Psychotherapy relationships that work: volume 2: evidence-based therapist responsiveness john c norc
Psychotherapy Relationships That Work: Volume 2: Evidence-Based Therapist Responsiveness John
Norcross
C
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Psychotherapy Relationships That Work: Volume 1: Evidence-Based Therapist Contributions 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 978–0–19–084396–0
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Printed by Sheridan Books, Inc., United States of America
Dedicated to Larry E. Beutler and Jerome D. Frank pioneers in fitting psychotherapy to each patient
“My position is not that technique is irrelevant to outcome. Rather, I maintain that . . . the success of all techniques depends on the patient’s sense of alliance with an actual or symbolic healer. This position implies that ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem.”
Jerome D. Frank, Persuasion and Healing (1991, p. xv)
Preface ix
About the Editors xv
Contributors xvii
1. Evidence-Based Psychotherapy Responsiveness: The Third Task Force 1
John C. Norcross and Bruce E. Wampold
2. Attachment Style 15
Kenneth N. Levy, Benjamin N. Johnson, Caroline V. Gooch, and Yogev Kivity
3. Coping Style 56
Larry E. Beutler, Christopher J. Edwards, Satoko Kimpara, and Kimberley Miller
4. Cultural Adaptations and Multicultural Competence 86
Alberto Soto, Timothy B. Smith, Derek Griner, Melanie Domenech Rodríguez, and Guillermo Bernal
5. Gender Identity 133
Stephanie L. Budge and Bonnie Moradi
6. Preferences 157
Joshua K. Swift, Jennifer L. Callahan, Mick Cooper, and Susannah R. Parkin
7. Reactance Level 188
Christopher J. Edwards, Larry E. Beutler, and Kathleen Someah
8. Religion and Spirituality 212
Joshua N. Hook, Laura E. Captari, William Hoyt, Don E. Davis, Stacey E. McElroy, and Everett L. Worthington Jr.
9. Sexual Orientation 264
Bonnie Moradi and Stephanie L. Budge
10. Stages of Change 296
Paul Krebs, John C. Norcross, Joseph M. Nicholson, and James O. Prochaska
11. Personalizing Psychotherapy: Results, Conclusions, and Practices 329
John C. Norcross and Bruce E. Wampold
Index 343
Preface
A warm 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 adapting therapy to patients, under the same cover. In this third edition, we separate those “two books” into two volumes as the number of chapters and the amount of research have grown considerably over the past decade. This volume 2 features evidence-based therapist responsiveness to patient transdiagnostic characteristics; volume 1 addresses evidence-based therapist contributions to the relationship. As we move from volume 1 to volume 2, we transition from relationship elements to treatment adaptations or interpersonal responsiveness. We also move from primarily correlational research designs to randomized clinical trials.
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 shows the efficacy of tailoring psychotherapy to the individual client and context. Adapting brand-name treatments to particular disorders does not begin to address the complexity of psychotherapy nor does it leverage the central sources of healing: the therapeutic relationship and the patient himor herself.
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 an interdivisional Task Force on Evidence-Based Relationships and Responsiveness co-sponsored by the Society for the Advancement of Psychotherapy (Division 29 of the American Psychological Association [APA]) and the Society of Counseling Psychology (Division 17 of the APA). This edition also boasts a practice-friendlier smaller trim size (the physical size of the book). As noted, we have expanded the book into two volumes, each now co-edited by a prominent psychotherapy research (Bruce Wampold on this volume and Michael Lambert on volume 1).
We have expanded the breadth of coverage. New reviews were commissioned on tailoring psychotherapy to the client’s gender identity, sexual orientation, and functional
impairment, although the latter did not survive the rigors of the meta-analytic process and the pressing timeline of the project. Of course, updated meta-analyses were conducted on all returning chapters.
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. The causal evidence for these treatment adaptations or therapist responsiveness has increased steadily over the years; the authors of the majority of these meta-analyses can now legitimately claim that these adaptations cause improvements in treatment outcomes.
The net result is a compilation of nine, original cutting-edge meta-analyses on what works in personalizing psychotherapy to the individual client and his or her singular situation. This new edition, appearing nine years after the last incarnation, also proves more practical and reader-friendly: more clinical examples, sections on landmark studies, and ending with bulleted recommendations for 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 clinical practitioners and trainees of diverse theoretical orientations and professional disciplines. They need to address urgent pragmatic questions: What do we know from the research evidence about cultivating and maintaining the therapeutic relationship? What are the researchsupported means of adapting treatment to the individual patient beyond his or 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 payors (health insurance companies, managed care organization, and government entities) and accreditation organizations, many of which have unintentionally devalued the person of the therapist and the personalization of psychotherapy. Finally, this book is intended for psychotherapy researchers seeking a central resource on these urgent matters.
ORGANIZATION OF THE BOOK
Our 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 original meta-analyses and systematic reviews on adapting psychotherapy to patient’s transdiagnostic characteristics, or what we call “creating a new therapy for each patient.” It features nine chapters on fitting treatment methods and relational behaviors to a client’s attachment style, coping style, racial/ ethnic culture, gender identity, therapy preferences, reactance level, religious/spiritual commitment, sexual orientation, and stage of change. For good measure, the chapter on cultural identity also explores the relation of the therapist’s cultural competence to treatment outcome.
The concluding chapter presents the Task Force conclusions on evidence-based relationships and responsiveness and our reflections on what works and what doesn’t. We also feature 28 Task Force recommendations, divided into general, practice, training, research, and policy recommendations.
CHAPTER GUIDELINES
Except for the bookends (Chapters 1 and 11), all chapters use the same section headings and follow a consistent structure, as follows:
◆ Introduction (untitled). Introduces the patient transdiagnostic characteristics and the chapter in a few, reader-friendly paragraphs.
◆ Definitions. Defines in theoretically neutral language the patient characteristic and identifies any highly similar or equivalent constructs from diverse theoretical traditions.
◆ Measures. Reviews the popular measures used in the research and included in the ensuing meta-analysis.
◆ Clinical Examples. Provides several concrete examples of the patient characteristic being reviewed. Portions of psychotherapy transcripts are encouraged here while protecting the privacy of patients.
◆ Landmark Studies. Walks the reader through two to four landmark studies on the topic (including one qualitative study), describing their design, participants, and results.
◆ Results of Previous Meta-Analyses. Offers a quick synopsis of the findings of previous meta-analyses and systematic reviews on the topic.
◆ Meta-Analytic Review. Conducts an original meta-analysis of all available studies employing a random effects model. Systematically compiles all available empirical studies on the psychotherapy adaptation of the client characteristic to distal, endof-treatment outcome in the English language (and other languages, if possible). Includes only actual psychotherapy studies and no analogue studies. Uses the MetaAnalysis Reporting Standards as a general guide for the information to include.
Performs and reports a test of heterogeneity. Reports the effect size as d or g (or other standardized mean difference). Includes a fail-safe statistic to address the file-drawer problem and provides a table or funnel plot for each study in the meta-analysis.
◆ Moderators and Mediators. Presents the results of the potential mediators and moderators in the meta-analysis. 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. Summarizes the evidence demonstrating that the adaptation or match causally contributes to treatment outcome. How strong is the extant research for a causal link?
◆ Limitations of the Research. Points to the major limitations of the research conducted to date. A concise paragraph or two here on future research directions is also sometimes included.
◆ Diversity Considerations. Addresses 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. Explicates briefly the take-home points of the meta-analysis for clinical educators and supervisors. Mentions any training resources or programs that have a proven record of teaching the treatment adaptation or responsiveness.
◆ Therapeutic Practices. Places the emphasis here squarely on what works. Practice implications from the foregoing research, primarily in terms of the therapist’s contribution and secondarily in terms of the patient’s perspective, are set as bulleted points.
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 Society for the Advancement of Psychotherapy (APA Division 29) consistently supported the interdivisional task force, and the Society of Counseling Psychology (APA Division 17) co-sponsored 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 the knowledge in this book 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 and Modum Bad Psychiatric Center
We gratefully dedicate this book to Larry Beutler and Jerome Frank, pioneers in researching and advancing responsiveness in mental health. In both word and deed, they have inspired others and us to personalize or fit the treatment to each client.
Last but never least, our immediate families tolerated our absences, preoccupations, and irritabilities associated with editing this book. They did so with a combination of empathy and patience that would do any seasoned psychotherapist proud.
John C. Norcross and Bruce E. Wampold
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. His recent books include Clinician’s Guide to Evidence-Based Practice in Behavioral Health and Addictions, Systems of Psychotherapy: A Transtheoretical Analysis, Self-Help That Works, Psychologists’ Desk Reference, History of Psychotherapy, Changeology, and a dozen editions of the Insider’s Guide to Graduate Programs in Clinical & Counseling Psychology. He has served as president of the American Psychological Association (APA) Division of Clinical Psychology, the APA Division of Psychotherapy, and the Society for the Exploration of Psychotherapy Integration. 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.
Bruce E. Wampold, PhD, ABPP, is Director of the Research Institute at Modum Bad Psychiatric Center in Vikersund, Norway, and Emeritus Professor of Counseling Psychology at the University of Wisconsin–Madison. He is a Fellow of the APA (Divisions 12, 17, 29, 45), is board certified in counseling psychology by the American Board of Professional Psychology, and is 2019 president of the Society for Psychotherapy Research. He is the recipient of the Distinguished Professional Contributions to Applied Research Award from the APA and the Distinguished Research Career Award from the Society for Psychotherapy Research. Currently his work, summarized in The Great Psychotherapy Debate: The Evidence for What Makes Psychotherapy Work (with Z. Imel), involves understanding psychotherapy from empirical, historical, social, and anthropological perspectives.
Guillermo Bernal, PhD
Contributors
Clinical Psychology Program, Carlos Albizu University
Larry E. Beutler, PhD
Department of Clinical Psychology, Palo Alto University
School of Education, University of California, Santa Barbara
Stephanie L. Budge, PhD
Department of Counseling Psychology, University of Wisconsin-Madison
Department of Orthopedics and Rehabilitation, University of Wisconsin Hospitals and Clinics
Jennifer L. Callahan, PhD
Department of Psychology, University of North Texas
Laura E. Captari, MA, MS
Department of Psychology, University of North Texas
Mick Cooper, PhD
Department of Psychology, University of Roehampton
Don E. Davis, PhD
Department of Counseling and Psychological Services, Georgia State University
Christopher J. Edwards, MA, MS
Department of Clinical Psychology, Palo Alto University
Caroline V. Gooch, BS
Department of Psychology, Ohio University
Derek Griner, PhD
Counseling and Psychological Services, Brigham Young University
Joshua N. Hook, PhD
Department of Psychology, University of North Texas
William Hoyt, PhD
Department of Counseling Psychology, University of Wisconsin-Madison
Benjamin N. Johnson, MS Department of Psychology, Pennsylvania State University
Satoko Kimpara, PhD Department of Clinical Psychology, Palo Alto University
Yogev Kivity, PhD Department of Psychology, Pennsylvania State University
Paul Krebs, PhD Department of Population Health, New York University School of Medicine
Department of Psychology, VA New York Harbor Healthcare System
Kenneth N. Levy, PhD Department of Psychology, Pennsylvania State University
Stacey E. McElroy, PhD Department of Counseling and Psychological Services, Georgia State University
Kimberley Miller, BA Department of Clinical Psychology, Palo Alto University
Bonnie Moradi, PhD Department of Psychology, University of Florida
Center for Gender, Sexualities, and Women’s Studies, University of Florida
Joseph M. Nicholson, MPH Medical Library, New York University School of Medicine
John C. Norcross, PhD Department of Psychology, University of Scranton
Department of Psychiatry, SUNY Upstate Medical University
Susannah R. Parkin, BS Department of Psychology, Idaho State University
James O. Prochaska, PhD Department of Psychology and Cancer Prevention Research Center, University of Rhode Island
Melanie Domenech Rodríguez, PhD Department of Psychology, Utah State University
Timothy B. Smith, PhD Department of Counseling and Special Education, Brigham Young University
Kathleen Someah, MS Department of Clinical Psychology, Palo Alto University
Alberto Soto, PhD Department of Psychology & Counseling, University of Central Arkansas
Joshua K. Swift, PhD Department of Psychology, Idaho State University
Bruce E. Wampold, PhD Modum Bad Psychiatric Center, Norway Department of Counseling Psychology, University of Madison-Wisconsin
Everett L. Worthington Jr., PhD Department of Psychology, Virginia Commonwealth University
Psychotherapy Relationships That Work
Evidence- Based Psychotherapy
Responsiveness: The Third Task Force
John C. Norcross and Bruce E. Wampold
The need to adapt or fit psychotherapy to the individual patients has been universally recognized from the beginning of modern psychotherapy. As early as 1919, Freud introduced psychoanalytic psychotherapy as an alternative to classical analysis based on the recognition that the more rarified approach lacked universal applicability and that many patients did not possess the requisite psychological-mindedness (Wolitzky, 2011). The mandate for individualizing psychotherapy was embodied in Gordon Paul’s (1967) iconic question: What treatment, by whom, is most effective for this individual with that specific problem, and under which set of circumstances? Every psychotherapist recognizes that what works for one person may not work for another; we seek “different strokes for different folks” (Blatt & Felsen, 1993).
To many, the means of such matching was to tailor the psychotherapy to the patient’s disorder or presenting problem—that is, to find the best treatment method for a particular disorder. The research suggests that Treatment A for Disorder Z may prove differentially useful for a handful of disorders, such as some form of exposure for trauma and parent management training for childhood externalizing disorders. Although some psychotherapies may make better marriages with some mental health disorders (Barlow, 2014; Nathan & Gorman, 2015), the repeated Dodo Bird conclusion indicates that bona fide psychotherapies produce similar outcomes, once the researchers allegiance effect is identified and controlled (Wampold & Imel, 2015).
Still, the overwhelming majority of randomized clinical trials in psychotherapy compare the efficacy of specific treatments for specific disorders. Those research studies problematically collapse numerous clients under a single diagnosis. It is a false and, to be blunt, misleading presupposition in randomized controlled/clinical trials (RCTs) that the patient sample is homogenous (Beutler & Clarkin, 1990). Perhaps the patients are diagnostically homogeneous, but nondiagnostic variability is the rule. It is precisely the unique individual and the singular context that many psychotherapists attempt to “treat” (Norcross & Beutler, 2014).
As every clinician knows, matching psychotherapy solely to a disorder is incomplete and not always effective. Particularly absent from much of the controlled research and clinical training has been adapting psychotherapy to the person of the patient, beyond his or her disorder. As Sir William Osler (1906), father of modern medicine, wrote: “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.” The accumulating research demonstrates that it is indeed frequently effective to tailor or match psychotherapy to the entire person (Norcross, 2011).
Hundreds of potential client characteristics have been proposed as markers for using one type of treatment or style rather than another (Clarkin & Levy, 2004); however, it has been only in the past 20 years that the perennial quest for adapting psychotherapy to transdiagnostic patient characteristics on sound research has been fulfilled. As manifested in the meta-analyses and systematic reviews in this book, multiple methods of relational responsiveness or treatment adaptations have proven effective. These rightfully carry the designation of evidence-based practices.
In this chapter, we introduce volume 2 of Psychotherapy Relationships That Work devoted to evidence-based means of adapting psychotherapy to the patient’s transdiagnostic characteristics. (The first volume features evidence-based elements of the psychotherapy relationship.) We begin by reviewing the innumerable terms accorded to this process of matching therapy and client. We summarize the purposes and processes of the third interdivisional task force cosponsored by APA Division of Psychotherapy and the APA Division of Counseling Psychology. We then discuss the clinical and research process of determining what works for whom. The latter part of the chapter features the limitations of the task force’s work and responds to frequently asked questions.
A ROSE BY ANY NAME
The process of creating the optimal match in psychotherapy has been accorded multiple names over the years. In alphabetical order, these terms include aptitude by treatment interaction (a research design), attunement, customizing, differential therapeutics, fitting, individualizing, matchmaking, personalizing, prescriptionism, responsiveness, specificity factor, tailoring, therapy fit, treatment adaptation, and treatment selection. In the professional literature, treatment adaptation and responsiveness tend to prevail; we employ both terms interchangeably here in the interest of theoretical neutrality (adaptation is favored by cognitive-behavior therapists, while responsiveness is favored by relational, humanistic, and psychotherapies therapists). In clinical work, clients tend to prefer the terms individualizing and personalizing as they are self-explanatory and parallel language in personalized medicine (these conclusions hail from focus groups on actual and potential psychotherapy clients).
By whatever name, the goal is to enhance treatment effectiveness by tailoring it to the unique individual and his/her singular situation. In other words, psychotherapists endeavor to create a new therapy for each client. They do so by capitalizing on both the nomothetic and idiographic traditions: attuning psychotherapy to the particulars
of the individual according to the generalities of the research findings. And when we speak of the individual, we naturally recognize that the person may be in individual therapy or in a larger treatment format, such as a couple or in a group.
This position can be effortlessly misunderstood as an authority-figure therapist prescribing a specific form of psychotherapy for a passive client. Far from it; the goal is for an empathic therapist to collaboratively create an optimal relationship with an active client on the basis of the client’s personality, culture, and preferences. When a client frequently resists in session, for example, then the therapist considers whether he or she is pushing something that the client finds incompatible (preferences) or the client is not ready to make those changes (stage of change) or is uncomfortable with a directive style (reactance). Clinicians strive to offer a therapy that fits or resonates to the patient’s characteristics, proclivities, and worldviews—in addition to diagnosis.
THE THIRD INTERDIVISIONAL TASK FORCE
The dual purposes of the 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.
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 evidence-based practice to treatment adaptations and therapy relationships. Focusing on one area—in this volume, responsiveness—may unfortunately convey the impression that this is the only area of import. Thus, we take pains here and elsewhere in the two volumes to repeat that that our work acknowledges the simultaneous contribution of treatment methods to client success.
At the same time, decades of careful research indicate that the patient, the therapy relationship, and these transdiagnostic adaptations exercise more influence on outcome than the particular treatment method. Put differently, culture eats strategy, as the famed management consultant Peter Drucker has said. The relational ambience of psychotherapy and responsiveness to clients prove typically more powerful than the particular therapeutic method or strategy. We endorse Jerome Frank’s position, in his classic Persuasion and Healing (Frank & Frank, 1991, p. xv), which we selected for our epigraph.
My position is not that technique is irrelevant to outcome. Rather, I maintain that . . . the success of all techniques depends on the patient’s sense of alliance with an actual or symbolic healer. This position implies that ideally therapists should select for each patient the therapy that accords, or can be brought to accord, with the patient’s personal characteristics and view of the problem.
We consulted psychotherapy experts, the research literature, and potential authors to discern whether there were sufficient numbers of studies on a treatment adaptation or matching strategy to conduct a systematic review and meta-analysis. Seven such
client characteristics—attachment style, coping style, culture, preferences, reactance level, religion/spirituality, and stages of change—returned from the second edition of the book. We requested that a meta-analysis on functional impairment style also return from the first edition, but the authors could not accommodate the publication schedule. Two client characteristics not represented in the previous edition—gender identity and sexual orientation—were added, resulting in nine systematic reviews and meta-analyses on their respective effectiveness.
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 analyzed the efficacy of adapting psychotherapy to that patient quality. Outcome was primarily defined as distal posttreatment outcomes, which sharpened our focus on “what works.”
The chapters and the meta-analyses therein were peer reviewed by at least two editors and subsequently underwent at least one substantive 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 11) reviewed and rated the evidentiary strength of the effectiveness of fitting psychotherapy to that client dimension. They did so according to the following criteria: number of empirical studies, consistency of empirical results, independence of supportive studies, magnitude of the effect size, evidence for causal link, 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 reach a consensus conclusion on each adaptation method. These conclusions are summarized in the last chapter of this volume, as are 28 recommendations approved by all members of the steering committee.
WHAT WORKS FOR WHOM
As the field of psychotherapy has matured, the identical psychosocial treatment for all patients is now recognized as inappropriate and, in select cases, perhaps even unethical. We will not progress, and our patients will not benefit, by imposing a Procrustean bed onto unwitting consumers of psychological services. In his Foreword to the landmark Differential Therapeutics in Psychiatry (Frances et al., 1984), Robert Michels (1984, p. xiii) summed it as follows:
The easiest way to practice psychiatry is to view all patients and problems as basically the same, and to apply one standard therapy or mix of therapies for their treatment. Although some may still employ this model, everything we have learned in recent decades tells us that it is wrong—wrong for our patients in that it deprives them of the most effective treatment, and wrong for everyone else in that it wastes scarce resources.
The clinical reality is that no single psychotherapy is effective for all patients and situations, no matter how good it is for some. Evidence-based practice has come to demand a flexible, if not integrative, perspective. One size fits all therapy is proving impossible. Of course, as Michels notes, that would simplify treatment selection—give every client the same psychotherapy!—but it flies in the face of what we know about individual differences, patient preferences, and disparate cultures.
Imposing a parallel situation onto other healthcare professions drives the point home (Norcross & Beutler, 2014). To take a medical metaphor, would you entrust your health to a physician who prescribed the identical treatment (say, antibiotics or neurosurgery) for every patient and illness encountered? Or, to take an educational analogy, would you prize instructors who employed the same pedagogical method (say, a lecture) for every educational opportunity? Or would you entrust your child to a child care worker who delivers the identical response (say, a nondirective attitude or a slap on the bottom) to every child and every misbehavior? “No” is probably your resounding answer. Psychotherapy clients deserve no less consideration.
Concisely put, no theory is uniformly valid and no mechanism of therapeutic action is equally applicable to all individuals. As a consequence, the goal is to select different methods, stances, and relationships according to the patient and the context. The result is a more efficient and efficacious therapy—and one that fits both the client and the clinician.
On the face of it, of course, virtually every clinician endorses matching the therapy to the individual client. After all, who can seriously dispute the notion that psychological treatment should be tailored to the needs of the individual patient? However, the treatment adaptations in this volume go beyond this simple acknowledgment of the need for flexibility in several ways (Norcross & Beutler, 2014). These adaptation or responsiveness methods
◆ are derived directly from outcome research rather than from an idiosyncratic theory or seat-of-the-pants experimentation.
◆ embrace the potential contributions of multiple systems of psychotherapy rather than working from within a single theoretical system.
◆ are predicated on multiple transdiagnostic and occasionally diagnostic client characteristics, in contrast to relying on patient diagnosis alone.
◆ offer optimal treatment methods and healing relationships, whereas many matches historically focused narrowly on selecting methods.
◆ occur throughout the course of therapy, not only at pretreatment as a case formulation.
Psychotherapy matching is an old idea come to evidence-based fruition. The decision-making may be expressed in a series of when . . . then statements. When the client presents with this (feature), then consider doing this. In that way, the clinician matches to the entire person, not simply diagnoses.
One of our favorite clinical tales of responsiveness comes from the late Arnold Lazarus (1993), who related an illuminating incident with a Mrs. Healy, a middle-aged woman who indicated she sought an assertive, humorous, and challenging relationship with her therapist. When she first entered the office, she looked Lazarus up and down and asked, “Why do you have graves outside your office?” In perfect Rogerian style Lazarus responded, “I have graves outside my office?” “Look out the window, dummy!” she replied. He went to the office window and looked out. Two new flower beds had been installed alongside the front walk on the grass. It was early spring and the shoots had yet to emerge from the soil. “Well, since you ask,” Lazarus replied, “I have just buried one of my clinical failures in the one grave and the other is earmarked for you Mrs. Healy if you turn out to be an uncooperative client.” The twinkle in her eye told Lazarus that the response was an appropriate one. Had he responded in a stodgy or serious way—“Oh, those are merely newly planted flower beds,”—he doubted whether the necessary rapport would have developed, because she strongly valued “people with a sense of humor.” Indeed, each session would start with some friendly banter and jesting, followed by attention to the serious problems for which she sought psychotherapy.
Others of his patients, Lazarus discovered, sought a good listener and only a good listener. No interpretations, no advice, no self-disclosure. Different strokes for different folks indeed. We all have similar clinical tales in which we met the patient where he or she was.
The adaptation or responsiveness can be based on client–therapist similarity or complementarity. In general, the research favors therapists adopting a complimentary style of interaction—a theory of opposites for interpersonal dimensions. Highly resistant clients usually benefit more from lower therapist directiveness, whereas low resistant clients benefit from more guidance and direction (Chapter 6). In the Vanderbilt psychotherapy research studies, for instance, Hans Strupp and associates (1986; Strupp, 1993) found that increasing anticomplementarity between therapist self-concept and therapists’ perceptions of patient behavior was negatively associated with outcome. At other times, research favors similarity for more direct, conscious patient requests, such as cultural adaptations (Chapter 4), therapy preferences (Chapter 6), and religious/ spiritual accommodations (Chapter 8).
The number of permutations for every possible interaction or matching algorithm among patient, therapist, and relationship would prove endless without some empirical-driven guidance. The meta-analyses in this book delimit the universe of possible client variables to a manageable number for clinical purposes. Research has isolated a handful of readily assessed client features that are reliably associated with differential responses to various styles of therapeutic relating. While consensus is no epistemic warrant and while research will never provide definitive answers to all matching questions (Mahoney & Norcross, 1993), we can enhance psychotherapy efficacy and
efficiency by means of the nine adaptation/responsiveness methods highlighted in this volume.
EFFECT SIZES
The subsequent chapters feature original meta-analyses on the effectiveness of adapting or responsively matching psychotherapy to a particular patient characteristic. Insisting on quantitative meta-analyses for all the chapters (with the exceptions of the chapters on gender identity and sexual orientation) enables direct estimates of the magnitude or strength of effectiveness in the form of effect sizes. These are standardized differences between two group means, say, psychotherapy and a control, divided by the (pooled) standard deviation. The resultant effect size is in standard deviation units. Both Cohen’s d and Hedges’ g estimate the population effect size.
All of the meta-analyses in this volume employed d or g. This increased the consistency among the meta-analyses, enhancing their interpretability, and enabled direct comparisons of the meta-analytic results to one another. In all of these analyses, the larger the magnitude of d or g, the higher the probability of client success in psychotherapy.
Table 1.1 presents several practical ways to interpret the effect sizes d and g in behavioral health. By convention (Cohen, 1988), a d of .30 is considered a small effect, .50 a medium effect, and .80 a large effect. For the sake of comparison, across thousands of studies, average d for psychotherapy versus no psychotherapy is .80 to .85 and the average for one bona fide treatment method versus another (controlled for researcher allegiance) is 0 to .20 (Wampold & Imel, 2015).
Of course, these general rules or conventions cannot be dissociated from the context of decisions and comparative values. There is little inherent value to an effect size of 2.0 or 0.2; it depends on what benefits can be achieved at what cost (Smith et al., 1980).
For example, the authors of Chapter 7 conducted a meta-analysis of 13 RCTs that investigated the effectiveness of matching therapist directiveness to the client’s reactance level. Their meta-analysis, involving a total of 1,208 patients, found a weighted mean d of .78. As shown in Table 1.1, this is a medium to large effect size. In concrete terms, this effect size indicates that matching versus not increases success rates by 18% to 20%. Such numbers translate into happier and healthier clients; responsively adapting or tailoring leads more progress and fewer dropouts in psychotherapy.
LIMITATIONS OF THE WORK
A single task force can accomplish only so much work and cover only so much content, even in two volumes. As such, we wish to publicly acknowledge early in the book several necessary omissions and unfortunate truncations in our work.
First, this volume probably suffers from content overlap. A client’s therapy preferences probably reflect in part his or her cultural identities, although these are considered in separate chapters. A client’s level of trait reactance correlates in the .30
Table 1.1.
Practical Interpretation of d and g Values
Cohen’s
Adapted from Cohen (1988), Norcross et al. (2017), and Wampold and Imel (2015).
a Each effect size can be conceptualized as reflecting a corresponding percentile value; in this case, the percentile standing of the average treated patient after psychotherapy relative to untreated patients.
b Each effect size can also be translated into a success rate of treated patients relative to untreated patients; a d of .80, for example, would translate into approximately 70% of patients being treated successfully compared to 50% of untreated patients.
range with the precontemplation stage of change for a particular problem, but these two client dimensions are treated in different chapters. We also suspect that a person’s attachment style and coping style are intertwined. The field requires a gigantic factor analysis of sorts to identify the construct overlap and to determine superordinate adaptation methods.
Researcher allegiance may have also posed a problem in conducting and interpreting the meta-analyses. We invited authors with an interest and expertise in a particular client characteristic and adaptation method, but, in some cases, the authors might have experienced conflicts of interest due to their emotional, academic, or financial interests. In dozens of implicit ways and explicit decisions, authors may have favored the effectiveness of their scholarly offspring. The use of objective meta-analytic guidelines, peer review, and transparent data reporting probably attenuated effects of their allegiance, but it remains a strong human propensity in any discipline.
Another prominent limitation of the work as a whole is the relatively small number of research-supported methods to responsively match psychotherapy to the individual. There are but nine represented in this volume, and two of those did not possess any controlled studies to meta-analyze. Seven probably overlapping methods is a modest number, although they all possess robust meta-analytic research support.
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Title: The black cat (vol. I, no. 3, December 1895)
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The Black Cat
December 1895
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CONTENTS
Title Author Page
The Great Star Ruby B M G 1
The Interrupted Banquet. R B . 11
The Archangel. J Q. H . 19
Asleep at Lone Mountain. H. D. U . 24 Kootchie. H K . 37 Frazer's Find. R L . 40 Advertisements. 47
The Great Star Ruby.
BY BARNES MACGREGGOR.
IT was late in the evening of Melbourne Cup Day. In one of the dining-rooms of the Victoria Club three men sat smoking and talking earnestly together. Certainly the events of the last sixteen hours furnished ample subject for conversation. Melbourne Cup Day means to the Australian all that Derby Day does to the Englishman. It means, also, many things that even the greatest sporting event of the English year cannot mean to the inhabitants of the compact little island, provided with so many other facilities for amusement and intercourse. In this land of tremendous distances—where four million people occupy an area equal to that of the United States,—in this island continent of opposites—where Christmas comes in midsummer and Fourth of July in midwinter, where swans are black and birds are songless,—this is the one day when all classes and conditions assemble at one place and take their pleasures as a unit. From Victoria and New South Wales, from North, South, and West Australia, from Queensland, even from Tasmania and the sister colony of New Zealand, separated from the continent by miles of water, visitors of all kind and degree had flocked by the thousands. When the starting flag fell that morning there were assembled about the track picturesque miners and rugged bushmen, self-made capitalists, book-makers, and millionaire wool growers, charming women and well-groomed men, to the number of almost a quarter of a million. To all of these the occasion was one anticipated and planned for during twelve months past. It was the occasion when their long pent Anglo-Saxon sporting taste—for nine out of every ten Australians are of English ancestry—intensified by the free, out-ofdoor life, and by the absence of the outlets furnished in a more concentrated state of civilization, found exuberant expression. To each it carried, besides, some special significance, according to his
rank and occupation. To the betting man it meant that a single firm of book-makers had on deposit in the banks of Melbourne and Sidney wagers to the amount of over one hundred thousand pounds sterling; for, like the English Derby, this is a "classical" event, upon which bets are often made for the coming year the very day after the preceding race has been run. Among the women it meant triumphs of millinery, gowns that had been ordered from London and Paris many months or even a year in advance, the fashionable display of Goodwood, the Derby, and the Ascot all compressed into a single day
Among the mine owners and wool growers it meant journeys by rail, boat, or private coach, extending over hundreds, sometimes thousands of miles, and lasting for days and weeks, even months. Australia has well been called "The Land of the Golden Fleece." Its flocks of sheep are the largest, its gold mines and coal mines the richest in the world. Its flocks are counted not merely by hundreds or thousands, but by hundreds of thousands; and a single sheep station often extends over a hundred thousand acres. But with this immensity of interests there is linked the familiar loneliness of grandeur. The greater a country gentleman's possessions, the farther he is removed from society, until the largest proprietors are often separated by forty or fifty miles from their nearest neighbors. For this solitude the one outlet is the journey to Melbourne for the annual cup races.
Upon this particular day the fashionable parade had eclipsed in size and splendor that of any previous year. In addition to the races, there had been the notable first night of the Grand Opera House, opened now for the first time to the public; and the day had culminated in an evening of such brilliancy and distinction that the three men who sat talking at the Victoria Club found superlatives too weak to express their enthusiasm.
"Rather than miss this day, I would have lost five years of my life," said one of the group. Then, turning to beckon the waiter, in order that he might emphasize his words by some refreshment, he observed a guest of the club—evidently a stranger—sitting alone at an adjoining table. With the exuberant new-world hospitality of a man
who had evidently not been a loser in the day's exchange of wealth, he stretched out a welcoming hand, with, "Stranger, won't you join us?"
Without waiting for further formality, the solitary man strode up to the group and seated himself at their table.
"Gentlemen," he began, "I couldn't help overhearing what you said. I, too, would have given a good deal to have been a spectator. In fact, I had been looking forward to this event for a whole year, and, as luck would have it, missed it by the delay of an hour. If the steamer from Calcutta had reached Sydney half an hour before sundown yesterday, instead of half an hour after, I should have been in Melbourne early this morning, instead of late to-night. As it is, I arrived only ten minutes ago, and, having a card to your club from the Wanderer's in London, I came here to take the edge off my disappointment. The next best thing to being on the scene of action is to hear about it from an eye-witness. So I depend upon you to give me an account of the affair. At any rate, I only hope the races aren't finished."
"Oh, of course there will be more races," said the spokesman of the party; "but such a sight as the opening of the Opera House Melbourne isn't likely to see again. There were stars, of course, but no one noticed what was going on on the stage, you understand; the real show was in the house, which was simply packed. Such women! Such stunning gowns! And the jewels—why, it looked as though half the kingdoms of Europe had lent their crown jewels for the occasion.
"In all that gorgeousness it was mighty hard to pick out the handsomest face or the finest ornaments. But of course there was one woman here, just as there is everywhere, who carried off the palm. It wasn't only that she was beautiful, though in her dark, stately fashion she was far and away the handsomest woman present; and it wasn't only that she sat where she did in the front of the stage box, with her solitary escort in the background, when every other box in the theater was crammed; but upon the bodice of her gown—it was a gorgeous gold and white brocaded and lace-trimmed affair, so I heard it whispered among the women—she wore the most striking
and gorgeous ornament in the entire audience. This was a jockeycap made entirely of precious stones; the peak was a solid mass of diamonds, the band a row of sapphires, while the crown consisted of an enormous ruby. 'Twas rather showy, of course, but so appropriate for this particular race night that no woman could have resisted wearing it. Of course it stood out wonderfully—it was as big as a half-crown piece, you understand,—and it wasn't long before every glass in the house was fixed upon that pin and the beautiful woman that wore it.
"I turned my glass on it with the rest," he added, laughing, "and that's how I got such a good photograph of it."
"Speaking of precious stones," said the stranger, who so far had listened without comment, "reminds me of a fifty-thousand-pound ruby that once involved a daring young Englishman in a series of strange adventures."
"Give us the adventures," said the spokesman of the party, scenting at once a stirring tale that would make a fitting wind-up to the day's varied excitements. "A jewel always serves as a magnet for romance, especially if the jewel is a fifty-thousand-pound ruby."
"To begin with," said the strange man, apparently unmoved by his host's last remarks, "you must understand that, while there are millions of rubies mined every year, a really first-class stone is one of the rarest as well as the most valuable gems in the world. In Ceylon, where some of the largest ruby mines in the world are located, the Moormen, who have a monopoly of the gem trade, often bring down from the north country bullock cartloads of uncut rubies, but probably in handling ten million gems not one will be found of the desired fineness and of flawless purity and luster. These Moormen are the shrewdest, with a few exceptions the most unscrupulous, and always the most wonderful judges of gems in the world, and they are without exception rich. They have parceled out the gem-fields in the Tamil districts, and the natives whom they hire to hunt gems along the river bottoms, where the finest are found, are subjected to the most rigid scrutiny and daily search; for, though the diggers are always naked, they often attempt to conceal gems in their ears, nostrils, armpits, or
elsewhere, with the end in view of disposing of them to rival Moormen. For, though these Moormen are openly fair dealers among themselves, they cannot resist buying gems smuggled from their neighbors' fields. Consequently, a complete detective service is attached to each one of these diggings, and woe to the Tamil who is caught attempting to smuggle gems across the lines! He simply disappears, that's all. No one is ever called to account, and the awful secrecy of his captors and the mystery surrounding his end appal his fellows, keeping them in a subjection that is all but slavery, and in some respects infinitely worse.
"But these Tamil diggers are very wise, and they know when they happen upon a grand uncut gem. Perhaps they will bury it again and spend a whole year maneuvering to get the jewel over the lines to the rival buyers, finally giving it up, and turning it over to the owners of the fields. As the really fine ones are rarely larger than a hazelnut, and each is worth from twenty to one hundred times as much as a diamond of the same size, it is worth the digger's while to make a lifelong study of the relative values, and then profit thereby.
"Now, this young Englishman had a curious hobby For years he had desired to possess one of these almost priceless rubies, and it was partly with the hope of obtaining one that he visited Ceylon, where he had left orders with the Moormen gem dealers to reserve for him the finest and largest stone that could be found.
"Meantime he headed an exploring party, whose way lay through the jungles about a hundred miles north of Kandy, toward the ancient Buddhist city Anarajapoora, the throne of the famous King Tissa, the shrine of the oldest tree in the world,—the sacred Bo. It was a long and tedious march. The travelers usually halted at mid-morning, slept till the shadows cooled the air a little, then resumed the journey as far into the night as possible, sometimes continuing till the next mid-morning, when the sun's heat again brought them to a standstill. On this particular daybreak they had halted beside a swift stream, doubtful at which point to attempt to ford it. The leader had sent men both up and down the stream to search for a suitable spot, and wandered along its banks, more occupied with the glories of the tropic sunrise, the sparkle of the dew on the giant spider-threads
stretched from limb to limb, the stir of rare birds and animals with which the jungle was more than alive, than with the problem of fording the stream. Upon reaching an inviting nook, he sat down to roll a cigarette, first taking care to search for any jungle enemies in ambush which might make him legitimate prey. Suddenly he heard a great crashing of branches in the thicket on the opposite side of the river. Then, like a flash of lightning, a naked Tamil, red with blood, a look of desperation and hopeless despair on his face, plunged out of the avalanche of green beyond, and, leaping headlong into the water, struck out across the stream. The traveler had risen to his feet, and stood watching amazedly the course of the swimmer, which was aimless, like that of a desperate man wandering through a totally unfamiliar country. His head was shaven closely, though the natives usually wear their hair long. He swam with great effort. Indeed, the watcher on the bank saw that it was ten to one against the swimmer's success, and instinctively his heart went out in pity. The unfortunate wretch was now being carried rapidly down stream and toward the man on the bank, who could see the straining of every fiber in the Tamil's body, even the look of despair in his bloodshot eyes. Suddenly, just as success seemed assured, the swimmer threw up his hands, uttered a strange moan, and went down. The man on the bank rushed down the stream, stopped at a point where a huge banyan tree spread its branches far over the swollen waters, and climbed out on a thick limb. A moment later he saw the body of the Tamil rise almost directly beneath him. Clinging with one hand to the tree, he lowered himself over the treacherous torrent, and with a mighty effort seized the drowning man by the ankle and so dragged him to the shore.
"Back into ambush he half carried the poor wreck, and, laying him on the sod, began the task of reviving him. In less than ten minutes the Tamil opened his eyes, discharged a gallon of water, then gasped, struggled up into a half-sitting posture, and looked about him. When he saw the Englishman bending over him, and comprehended, he uttered the most pitiful wails of gratitude imaginable, groveling in the dust, kissing his preserver's feet. The water had washed the blood from him, but he was a mass of wounds, scars, bruises, lash marks, and bullet cuts. How he ever managed to go as far as he must have
gone, leaving a trail of blood behind him, was a mystery But what specially attracted the Englishman's attention was a blood-stained bandage around the fugitive's leg, midway between the knee and thigh, which was the only rag on the poor fellow's body. He was about to question him, by signs and syllables, for his knowledge of the Tamil patois was very limited, when he heard another great crashing of the thicket across the stream, accompanied by the sound of voices. Instantly, there flashed across the poor creature's face a look of unspeakable terror, as he panted out in hoarse gutturals, 'Saya-ta! Sa-ya-ta!' an appeal for salvation which would have moved a heart of stone. Motioning to him to remain quiet—an unnecessary precaution, since he was scarcely able to lift his head from the marshy ground—his preserver gave him brandy; then, by a circuitous route, ran up stream, coming out directly opposite four mounted Moormen who were ranting up and down the shore.
"Upon his appearance, the horsemen approached, and asked if he had seen any one go by. They were on the track, they explained, of a Tamil gem-digger, who was smuggling a ruby worth fifty thousand pounds over the lines of the Bakook-Khan gem-fields, and with the owner of the fields had chased him sixty miles. The man could be recognized, they said, because his head was shaven, and he was quite naked, except for a bandage tied around one leg, in which he had cut a hole and buried the ruby.
"To all of this the Englishman answered that he had seen such a man leap from the jungle and plunge into the river only a few moments ago, adding that they would better wait until the flood went down before searching the river bottom, as it would be impossible to find even an elephant in that muddy water At this the Moormen set up a howl of rage, and, after an angry consultation, passed on down the stream, scanning the river bank. The traveler was about to return to the Tamil, realizing the man's immediate danger, when another crowd burst through the jungle opposite, and at the sight of the Englishman approached him with much the same story as had the first, except that, according to their tale, the gem-digger had been smuggling from the Sabat- Keel fields. To them he made the same reply, adding that another party had just been there from the Bakook-
