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RUNNING HEAD: EBPR ON-LINE CE

Evidence-Based Psychotherapy Relationships:

What Works in General

The Division of Psychotherapy Task Force on Empirically Supported

Psychotherapy Relationships

Abraham W. Wolf, PhD, Editor

APA Division 29 - Psychotherapy

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EVIDENCE-BASED PSYCHOTHERAPY RELATIONSHIPS

Health care practices are increasingly driven by practice guidelines based on

evidence-based treatments. In psychology, the APA Society of Clinical Psychology’s

Task Force proposed a list of evidence-based, manualized psychological interventions for

adult disorders based on randomized controlled studies (Chambless et al., 1996;

Chambless & Hollon, 1998; Task Force on Promotion and Dissemination of

Psychological Procedures, 1995). In psychiatry, the American Psychiatric Association

has published more than a dozen practice guidelines on a wide range of disorders. Efforts

to promulgate evidence-based psychotherapies are important initiatives that distill

scientific research into clinical applications and that guide practice and training. In a

climate of accountability, they demonstrate that psychotherapy efficacy and effectiveness

stands with the best of health care interventions.

Nevertheless, initiatives on evidence-based treatments can be incomplete and

potentially misleading. The early efforts to compile a set of evidence-based practices

suffer from two important omissions. First, they neglect the therapy relationship. This

interpersonal quality makes substantial and consistent contributions to psychotherapy

outcome independent of the specific type of treatment. The therapy relationship accounts

for at least as much treatment outcome as specific treatment methods (Wampold, 2001;

Lambert, 2003). Second, these efforts focus on individual DSM-IV diagnoses and ignore

matching the treatment and the relationship to the individual client beyond an Axis I

diagnosis. Different types of clients respond more effectively to different types of

treatments and relationships, and psychological therapies will increasingly emphasize

matching to people, not only diagnoses. Psychotherapists strive to offer or select a

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psychotherapy that fits a client’s personal characteristics, proclivities, worldviews – and

diagnosis.

Within this context, the APA Division of Psychotherapy created a task force,

chaired by John C. Norcross, Ph.D., to identify, operationalize, and disseminate

information on evidence-based psychotherapy relationships rather than evidence-based

psychotherapy treatments. The two aims of the Division of Psychotherapy Task Force

were to: 1) identify elements of effective therapy relationships; and 2) identify effective

methods of tailoring psychotherapy to the individual client on the basis of his/her

(nondiagnostic) characteristics. That is, the Task Force members sought to answer the

two pressing questions of “What works in general in the psychotherapy relationship?”

and “What works best for this particular client?”

The Task Force reviewed an extensive body of empirical research and generated a

list of evidence-based relationship elements and a list of means for customizing

psychotherapy to the individual client. For each, it judged whether the element was

demonstrably effective or promising and probably effective as follows:

Demonstrably Effective Promising and Probably Effective

Therapeutic Alliance Positive Regard

Cohesion in Group Psychotherapy Congruence/Genuineness

Empathy Feedback

Goal Consensus and Collaboration Repair of Alliance Ruptures

Self-Disclosure

Management of Counter-transference

Relational Interpretations

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The criteria for making these judgments were the number of supportive studies, the

consistency of the research results, the magnitude of the positive relation between the

element and outcome, the directness of the link between the element and outcome, the

experimental rigor of the studies, and the external validity of the research base. The

research reviews and clinical practices were compiled in Psychotherapy Relationships

That Work (2002) and summarized in a special issue of Psychotherapy (Norcross, 2001).

THE DEMONSTRABLY EFFECTIVE ELEMENTS

THE THERAPEUTIC ALLIANCE (Horvath, 2001)

The therapeutic alliance refers to the quality and strength of the collaborative

relationship between client and psychotherapist. It is operationally defined by (a) the

cognitive components of agreement on the goals of treatment and consensus on the tasks

by which those goals can be reached, and (b) the affective component of the bond

between the client and psychotherapist. It is rooted in psychoanalytic ideas of the positive

transference and the differentiation of the analytic relationship into the transference, the

real relationship, and the working alliance. In contemporary discussions, it provides an

atheoretical ground for explaining essential components in all helping relationships.

Research. A review of 90 studies on the positive associations between the

therapeutic alliance and psychotherapy outcome yielded an average effect size of .21.

This association did not vary as a function of how either the alliance or outcomes was

measured. Alliance measured early in treatment is marginally better at predicting

outcome than midterm alliance, and the strength of the alliance early in treatment is a

good predictor of premature termination. An initially lower and gradually increasing

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alliance may be more reliably associated with positive outcome. The effect size did not

vary with respect to psychotherapeutic orientation.

There was no association between quality of alliance and problem severity, type

of impairment, and quality of object relations or attachment. Clients with poor alliances

are more likely terminate early in treatment. Alliance is harder to establish with clients

who are delinquent, homeless, and drug dependent; have attachment styles that are

fearful, anxious, dismissive, or preoccupied; and, borderline and other personality

disorders.

Clients who have difficulty forming intimate relationships have stronger alliances

with experienced psychotherapists, while less relationally handicapped clients do not

respond differentially. Experienced psychotherapists appear better able than less

experienced psychotherapists at identifying deteriorating or poor alliances.

Psychotherapists who form alliances that tend to be hostile, distant, challenging,

controlling, or competitive have poorer outcomes. Collaboration is one of the key

features of the alliance concept, and most alliance measures seek information on the

degree of felt collaboration from psychotherapist and client. Preliminary evidence links

collaboration and better alliance.

Psychotherapeutic Practices. A stronger alliance is fostered when

psychotherapists convey an understanding and appreciation of client’s perspective

through empathy, openness, and flexibility. The alliance is impeded by the

psychotherapist’s “relational control,” i.e., needing to take control of a session. In the

early phases of treatment, developing the alliance takes precedence over technical

interventions. Psychotherapists actively solicit clients’ perspectives on various aspects of

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the alliance and negotiate both the goals of treatment and the content of sessions to secure

clients’ active engagement. Close attention is important early in treatment with clients

who have relational problems, personality disorders, poor object relations, or dismissing

attachment style. These clients are difficult to engage in any intimate relationship and are

likely to elicit negative or rejecting responses from the psychotherapist.

The link between positive alliances and psychotherapist flexibility and

willingness to negotiate suggests a need to think carefully about the potential limiting

effects of strict adherence to treatment manuals. The larger lesson learned from reviewing

the literature is that the traditional idea of the therapy relationship plus technique, may

need to be replaced with a model in which the alliance is understood as one perspective

of clinical practice, whereas techniques are the same phenomena viewed through a

different lens.

EMPATHY (Greenberg, Watson, Elliot, & Bohart, 2001)

Carl Rogers defined empathy as “the psychotherapist's sensitive ability and

willingness to understand the client's thoughts, feelings, and struggles from the client's

point of view.” Empathy has been operationally defined in terms of three different

components: (a) the psychotherapist's experience (empathic resonance), (b) the observers'

view (expressed empathy), (c) and the client's experience (received empathy). Observer-

rated empathy measures have raters decide if a psychotherapist’s responses detract from

the client’s response or enhance it by responding to its feeling components. The most

frequently used client-rated and psychotherapist self-report measure of empathy is the

Barrett-Leonard Relationship Inventory.

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Research. A review of 47 studies on the association between empathy and

psychotherapy outcome yielded an effect size of .32. The relation between empathy and

outcome did not vary as a function of theoretical orientation but was greater for less

experienced psychotherapists than for more experienced psychotherapists. Two

explanations for this finding are, first, less experienced psychotherapists vary more in

their levels of empathy than more experienced psychotherapists whose ratings fall in a

restricted range or have a ceiling effect, and, second, more experienced psychotherapists

may have developed additional skills so that clients are more forgiving of lapses in

empathy. Empathy is more predictive of improvement with non-specific measures of

outcome, such as global improvement or client satisfaction, than with more specific,

problem-focused measures. Some studies suggest that empathy is not solely a

psychotherapist-determined, but may be a function of the mutually created climate

between psychotherapist and client.

Four factors have been identified to explain the positive association between

empathy and outcome. Empathy as relationship condition: Feeling understood increases

client satisfaction with one’s psychotherapist and thereby increases compliance and

decreases premature termination. Feeling understood increases feelings of safety,

facilitates self-disclosure, and the willingness to discuss difficult personal areas. Empathy

as a corrective emotional experience: An empathic relationship may break isolation and

help clients learn that they are worthy of respect and being listened to, and that their

thoughts and behaviors make sense. Empathy and cognitive-affective processing:

Empathy has been found to promote exploration and meaning creation, help clients think

more productively, raise levels of productive experiencing, and facilitate emotional

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reprocessing. Empathy and the client as active healer: Empathy contributes to promoting

clients’ self healing by creating a space for client involvement and openness to the

clinical process. It helps the psychotherapist choose interventions compatible with the

client's frame of reference, which also promotes the client’s active participation.

Psychotherapeutic Practices. Psychotherapists are advised to make efforts to

respond to their clients through responses that address a client’s needs as the client

perceives them on an ongoing basis. Empathic responses that add to or carry forward the

meaning of the client’s communications are useful. Empathic psychotherapists do not

parrot their clients’ words or reflect only the content of words, but strive to understand

and respond to overall goals and moment-to-moment experiences at explicit and implicit

levels meaning. Some clients have a negative response to expressions of empathy, and

some fragile clients may find empathic responses intrusive. Highly resistant clients may

find empathy too directive, while other clients may find an empathic focus on feelings

too foreign. Psychotherapists therefore need to know how to time empathic responses.

Throughout the treatment, they need to determine when and how to communicate

empathic understanding and at what level to focus their empathic responses on a

moment-to-moment basis. Empathic psychotherapists assist clients to articulate their

experience and track their emotional responses, so that clients can deepen their

experience and examine their own feelings, values, and goals. To this end, they need to

attend to what is not said, or what is at the periphery of awareness, as well as what is said

and is figural in awareness.

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COHESION IN GROUP PSYCHOTHERAPY (Burlingame, Fuhriman, & Johnson,

2001)

The therapeutic relationship in group psychotherapy refers to group cohesion. It is

defined as including all the relationships emerging from the group, namely, (a) member-

to-leader, (b) member-to-member, and (c) member-to-group relationships. Processes of

group cohesion include both intrapersonal components, that is, a group member's sense

of belonging and acceptance and a personal commitment and allegiance to the group, and

intragroup components, including attractiveness and compatibility felt among group

members.

Research. The review of studies on the association between group cohesion and

psychotherapy outcome found a positive association in 80% of the studies. The

experience of individual members in the group, an aspect of the member-to-group

cohesion, is related to outcome in terms of how the group member felt understood,

protected, and comfortable in the group. Perception of group leaders, the member-to-

leader dimension, was associated with outcome in terms of how group member felt

warmth, understanding, hope, and being personally valued by the group leader. Group

processes that affect cohesiveness include high and positive emotional relatedness among

group members that leads to self-disclosure, ability to tolerate conflicts in the work

phase, and focus on the welfare of the group rather than the leader or individual

members.

Psychotherapeutic Practices. The following six principles have strong empirical

support and can guide the clinician in managing group cohesiveness:

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1. Pregroup preparation sets treatment expectations, defines group rules, and

instructs members in appropriate roles and skills needed for effective group participation

and group cohesion. Pregroup training may be one of the most powerful factors in

creating a cohesive group. Pregroup preparation should include setting treatment

expectations (rationale, discussion of fears), establishing group procedures (time, fees,

etc.), engaging in role preparation, building skills, and setting process norms.

2. The group leader should establish clarity regarding group processes in early

sessions since higher levels of structure probably lead to higher levels of disclosure and

cohesion. Group members experience discomfort when they enter the group. Unless the

leader deals effectively with this anxiety, it can lead to client attrition and poor

cohesiveness.

3. Leader modeling real-time observations, guiding effective interpersonal

feedback, and maintaining a moderate level of control and affiliation may positively

impact cohesion. The leader can explicitly set norms and reinforce interactional patterns

that can lead to more interactions. Leadership styles that are moderate in directiveness

and affiliation have been related to increased levels of cohesion.

4. The timing and delivery of feedback should be pivotal considerations for

leaders as they facilitate this relationship-building process. Positive feedback should

predominate in early sessions, and corrective feedback should occur in later sessions. The

latter is best received when preceded by positive feedback focusing on specific and

observable behaviors. Corrective feedback requires careful consideration of the readiness

of the receiver with leader providing instruction and modeling of useful feedback.

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5. The group leader's presence not only affects the relationship with individual

members, but all group members as they vicariously experience the leader's manner of

relating, and thus the importance of managing one's own emotional presence in the

service of others. Positive outcomes are associated with group psychotherapists who are

warm, accepting, empathic, and convey a positive regard for the individual client member

and the group. Positive relationship-building attitudes and behaviors early in the group

prevent early client dropout.

6. A primary objective of the group leader should be facilitating group members'

emotional expression, the responsiveness of others to that expression, and the shared

meaning derived from such expression. The leader characteristics that contribute to the

emotional climate of the group are also useful characteristics in group members, namely,

empathy, support and caring, acceptance, and trust. The basic skills of listening and

conveying that one has heard and understands are important client factors in creating a

healthy emotional climate.

GOAL CONSENSUS AND COLLABORATION (Tryon & Winograd, 2001)

The concepts of goal consensus and collaboration involvement apply to all

psychotherapies regardless of theoretical orientations and practice settings. Goal

consensus is one aspect of the working alliance and is defined as psychotherapist-client

agreement on goals and expectations. Collaborative involvement is the mutual

involvement of client and psychotherapist in the helping relationship. Both goal

consensus and collaborative involvement are elements of the therapeutic contract,

referring to how the client understands his or her role for engaging with the

psychotherapist.

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Research. Of 25 studies, 68% found a positive relation between goal consensus

and psychotherapy outcome. These studies evaluated how goal consensus functioned in

the treatment relationship in terms of (a) client-psychotherapist agreement on goals; (b)

the extent to which a psychotherapist explains the nature and expectations of

psychotherapy, and the client's understanding of this information; (c) the extent to which

goals are discussed, and the client's belief that goals are clearly specified; (d) client

commitment to goals; and (e) client-psychotherapist congruence on the origin of the

client's problem, and congruence on who or what is responsible for problem solution.

Of 24 studies, 89% found a positive relation between collaborative involvement

and psychotherapy outcome. The studies examined how collaborative involvement

functioned in the treatment relationship in terms of client cooperation, role involvement,

and homework compliance. Withdrawn and psychotic clients were less likely to

cooperate and showed less involvement. Clients contributed to a collaborative

relationship by completing homework assignments, which was positively related to

psychotherapy outcome.

Psychotherapeutic Practices. It is difficult to assess goal consensus, since client

and psychotherapist may be working on the same goals but talking about them in

different ways. Psychotherapists and clients should frequently discuss and agree upon

goals in a shared decision-making process. When psychotherapists address topics of

importance to clients and resonate to their concerns, clients feel understood, which leads

to greater collaboration. When clients are given clear explanations of the treatment plan

and how it relates to their presenting complaints, they are more satisfied with

psychotherapy sessions and more willing to work on their problems.

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Research suggests that positive outcome is associated with collaborative

involvement that includes cooperation and affiliation on the part of both client and

psychotherapist. Clients achieve better outcomes when they are actively involved in the

treatment process, and discuss their concerns, feelings, and goals rather than resisting or

passively receiving them. Clients who resist have poorer outcomes. Although,

psychotherapists who assign and review homework have better outcomes, it is not the

quantity of assigned homework but the quality of completed homework that leads to

better outcomes.

PROMISING AND PROBABLY EFFECTIVE

POSITIVE REGARD (Farber & Lane, 2001)

Positive regard, or unconditional positive regard, refers to a psychotherapist

treating a client in a consistently warm, totally accepting, and highly regarded manner. It

has been characterized as prizing, nonpossessive warmth, and affirmation. The

correlation between psychotherapists’ ability to communicate positive regard and

psychotherapy outcome were modest in research studies. Associations were most robust

when outcome was assessed by clients’ ratings rather than psychotherapist ratings or by

an objective measure.

Nevertheless, the psychotherapist’s ability to provide positive regard appears to

be significantly related to outcome and, therefore, is indicated in clinical practice. It

creates an interpersonal context for other interventions and may, in some cases, be

sufficient in itself to effect change. It is the client’s perception of a psychotherapist

positive regard that is most robustly associated with good outcome. This indicates that

psychotherapists cannot rely on merely feeling good about their clients, but make sure

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that they communicate those positive feelings in the form of caring and respect that

affirms the client’s sense of self-worth.

CONGRUENCE/GENUINENESS (Klein, Michels, Kolden, & Chisolm-Stockard, 2001)

Therapist congruence, in addition to empathy and positive regard, are Carl

Roger’s core conditions for psychotherapeutic change. Congruence and genuineness refer

to both the psychotherapist’s personal integration, that is, the ability to freely and deeply

be him/herself, and the psychotherapist’s ability to communicate his or her personhood to

the client. In the 20 studies reviewed, 34% of the results found a positive relation

between psychotherapist congruence and treatment outcome, and 66% reported

nonsignificant associations. The proportion of positive findings increased to 68% when

congruence was tested in connection with empathy and positive regard. This supports the

notion that the facilitative conditions work together and cannot be easily distinguished.

Psychotherapist characteristics associated with higher congruence include more

self-confidence, good mood, increased involvement or activity, responsiveness, and

smoothness of speaking exchanges. Client congruence was associated with higher levels

of self-exploration/experiencing and absence of severe disorders, suggesting that these

may mediate or moderate the relationship between congruence and outcome, such that it

is easier for a psychotherapist to communicate congruence with more expressive and

higher functioning clients.

Congruent responses include self-disclosure of personal information, articulation

of thoughts and feelings, and feedback on client behavior. These responses are honest,

respectful, sincere, and not intellectualized. They serve as a vehicle for communicating

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empathy and regard. Psychotherapists need to be aware that clients have differing needs

and expectations with respect to congruence.

FEEDBACK (Claiborn, Goodyear, & Horner, 2001)

Feedback is descriptive or evaluative information provided by the psychotherapist

to the client about the client’s behavior or its effects. It has been called praise,

reinforcement, immediacy, and confrontation. Since feedback can be motivational, the

psychotherapist needs to manage how information is presented such that the client’s

emotions do not distort the information or elicit resistance. The effects of feedback have

not been extensively researched; of 11 studies, 73% found a positive association with

outcome and 27% were nonsignificant.

Clients usually accept positive feedback that affirms their self-perception.

Negative feedback serves to correct client attitude and behavior and is more acceptable in

the context of a safe and trusting relationship and when preceded by positive feedback.

Client’s processing of feedback is attenuated by low self-esteem and negative mood. A

collaborative relationship is the context for the exchange of feedback, which, especially

with positive feedback, helps to establish and strengthen that relationship. A structure for

feedback is created by the psychotherapist describing the feedback process and goals to

the client, by training clients in giving and receiving feedback, and allowing clients to

work through feedback.

REPAIR OF ALLIANCE RUPTURES (Safran, Muran, Samstag, & Stevens, 2001)

Research on the therapeutic alliance, as reviewed earlier, consistently finds that a

strong therapeutic alliance is associated with positive treatment outcome. Therefore, it

follows that breakdowns in the relationship – alliance ruptures – are an important part of

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the treatment process. Even experienced psychotherapists have considerable difficulty

discerning when there are problems in the relationship, for example, secrets and things

left unsaid. The small body of research indicated that the frequency and severity of

alliance ruptures was associated with more defensive psychotherapist behavior, such as

greater adherence to treatment manuals or increased concentration on transference

interpretations, both of which resulted in poor outcomes. When psychotherapists attend to

ruptures as they occur and adjust their behaviors, not only does the alliance improve but

these moments may also be an intrinsic part of the change process. The limited research

suggests that poor outcome cases are characterized by attack-and-defend patterns of

communication between psychotherapist and client. It is difficult to train

psychotherapists to deal constructively with these patterns of communication.

Since clients are typically reluctant to articulate their negative feelings about

psychotherapy and the treatment relationship, psychotherapists need to be attuned to

ruptures in the alliance and take the initiative in exploring these. Clients benefit from the

opportunity to express negative feelings and assert differing perspectives. It is important

for psychotherapists to respond in a non-defensive manner when criticized and take

responsibility for their contribution to the interaction. Exploring clients’ fears about

discussing negative feelings contributes to the process of resolving alliance ruptures.

SELF-DISCLOSURE (Hill & Knox, 2001)

Therapist self-disclosures, one of the most controversial interventions, are

statements that reveal something personal about the psychotherapist. It is important to

distinguish self-disclosures, which reveal non-immediate personal information, from

immediacy statements, which reveal immediate feelings about the client.

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Analogue research (designs involving simulations of psychotherapy rather than

actual psychotherapy) suggests that nonclients generally have positive perceptions of

psychotherapists who self-disclose and like psychotherapists who moderately self-

disclosed personal information. Research of actual psychotherapy suggests that

psychotherapists disclose infrequently and disclose mostly about their professional

background. Psychotherapists try to avoid self-disclosure when it gratified their own

needs and distracted the client’s work Disclosures were perceived as helpful in terms of

the immediate outcomes of the therapy, although their effects on the longer term

outcomes remain unclear. Humanistic-existential psychotherapists disclose more than

psychoanalytic psychotherapists

Psychotherapists should disclose infrequently and, when they do, strive to validate

reality, normalize, model, strengthen the alliance, or offer alternative ways of thinking.

The most appropriate self-disclosures involve professional boundaries and the least

appropriate are sexual beliefs and practices. They should avoid disclosures that are used

for their own needs, distract from the client, or blur the treatment boundary.

Psychotherapists should observe carefully how clients respond to disclosures and use that

information in deciding how to proceed in the future. Self-disclosures may be especially

important with clients who have difficulty forming treatment relationships.

MANAGEMENT OF COUNTERTRANSFERENCE (Gelso & Hayes, 2001)

First described by Freud, countertransference refers to a psychotherapist’s

reactions to clients based on the psychotherapist’s conscious and unconscious conflicts.

The conventional view is that countertransference that is not understood or controlled

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injures the psychotherapeutic process, and, conversely, countertransference that is

understood and managed facilitates the process.

There have been few empirical investigations of countertransference and

psychotherapy outcome. These studies focused on immediate effects of

countertransference, that is, effects observed in a given hour, or countertransference as a

mediating factor. These studies support the idea that unmanaged countertransference

adversely affects outcome. Although there has been a paucity of research on the effects of

countertransference on distal outcomes, the available research suggests that

countertransference weakens the therapeutic alliance.

Effective psychotherapists work to prevent countertransference acting out and

manage countertransference reactions in a manner that facilitates the treatment process.

Countertransference management involves five interrelated skills: self-insight, the

psychotherapist’s ability to understand their own reactions to the client; self-integration,

the ability to maintain a healthy boundary between self and client; anxiety management,

the ability to experience and tolerate anxiety without “acting-out;” empathy, the ability to

climb into the client’s world; and, conceptualizing ability, the ability to conceptually

grasp client and treatment dynamics.

RELATIONAL INTERPRETATIONS (Crits-Christoph & Gibbons, 2001)

Interpretations are defined in the psychoanalytic literature as interventions that

bring material to consciousness that was previously out of awareness. Relational

interpretations address the psychotherapeutic relationship and include transference

interpretations. Operational definitions of relational interpretations emphasize

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psychotherapist statements that go beyond what the client has overtly recognized and

pointing out themes in the client’s behavior or personality.

Research has focused on the association of treatment outcome to the frequency of

transference interpretations and the quality of these interpretations. The association

between frequency of interpretations and psychotherapy outcome has yielded mixed

results, but converge towards the conclusion that high rates of transference interpretations

lead to poor outcomes, particularly for clients with low quality object relations. Studies of

the quality of transference interpretations suggest that positive outcomes are associated

with a psychotherapist accurately addressing central features of a client’s interpersonal

dynamics.

Three main implications for clinical practice are, first, avoid high levels of

transference interpretation, second, interpretations should focus on the central

interpersonal themes, and, third, psychotherapist should strive to make these

interpretations accurate.

PRACTICE RECOMMENDATIONS

Decades of empirical research, despite the inevitable limitations, point to the

following practice recommendations:

• Practitioners are encouraged to make the creation and cultivation of a

psychotherapy relationship as characterized by the demonstrably and probably

effective elements a primary aim in the treatment of patients.

• Practitioners are encouraged to routinely monitor patients’ responses to the

therapy relationship and ongoing treatment in order to repair alliance ruptures, to

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improve the relationship, to modify technical strategies, and to avoid premature

termination.

• Concurrent use of empirically supported relationships and empirically supported

treatments tailored to the patient’s disorder and characteristics is likely to generate

the best outcomes.

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