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In this closing article of the special issue, we present the conclusions and recommendations of the interdivi-
sional task force on evidence-based therapy relationships. The work was based on a series of meta-analyses
conducted on the effectiveness of various relationship elements and methods of treatment adaptation. A panel
of experts concluded that several relationship elements were demonstrably effective (alliance in individual
psychotherapy, alliance in youth psychotherapy, alliance in family therapy, cohesion in group therapy,
empathy, collecting client feedback) while others were probably effective (goal consensus, collaboration,
positive regard). Three other relationship elements (congruence/genuineness, repairing alliance ruptures, and
managing countertransference) were deemed promising but had insufficient evidence to conclude that they
were effective. Multiple recommendations for practice, training, research, and policy are advanced.
We shall not cease from exploration } The therapy relationship accounts for why clients improve
And the end of all our exploring (or fail to improve) at least as much as the particular treatment
method.
Will be to arrive where we started
} Practice and treatment guidelines should explicitly address ther-
And know the place for the first time. apist behaviors and qualities that promote a facilitative therapy rela-
—T. S. Eliot (Little Gidding in Four Quartets) tionship.
} Efforts to promulgate best practices or evidence-based prac-
Having traversed more than a dozen meta-analyses and arrived at tices (EBPs) without including the relationship are seriously in-
the end of this special issue, we have a final opportunity to present the complete and potentially misleading.
interdivisional task force conclusions and to reflect on its work. Like } Adapting or tailoring the therapy relationship to specific
the tireless traveler in Eliot’s poem, we have rediscovered the therapy patient characteristics (in addition to diagnosis) enhances the ef-
relationship and know it, again, for the first time. fectiveness of treatment.
This closing article presents the conclusions and recommendations } The therapy relationship acts in concert with treatment meth-
of the second Task Force on Evidence-Based Therapy Relationships. ods, patient characteristics, and practitioner qualities in determin-
These statements reaffirm and, in several instances, update those of ing effectiveness; a comprehensive understanding of effective (and
the earlier task force (Norcross, 2001, 2002). We then offer some final
ineffective) psychotherapy will consider all of these determinants
thoughts on what works, what does not work, and clinical practice.
and their optimal combinations.
} Table 1 summarizes the task force conclusions regarding
Conclusions of the Task Force the evidentiary strength of (a) elements of the therapy relation-
} The therapy relationship makes substantial and consistent ship primarily provided by the psychotherapist and (b) methods
contributions to psychotherapy outcome independent of the spe- of adapting psychotherapy to particular patient characteristics.
cific type of treatment. } The conclusions do not by themselves constitute a set of
practice standards but represent current scientific knowledge to be
understood and applied in the context of all the clinical evidence
available in each case.
John C. Norcross, Department of Psychology, University of Scranton;
Bruce E. Wampold, Department of Counseling Psychology, University of
Wisconsin, Madison.
Recommendations of the Task Force
Portions of this article are adapted, by special permission of Oxford
University Press, from a chapter of the same title by the same authors in General Recommendations
J. C. Norcross (Ed.), 2011, Psychotherapy relationships that work (2nd
ed.). New York, NY: Oxford University Press. The book project was 1. We recommend that the results and conclusions
cosponsored by the APA Division of Psychotherapy.
Correspondence regarding this article should be addressed to John C.
of this second task force be widely disseminated
Norcross, PhD, Department of Psychology, University of Scranton, Scran- in order to enhance awareness and use of what
ton, PA 18510-4596. E-mail: norcross@scranton.edu “works” in the therapy relationship.
98
SPECIAL ISSUE: EVIDENCE-BASED THERAPY RELATIONSHIPS 99
Table 1
Task Force Conclusions
2. Readers are encouraged to interpret these findings in the demonstrably and probably effective ele-
in the context of the acknowledged limitations of ments of the therapy relationship.
the task force’s work.
9. Training and continuing education programs are
3. We recommend that future task forces be estab- encouraged to provide competency-based training
lished periodically to review these findings, in- in adapting psychotherapy to the individual pa-
clude new elements of the relationship, incorpo- tient in ways that demonstrably and probably en-
rate the results of non-English language hance treatment success.
publications (where practical), and update these
conclusions. 10. Accreditation and certification bodies for mental
health training programs should develop criteria
Practice Recommendations for assessing the adequacy of training in
evidence-based therapy relationships.
4. Practitioners are encouraged to make the creation
and cultivation of a therapy relationship, charac-
terized by the elements found to be demonstrably Research Recommendations
and probably effective, a primary aim in the treat- 11. Researchers are encouraged to progress beyond
ment of patients. correlational designs that associate the frequency
5. Practitioners are encouraged to adapt or tailor of relationship behaviors with patient outcomes to
psychotherapy to those specific patient character- methodologies capable of examining the complex
istics in ways found to be demonstrably and prob- associations among patient qualities, clinician be-
ably effective. haviors, and treatment outcome. Of particular im-
portance is disentangling the patient contributions
6. Practitioners are encouraged to routinely monitor and the therapist contributions to relationship el-
patients’ responses to the therapy relationship and ements and, ultimately, outcome.
ongoing treatment. Such monitoring leads to in-
creased opportunities to reestablish collaboration, 12. Researchers are encouraged to examine the spe-
improve the relationship, modify technical strat- cific mediators and moderators of the links be-
egies, and avoid premature termination. tween the relationship elements and treatment
outcome.
7. Concurrent use of evidence-based therapy rela-
tionships and evidence-based treatments adapted 13. Researchers are encouraged to address the obser-
to the patient is likely to generate the best out- vational perspective (i.e., therapist, patient, or ex-
comes. ternal rater) in future studies and reviews of “what
works” in the therapy relationship. Agreement
Training Recommendations among observational perspectives provides a
solid sense of established fact; divergence among
8. Training and continuing education programs are perspectives holds important implications for
encouraged to provide competency-based training practice.
100 NORCROSS AND WAMPOLD
highlight those therapist relational behaviors that are ineffective, crustes, the legendary Greek giant who would cut the long limbs of
perhaps even hurtful, in psychotherapy. clients or stretch short limbs to fit his one-size bed.
One means of identifying ineffective qualities of the therapeutic We can optimize therapy relationships by simultaneously using
relationship is to simply reverse the effective behaviors. Thus, what works and studiously avoiding what does not work.
what does not work includes a low quality alliance in individual
psychotherapy, lack of cohesion in group therapy, and discordance Concluding Thoughts
in couple and family therapy. Paucity of empathy, collaboration,
consensus, and positive regard predict treatment drop out and In the culture wars of psychotherapy that pit the therapy
failure. The ineffective practitioner will resist client feedback, relationship against the treatment method (Norcross & Lambert,
ignore alliance ruptures, and discount his or her countertransfer- pp. 4 – 8, this issue), it is easy to chose sides, ignore discon-
ence. firming research, and lose sight of our superordinate commit-
Another means of identifying ineffective qualities of the rela- ment to patient benefit. Instead, let us conclude, like T. S. Eliot,
tionship is to scour the research literature and conduct polls of by “arriving where we started” and underscoring three incon-
experts. Here are six behaviors to avoid according to that research trovertible but oft-neglected truths about psychotherapy rela-
(Duncan, Miller, Wampold, & Hubble, 2010) and a Delphi poll tionships.
(Norcross, Koocher, & Garofalo, 2006): First, the interdivisional taskforce was commissioned in order to
} Confrontations. Controlled research trials, particularly in the augment patient benefit. We continue to explore what works in the
addictions field, consistently find a confrontational style to be therapy relationship and what works when we adapt that relation-
ineffective. In one review (Miller, Wilbourne, & Hettema, 2003), ship to (nondiagnostic) patient characteristics. That remains our
confrontation was ineffective in all 12 identified trials. By contrast, collective aim: improving patient success, however measured and
expressing empathy, rolling with resistance, developing discrep- manifested in a given case.
ancy, and supporting self-efficacy, characteristic of motivational Second, psychotherapy is at root a human relationship. Even
interviewing, have demonstrated large effects with a small number when “delivered” via distance or on a computer, psychotherapy is
of sessions (Lundahl & Burke, 2009). an irreducibly human encounter. Both parties bring themselves—
} Negative processes. Client reports and research studies con- their origins, culture, personalities, psychopathology, expectations,
biases, defenses, and strengths—to the human relationship. Some
verge in warning therapists to avoid comments or behaviors that
will judge that relationship a precondition of change and others a
are hostile, pejorative, critical, rejecting, or blaming (Binder &
process of change, but all agree that it is a relational enterprise.
Strupp, 1997; Lambert & Barley, 2002). Therapists who attack a
Third, how we create and cultivate that powerful human rela-
client’s dysfunctional thoughts or relational patterns need, repeat-
tionship can be guided by the fruits of research. As Carl Rogers
edly, to distinguish between attacking the person versus her be-
(1980) compellingly demonstrated, there is no inherent tension
havior.
between a relational approach and a scientific one. Science can,
} Assumptions. Psychotherapists who assume or intuit their
and should, inform us about what works in psychotherapy, be it a
client’s perceptions of relationship satisfaction and treatment suc-
treatment method, an assessment measure, a patient behavior, or,
cess are frequently inaccurate. By contrast, therapists who specif-
yes, a therapy relationship.
ically and respectfully inquire about their client’s perceptions
frequently enhance the alliance and prevent premature termination
(Lambert & Shimokawa, pp. 72–79, this issue). References
} Therapist-centricity. A recurrent lesson from process- Ackerman, S. J., & Hilsenroth, M. J. (2001). A review of therapist char-
outcome research is that the client’s observational perspective on acteristics and techniques negatively impacting the therapeutic alliance.
the therapy relationship best predicts outcome (Orlinsky, Ron- Psychotherapy, 38, 171–185.
nestad, & Willutzki, 2004). Psychotherapy practice that relies on Binder, J. L., & Strupp, H. H. (1997). “Negative process”: A recurrently
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predict outcome as well. Therefore, privileging the client’s expe- in the individual psychotherapy of adults. Clinical Psychology: Science
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} Rigidity. By inflexibly and excessively structuring treatment,
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all clients is now recognized as inappropriate and, in select cases,
analyses. Journal of Clinical Psychology: In Session, 11, 1232–1245.
even unethical. The efficacy and applicability of psychotherapy Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2003). What works? A
will be enhanced by tailoring it to the unique needs of the client, summary of alcohol treatment outcome research. In R. K. Hester &
not by imposing a Procrustean bed onto unwitting consumers of W. R. Miller (Eds.), Handbook of alcoholism treatment approaches:
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Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of Accepted October 28, 2010 䡲
The author has requested enhancement of the downloaded file. All in-text references underlined in blue are linked to publications on ResearchGate.