The Relationship Effect

John C. Norcross, PhDUniversity 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 MagicΨ EBPs have profound implications for

practice, training, research, and policy

Ψ No one is arguing for the converse (non-evidence 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

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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

Unexplained Variance

45%

Patient Contribution

25%

Therapy Relationship

10%

Treatment Method

8%

Individual Therapist

7%

Interaction5%

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: AddictionsNIDA 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-to-member) and therapy outcome

Increase cohesion: conduct pre-group preparation, address early discomfort using structure, encourage member-to-member interaction, set norms (but not overly directive), develop emotional climate

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: AddictionsEarly 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: AddictionsKarno & 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 RecommendationsTraining 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 EBPsNorcross, Beutler, & Levant (2005)

1. What Qualifies as Evidence of Effective Practice?Clinical expertise, scientific research, patient values

2. What Qualifies as Research for Effective Practice? Case studies, single-participant, qualitative, change process, effectiveness, RCTs

3. What Tx Outcomes Should Establish EBPs?Self-report, objective behavioral indices, therapist judgment, external/society decisions

4. Does Manualization Improve Therapy Outcomes?5. Are Research Patients & Clinical Trials Represent-

ative of Practice?

Unresolved Questions IINorcross, Beutler, & Levant (2005)

6. What Should be Validated? Tx method, therapist, therapy relationship, patient, principles of change

7. What Materially Influences What is Published as Evidence?Theoretical allegiance, funding source

8. Do ESTs Produce Outcomes Superior to Non-ESTs? 9. How Well Do EBPs Address of Diversity?

Ethnicity, gender, sexual orientation, disability status 10. Are Efficacious Laboratory-Validated Treatments

Readily Transportable to Clinical Practice?

APA book edited by Norcross. Beutler, & Levant