Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303-315.
Relationship factors in psychotherapy are some of the most important predictors of patient outcomes. They outweigh factors like the type of therapy provided in determining whether patients get better after psychotherapy. In this second overview article, Norcross and Lambert provide a review of 17 meta-analyses of relationship factors in psychotherapy that contribute to positive outcomes. Like the review of patient factors also found in this blog and E-Newsletter, this article briefly outlines those evidence-based relationship factors that reliably predict patient outcomes in psychotherapy. The therapeutic relationship refers to how the therapist and patient relate to each other, or their interpersonal behaviors. By contrast, techniques or interventions refer to what is done by the therapist. Practice guidelines typically focus on interventions or therapeutic orientation. As the authors argue, what is missing from treatment guidelines are the person of the therapist and the therapeutic relationship – evidence for which is backed up by 5 decades of research. Even in studies of highly structured manualized psychotherapy for a specific disorder in which efforts were made to reduce the effect of individual therapist, up to 18% of outcomes (a moderate to large effect) could be attributed to the person of the therapist. By contrast somewhere between 0% and 10% of outcomes (a small to moderate effect) is attributable to specific treatment methods. So, which therapeutic relationship factors are reliably related to patient outcomes? These include: the therapeutic alliance in individual therapy (306 studies, g = .57) couple therapy (40 studies, g = .62), and adolescent psychotherapy (43 studies, g = .40), collaboration (53 studies, g = .61) and goal consensus (54 studies, g = .49), cohesion in group therapy (55 studies, g = .56), therapist empathy (82 studies, g = .58), collecting and delivering client feedback or progress monitoring (24 studies, g = .14 to .49), managing countertransference (9 studies, g = .84), and repairing therapeutic alliance ruptures (11 studies, g = .62) among others. Over the next few months, I will be reviewing these meta analyses in more detail to discuss how therapists can use this evidence base to improve their patients’ outcomes.
The research as a whole indicates that therapists should make the creation and cultivation of the therapeutic relationship a primary goal of therapy. Factors such as managing the therapeutic alliance, repairing alliance ruptures, engaging in ongoing progress monitoring, managing countertransference and others should be used to modify treatments and interpersonal stances in order to maximize outcomes. When seeking out professional development and training, practitioners should focus on evidence-based relationship factors (managing the alliance, judicious self disclosure, managing emotional expression, promoting credibility of the treatment, collecting formal feedback, managing countertransference) in addition to focusing on evidence-based treatments.