On Friday night, we were lucky enough to have leading psychological researcher Prof Analise O’Donovan give a presentation at Benchmark about the factors that make psychotherapy relationships work or fail. Analise has had a long passion for the question of what makes psychological therapy work, and was presenting some research that she had recently come across that had really excited her.


Analise explained that she had recently attended a workshop by Prof John Norcross in Paris who, rather than simply giving the usual advice of “make sure you have a good therapeutic relationship”, has systematically gone through the literature to identify the key ways in which clinicians can ensure that this relationship is optimal.  Much of this work is published in “Psychotherapy Relationships That Work: Evidence-Based Responsiveness


The rest of this blog is the summary of this presentation that was compiled by Analise based largely on the work of Norcross.


question head

What do we know about What Works:

  • The therapy relationship makes substantial and consistent contributions to outcome independent of the type of treatment
  • Practice and treatment guidelines should address therapist behaviors and qualities that promote the therapy relationship
  • Efforts to promulgate best practices without considering the relationship or how to adaptation it are seriously incomplete
  • The relationship acts in concert with treatment methods, patient characteristics, & clinician qualities in determining effectiveness
  • Adapting or tailoring the relationship to patient characteristics (in addition to diagnosis) enhances effectiveness



Alliance in Individual Therapy (Horvath, Del Re, Flückiger, & Symonds)

  • Quality and strength of the collaborative relationship
  1. Agreed Goals
  2. Agreement on Approach
  3. Strong Bond
  • Across 201 adult studies (≈ 14,000 patients), median correlation between  alliance and treatment outcome = .28, a modest but very robust association
  • Correlation of .28 translates into an effect size of d = .57 (medium effect)
  • Average d for psychotherapy vs. no treatment is .80 (a big chunk of overall effect is just relationship)
  • Decades of research indicates – the relationship works: it makes substantial and consistent contributions to outcome independent of the type of treatment. HOWEVER – its not the only thing that works:


What work in Particular:

  • No treatment works for all patients; what works for one patient may not work for another
  • Paul’s 1967 iconic question:  What treatment, by whom, is most effective for this individual with that specific problem?
  • Simply matching psychotherapy to a disorder is incomplete and not always effective
  • Most patients prefer the terms  personalizing and individualizing
  • Create a new therapy for each patient
  • Tailor to the particulars of the patient according to the general research     evidence


Six elements to consider when personalising psychotherapy:

  • Reactance level
  • Culture
  • Preferences
  • Religion/spirituality
  • Stages of change
  • Coping style


1.     Reactance (Beutler et al.)smiley spectrum

  • Refers to being easily provoked & responding oppositionally to external demands
  • Meta-analysis of 12 select studies (N = 1,102) reveals large ES (d = .82) for matching therapist directiveness to patient reactance
  • High-reactance patients benefit more from self-control methods, minimal direction, & paradoxical interventions
  • Low-reactance clients benefit more from therapist directiveness and explicit guidance


2.     Culture (Smith, Rodríguez, & Bernal)

  • Meta-analysis of 65 studies (N = 8,620) evaluated the impact of culturally adapted txs vs. traditional (non-adapted) txs
  • d = .46 in favor of clients receiving culturally adapted treatments; “cultural fit” works
  • Most frequent methods of adaptation: 84% incorporated cultural content/values, 75% used clients’ preferred language, 53% matched clients with therapists of similar ethnicity/race


choices3.     Preferences (Swift, Callahan, & Vollmer)

  • Meta-analysis of 35 studies comparing outcomes of clients matched vs. non-matched to their preferences
  • d = .31 in favor of clients matched to their treatment, role, and therapist preferences
  • Patients receiving their preferences were a third less likely to drop out of treatment prematurely
  • Treatment method, relationship style, therapist characteristics, treatment length, etc.
  • Accommodate strong preferences when possible




Research does NOT support routine matching on the following variables:

  • Gender
  • Race/Ethnicity
  • Religion/Spirituality 
  • Unless client expresses strong preference


4.     Religion / Spirituality (Worthington et al.)

  • In 29 studies (N = 3,290), patients in Religious treatments showed greater improvement than those in alternate secular psychotherapies on both psychological (d = .26) and spiritual (d = .41) outcomes
  • In 11 rigorous dismantling designs, in which Religious and alternate treatments shared same theoretical orientation and treatment duration, no difference in psychological outcomes but differences in spiritual outcomes (d = .33) favouring Religious or Spiritual therapies


5.     Stages of Change (Norcross, Krebs, & Prochaska)Stages

  • Precontemplation, contemplation, preparation, action, & maintenance
  • Meta-analysis of 47 studies:  d = .70 – .80 for different change processes in different stages
  • Stages reliably predict psychotherapy outcomes (k = 39, N = 8,238, d = .46)
  • Therapist optimal stance also varies with stage of change: Nurturing parent, a Socratic teacher, experienced coach, a consultant


6.     Coping Style (Beutler, Harwood, et al.)

  • Habitual, enduring pattern:  Externalizing vs. internalizing
  • Meta-analysis indicates medium effect sizes (d = .55) for matching therapist method to patient coping style (k = 12, N = 1,291 patients)
  • Interpersonal & insight-oriented txs more effective among internalizing patients
  • Symptom-focused & skill-building txs more effective among externalizing patients


Not yet fully proven, but probably important:


1.     Attachment Style (Levy et al.)

  • In 14 studies involving 1,467 patients, relation between attachment anxiety and treatment  outcome  d = .46
  • Relation between attachment avoidance and treatment outcome d = .03.  Nada
  • Relation  between attachment security and treatment outcome d = .37
  • Only a couple of matching studies


2.     Expectations (Constantino, Glass, Arnkoff, et al.)


  • In 46 studies (N = 8,016), patient expectations for successful therapy were routinely associated with better tx outcomes d = .24
  • Therapist behaviors can cultivate positive expectancies both at pre-treatment and during the course of therapy
  • Pretreatment socialization and role inductions generally successful, but not many controlled studies



Practice recommendations:Recommended

  • Not What is my preferred theoretical orientation or treasured proficiency?
  • But What therapeutic approach best suits this particular client in this context?
  • Make the creation and cultivation of a therapy relationship a primary aim
  • Adapt therapy to patient characteristics in ways shown to enhance outcome
  • Routinely monitor patients’ responses to the therapy relationship and ongoing tx
  • Concurrent use of EBRs and EBTs tailored to patient likely to generate best outcomes
  • Cultivate the therapy relationship
  • Adapt or tailor psychotherapy to individual patient and context






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