapy relationships that

work (2nd ed., pp. 168–186). New York, NY: Oxford University Press.

Farber, B. A., & Lane, J. S. (2002). Effective elements of the therapy relationship: Positive regard. In J.Norcross

(Ed.), Psychotherapy relationships that work: Therapist contributions and responsiveness to patients (pp.

175–194). New York, NY: Oxford.

Farber, B. A., & Suzuki, J. Y. (2018). Affirming the case for positive regard. In O.Tishby & H.Wiseman (Eds.),

Significant moments in the therapeutic relationship: Clinical case studies from research to practice.

Washington, DC: APA Books.

*Ford, J. D. (1978). Therapeutic relationship in behavior therapy: An empirical analysis. Journal of Consulting

and Clinical Psychology, 46, 1302–1314. 10.1037/0022-006X.46.6.1302

*Garfield, S. L., & Bergin, A. E. (1971). Therapeutic conditions and outcome. Journal of Abnormal Psychology,

77, 108–114. 10.1037/h0030732

Gaston, L., Marmar, C. R., Gallagher, D., & Thompson, L. W. (1991). Alliance prediction of outcome beyond in-

treatment symptomatic change as psychotherapy processes. Psychotherapy Research, 1, 104–112.

10.1080/10503309112331335531

*Green, R. J., & Herget, M. (1991). Outcomes of systemic/strategic team consultation: III. The importance of

therapist warmth and active structuring. Family Process, 30, 321–336. 10.1111/j.1545-5300.1991.00321.x

Gurman, A. (1977). The patient’s perception of the therapeutic relationship. In A. S.Gurman & A. M.Razin

(Eds.), Effective psychotherapy (pp. 503–543). New York, NY: Pergamon Press.

*Gustavson, B., Jansson, L., Jerremalm, A., & Ost, L. G. (1985). Therapist behavior during exposure treatment

of agoraphobia. Behavior Modification, 9, 491–504. 10.1177/01454455850094006

*Hayes, A. M., & Strauss, J. L. (1998). Dynamic systems theory as a paradigm for the study of change in

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

16 of 22 2/23/2019, 4:33 PM

psychotherapy: An application to cognitive therapy for depression. Journal of Consulting and Clinical

Psychology, 66, 939–947. 10.1037/0022-006X.66.6.939

Hedges, L. V. (1982). Estimating effect sizes from a series of independent experiments. Psychological Bulletin,

92, 490–499. 10.1037/0033-2909.92.2.490

Henry, W. P., Schacht, T. E., & Strupp, H. H. (1990). Patient and therapist introject, interpersonal process, and

differential psychotherapy outcome. Journal of Consulting and Clinical Psychology, 58, 768–774.

10.1037/0022-006X.58.6.768

Hill, C. E. (Ed.). (2012). Consensual qualitative research: A practical resource for investigating social science

phenomena. Washington, DC: American Psychological Association.

Horvath, A. O., & Greenberg, A. (1989). Development and validation of the Working Alliance Inventory. Journal

of Counseling Psychology, 36, 223–233. 10.1037/0022-0167.36.2.223

*Hynan, D. J. (1990). Client reasons and experiences in treatment that influence termination of psychotherapy.

Journal of Clinical Psychology, 46, 891–895. 10.1002/1097-4679(199011)46:6<891::AID-

JCLP2270460631>3.0.CO;2-8

James, W. (1981). The principles of psychology. Cambridge, MA: Harvard University Press. (Original work

published 1890)

Jourard, S. M. (1971). The transparent self. New York, NY: Van Nostrand.

*Karpiak, C. P., & Benjamin, L. S. (2004). Therapist affirmation and the process and outcome of psychotherapy:

Two sequential analytic studies. Journal of Clinical Psychology, 60, 659–676. 10.1002/jclp.10248

*Keijsers, G. P., Hoogduin, C. A., & Schaap, C. P. (1994). Predictors of treatment outcome in the behavioural

treatment of obsessive-compulsive disorder. The British Journal of Psychiatry, 165, 781–786.

10.1192/bjp.165.6.781

*Keijsers, G., Schaap, C., Hoogduin, K., & Peters, W. (1991). The therapeutic relationship in the behavioural

treatment of anxiety disorders. Behavioural and Cognitive Psychotherapy, 19, 359–367.

10.1017/S0141347300014051

Klassen, D. (1979). An empirical investigation of the Rogerian counseling conditions and locus of control

(Doctoral dissertation). Ottawa, ON: uO Research. 10.20381/ruor-8549

Klein, C. F. (2001). Clinical process related to outcome in psychodynamic psychotherapy for panic

disorder(Doctoral Dissertation). Retrieved from ProQuest Dissertations. (UMI number 3024807)

Knox, S., & Hill, C. E. (2003). Therapist self-disclosure: Research-based suggestions for practitioners. Journal

of Clinical Psychology/In Session, 59, 529–540.

*Kolb, D. L., Beutler, L. E., Davis, C. S., Crago, M., & Shanfield, S. B. (1985). Patient and therapy process

variables relating to dropout and change in psychotherapy. Psychotherapy, 22, 702–710. 10.1037/h0085556

Konstantopoulos, S. (2011). Fixed effects and variance components estimation in three-level meta-analysis.

Research Synthesis Methods, 2, 61–76. 10.1002/jrsm.35

Leahy, R. L. (2001). Overcoming resistance in cognitive therapy. New York, NY: Guilford Press.

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

17 of 22 2/23/2019, 4:33 PM

Leahy, R. L. (2008). The therapeutic relationship in cognitive-behavioral therapy. Behavioural and Cognitive

Psychotherapy, 36, 769–777. 10.1017/S1352465808004852

Lemoire, S. J., & Chen, C. P. (2005). Applying person-centered counseling to sexual minority adolescents.

Journal of Counseling and Development, 83, 146–154. 10.1002/j.1556-6678.2005.tb00591.x

Lietaer, G. (1984). Unconditional positive regard: A controversial basic attitude in client-centered therapy. In R.

F.Levant & J. M.Shlien (Eds.), Client-centered therapy and the person-centered approach: New directions in

theory, research, and practice (pp. 41–58). New York, NY: Praeger.

Linehan, M. M. (1993). Cognitive behavioral treatment of borderline personality disorder. New York, NY:

Guilford Press.

Linehan, M. M. (1997). Validation and psychotherapy. In A.Bohart & L.Greenberg (Eds.), Empathy

reconsidered: New directions in psychotherapy (pp. 353–392). Washington, DC: American Psychological

Association. 10.1037/10226-016

*Litter, M. (2004). Relationship-based psychotherapy with court-involved youth: The therapy relationship’s effect

on outcome. Dissertation Abstracts International, 65, 4474.

*Loneck, B., Banks, S., Way, B., & Bonaparte, E. (2002). An empirical model of therapeutic process for

psychiatric emergency room clients with dual disorders. Social Work Research, 26, 132–144. 10.1093/swr

/26.3.132

Meyer, A. E. (1990, June). Nonspecific and common factors in treatment outcome: Another myth?Paper

presented at the annual meeting, society for psychotherapy research, Wintergreen, VA.

Mitchell, K., Bozarth, J., & Krauft, C. (1977). A reappraisal of the therapeutic effectiveness of accurate empathy,

non-possessive warmth and genuineness. In A. S.Gurman & A. M.Razin (Eds.), Effective psychotherapy (pp.

482–502). New York, NY: Pergamon Press.

Mitchell, K., Bozarth, J., Truax, C., & Krauft, C. (1973). Antecedents to psychotherapeutic outcome(NIMH Final

Report 12306). Arkansas Rehabilitation Research and Training Center, University of Arkansas, Fayetteville,

AR.

Mitchell, S. A., & Aron, L. (1999). Relational psychoanalysis. New York, NY: Analytic Press.

*Murphy, D., & Cramer, D. (2010, July). Mutuality as relational empowerment. Conference paper presented in

Relational Depth Symposium. Symposium at the World Association for Person-Centered and Experiential

Psychotherapy and Counselling, Rome, Italy.

*Najavits, L. M., & Strupp, H. H. (1994). Differences in the effectiveness of psychodynamic therapists: A

process-outcome study. Psychotherapy, 31, 114–123. 10.1037/0033-3204.31.1.114

Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. New York, NY: Oxford University Press.

Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). New York, NY: Oxford University

Press. 10.1093/acprof:oso/9780199737208.001.0001

O’Malley, S. S., Suh, C. S., & Strupp, H. H. (1983). The Vanderbilt Psychotherapy Process Scale: A report on

the scale development and a process-outcome study. Journal of Consulting and Clinical Psychology, 51,

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

18 of 22 2/23/2019, 4:33 PM

581–586. 10.1037/0022-006X.51.4.581

Orlinsky, D. E., Grawe, K., & Parks, B. K. (1994). Process and outcome in psychotherapy—Noch einmal. In A.

E.Bergin & S. L.Garfield (Eds.), Handbook of psychotherapy and behavior change (4th ed., pp. 27–376). New

York, NY: Wiley.

Orlinsky, D. E., & Howard, K. (1978). The relation of process to outcome in psychotherapy. In S. L.Garfield & A.

E.Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 283–329). New York, NY:

Wiley.

Parloff, M. B., Waskow, I. E., & Wolfe, B. E. (1978). Research on therapist variables in relation to process and

outcome. In S. L.Garfield & A. E.Bergin (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp.

233–282). New York, NY: Wiley.

Prager, R. A. (1971). The relationship of certain client characteristics to therapist-offered conditions and

therapeutic outcome (Doctoral dissertation). Retrieved from ProQuest Digital Dissertations.

Quintana, S. M., & Meara, N. M. (1990). Internalization of therapeutic relationships in short-term

psychotherapy. Journal of Counseling Psychology, 2, 123–130.

*Rabavilas, A. D., Boulougouris, J. C., & Perissaki, C. (1979). Therapist qualities related to outcome with

exposure in vivo in neurotic patients. Journal of Behavior Therapy and Experimental Psychiatry, 10, 293–294.

10.1016/0005-7916(79)90005-3

Reese, L. R. (1984). A study of patients’ perceptions of the psychotherapeutic relationships with the treatment

staff at an acute-care community psychiatric facility (Doctoral dissertation). Retrieved from ProQuest Digital

Dissertations.

*Roback, H. B., & Strassberg, D. S. (1975). Relationship between perceived therapist-offered conditions and

therapeutic movement in group psychotherapy. Small Group Behavior, 6, 345–352.

10.1177/104649647500600307

Rogers, C. R. (1942). Counseling and psychotherapy. Boston, MA: Houghton Mifflin.

Rogers, C. R. (1951). Client-centered therapy. Boston, MA: Houghton Mifflin.

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of

Consulting Psychology, 21, 95–103. 10.1037/h0045357

Rogers, C. R. (1959). A theory of therapy, personality, and interpersonal relationships: As developed in the

client-centered framework. In S.Koch (Ed.), Psychology: A study of a science. Study 1: Formulations of the

person and the social context (Vol. 3, pp. 184–256). New York, NY: McGraw-Hill.

Rogers, C. R. (1966). Client centered therapy. In S.Arieti (Ed.), American handbook of psychiatry (Vol. 3, pp.

183–200). New York, NY: Basic Books.

Rogers, C. R., & Truax, C. B. (1967). The therapeutic conditions antecedent to change: A theoretical view. In C.

R.Rogers, E. T.Gendlin, D. J.Kiesler, & C. B.Truax (Eds.), The therapeutic relationship and its impact: A study

of psychotherapy with schizophrenics (pp. 97–108). Madison, MI: University of Wisconsin Press.

Rothman, D. B. (2007). The role of the therapeutic alliance in psychotherapy with sexual offenders (Doctoral

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

19 of 22 2/23/2019, 4:33 PM

dissertation). Retrieved from ProQuest Digital Dissertations.

*Rounsaville, B. J., Chevron, E. S., Prusoff, B. A., Elkin, I., Imber, S., Sotsky, S., & Watkins, J. (1987). The

relation between specific and general dimensions of the psychotherapy process in interpersonal psychotherapy

of depression. Journal of Consulting and Clinical Psychology, 55, 379–384. 10.1037/0022-006X.55.3.379

*Ryan, V. L., & Gizynski, M. N. (1971). Behavior therapy in retrospect: Patients’ feelings about their behavior

therapies. Journal of Consulting and Clinical Psychology, 37, 1–9. 10.1037/h0031293

*Saunders, S. M. (2000). Examining the relationship between the therapeutic bond and the phases of treatment

outcome. Psychotherapy, 37, 206–218. 10.1037/h0087827

*Saunders, S. M., Howard, K. I., & Orlinsky, D. E. (1989). The Therapeutic Bond Scales: Psychometric

characteristics and relationship to treatment effectiveness. Psychological Assessment: A Journal of Consulting

and Clinical Psychology, 1, 323–330. 10.1037/1040-3590.1.4.323

*Schade, L. C., Sandberg, J. G., Bradford, A., Harper, J. M., Holt-Lunstad, J., & Miller, R. B. (2015). A

longitudinal view of the association between therapist warmth and couples’ in-session process: An

observational pilot study of emotionally focused couples therapy. Journal of Marital and Family Therapy, 41,

292–307. 10.1111/jmft.12076

*Schauble, P. G., & Pierce, R. M. (1974). Client in-therapy behavior: A therapist guide to progress.

Psychotherapy, 11, 229–234. 10.1037/h0086346

*Sells, D., Davidson, L., Jewell, C., Falzer, P., & Rowe, M. (2006). The treatment relationship in peer-based and

regular case management for clients with severe mental illness. Psychiatric Services, 57, 1179–1184.

10.1176/ps.2006.57.8.1179

Shostrom, E. L. (Producer). (1965). Three approaches to psychotherapy (Part I) [Film]. Orange, CA:

Psychological Films.

*Staples, F. R., & Sloane, R. B. (1976). Truax factors, speech characteristics, and therapeutic outcome. Journal

of Nervous and Mental Disease, 163, 135–140. 10.1097/00005053-197608000-00008

*Strupp, H. H., Wallach, M. S., & Wogan, M. (1964). Psychotherapy experience in retrospect: Questionnaire

survey of former patients and their therapists. Psychological Monographs: General and Applied, 78, 1–45.

10.1037/h0093869

Sue, D. W., & Sue, D. (1999). Counseling the culturally different: Theory and practice (3rd ed.). New York, NY:

Wiley.

Suh, C. S., Strupp, H. H., & O’Malley, S. S. (1986). The vanderbilt process measures: The Psychotherapy

Process Scale (VPPS) and the Negative Indicators Scale (VNIS). In L. S.Greenberg & W. M.Pinsof (Eds.), The

psychotherapeutic process: A research handbook (pp. 285–323). New York, NY: Guilford Press.

Suzuki, J. (2018). A qualitative investigation of psychotherapy clients’ perceptions of positive regard

(Unpublished doctoral dissertation). Teachers College, New York, NY.

Suzuki, J. Y., & Farber, B. A. (2016). Towards greater specificity of the concept of positive regard. Person-

Centered and Experiential Psychotherapies, 15, 263–284. 10.1080/14779757.2016.1204941

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

20 of 22 2/23/2019, 4:33 PM

*Tillman, D. (2016). The effects of unconditional positive regard on psychotherapy outcome (Doctoral

dissertation). Retrieved from ProQuest Digital Dissertations (10108864).

Traynor, W., Elliott, R., & Cooper, M. (2011). Helpful factors and outcomes in person-centered therapy with

clients who experience psychotic processes: Therapists’ perspectives. Person-Centered and Experiential

Psychotherapies, 10, 89–104. 10.1080/14779757.2011.576557

*Truax, C. B. (1966). Therapist empathy, warmth, and genuineness and patient personality change in group

psychotherapy: A comparison between interaction unit measures, time sample measures, patient perception

measures. Journal of Clinical Psychology, 22, 225–229. 10.1002/1097-4679(196604)22:2<225::AID-

JCLP2270220236>3.0.CO;2-O

*Truax, C. B. (1968). Therapist interpersonal reinforcement of client self-exploration and therapeutic outcome in

group psychotherapy. Journal of Counseling Psychology, 15, 225–231. 10.1037/h0025865

*Truax, C. B., Altmann, H., Wright, L., & Mitchell, K. M. (1973). Effects of therapeutic conditions in child therapy.

Journal of Community Psychology, 1, 313–318. 10.1002/1520-6629(197307)1:3<313::AID-

JCOP2290010319>3.0.CO;2-T

Truax, C. B., & Carkhuff, R. R. (1967). Toward effective counseling and psychotherapy: Training and practice.

Chicago, IL: Aldine.

*Truax, C. B., Wittmer, J., & Wargo, D. G. (1971). Effects of the therapeutic conditions of accurate empathy,

non-possessive warmth, and genuineness on hospitalized mental patients during group therapy. Journal of

Clinical Psychology, 27, 137–142. 10.1002/1097-4679(197101)27:1<137::AID-JCLP2270270135>3.0.CO;2-4

Turner, S. M. (1997). Process variables in small-group cognitive therapy for the irritable bowel syndrome

(Doctoral dissertation). Retrieved from ProQuest Digital Dissertations.

*Van der Veen, F. (1967). Basic elements in the process of psychotherapy: A research study. Journal of

Consulting Psychology, 31, 295–303. 10.1037/h0024668

Wachtel, P. L. (2008). Relational theory and the practice of psychotherapy. New York, NY: Guilford Press.

Wampold, B. E., Mondin, G. W., Moody, M., Stich, F., Benson, K., & Ahn, H. (1997). A metaanalysis of outcome

studies comparing bona fide psychotherapies: Empirically, “all must have prizes”. Psychological Bulletin, 122,

203–215.

Williams, K. E., & Chambless, D. L. (1990). The relationship between therapist characteristics and outcome of

in vivo exposure treatment for agoraphobia. Behavior Therapy, 21, 111–116. 10.1016/S0005-7894(05)80192-3

Williams, S. A. (1996). Therapeutic factors affecting denial change in substance abuse treatment groups

(Doctoral dissertation). Retrieved from ProQuest Digital Dissertations.

Yalom, I. D. (2002). The Gift of therapy: An Open letter to a new generation of therapists and their patients.

New York, NY: HarperCollins.

Zuroff, D. C., & Blatt, S. J. (2006). The therapeutic relationship in the brief treatment of depression:

Contributions to clinical improvement and enhanced adaptive capacities. Journal of Consulting and Clinical

Psychology, 74, 130–140. 10.1037/0022-006X.74.1.130

EBSCOhost http://web.a.ebscohost.com.library.capella.edu/ehost/delivery?sid=e7be7...

21 of 22 2/23/2019, 4:33 PM

*Zuroff, D. C., Kelly, A. C., Leybman, M. J., Blatt, S. J., & Wampold, B. E. (2010). Between-therapist and within-

therapist differences in the quality of the therapeutic relationship: Effects on maladjustment and self-critical

perfectionism. Journal of Clinical Psychology, 66, 681–697.

Submitted: March 14, 2018 Accepted: March 16, 2018

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Source: Psychotherapy. Vol. 55. (4), Dec, 2018 pp. 411-423)

Accession Number: 2018-51673-007

Digital Object Identifier: 10.1037/pst0000171

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