Transcript Empirically Supported Therapy Relationships

The Relationship Effect
John C. Norcross, PhD
University of Scranton
Thought Experiments
What accounts for the success of
treatment for the addictions?
What accounts for the success of your
personal therapy?
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”
EBP Words are Magic
Ψ EBPs have profound implications for
practice, training, research, and policy
Ψ No one is arguing for the converse (nonevidence based practices)
Ψ What is privileged as “evidence-based” will
determine, in large part, what treatment is
conducted, what is taught, what is funded
Ψ EBPs are noble in intent, but ripe for misuse
and abuse
Number of Articles Retrieved
Using "Evidence-Based" as a Keyword
5000
4000
Articles Retrieved
Medline
Cinahl
3000
PsycINFO
2000
1000
0
1992
1994
1996
1998
2000
Year
2002
2004
2006
What’s Missing from EBPs?
 The person of the therapist
 The therapy relationship
 The patient’s (nondiagnostic)
characteristics
Do treatments cure disorders,
or do relationships heal people?
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.
% of Psychotherapy Outcome Variance
Atrributable to Therapeutic Factors
Interaction
5%
Individual
Therapist
7%
Treatment
Method
8%
Therapy
Relationship
10%
Patient
Contribution
25%
Unexplained
Variance
45%
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)
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
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.
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
Demonstrably Effective Elements
of Therapy Relationship
♦ The Alliance
♦ Cohesion in Group Therapy
♦ Empathy
♦ Goal Consensus & Collaboration
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
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
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-tomember) 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
Empathy
 Therapist’s sensitive ability to understand
the clients’ thoughts, feelings, and struggles
from client’s view
 Meta-analysis of 47 studies (190 tests of
empathy-outcome association): median r of
.32
 Highest effect size in the relationship
 Use the client’s perspective (not clinician’s
perspective or external ratings)
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
Probably Effective Elements of
Therapy Relationship
 Positive Regard
 Congruence/Genuineness
 Feedback
 Repair of Alliance Ruptures
 Self-Disclosure
 Countertransference Management
 Quality of Relational Interpretations
Lethality of One Size Fits All
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
Demonstrably Effective Means of
Customizing the Relationship
 Resistance
 Functional Impairment
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
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
Probably Effective Means of
Customizing the Relationship
 Coping Style
 Stages of Change
 Anaclitic & Introjective Dimensions
 Expectations
 Assimilation of Problematic
Experiences
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
Insufficient Research to Judge
 Attachment Style
 Gender Matching
 Ethnicity Matching
 Preferences
 Religion and Spirituality
 Personality Disorders
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
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
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.
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.
Frequent Questions &
Objections
Are you saying that techniques or methods
are immaterial to outcome?
Isn’t this just warmed over Carl Rogers?
But isn’t this all correlational research?
Where are the RCTs?
Yes, yes, the relationship is terribly
important, but….
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?
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
Unresolved Questions re EBPs
Norcross, 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 Representative of Practice?
Unresolved Questions II
Norcross, 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?
APA book
edited by
Norcross.
Beutler, &
Levant