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Psychotherapy Relationships That Work: Volume 2: Evidence-Based Therapist Responsiveness John C Norcross
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
Second Edition published in 2011 Third Edition published in 2019
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CIP data is on file at the Library of Congress ISBN 978–0–19–084395–3
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Printed by Sheridan Books, Inc., United States of America
Dedicated to Carl R. Rogers and Edward S. Bordin pioneers in investigating and advancing the therapeutic relationship
Contents
Preface ix
About the Editors xv
List of Contributors xvii
1. Evidence-Based Psychotherapy Relationships: The Third Task Force 1
John C. Norcross and Michael J. Lambert
2. Alliance in Adult Psychotherapy 24
Christoph Flückiger, A. C. Del Re, Bruce E. Wampold, and Adam O. Horvath
3. Alliance in Child and Adolescent Psychotherapy 79
Marc S. Karver, Alessandro S. De Nadai, Maureen Monahan, and Stephen R. Shirk
4. Alliances in Couple and Family Therapy 117
Myrna L. Friedlander, Valentín Escudero, Marianne J. Welmers-van de Poll, and Laurie Heatherington
5. Goal Consensus and Collaboration 167
Georgiana Shick Tryon, Sarah E. Birch, and Jay Verkuilen
6. Cohesion in Group Therapy 205
Gary M. Burlingame, Debra Theobald McClendon, and Chongming Yang
7. Empathy 245
Robert Elliott, Arthur C. Bohart, Jeanne C. Watson, and David Murphy
8. Positive Regard and Affirmation 288
Barry A. Farber, Jessica Y. Suzuki, and David A. Lynch
9. Congruence/Genuineness 323
Gregory G. Kolden, Chia-Chiang Wang, Sara B. Austin, Yunling Chang, and Marjorie H. Klein
10. The Real Relationship 351
Charles J. Gelso, Dennis M. Kivlighan Jr., and Rayna D. Markin
11. Self-Disclosure and Immediacy 379
Clara E. Hill, Sarah Knox, and Kristen G. Pinto-Coelho
12. Emotional Expression 421
Paul R. Peluso and Robert R. Freund
13. Cultivating Positive Outcome Expectation 461
Michael J. Constantino, Andreea Vîslă, Alice E. Coyne, and James F. Boswell
14. Promoting Treatment Credibility 495
Michael J. Constantino, Alice E. Coyne, James F. Boswell, Brittany R. Iles, and Andreea Vîslă
15. Managing Countertransference 522
Jeffrey A. Hayes, Charles J. Gelso, D. Martin Kivlighan, and Simon B. Goldberg
16. Repairing Alliance Ruptures 549
Catherine F. Eubanks, J. Christopher Muran, and Jeremy D. Safran
17. Collecting and Delivering Client Feedback 580
Michael J. Lambert, Jason L. Whipple, and Maria Kleinstäuber
18. What Works in the Psychotherapy Relationship: Results, Conclusions, and Practices 631
John C. Norcross and Michael J. Lambert
Index 647
Preface
A cordial welcome to the third edition of Psychotherapy Relationships That Work. This book seeks, like its predecessors, to identify effective elements of the psychotherapy relationship and to determine effective methods of adapting or tailoring that relationship to the individual patient. That is, we summarize the research evidence on what works in general as well as what works in particular.
This dual focus has been characterized as “two books in one”: one book on relationship behaviors and one book on adaptation methods under the same cover. In this third edition, we physically separate the “two books” into two volumes as the number of chapters and the amount of research have grown considerably over the past decade. This Volume 1 features evidence-based therapist contributions to the relationship; Volume 2 addresses evidence-based therapist responsiveness to patient transdiagnostic characteristics.
Our hope in this book, as with the earlier editions, is to advance a rapprochement between the warring factions in the culture wars of psychotherapy and to demonstrate that the best available research clearly demonstrates the healing capacity of the therapy relationship. Previous editions brought renewed and corrective attention to the substantial research behind the therapy relationship and, in the words of one reviewer, “will convince most psychotherapists of the rightful place of ESRs (empirically supported relationships) alongside ESTs in the treatments they provide” (p. 532). Note the desired emphasis on “alongside” treatments, not “instead of” or “better than.”
CHANGES IN THE NEW EDITION
The aims of this third edition of Psychotherapy Relationships That Work remain the same as its predecessors, but its sponsorship, format, and editorship differ somewhat. This edition was overseen by a task force co-sponsored by the American Psychological Association (APA) Division of Psychotherapy/Society for the Advancement of Psychotherapy and the APA Division of Counseling Psychology/Society of Counseling Psychology. This edition also boasts a practice-friendlier smaller trim size (the physical size of the book).
We have expanded the breadth of coverage. New reviews were commissioned on the real relationship, self-disclosure, immediacy, emotional expression, and treatment credibility in this volume. Of course, updated meta-analyses were conducted for all returning chapters. As noted, we have expanded the book into two volumes, each now
co-edited by a stellar psychotherapy researcher (Michael Lambert on this volume, and Bruce Wampold on Volume 2).
The content of each chapter has also expanded. Five new sections appear in each chapter: landmark studies, results of previous meta-analyses, evidence for causality, diversity considerations, and training implications. These additions help readers appreciate the context of the research evidence and unpack its results, especially for treating diverse clients and training psychotherapy students. Since many of the relationship behaviors in this volume cannot be randomly assigned for clinical and ethical reasons (as discussed in Chapters 1 and 18), the causality section summarizes what can (and cannot) be said about the direct impact of the therapist’s relational contributions.
The net result is a compilation of 30, cutting-edge meta-analyses on what works in the therapy relationship (this volume) and what works in adapting that relationship to the individual client and his or her singular situation (the second volume). This new edition, appearing nine years after the last incarnation, offers more practical, bulleted information on clinical practice at the end of each chapter.
PROBABLE AUDIENCES
In planning the first edition of the book more than 20 years ago, we struggled to identity the intended audiences. Each of psychotherapy’s stakeholders—patients, practitioners, researchers, educators, students, organizations, insurance companies, and policymakers—expressed different preferences for the content and length of the volume.
We prepared Psychotherapy Relationships That Work for multiple audiences but in a definite order of priority. First came psychotherapy practitioners and trainees of diverse theoretical orientations and professional disciplines. They need to address urgent pragmatic questions: We know the therapy relationship is crucial to treatment success, but what exactly has been shown to work? What do we know from the research evidence about cultivating and maintaining the therapeutic relationship? What are the research-supported means of adapting treatment to the individual patient beyond his/ her diagnosis?
Our second priority was accorded to the mental health disciplines themselves, specifically those committees, task forces, and organizations promulgating lists of evidence-based practices or treatment guidelines. We hope our work will inform and balance any efforts to focus exclusively on techniques or treatments to the neglect of the humans involved in the enterprise.
Our third priority were insurance carriers and accreditation organizations, many of which have unintentionally devalued the person of the therapist and the centrality of the relationship by virtue of reimbursement decisions. Although supportive of the recent thrust toward research informing practice, we must remind all parties to the therapy relationship that healing cannot be replaced with treating, caring cannot be supplanted by managing. Finally, this book is intended for psychotherapy researchers seeking a central resource on the empirical status of the multiple, interdependent qualities of the therapy relationship.
ORGANIZATION OF THE BOOK
The opening chapter introduces the book by outlining the purpose and history of the interdivisional task force and its relation to previous efforts to identify evidence-based practices in psychotherapy. That chapter also presents the key limitations of our work. The heart of the book is composed of research reviews on the therapist’s relational contributions and recommended therapeutic practices based on that research. It features 16 chapters on relationship elements primarily provided by the psychotherapist. Several chapters, such as Chapter 5, Goal Consensus and Collaboration, and Chapter 11, Self-Disclosure and Immediacy, each cover two closely related relationship behaviors.
The concluding chapter presents our reflections and the Task Force conclusions. The latter includes, inter alia, a list of evidence-based relationship elements and our consensual recommendations, divided into general, practice, training, research, and policy recommendations.
CHAPTER GUIDELINES
Except for the bookends (Chapters 1 and 18), all chapters use the same section headings and follow a consistent structure, as follows:
◆ Introduction (untitled). Introduce the relationship element and its historical context in several paragraphs.
◆ Definitions. Define in theoretically neutral language the relationship element and identify highly similar or equivalent constructs from diverse theoretical traditions.
◆ Measures. Review the popular measures used in the research and included in the ensuing meta-analysis.
◆ Clinical Examples. Provide several concrete examples of the relationship behavior being reviewed. Portions of psychotherapy transcripts are encouraged here while protecting the privacy of patients.
◆ Landmark Studies. Walk the reader through two to four landmark studies on the topic (including one qualitative study), describing the design, participants, and results.
◆ Results of Previous Meta-Analyses. Offer a quick synopsis of the findings of previous meta-analyses and systematic reviews.
◆ Meta-Analytic Review. Conduct an original meta-analysis of all available studies employing a random effects model. Systematically compile all available empirical studies linking the relationship behavior to distal, end-of-treatment outcome in the English language (and other languages, if possible). Include only actual psychotherapy studies; no analogue studies. Use the Meta-Analysis Reporting Standards as a general guide for the information to include. Perform and report a test of heterogeneity. Report the effect size as both weighted r and d (or other standardized mean difference). Include a fail-safe statistic to address the file-drawer problem and provide a table or funnel plot for each study in the meta-analysis.
◆ Moderators and Mediators. Present the results of the potential mediators and moderators on the between the relationship element and treatment outcome. Examples include year of publication, rater perspective (assessed by therapist, patient, or external raters), therapist variables, patient factors (including cultural diversity), different measures of the relationship element and treatment outcome, time of assessment (when in the course of therapy), and type of psychotherapy/theoretical orientation.
◆ Evidence for Causality. Summarize the evidence (e.g., lagged correlations, structural equations, unconfounded regressions, growth curve studies) demonstrating that the relational element may causally contribute to treatment outcome. Is there research evidence for a causal link or strictly for correlational association/prediction?
◆ Patient Contributions. Address the patient’s contribution to the therapeutic relationship and the distinctive perspective he/she brings to the interaction (especially since the meta-analyses pertain primarily to the psychotherapists’ contribution to the relationship).
◆ Limitations of the Research. Point to the major limitations of the research conducted to date. A concise paragraph or two here on future research directions is also welcomed.
◆ Diversity Considerations. Address how dimensions of diversity (e.g., gender, race/ ethnicity, sexual orientation, socioeconomic status) fare in the research studies and the meta-analytic results.
◆ Training Implications. Explicate briefly the take-home points of your meta-analysis for clinical educators and supervisors. Mention any training resources or programs that have a proven record of teaching the relationship element to competence.
◆ Therapeutic Practices. Place the emphasis here squarely on what works. Bullet the practice implications from the foregoing research, primarily in terms of the therapist’s contribution and secondarily in terms of the patient’s perspective.
ACKNOWLEDGMENTS
Psychotherapy Relationships That Work would not have proved possible without two decades of organizational and individual support. On the organizational front, the board of directors of the APA Division of Psychotherapy consistently supported the interdivisional task force, and the APA Division of Counseling Psychology cosponsored this iteration. At Oxford University Press, Sarah Harrington and Joan Bossert shepherded these books through the publishing process and recognized early on that they would complement Oxford’s landmark Treatments That Work. We are particularly appreciative of Oxford’s flexibility in copyright matters that have enabled us to disseminate farther these consequential meta-analytic results. Their commitment to spreading this book’s knowledge through special journal issues and other practitioner publications, even at the expense of their occasional loss of book sales, is noble and probably unprecedented in publishing circles.
On the individual front, many people modeled and manifested the ideal therapeutic relationship throughout the course of the project. The authors of the respective chapters, of course, were indispensable in generating the research reviews and were generous in sharing their expertise. The Steering Committee of the previous task forces assisted in canvassing the literature, defining the parameters of the project, selecting the contributors, and writing the initial conclusions. We are grateful to them all: Steven J. Ackerman, Lorna Smith Benjamin, Guillermo Bernal, Larry E. Beutler, Franz Caspar, Louis Castonguay, Charles J. Gelso, Marvin R. Goldfried, Clara Hill, Mark J. Hilsenroth, Michael J. Lambert, David E. Orlinsky, Jackson P. Rainer, and Bruce E. Wampold. For this task force and this edition of the book, we thank the following for serving on the Steering Committee:
Franz Caspar, PhD, University of Bern
Melanie M. Domenech Rodriguez, PhD, Utah State University
Clara E. Hill, PhD, University of Maryland
Michael J. Lambert, PhD, Brigham Young University
Suzanne H. Lease, PhD, University of Memphis (representing APA Division 17)
James W. Lichtenberg, PhD, University of Kansas (representing APA Division 17)
Rayna D. Markin, PhD, Villanova University (representing APA Division 29)
John C. Norcross, PhD, University of Scranton (chair)
Jesse Owen, PhD, University of Denver
Bruce E. Wampold, PhD, University of Wisconsin
Last but never least, our immediate families—Nancy, Rebecca, and Jonathon (JCN) and Linda, Ritchie, Hillary, Allison, John, and Chris (MJL)—tolerated our absences, preoccupations, and irritabilities associated with editing this book with a combination of empathy and patience that would do any seasoned psychotherapist proud. We gratefully dedicate this book to our grandchildren for teaching us about the value of loving relationship—Emma, Owen, Ethan, Owen, Wyatt, Dylan, Maddie, Spencer, Zippy, the three Tenzins, Ryan, Luke, Noah, Jessi, and Squishy.
John C. Norcross & Michael J. Lambert
About the Editors
John C. Norcross, PhD, ABPP, is Distinguished Professor of Psychology at the University of Scranton, Adjunct Professor of Psychiatry at SUNY Upstate Medical University, and a board-certified clinical psychologist. Author of more than 400 scholarly publications, Dr. Norcross has co-written or edited 25 books, including Clinician’s Guide to Evidence-Based Practice in Behavioral Health and Addictions, Self-Help That Works, the Psychologists’ Desk Reference, History of Psychotherapy, Changeology, Leaving It at the Office: Psychotherapist Self-Care, 12 editions of the Insider’s Guide to Graduate Programs in Clinical & Counseling Psychology, and Systems of Psychotherapy: A Transtheoretical Analysis, now in its ninth edition. He has served as president of the American Psychological Association (APA) Division of Clinical Psychology, the APA Division of Psychotherapy, Society for the Exploration of Psychotherapy Integration, and on the Board of Directors of the National Register of Health Service Psychologists. Dr. Norcross has received multiple professional awards, such as APA’s Distinguished Career Contributions to Education & Training Award, Pennsylvania Professor of the Year from the Carnegie Foundation, and election to the National Academies of Practice. An engaging teacher and clinician, John has conducted workshops and lectures in 30 countries.
Michael J. Lambert, PhD, was Professor of Psychology and held the Susa Young Gates University Professorship at Brigham Young University until his retirement in 2016 after teaching for 45 years in the clinical psychology program. He has been in private practice as a psychotherapist throughout his career. He has edited, authored, or coauthored nine books, most notably the fifth and sixth editions of Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change. His scholarly contributions include more than 40 book chapters, more than 150 scientific articles on treatment outcome, and over 200 presentations across the world, many of them invited addresses. He is coauthor of the Outcome Questionnaire-45, a measure of treatment effects widely used to measure and monitor treatment response during psychotherapy. Among Dr. Lambert’s awards are Brigham Young University’s highest honor for faculty research (the Maeser Award), the Distinguished Psychologist Award from APA Division 29 (Psychotherapy), the Academic Excellence Award from the Utah Psychological Association, and the Distinguished Career Research Award from the Society of Psychotherapy Research. In recognition of his contributions to psychological science, the University of Jyväskylä, Finland, bestowed him with an honorary doctorate in 2013.
Sara B. Austin, BA
Contributors
Department of Psychology, Simon Fraser University
Sarah E. Birch, PhD
Department of Child Study, St. Joseph’s College
Arthur C. Bohart, PhD
Department of Psychology, California State University Dominguez Hills
Counseling Psychology Department, Santa Clara University
James F. Boswell, PhD
Department of Psychology, University at Albany, State University of New York
Gary M. Burlingame, PhD
Department of Psychology, Brigham Young University
Yunling Chang, MS
Department of Educational Psychology, Texas A&M University
Michael J. Constantino, PhD
Department of Psychological and Brain Sciences, University of Massachusetts Amherst
Alice E. Coyne, MS
Department of Psychological and Brain Sciences, University of Massachusetts Amherst
Alessandro S. De Nadai, PhD Department of Psychology, Texas State University
A. C. Del Re, PhD Palo Alto Veterans Administration Medical Center
Robert Elliott, PhD
School of Psychological Sciences & Health, University of Strathclyde
Valentín Escudero, PhD
Departamento de Psicología, Universidad de A Coruña (Spain)
Catherine F. Eubanks, PhD
Ferkauf Graduate School of Psychology, Yeshiva University
Mount Sinai Beth Israel Psychotherapy Research Program, Mount Sinai School of Medicine
Barry A. Farber, PhD Program in Clinical Psychology, Teachers College, Columbia University
Christoph Flückiger, PhD Department of Psychology, University of Zürich, Switzerland
Robert R. Freund, PhD
Department of Counseling and Psychological Services, SUNY–Oswego
Myrna L. Friedlander, PhD Department of Educational and Counseling Psychology, University at Albany/SUNY
Charles J. Gelso, PhD Department of Psychology, University of Maryland
Simon B. Goldberg, PhD Department of Counseling Psychology, University of Wisconsin–Madison VA Puget Sound Health Care System–Seattle Division
Jeffrey A. Hayes, PhD Department of Educational Psychology, Counseling, and Special Education, Penn State University
Laurie Heatherington, PhD Department of Psychology, Williams College
Clara E. Hill, PhD Department of Psychology, University of Maryland
Adam O. Horvath, PhD Department of Psychology, Simon Fraser University
Brittany R. Iles, BS Department of Psychology, University at Albany, State University of New York
Marc S. Karver, PhD Department of Psychology, University of South Florida
Dennis M. Kivlighan Jr., PhD Department of Counseling, Higher Education, and Special Education, University of Maryland
D. Martin Kivlighan III, PhD Department of Psychological and Quantitative Foundations, University of Iowa
Marjorie H. Klein, PhD Department of Psychiatry, University of Wisconsin
Maria Kleinstäuber, PhD Department of Psychology, PhilippsUniversity, Marburg (Germany) Department of Psychological Medicine, University of Auckland, Auckland (New Zealand)
Sarah Knox, PhD Department of Counselor Education & Counseling Psychology
Marquette University
Gregory G. Kolden, PhD Department of Psychiatry, University of Wisconsin School of Medicine and Public Health Department of Psychology, University of Wisconsin-Madison
Michael J. Lambert, PhD Department of Psychology, Brigham Young University
David A. Lynch, MPhil Program in Clinical Psychology, Teachers College, Columbia University
Rayna D. Markin, PhD Department of Education and Counseling, Villanova University
Debra Theobald McClendon, PhD Private Practice, Woodland Hills, Utah
Maureen Monahan, MA Department of Psychology, University of South Florida
J. Christopher Muran, PhD Gordon F. Derner School of Psychology, Adelphi University
Mount Sinai Beth Israel Psychotherapy Research Program, Mount Sinai School of Medicine
David Murphy, PhD School of Education, University of Nottingham
John C. Norcross, PhD Department of Psychology, University of Scranton Department of Psychiatry, SUNY Upstate Medical University
Paul R. Peluso, PhD Department of Counselor Education, Florida Atlantic University
Kristen G. Pinto-Coelho, PhD Private Practice, Ellicott City, Maryland
Jeremy D. Safran, PhD Department of Psychology, New School for Social Research
Stephen R. Shirk, PhD Department of Psychology, University of Denver
Jessica Y. Suzuki, PhD Program in Clinical Psychology, Teachers College, Columbia University
Georgiana Shick Tryon, PhD Program in Educational Psychology, Graduate School and University Center of the City University of New York
Jay Verkuilen, PhD Program in Educational Psychology, Graduate School and University Center of the City University of New York
Andreea Vîslă, PhD Department of Psychology, University of Zurich
Bruce E. Wampold, PhD Modum Bad Psychiatric Center, Norway Department of Counseling Psychology, University of Madison-Wisconsin
Chia-Chiang Wang, PhD Department of Counseling, School, and Educational Psychology, University at Buffalo
Jeanne C. Watson, PhD Department of Applied Psychology and Human Development, University of Toronto
Marianne J. Welmers-van de Poll, MSc Research Centre Youth Care, Windesheim University of Applied Sciences
Jason L. Whipple, PhD Alaska VA Healthcare System
Chongming Yang, PhD College of Family, Home, and Social Sciences, Brigham Young University
Psychotherapy Relationships That Work
1
Evidence- Based Psychotherapy Relationship: The Third Task Force
John C. Norcross and Michael J. Lambert
Ask patients what they find most helpful in their psychotherapy. Ask practitioners which component of psychotherapy ensures the highest probability of success. Ask researchers what the evidence favors in predicting effective psychological treatment. Ask psychotherapists what they are most eager to learn about (Tasca et al., 2015). Ask proponents of diverse psychotherapy systems on what point they can find commonality. The probable answer, for all these questions, is the psychotherapy relationship, the healing alliance between client and clinician.
To value or highlight the therapeutic relationship is not to say that it is “all about” or “only” the relationship. Alas, that is frequently the erroneous conclusion reached in the culture wars in psychotherapy that dramatically pit the treatment method against the therapeutic relationship. Do treatments cure disorders, or do relationships heal people? Which is the most accurate vision for practicing, researching, and teaching psychotherapy?
Like most dichotomies, this one is misleading and unproductive on multiple counts. For starters, the patient’s contribution to psychotherapy outcome is vastly greater than that of either the particular treatment method or the therapy relationship (Lambert, 2011, 2013; Wampold & Imel, 2015). The research evidence should keep us mindful and a bit humble about our collective tendency toward therapist-centricity (Bohart & Tallman, 1999; Bohart & Wade, 2013). For another, decades of psychotherapy research consistently attest that the patient, the therapist, their relationship, the treatment method, and the context all contribute to treatment success (and failure). We should be looking at all of these determinants and their optimal combinations.
But perhaps the most pernicious and insidious consequence of the false dichotomy of method versus relationship has been its polarizing effect on the discipline. Rival camps have developed, and countless critiques have been published on each side of the culture war. Are you on the side of the treatment method, the randomized controlled/clinical trial (RCT), and the scientific-medical model? Or do you embrace the therapy relationship, the effectiveness and process-outcome studies, and the
relational-contextual model? Such polarizations not only impede psychotherapists from working together but also hinder our provision of the most efficacious psychological services to our patients and the best training to our students.
We hoped that a balanced perspective would be achieved by the adoption of an inclusive, neutral definition of evidence-based practice (EBP). The American Psychological Association (APA; 2006, p. 273) did endorse just such a definition: “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences.” However, even that definition has been commandeered by the rival camps as polarizing devices. On the one side, some erroneously equate EBP solely with the best available research and particularly the results of RCTs on treatment methods, while on the other side, some mistakenly exaggerate the primacy of clinical or relational expertise while neglecting research support.
Within this polarizing context, in 1999, the APA Division of Psychotherapy commissioned a task force to identify, operationalize, and disseminate information on empirically supported therapy relationships. That task force summarized its findings and detailed its recommendations in the first edition of this book (Norcross, 2002). In 2009, the APA Division of Psychotherapy along with the Division of Clinical Psychology commissioned a second task force on evidence-based therapy relationships to update the research base and clinical practices on the psychotherapist–patient relationship. That second edition (Norcross, 2011), appearing 10 years after its predecessor, did just that.
Our aim for the third task force and in this third edition of the book (now in two volumes) remains to advance a rapprochement between the warring factions and to demonstrate that the best available research clearly supports the healing qualities of the therapy relationship (Volume 1) and the beneficial value of adapting that relationship to individual patients beyond their diagnosis (Volume 2). This third edition expands upon the first two editions, in terms of both the research evidence for relational elements and the number of topics under consideration. These two volumes summarize the best available research and clinical practices on numerous elements of the therapy relationship and on several methods of treatment adaptation. In doing so, our grander goal is to repair some of the damage incurred by the culture wars in psychotherapy and to promote rapprochement between the research and practice communities.
In this chapter, we begin by tracing the purposes and processes of the third interdivisional task force cosponsored by APA Division of Psychotherapy and the APA Division of Counseling Psychology. We explicate the need for identifying evidence-based elements of the therapy relationship and, in a tentative way, offer two models to account for psychotherapy outcome as a function of various therapeutic factors (e.g., patient, relationship, technique). The latter part of the chapter features the limitations of the task force’s work and responds to frequently asked questions.
THE THIRD INTERDIVISIONAL TASK FORCE
The dual purposes of the Third Interdivisional APA Task Force on Evidence-Based Relationships and Responsiveness were to identify effective elements of the therapy relationship and to determine effective methods of adapting or tailoring therapy to the individual patient on the basis of transdiagnostic characteristics. In other words, we were interested in both what works in general and what works for particular patients.
For the purposes of our work, we again adopted Gelso and Carter’s (1985, 1994) operational definition of the relationship: The therapeutic relationship is the feelings and attitudes that therapist and client have toward one another and the manner in which these are expressed. This definition is quite general, and the phrase “the manner in which it is expressed” potentially opens the relationship to include everything under the therapeutic sun (see Gelso & Hayes, 1998, for an extended discussion). Nonetheless, it serves as a concise, consensual, theoretically neutral, and sufficiently precise definition.
We acknowledge the deep synergy between treatment methods and the therapeutic relationship. They constantly shape and inform each other. Both clinical experience and research evidence point to a complex, reciprocal interaction between the interpersonal relationship and the instrumental methods. Consider this finding from a large collaborative study: For patients with a strong therapeutic alliance, adherence to the treatment manual was irrelevant for treatment outcome, but for patients with a weak alliance, a moderate level of therapist adherence was associated with the best outcome (Barber et al., 2006). The relationship does not exist apart from what the therapist does in terms of method, and we cannot imagine any treatment methods that would not have some relational impact. Put differently, treatment methods are relational acts (Safran & Muran, 2000).
For historical and research convenience, the field has distinguished between relationships and techniques. Words like “relating” and “interpersonal behavior” are used to describe how therapists and clients behave toward each other. By contrast, terms like “technique” or “intervention” are used to describe what is done by the therapist. In research and theory, we often treat the how and the what—the relationship and the intervention, the interpersonal and the instrumental—as separate categories.
In reality, of course, what one does and how one does it are complementary and inseparable. To remove the interpersonal from the instrumental may be acceptable in research, but it is a fatal flaw when the aim is to extrapolate research results to clinical practice (see Gelso, 2005, a special issue of Psychotherapy on the interplay of techniques and therapeutic relationship).
In other words, the value of a treatment method is inextricably bound to the relational context in which it is applied. Hans Strupp, one of our first research mentors, offered an analogy to illustrate the inseparability of these constituent elements. Suppose you want your teenager to clean his or her room. Two methods for achieving this are to establish clear standards and to impose consequences. A reasonable approach, but the effectiveness of these two evidence-based methods depends on whether the relationship between you and the teenager is characterized by warmth and mutual respect or
by anger and mistrust. This is not to say that the methods are useless, merely how well they work depends upon the context in which they are used (Norcross, 2010).
The task force applies psychological science to the identification and promulgation of effective psychotherapy. It does so by expanding or enlarging the typical focus of EBP to therapy relationships. Focusing on one area—in this case, the therapeutic relationship—may unfortunately convey the impression that this is the only area of importance. We review the scientific literature on the therapy relationship and provide clinical recommendations based on that literature in ways, we trust, that do not degrade the simultaneous contributions of the treatment methods, patients, or therapists to outcome. Indeed, we wish that more psychotherapists would acknowledge the inseparable context and practical interdependence of the relationship and the treatment. That can prove a crucial step in reducing the polarizing strife of the culture wars and in improving the effectiveness of psychotherapy (Lambert, 2013).
An immediate challenge to the task force was to establish the inclusion and exclusion criteria for the elements of the therapy relationship. We readily agreed that the traditional features of the therapeutic relationship—the alliance in individual therapy, cohesion in group therapy, and the Rogerian facilitative conditions, for example—would constitute core elements. We further agreed that discrete, relatively nonrelational techniques were not part of our purview but that a few explicitly relationship-oriented methods would be included. Therapy methods were considered for inclusion if their content, goal, and context were inextricably interwoven into the emergent therapy relationship. We settled on several “relational” methods (collecting real-time client feedback, repairing alliance ruptures, facilitating emotional expression, and managing countertransference) because these methods are deeply embedded in the interpersonal character of the relationship itself. As “methods,” they also prove possible to randomly assign patients to one treatment condition with the method (for instance, feedback or rupture repairs) and other patients to a condition without them. Indeed, the meta-analyses on both feedback and repair of alliance ruptures feature mostly randomized controlled trials that permit casual conclusions. But which relational behaviors to include and which to exclude under the rubric of the therapy relationship bedeviled us, as it has the field.
How does one divide the indivisible relationship? For example, is support similar enough to positive regard or validation to be considered in the same meta-analysis, or is it distinct enough to deserve a separate research review? We struggled on how finely to slice the therapy relationship. As David Orlinsky opined in one of his emails, “it’s okay to slice bologna that thin, but I doubt that it can be meaningfully done to the relationship.” We agreed, as a group, to place the research on support in the positive regard chapter, but we understood that some practitioners would justifiably take exception to collapsing these relationship elements. Consideration also had to be given to the existence of research evidence; in what ways have researchers operationalized relationship elements in studies. As a general rule, we opted to divide the research reviews into smaller chunks so that the research conclusions were more specific and the practice and training implications more concrete.
In our deliberations, several members of the steering committee advanced a favorite analogy: the therapy relationship is like a diamond—a diamond composed of multiple,
interconnected facets. The diamond is a complex and multidimensional entity. The task force endeavored to separate and examine many of these facets.
We consulted psychotherapy experts, the research literature, and potential authors to discern whether there were sufficient numbers of studies on a particular relationship element to conduct a systematic review and meta-analysis. Three relational elements— therapist humor, self-doubt/humility, and deliberate practice—exhibited initial research support but not a sufficient number of empirical studies for a review. Five new relationship behaviors surpassed our research threshold, and thus we included the real relationship, self-disclosure, immediacy, emotional expression, and treatment credibility in this volume.
Once these decisions were finalized, we commissioned original meta-analyses on the relationship elements (Volume 1) and the adaptation/responsiveness methods (Volume 2). Authors followed a comprehensive chapter structure (provided in the preface) and specific guidelines for their meta-analyses. The analyses quantitatively linked the relationship element (or adaptation method) to psychotherapy outcome. Outcome was primarily defined as distal posttreatment outcomes. Authors specified the outcome criterion when a particular study did not employ a typical end-oftreatment measure. Indeed, the type of outcome measure was frequently analyzed as a possible moderator of the overall effect size.
In these meta-analyses, we continually emphasized the association with and prediction of psychotherapy outcome, instead of process variables or other relationship elements. This emphasis on distal outcomes sharpened our focus on “what works” and countered the partial truth that some of the meta-analyses examining predominantly proximal outcome measures in earlier iterations of the book merely illustrated that “the good stuff in session correlates with other good stuff in session.” We have responded to that criticism in this third edition while explicating several consequential process linkages.
The chapters and the meta-analyses therein were peer-reviewed by at least two editors and subsequently underwent at least one revision. In particular, the review established that the meta-analyses adhered to the Meta-Analysis Reporting Standards and reported the requisite information (outlined in the preface).
When the chapters were finalized, a 10-person expert panel (identified in the preface and in Chapter 18) reviewed and rated the evidentiary strength of the relationship element. They did so according to the following criteria: number of empirical studies; consistency of empirical results; independence of supportive studies; magnitude of association between the relationship element and outcome; evidence for causal link between relationship element and outcome; and the ecological or external validity of research. Using these objective criteria, experts independently judged the strength of the research evidence as:
Demonstrably effective, Probably effective, Promising but insufficient research to judge, Important but not yet investigated, or Not effective.
We then aggregated the individual ratings to render a consensus conclusion on each relationship element. These conclusions are summarized in the last chapter of this volume, as are 25 recommendations approved by all members of the steering committee.
Our deliberations were rarely unanimous, but invariably conducted in a collegial spirit and toward a common goal. Democratic process proves messy and inefficient; science is even slower and painstaking. We relied on expert opinion referencing best practices, professional consensus using objective rating criteria, and, most important, systematic reviews of the research evidence. But these were all human decisions—open to cavil, contention, and future revision.
THERAPY RELATIONSHIP
Recent decades have witnessed the controversial compilation of practice guidelines and evidence-based treatments in mental health. In the United States and other countries, the introduction of such guidelines has provoked practice modifications, training refinements, and organizational conflicts. Insurance carriers and government policymakers increasingly turn to such guidelines to determine which psychotherapies to approve and fund. Indeed, along with the negative influence of managed care, there is probably no issue more central to clinicians than the evolution of evidence-based treatments in psychotherapy (Barlow, 2000; Norcross et al., 2017).
The efforts to promulgate evidence-based psychotherapies have been noble in intent and timely in distribution. They are praiseworthy efforts to distill scientific research into clinical applications and to guide practice and training. They wisely demonstrate that, in a climate of accountability, psychotherapy stands up to empirical scrutiny with the best of healthcare interventions. And within psychology, these have proactively counterbalanced documents that accorded primacy to biomedical treatments for mental disorders and largely ignored the outcome data for psychological therapies. On many accounts, then, the extant efforts addressed the realpolitik of the socio-economic situation (Messer, 2001; Nathan & Gorman, 2015).
At the same time, many practitioners and researchers have found these recent efforts to codify evidence-based treatments seriously incomplete. While scientifically laudable in their intent, these efforts largely ignored the therapy relationship and the person of the therapist. Practically all treatment guidelines have followed the antiquated medical model of identifying particular treatment methods for specific diagnoses: Treatment A for Disorder Z. If one reads the documents literally, disembodied providers apply manualized interventions to discrete disorders. Not only is the language offensive on clinical grounds to some practitioners, but also the research evidence is weak for validating treatment methods in isolation from specific therapists, the therapy relationship, and the individual patient.
Suppose we asked a neutral scientific panel from outside the field to review the corpus of psychotherapy research to determine the most powerful phenomenon we should be studying, practicing, and teaching. Henry (1998, p. 128) concluded that 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 decades of empirical research.
What’s missing, in short, are the person of the therapist and the therapeutic relationship.
Person of the Therapist
Most practice guidelines and EBP compilations depict interchangeable providers performing treatment procedures. This stands in marked contrast to the clinician’s and client’s experience of psychotherapy as an intensely interpersonal and deeply emotional experience. Although efficacy research has gone to considerable lengths to eliminate the individual therapist as a variable that might account for patient improvement, the inescapable fact of the matter is that it is simply not possible to mask the person and the contribution of the therapist (Castonguay & Hill, 2017; Orlinsky & Howard, 1977). The curative contribution of the person of the therapist is, arguably, as evidence based as manualized treatments or psychotherapy methods (Hubble et al., 2011).
Multiple and converging sources of evidence indicate that the person of the psychotherapist is inextricably intertwined with the outcome of psychotherapy. A large, naturalistic study estimated the outcomes attributable to 581 psychotherapists treating 6,146 patients in a managed care setting. About 5% of the outcome variation was due to therapist effects, and 0% was due to specific treatment methods (Wampold & Brown, 2005).
Quantitative reviews of therapist effects in psychotherapy outcome studies show consistent and robust therapist effects—probably accounting for 5% to 8% of psychotherapy outcome (Baldwin & Imel, 2013; Barkham et al., 2017; Crits-Christoph et al., 1991; Johns et al., 2019). The Barkham study combined data from four countries, 362 therapists, 14,254 clients, and four outcome measures. They found that about 8% of the variance in outcome was due to the therapist, so-called therapist effects (Castonguay & Hill, 2017). Moreover, the size of the therapist effect was strongly related to initial client severity. The more disturbed a client was at the beginning of therapy, the more it mattered which therapist the client saw.
They also reported that to a large degree the middle two thirds of therapists could not be reliably and confidently distinguished from each other based on their clients’ outcomes. At the same time, 15% to 20% of therapists could be identified whose clients had distinguishably better outcomes with the same percentages having worse outcomes. These therapist effects appeared stable over time. Of course, therapist effects may well be directly related to relationship factors, such as the therapeutic alliance (Wampold et al., 2017).
Two controlled studies examining therapist effects in the outcomes of cognitivebehavioral therapy prove instructive (Huppert et al., 2001; Project MATCH Research Group, 1998). In the Multicenter Collaborative Study for the Treatment of Panic
