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Purposes, Processes, and Products of the Task
Force on Empirically Supported Therapy Relationships
John C. Norcross
University of Scranton
Department of Psychology
University of Scranton
Scranton, PA 18510-4596
+1 570-941-7638 (voice)
norcross@scranton.edu
+1
570-941-7899 (fax)
Author's Notes
Portions of this article are adapted from
"Empirically Supported Therapy Relationships" in J. C. Norcross (Ed.).
(2002). Psychotherapy relationships that work: Therapist contributions and
responsiveness to patient need. New York: Oxford University Press.
Correspondence concerning this article should be addressed to John C. Norcross,
Ph.D., Department of Psychology, University of Scranton, Scranton, PA 18510-4596
or norcross@scranton.edu
Abstract
This article introduces the special issue of Psychotherapy devoted to
evidence-based therapy relationships. It explicates the purposes, summarizes the
processes, and introduces the products of the Division of Psychotherapy's Task
Force on Empirically Supported Therapy Relationships. The dual aims of the
Division 29 Task Force were to identify elements of effective therapy
relationships and to determine efficacious methods of customizing or tailoring
therapy to the individual patient. The article concludes by featuring the
limitations of the Task Force's work and by responding to frequently asked
questions about its objectives and conclusions.
Recent years have witnessed the controversial
promulgation of practice guidelines and evidence-based treatments in mental
health. The introduction of such guidelines has provoked practice modifications,
training refinements, organizational conflicts, and strident rebuttals. For
better or worse, insurance carriers and government policymakers are increasingly
turning to such guidelines and compilations to determine which psychotherapies
to approve and fund. Indeed, along with the negative influence of managed care,
there is probably no more issue central to clinicians than the evolution of
evidence-based practice in psychotherapy (Barlow, 2000).
Foremost among these initiatives in psychology
was the APA Society of Clinical Psychology's Task Force efforts to identify
empirically supported treatments (ESTs) for adults and to publicize these
treatments to fellow psychologists and training programs. Since 1993 a
succession of APA Division 12 Task Forces (now a standing committee) has
constructed and elaborated a list of empirically supported, manualized
psychological interventions for specific disorders based on randomized
controlled studies that pass for methodological rigor (Chambless & Hollon,
1998; Chambless et al., 1996, 1998: Task Force on Promotion and Dissemination of
Psychological Procedures, 1995). Subsequently, ESTs have been applied to both
older adults and children (e.g., Gatz et al., 1998; Lonigan, Elbert, &
Johnson, 1998).
APA's Society of Clinical Psychology has not been
alone in developing and promoting such guidelines, however. The APA Division of
Counseling Psychology has issued their own principles of empirically supported
interventions (Wampold, Lichtenberg, & Waehler, in press), and the APA
Division of Humanistic Psychology (Task Force, 1997) published guidelines for
the provision of humanistic psychosocial services. The Practice Guidelines
Coalition, a developing organization sponsored by the Association for
Advancement of Behavior Therapy and the American Association of Applied and
Preventive Psychology, is creating clinical practice guidelines that are brief,
evidence-based, multidisciplinary, and disorder-specific. In Great Britain, a
Guidelines Development Committee of the British Psychological Society authored a
Department of Health (2001) document entitled Treatment Choice in
Psychological Therapies and Counselling: Evidence-Based Practice Guidelines.
In psychiatry, the American Psychiatric Association has published at least 10
practice guidelines, on disorders ranging from schizophrenia to anorexia to
nicotine dependence.
All of the efforts to promulgate evidence-based
psychotherapies have been noble in intent and timely in distribution. They are
praiseworthy efforts to distil scientific research into clinical applications
and to guide practice and training. They wisely demonstrate that, in a climate
of accountability, psychotherapy stands up to empirical scrutiny with the best
of health care interventions. And within psychology, they have attempted to
proactively counterbalance documents that accord primacy to biomedical
treatments for mental disorders and largely ignore the outcome data for
psychological therapies (such as the Depression Guideline Panel, 1993). On many
accounts, then, the extant efforts have addressed the realpolitik of the
socio-economic situation (Messer, 2001; Nathan, 1998).
What's Missing?
The ethical and professional commitment to evidence-based psychotherapy is
widely, if not universally, accepted among mental health practitioners. It is
similar to publicly prizing Mother and apple pie (Norcross, 1999). In principle,
we are all committed to identifying, practicing, and promulgating those
psychosocial treatments that "work." In principle.
In application, the controversies reside in the
definitions and details of identifying those evidence-based or empirically
supported therapies. The internecine conflicts occur around what material is
validated and what qualifies as evidence, a process described as decision rules.
Many researchers and practitioners find the
decisions rules in these early efforts to be seriously incomplete or
inapplicable. Examination of the Society of Clinical Psychology Task Force's
initial decision rules is illuminating and representative. Those treatments
designated as "empirically validated" -- or the more recent, accurate,
and felicitous phrase "empirically supported" -- were restricted to
manualized therapies for a fixed number of sessions. The treatments were brand
name or pure-form. (For scholarly reviews of the contributions and criticisms of
ESTs, refer to several special issues of journals, e.g., Elliott, 1998; Glass
& Arnkoff, 1996: Kazdin, 1996; Kendall, 1998). Three decision points are
particularly applicable here, beginning with the EST lists as oddly person-less.
The Person of the Therapist
The EST lists and most practice guidelines depict
disembodied therapists performing procedures on Axis I disorders. This stands in
marked contrast to the clinician's experience of psychotherapy as an intensely
interpersonal and deeply emotional experience. Although efficacy research has
gone to considerable lengths to eliminate the individual therapist as a variable
that might account for patient improvement, the inescapable fact is that the
therapist as a person is a central agent of change. The curative contribution of
the person of the therapist is, arguably, as empirically validated as manualized
treatments or psychotherapy methods (Hubble, Duncan, & Miller, 1999).
Multiple and converging sources of evidence
indicate that the person of the psychotherapist is inextricably
intertwined with the outcome of psychotherapy. Luborsky and colleagues (1986)
reanalyzed the results of four major studies of psychotherapy outcome to
determine the variance accounted for by therapist effects, finding that it
generally overshadowed that attributed to treatment differences. A subsequent
meta-analysis of therapist effects in psychotherapy outcome studies showed
consistent and robust effects - 5% to 9% in one of the best estimates (Crits-Christoph
et al., 1991). In reviewing the research, Wampold (2001, p. 200) concluded
"a preponderance of evidence indicates that there are large therapist
effects . . . and that the effects greatly exceed treatment effects."
Despite impressive attempts to experimentally render individual practitioners as
controlled variables, it is simply not possible to mask the person and the
contribution of the therapist.
The Therapy Relationship
Second, and most relevant for our purposes, have
been the decisions to validate the efficacy of treatments or technical
interventions, as opposed to the therapy relationship or therapist interpersonal
skills. This decision both reflects and reinforces the ongoing movement toward
high-quality comparative outcome studies on techniques or brand-name therapies.
"This trend of putting all of the eggs in the "technique" basket
began in the late 1970s and is now reaching the peak of influence" (Bergin,
1997, p. 83).
But both clinical experience and research
findings underscore that the therapeutic relationship accounts for as much as
the outcome variance as particular treatments. Quantitative reviews and
meta-analyses of psychotherapy outcome literature consistently reveal that
specific techniques account for only 5% to 15% of the outcome variance (e.g.,
Beutler, 1989; Lambert, 1992; Shapiro & Shapiro, 1982; Wampold, 2001), and
much of that is attributable to the investigator's therapy allegiance (Luborsky
et al., 1999). Suppose we asked a neutral scientific panel from outside the
field to review the corpus of psychotherapy research to determine what is the
most powerful phenomenon we should be studying, practicing, and teaching. Henry
(1998, p. 128) concludes that the panel would find the answer obvious, and empirically
validated. As a general trend across studies, the largest chunk of outcome
variance not attributable to pre-existing patient characteristics involves
individual therapist differences and the emergent therapeutic relationship
between patient and therapist, regardless of technique or school of therapy.
This is the main thrust of three decades of empirical research.
In my more strident moments, I have adapted Bill
Clinton's unofficial campaign slogan: "It's the relationship, stupid!"
Although most treatment manuals and practice guidelines mention the importance
of the therapy relationship, few specify what therapist qualities or in-session behaviours
lead to a curative relationship. As practice guidelines and treatment manuals
are increasingly required in training, research, and practice, there is a real
and imminent danger that the therapy relationship, therapist interpersonal
skills, and patient matches will be overlooked.
The Patient's (Nondiagnostic) Characteristics
Third, most practice guidelines and evidence-based
compilations unintentionally reduce our clients to a static diagnosis or
problem. The impressive, 90-chapter Treatments of Psychiatric Disorders (Gabbard,
2000), to take one prominent example, is hailed as the "cumulative
knowledge base of psychiatric treatment," yet the entire two volumes are
organized exclusively around diagnoses. Virtually all practice guidelines are
directed toward single, categorical disorders. DSM diagnoses have ruled the
evidence-based roost to date.
This choice flies in the face of clinical
practice and research findings that a categorical, non-psychotic Axis I
diagnosis exercises only a modest impact on treatment outcome (Beutler, 2000).
While the research indicates that certain psychotherapies make better marriages
for certain disorders, psychological therapies will be increasingly matched to
people, not simply diagnoses. In the behavioural medicine vernacular, it is
frequently more important to know what kind of patient has the disorder than
what kind of disorder the person has.
As every clinician knows, different types of patients respond more effectively
to different types of treatments and relationships. Different folks do require
different strokes. Clinicians strive to offer or select a therapy that accords
to the patient's personal characteristics, proclivities, and worldviews - in
addition to diagnosis. The differential effectiveness of different therapies may
well prove to be a function of cross-diagnostic patient characteristics, such as
treatment goals, coping styles, stages of change, personality dimensions, and
reactance level.
Moreover, practice guidelines and EST lists do
little for those psychotherapists whose patients and theoretical conceptualisations
do not fall into discrete disorders (Messer, 2001). Consider the client who
seeks more joy in his/her life, but who does not meet diagnostic criteria for
any disorder, whose psychotherapy stretches beyond 20 sessions, and whose
treatment objectives are not easily specified in measurable, symptom-based
outcomes. Current evidence-based compilations have little to contribute to
his/her therapist and his/her treatment (see O'Donohue, Buchanan, & Fisher,
2000, for general characteristics of ESTs). Not all psychotherapies or
practitioners embrace an action-oriented model in which treatment is rendered to
a patient.
All of this is to say that extant lists of empirically supported treatments and
practice guidelines give short shrift - some would say lip service - to the
person of the therapist, the individual patient's characteristics, and their
emergent relationship. Current attempts are thus seriously incomplete and
potentially misleading, both on clinical and empirical grounds.
Purposes of the Task Force
Within this context, in 1999 I commissioned an
APA Division of Psychotherapy Presidential Task Force to identify,
operationalize, and disseminate information on empirically supported therapy
relationships. We aimed to identify empirically supported (therapy)
relationships rather than empirically supported treatments - or ESRs rather than
ESTs. Specifically, the dual aims of the Division 29 Task Force were to:
* Identify elements of effective therapy relationships
* Determine efficacious methods of customizing or
tailoring therapy to the individual patient on
the basis of his/her (nondiagnostic) characteristics
This special issue of Psychotherapy summarizes
the findings, conclusions, and recommendations of the Task Force's four-year
work.
Compared to extant efforts, the Division 29 Task Force focused on relationship
qualities and therapist stances, as opposed to treatment techniques, and adopted
broader decision rules as to what qualifies as evidence for inclusion, including
both effectiveness and efficacy studies. In addition, we addressed the crucial
research on matching therapy relationships to client features beyond discrete
Axis I diagnoses. Table 1 summarizes the salient differences in decision rules
between our APA Division 29 Task Force and previous efforts, notably the
Division 12 Task Forces.
Processes of the Task Force
Definitions
One of our first process challenges was to define
the psychotherapy relationship. We adopted Gelso and Carter's (1985, 1994)
operational definition: "The relationship is the feelings and attitudes
that therapist and client have toward one another, and the manner in which these
are expressed." This definition is quite general, and the phrase "the
manner in which it is expressed" potentially opens the relationship to
include everything under the therapeutic sun (see Gelso & Hayes, 1998, for
an extended discussion). Nonetheless, it was concise, consensual, theoretically
neutral, and sufficiently precise for our use.
A related challenge was to establish the
inclusion and exclusion criteria for the elements of the therapy relationship.
We readily agreed that the traditional features of the therapy relationship --
the alliance in individual therapy and cohesion in group therapy, for example -
and the Rogerian facilitative conditions - empathy, positive regard, and
genuineness/congruence -would constitute core elements. We further agreed that
discrete, relatively nonrelational techniques were not part of our purview, but
that a few relational methods would be included. Therapy methods were considered
for inclusion if their content, goal, and context were inextricably interwoven
into the emergent therapy relationship. We settled on therapist self-disclosure
and relational interpretations because these methods are deeply embedded in the
interpersonal character of the relationship itself. But which relational
techniques to include and which to exclude under the rubric of the therapy
relationship bedevilled us, as it has the field.
We unanimously acknowledged the deep synergy between techniques and the
relationship. They constantly shape and inform each other. Both clinical
experience and research evidence (e.g., Rector, Zuroff, & Segal, 1999;
Rounsaville et al., 1987) point to a complex, reciprocal interaction between the
interpersonal relationship and the instrumental techniques. The relationship
does not exist apart from what the therapist does in terms of technique, and we
cannot imagine any techniques that would not have some relational impact. Put
differently, techniques and interventions are relational acts (Safran &
Muran, 2000).
The research reviews were based on the results of empirical research linking the
relationship element to psychotherapy outcome. This definition deliberately
included both quantitative and rigorous qualitative studies. Outcome was broadly
and inclusively defined, encompassing proximal in-session outcomes as well as
distal treatment outcomes. Authors were asked to specify the outcome criteria if
a particular study did not employ a typical end-of-treatment measure of symptom
or functioning.
Decision-Making
The Steering Committee's early deliberations were
not easy or unanimous. Democracy is messy and inefficient; science is even
slower and painstaking. We debated and, in most instances, voted on terminology,
on the division of the therapy relationship into manageable parts, and on the
minimal criteria for empirical evidence linking a relationship quality to
psychotherapy outcome.
How does one divide the indivisible relationship?
For example, is support similar enough to positive regard to be combined or is
it conceptually and technically distinct enough to deserve a separate chapter
and research review? We struggled on how finely to slice the therapy
relationship. We agreed, as a group, to place the research on support in the
positive regard chapter, but we understand that psychodynamic practitioners may
understandably take exception to collapsing these relationship elements. More
generally, we opted to divide the research reviews into smaller chunks so that
the research conclusions were more specific and the practice implications more
concrete.
In our deliberations, several members of the
Steering Committee advanced a favourite analogy: the therapy relationship is
like a diamond, a diamond composed of multiple, interconnected facets. The
diamond is a complex, reciprocal, and multidimensional entity. The Task Force endeavoured
to separate and examine many of these facets.
What sort of evidence is sufficient to declare that a relationship element is,
in fact, associated to treatment outcome? Some on the Steering Committee wanted
to see some true experimental evidence or persuasive, unconfounded lagged
correlational evidence that elements of the therapy relationship contribute to
treatment outcome. Other members of the Steering Committee scoffed at the value
or possibility of such methodological rigor in the area of the therapy
relationship where the "variables" cannot be readily controlled or
manipulated.
Upon review of the quantity and quality of the empirical research, the Steering
Committee characterized the strength of the research on the relationship element
as either demonstrably effective, promising and probably effective,
or insufficient research to judge. This tripartite categorization emerged
from our review of the research; fewer categories would have resulted in crude
and incomplete characterizations, and more categories would have accorded more
precision than warranted by the findings. Some elements were clearly established
as effective on the basis of the size and regularity of supportive studies.
Other elements were promising - few studies or lots of conflicting studies or
supportive but flawed studies. Still other elements were just tantalizing or
preliminary. Accordingly, we christened these as insufficient research to judge.
(Of course, these categorizations refer solely to the empirical evidence linking
relationship elements and outcome, and not to the "treatability" of
patients with specific characteristics.)
In sum, we employed a systematic and stepwise approach to identifying and
interpreting the evidence. First, the Steering Committee identified potential
relational and matching elements with sufficient empirical research and
practical importance. Second, we consulted extant reviews and gathered expert
opinions before commissioning chapters on those elements. Third, at least three
scholars independently reviewed the evidence as compiled by the chapter authors
and provided numerical ratings on six evaluative criteria. Fourth, the Steering
Committee reviewed the ratings, deliberated by e-mail, and voted using an expert
consensus method. The decisions were made both empirically and consensually -
the Steering Committee examined the empirical research and then followed
consensus.
These and other decisions were arrived at by expert opinion, professional
consensus, and review of the empirical evidence. But these were all human
choices - open to cavil, contention, and future revision.
Products of the Task Force
The Division 29 Task Force on Empirically
Supported Therapy Relationships has generated three products. First, we have
prepared and published a synopsis of our work in this special issue. Second, the
entire research reviews and detailed therapeutic practices are being published
in a book, Psychotherapy Relationships that Work (Norcross, 2002). Third,
members of the Task Force are presenting a series of addresses, workshops, and
symposia on its conclusions and recommendations. Presentations to date have been
made at conferences of the American Psychological Association, the Society for
Psychotherapy Research, the Society for the Exploration of Psychotherapy
Integration, and the International Society for Clinical Psychology.
The goals of these products are identical: to disseminate evidence-based means
of improving the therapy relationship and effective means of customizing that
relationship to the individual patient. A frequent lament of mental health
researchers is that their best research results often remain unused by
practitioner and policymakers alike. The dissemination and uptake problem is a
genuine concern for us as well. We plan to reach stakeholders by distributing
the results in their preferred communication formats. For researchers, a
scholarly book and academic presentations. For practitioners, a professional
journal and clinical workshops. Our fervent hope is that the Task Force's
multiple products and communication formats will increase awareness and use of
effective elements of the therapy relationship.
The Task Force and its products would not have
been possible without organizational and individual support. Organizationally,
the Board of Directors of the American Psychological Association's Division of
Psychotherapy approved and funded the Task Force on Empirically Supported
Therapy Relationships. Individually, Wade Silverman, the 1999 Division president
and Psychotherapy editor, was an ongoing source of encouragement and
advice. Finally, the Task Force's Steering Committee assisted in canvassing the
literature, defining the parameters of the project, organizing the special
issue, selecting the contributors, and reviewing early drafts of the articles.
The Steering Committee consisted of:
Steven J. Ackerman (student member)
Lorna Smith Benjamin (University of Utah)
Larry E. Beutler (University of California - Santa Barbara),
Charles J. Gelso (University of Maryland)
Marvin R. Goldfried (SUNY - Stony Brook)
Clara Hill (University of Maryland)
Michael J. Lambert (Brigham Young University)
David E. Orlinsky (University of Chicago)
Jackson P. Rainer (liaison to Publication Board)
Organization of the Special Issue
This special issue is divided into four parts.
Part I consists of this introductory article and a general research summary of
the centrality of the therapeutic relationship to treatment outcome.
Parts II and III are composed of research summaries on the therapist's
relational contributions, those in general (Part II) as well as those on
tailoring the therapeutic relationship to individual patients (Part III). Our
goal is to identify both relationship elements applied generally in
psychotherapy and therapist stances applied to specific circumstances and
clients.
All of the articles in Parts II and III are
adapted from lengthier chapters that followed guidelines in order to facilitate
comprehensiveness, comparison, and ease of reader use. Each article defines the
relationship or patient characteristic, provides a clinical example, reviews the
empirical research, and highlights therapeutic practices ensuing from the
research results.
The order of articles is in approximate rank
order of the empirical strength of the research on the respective therapist
elements or patient-matching characteristics. In Section II, the alliance is
demonstrably effective, with the quality of relational interpretations
exhibiting the weakest link with outcomes in the research literature. In Section
III, the research results on the effectiveness of matching the therapy
relationship to the magnitude of patient's resistance is robust, whereas
research on the positive outcome effects of ethnicity- and gender-matching is
rare.
Part IV of this issue consists of a single article, coauthored by the Task
Force's Steering Committee. It presents the Task Force conclusions, including a
list of empirically supported relationship elements, and our practical
recommendations, divided into general, practice, training, research, and policy
recommendations. The "list" characterizes the relationship elements as
demonstrably effective, promising and probably effective, or insufficient
research to judge. These decisions were made by the Steering Committee on
the strength of the empirical evidence. The evidentiary criteria encompassed the
number of supportive studies, the consistency of the research results, the
magnitude of the positive relationship between the element and outcome, the
directness to outcome, the experimental rigor of the studies, and the external
validity of the research base.
Limitations of the Task Force
A single task force can accomplish only so much
work and cover only so much content area. As such, the products of the Task
Force possess a number of necessary omissions and unfortunate truncations that
we wish to publicly acknowledge at the outset.
The products of the Task Force suffer, first,
from a series of omissions. We have not systematically reviewed the research
evidence pertaining to the therapy relationship in couples and family therapy.
Nor have we specifically provided research reviews on the therapy relationship
with children or older adults. Research findings from studies with children and
older adults have, however, been incorporated into the reviews of the respective
therapist behaviours and client characteristics. In addition, we have not and
could not canvas every possible therapist relationship behaviour. Three
therapist contributions to the relationship not covered are confrontation,
credibility, and the provision of a rationale or explanation. One element of
relational matchmaking neglected is a limited number of therapy sessions, which
clinically seems to impact the therapy relationship.
A converse concern with the Task Force's work is content overlap. We may have
cut the "diamond" of the therapy relationship too thin at times,
leading to a profusion of highly related and possibly redundant constructs. Goal
consensus, for example, correlates highly with parts of the therapeutic
alliance, but these are reviewed in separate articles. The stages of change and
assimilation of problematic experiences both track the patient's change over the
course of therapy; in fact, they were originally planned to appear in the same co-authored
article, but it did not functionally come to pass. Thus, to some the content may
appear swollen; to others, the Task Force may have failed to make necessary
distinctions.
Another lacuna in the Task Force work is that we
may have neglected, relatively speaking, the productive contribution of the
client to the therapy relationship. We decided not to commission a separate
chapter on the client's contributions, and by doing so, we may be understandably
accused of an omission akin to the previous error of leaving the relationship
out at the expense of technique. The Task Force work tends to be
"therapist-centric" in minimizing the client's relational contribution
and self-healing processes.
A prominent limitation across the Task Force research reviews is the modest
causal connection between the relationship element and treatment outcome. Causal
inferences are always difficult to make concerning process variables such as the
therapy relationship. Does the relationship cause improvement or simply reflect
it? Is the relationship produced by something the therapist does or is it a
quality brought to therapy by patients? The interpretation problems of
correlational studies (third variables, reverse causation) render such studies
less convincing then experiments. It is methodologically difficult to meet the
three conditions to make a causal claim: nonspuriousness, covariation between
the process variable and the outcome measure, and temporal precedence of the
process variable (Feeley, DeRubeis, & Gelfand, 1999). A central limitation
of our research base is the failure to convincingly demonstrate causal, as
opposed to correlational, linkages between relationship elements and treatment
outcomes.
Finally, an interesting drawback to the present
work - and psychotherapy research as a whole - is the paucity of attention paid
to the disorder-specific and therapy-specific nature of the therapy
relationship. It is too early to aggregate the research on how the patient's
primary disorder or the type of treatment impacts the therapy relationship, but
there are early links. For example, in the National Institute on Drug Abuse
Collaborative Cocaine Treatment Study, higher levels of the working alliance
were associated with increased retention in supportive-expressive therapy, but
in cognitive therapy, higher levels of alliance were associated with decreased
retention (Barber et al., 2001). In the treatment of anxiety disorders (GAD and
OCD), the specific treatments seem to exhibit many times the effect size than
for the therapy relationship, but in depression, the relationship appears more
powerful. The therapeutic alliance in the NIMH Treatment of Depression
Collaborative Research Program, in both psychotherapy and pharmacotherapy,
emerged as the leading force in reducing a patients' depression (Krupnick et
al., 1996). The therapeutic relationship probably exhibits more causal impact in
some disorders and in some therapies than others. As with research on specific
treatments, it may no longer suffice to ask "Does the relationship
work?" but "How does the relationship work for this disorder and this
therapy"
Frequently Asked Questions
The Division of Psychotherapy's Task Force on
Empirically Supported Therapy Relationships has provoked considerable interest
and enthusiasm in the professional community. At the same time, it has lead to
misunderstandings and reservations. I will conclude by addressing frequently
asked questions (FAQs) about the Task Force's objectives and results.
What is the relationship of the APA Division 29 Task Force to the
Division 12 Task Force (now the standing Committee on Science and Practice)?
Questions abound regarding the connection of the
Division of Psychotherapy (29) and the Society of Clinical Psychology (12) Task
Forces, probably because they are both divisions of the American Psychological
Association. Organizationally, the Task Forces are separate creatures, reporting
to different divisions. Their respective foci obviously diverge: one looking at
therapist contributions to the relationship and patient responsiveness, the
other looking at treatment methods for specific disorders. However, they do
share several task force members (Paul Crits-Christoph and Larry Beutler), a
publisher (Oxford University Press), and goals (to identify and promulgate
evidence-based practices) in common.
The aims of the Division of Psychotherapy Task
Force and the aims of previous evidence-based iniatives can be conceptualised in
three ways. First, the work of the Division of Psychotherapy Task Force
represents a continuation of previous efforts in that all attempt to
apply psychological science to the identification and promulgation of effective
psychotherapy. It is a complementary continuation of the elusive search for
evidence-based psychotherapy. Second, the Division of Psychotherapy Task Force
constitutes an expansion of extant work in that we enlarge the focus to
empirically supported therapist behaviours and emergent therapeutic
relationships. And third, the Division 29 Task Force represents, in several
ways, a reaction against previous decision rules that tend to represent
psychotherapy as the disembodied, manualized treatment of Axis I disorders
Are you saying that techniques or methods are immaterial to psychotherapy
outcome?
Absolutely not. The empirical research shows that both the therapy relationship
and the treatment method make consistent contributions to treatment outcome. It
remains a matter of judgment and methodology on how much each contributes, but
there is virtual unanimity that both the relationship and the method (insofar as
we can separate them) "work." Looking at either treatment
interventions or therapy relationships alone is incomplete. We encourage
practitioners and researchers to look at multiple determinants of outcome,
particularly client contributions.
But are you not exaggerating the effects of
relationship factors and/or minimizing the effects of treatments in order to set
up the importance of your work?
This may be true, but we think not and hope not.
With the guidance of Task Force members and external consultants, we have tried
to avoid dichotomies and polarizations. Focusing on one area - the psychotherapy
relationship - in the Task Force may unfortunately convey the impression that it
is the only area of importance. This is certainly not our intention.
Relationship factors are important, and we need to review the scientific
literature and provide clinical recommendations based upon that literature. This
can be done without trivializing or degrading the effects of specific
treatments.
What, then, is the association between techniques
and therapy relationship?
We conceive the association broadly and
atheoretically. We find any hard and fast distinctions between them untenable.
Further, we do not desire to impose any singular theoretical vision of their
association upon our colleagues.
For historical and research convenience, we have
made distinctions between relationships and techniques. Words like
"relating" and "interpersonal behaviour" are generally used
to describe how therapists and patients behave towards each other. In
contrast, terms like "technique" or "intervention" are used
to describe what is done in therapy, especially what is done by the therapist.
In research and theory, we often treat the how and the what - the relationships
and the interventions, the interpersonal and the instrumental - as separate
categories. In reality, of course, what one does and how one does it are
complementary and inseparable. To separate the interpersonal dimension of behaviour
from the instrumental may be acceptable in research, as done in this special
issue, but disregarding the connection may be a fatal flaw when the aim is to
extrapolate from research results to clinical practice. Thus, while we focus
here on important associations between treatment outcome and qualities of the
therapist-patient relationship, we never forget that what the therapist does is
also influential and inseparable (Orlinsky, 2000).
Isn't your report just warmed over Carl Rogers?
No. While Rogers' (1957) facilitative conditions are represented prominently
in the research base, they comprise less then 25% of the research we critically
review. More fundamentally, we have moved past simplified notions of a limited
and invariant set of necessary relationship conditions. Monolithic theories of
change and one-size-fits-all therapy relationships are out; tailoring the
therapy to the unique patient is in.
An interpersonal view of psychotherapy seems at odds with what managed care
and bean counters ask of me in my clinical practice. How do you reconcile these?
It is true that the dominant image of
psychotherapy today, among both researchers and reimbursers, is as a mental
health treatment. This "treatment" or "medical" model
inclines people to define process in terms of technique, therapists as providers
trained in the application of techniques, treatment in terms of number of
contact hours, patients as embodiments of psychiatric disorders, and outcome as
the end result of a treatment episode (Orlinsky, 1989).
It is also true that the Task Force members
believe this model to be restricted and inaccurate. The psychotherapy enterprise
is far more complex and interactive than the linear "Treatment operates on
patients to produce effects" (Bohart & Tallman, 1999). We would prefer
a broader, integrative model that incorporates the relational and educational
features of psychotherapy, one that recognizes both the interpersonal and
instrumental components of psychotherapy, one that appreciates the
bi-directional process of therapy, and one in which the therapist and patient
co-create an optimal process and outcome.
Finally, it is incontestably and sadly true that psychotherapy research to date
has exerted a negligible effect on reimbursement decisions.
Won't these results contribute further to deprofessionalising psychotherapy?
Aren't you unwittingly supporting efforts to have any warm, empathic person
perform psychotherapy?
Perhaps some will misuse our conclusions in the
way you fear, but that is neither our intent nor commensurate with the research.
It trivializes psychotherapy to characterize it as simply "a good
relationship with a caring person." The research shows an effective
psychotherapist is one who employs specific methods, who offers strong
relationships, and who customizes both discrete methods and relationship stances
to the individual person and condition. That requires considerable training and
experience; the antithesis of "anyone can do psychotherapy."
Are psychotherapists really able to adapt their
relational style to fit the proclivities and personalities of their patients?
Relational flexibility conjures up many concerns,
but two of particular import in this question: the limits of human capacity and
the possibility of capricious posturing (Norcross & Beutler, 1997). Although
the psychotherapist can, with training and experience, learn to relate in a
number of different ways, there are limits to our human capacity to modify
relationship stances.
Can one authentically differ from one's preferred or habitual style of relating?
There is meager research on this question. What does exist suggests that
experienced therapists are capable of more malleability and "mood
transcendence" than might be expected. In Gurman's (1973) research, for
example, expert therapists appeared to be less handicapped by their own
"bad moods" than were their less skilled peers. From the literature on
the cognitive psychology of expertise, Schacht (1991) affirms that experienced
psychotherapists are disciplined improvisationalists who have stronger
self-regulating skills and more flexible repertoires than novices. The research
on the therapist's level of experience suggests that experience begets
heightened attention to the client (less self-preoccupation), an innovative
perspective, and in general, more endorsement of an "eclectic"
orientation predicated on client need (Auerbach & Johnson, 1977). Indeed,
several research studies (see Beutler, Machado, & Neufeldt, 1994) have
demonstrated that therapists can consistently use different treatment models in
a discriminative fashion.
The question of whether they can shift back and forth among different
relationship styles for a given case is still unanswered. We expect, however,
that this is possible. When doing so, we caution therapists to be careful that
the blending of stances and strategies does not deteriorate into play-acting or
capricious posturing.
What should we do if we are unable or unwilling to adapt our therapy to the
patient in the manner that research indicates is likely to enhance psychotherapy
outcome?
Four possible avenues spring to mind. First, address the matter forthrightly
with the patient as part of the evolving therapeutic contract and the creation
of respective tasks, in much the same way one would with patients requesting a
form of therapy or a type of medication that research has indicated would fit
particularly well in their case but which is not in your repertoire. Second,
treatment decisions are the result of multiple, interacting, and recursive
considerations on the part of the patient, the therapist, and the context. A
single evidence-based guideline should be seriously considered, but only as one
of many determinants of treatment itself. Third, an alternative to the
one-therapist-fits-most-patients perspective is practice limits. Without a
willingness and ability to engage in a range of interpersonal stances, the
therapist may limit his or her practice to clients who fit the specific range of
behaviours he or she has to offer. And fourth, consider a judicious referral to
a colleague who can offer the relationship stance (or treatment method or
medication) indicated in a particular case.
Are these intended as practice standards?
No. These are research-based conclusions that can
lead, inform, and guide practitioners toward evidence-based therapy
relationships and responsiveness to patient needs. They are not intended as
legal, ethical, or professional mandates. As we state in the Conclusions:
"The preceding 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 data available in each
case."
Well, aren't these the official positions of the Division of Psychotherapy or
the American Psychological Association?
No. Neither is true.
Isn't is premature to launch a set of
research-based conclusions on the therapy relationship and patient matching?
Science is not a set of answers. Science is a
series of processes and steps by which we arrive closer and closer to elusive
answers. Considerable research over the past three decades has been conducted on
both the general elements of the therapy relationship and the particular means
of adapting it to individual patients. It is premature to proffer the last word
or the definitive conclusion; however, it is time to codify and disseminate what
we do know. We look forward to regular updates on our conclusions.
So, are you saying that the therapy relationship (in addition to discrete
method) is crucial to outcome, that it can be improved by certain therapist
contributions, and that it can be effectively tailored to the individual
patient?
Precisely. And the Task Force products show specifically how to do so on the
basis of the empirical research.
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