The Relationship Effect

1. The Relationship Effect John C. Norcross, PhDUniversity of Scranton

2. Thought Experiments What accounts for the success of treatment for the addictions? What accounts for the success of your personal therapy?

3. 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”

4. EBP Words are Magic ΨEBPs have profound implications for practice, training, research, and policy Ψ No one is arguing for the converse (non-evidence based practices) ΨWhat is privileged as “evidence-based” will determine, in large part, what treatment is conducted, what is taught, what is funded ΨEBPs are noble in intent, but ripe for misuse and abuse

6. 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?

7. 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.

9. 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)

10. 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

11. 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.

12. 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

13. Demonstrably Effective Elements of Therapy Relationship ♦The Alliance ♦ Cohesion in Group Therapy ♦ Empathy ♦ Goal Consensus & Collaboration

14. 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

15. 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

16. 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

17. 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)

18. 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

19. Probably Effective Elements of Therapy Relationship • Positive Regard • Congruence/Genuineness • Feedback • Repair of Alliance Ruptures • Self-Disclosure • Countertransference Management • Quality of Relational Interpretations

20. Lethality of One Size Fits All

21. 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

22. Demonstrably Effective Means of Customizing the Relationship • Resistance • Functional Impairment

23. 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

24. 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

25. Probably Effective Means of Customizing the Relationship • Coping Style • Stages of Change • Anaclitic & Introjective Dimensions • Expectations • Assimilation of Problematic Experiences

26. 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

27. Insufficient Research to Judge • Attachment Style • Gender Matching • Ethnicity Matching • Preferences • Religion and Spirituality • Personality Disorders

28. 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

30. 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

31. 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.

32. 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.

33. 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….

34. 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?

35. 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

36. 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?

37. 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?

38. APA book edited by Norcross. Beutler, & Levant