It’s All About the Relationship


The last decade has been the decade of “evidence based treatment” in our field. The last 10 years has seen a proliferation of evidence-based models galore. Of course, there is nothing wrong with insisting that there be evidence that what we are doing actually works but there now seems to be “evidence” for almost everything working. As a treatment provider, it has gotten very disruptive when funders and partners go to a conference and come back insisting that their providers begin using a new “evidence-based” model they learned about. Many organizations spent scarce time and money implementing a new practice only to have it supplanted by something else a year or two later. In many of my conversations with seasoned professionals about this, the conversation ends in “yes, but the therapeutic relationship is what is really important to outcomes. No matter what the context is, the relation is what helps.” After about a dozen of these conversations, I decided to do some looking around to see if there was any “evidence” that this was true. What I found out was that there are many factors that contribute to the success of therapy or treatment. Human beings are complex and there is no simple answer to why some succeed in therapy and some don’t. But there are some interesting conclusions to be found.

In 2011, the results of studying 20+ meta-analyses led to a series of research-supported conclusions with important implications for therapists and clients alike (Norcross, 2011). Many years of careful scientific research have documented the effectiveness of psychotherapy. Reviews of thousands of scientific studies have shown that about 75–80% of patients who enter psychotherapy show benefit (Lambert & Ogles, 2004; Wampold, 2001).

But what factors contribute to success? It seems that my colleagues were correct. The American Psychological Association’s (APA) Division of Psychotherapy and Division of Clinical Psychology jointly sponsored a task force to identify and disseminate what works in the therapy relationship (Norcross, 2011). They commissioned a series of studies to investigate the association between the client-therapist relationship and treatment effectiveness. They conducted a meta-analysis, or a study of studies, to analyze the results of multiple studies on the same topic. They defined the effectiveness of therapy in these studies as a clients’ improved functioning, reduced suffering, physiological indicators, treatment retention, enhanced interactions with other people, work performance, and other indexes of recovery.

Some of the findings were:

· The therapeutic relationship makes substantial and consistent contribution to client success in all types of psychotherapy studied (for example, psychodynamic, humanistic, cognitive, behavioral, systemic).

· The client-therapist relationship accounts for why clients improve (or fail to improve) as much as the particular treatment method.

· Practice and treatment guidelines should address the qualities and behaviors of therapists that promote the ability to form positive therapeutic relationships.

· Management, supervisors, and clinicians should regularly monitor clients’ responses to the therapeutic relationship and ongoing treatment. Monitoring leads to opportunities to improve the relationship, modify strategies, and avoid client termination of treatment.

· Efforts to introduce best practices or evidence-based practices without including the therapeutic relations are incomplete and misleading.

In my early training as a substance abuse counselor, we spent the majority of time learning how to develop a positive therapeutic relationship with our clients through accurate empathic understanding, genuiness, respect, concreteness, proper confrontation, and warmth. Learning to adopt these skills of therapeutic effectiveness was the foundation upon which the model of treatment rested. Maybe we need to spend more time on developing and nurturing this “evidence-based” practice.

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