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RUNNING HEAD: EBPR ON-LINE CE

Evidence-Based Psychotherapy Relationships:

What Works in General

The Division of Psychotherapy Task Force on Empirically Supported

Psychotherapy Relationships

Abraham W. Wolf, PhD, Editor

APA Division 29 - Psychotherapy

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EVIDENCE-BASED PSYCHOTHERAPY RELATIONSHIPS
Health care practices are increasingly driven by practice guidelines based on
evidence-based treatments. In psychology, the APA Society of Clinical Psychologys
Task Force proposed a list of evidence-based, manualized psychological interventions for
adult disorders based on randomized controlled studies (Chambless et al., 1996;
Chambless & Hollon, 1998; Task Force on Promotion and Dissemination of
Psychological Procedures, 1995). In psychiatry, the American Psychiatric Association
has published more than a dozen practice guidelines on a wide range of disorders. Efforts
to promulgate evidence-based psychotherapies are important initiatives that distill
scientific research into clinical applications and that guide practice and training. In a
climate of accountability, they demonstrate that psychotherapy efficacy and effectiveness
stands with the best of health care interventions.
Nevertheless, initiatives on evidence-based treatments can be incomplete and
potentially misleading. The early efforts to compile a set of evidence-based practices
suffer from two important omissions. First, they neglect the therapy relationship. This
interpersonal quality makes substantial and consistent contributions to psychotherapy
outcome independent of the specific type of treatment. The therapy relationship accounts
for at least as much treatment outcome as specific treatment methods (Wampold, 2001;
Lambert, 2003). Second, these efforts focus on individual DSM-IV diagnoses and ignore
matching the treatment and the relationship to the individual client beyond an Axis I
diagnosis. Different types of clients respond more effectively to different types of
treatments and relationships, and psychological therapies will increasingly emphasize
matching to people, not only diagnoses. Psychotherapists strive to offer or select a

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psychotherapy that fits a clients personal characteristics, proclivities, worldviews and
diagnosis.
Within this context, the APA Division of Psychotherapy created a task force,
chaired by John C. Norcross, Ph.D., to identify, operationalize, and disseminate
information on evidence-based psychotherapy relationships rather than evidence-based
psychotherapy treatments. The two aims of the Division of Psychotherapy Task Force
were to: 1) identify elements of effective therapy relationships; and 2) identify effective
methods of tailoring psychotherapy to the individual client on the basis of his/her
(nondiagnostic) characteristics. That is, the Task Force members sought to answer the
two pressing questions of What works in general in the psychotherapy relationship?
and What works best for this particular client?
The Task Force reviewed an extensive body of empirical research and generated a
list of evidence-based relationship elements and a list of means for customizing
psychotherapy to the individual client. For each, it judged whether the element was
demonstrably effective or promising and probably effective as follows:
Demonstrably Effective

Promising and Probably Effective

Therapeutic Alliance

Positive Regard

Cohesion in Group Psychotherapy

Congruence/Genuineness

Empathy

Feedback

Goal Consensus and Collaboration

Repair of Alliance Ruptures

Self-Disclosure
Management of Counter-transference
Relational Interpretations

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The criteria for making these judgments were the number of supportive studies, the
consistency of the research results, the magnitude of the positive relation between the
element and outcome, the directness of the link between the element and outcome, the
experimental rigor of the studies, and the external validity of the research base. The
research reviews and clinical practices were compiled in Psychotherapy Relationships
That Work (2002) and summarized in a special issue of Psychotherapy (Norcross, 2001).
THE DEMONSTRABLY EFFECTIVE ELEMENTS
THE THERAPEUTIC ALLIANCE (Horvath, 2001)
The therapeutic alliance refers to the quality and strength of the collaborative
relationship between client and psychotherapist. It is operationally defined by (a) the
cognitive components of agreement on the goals of treatment and consensus on the tasks
by which those goals can be reached, and (b) the affective component of the bond
between the client and psychotherapist. It is rooted in psychoanalytic ideas of the positive
transference and the differentiation of the analytic relationship into the transference, the
real relationship, and the working alliance. In contemporary discussions, it provides an
atheoretical ground for explaining essential components in all helping relationships.
Research. A review of 90 studies on the positive associations between the
therapeutic alliance and psychotherapy outcome yielded an average effect size of .21.
This association did not vary as a function of how either the alliance or outcomes was
measured. Alliance measured early in treatment is marginally better at predicting
outcome than midterm alliance, and the strength of the alliance early in treatment is a
good predictor of premature termination. An initially lower and gradually increasing

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alliance may be more reliably associated with positive outcome. The effect size did not
vary with respect to psychotherapeutic orientation.
There was no association between quality of alliance and problem severity, type
of impairment, and quality of object relations or attachment. Clients with poor alliances
are more likely terminate early in treatment. Alliance is harder to establish with clients
who are delinquent, homeless, and drug dependent; have attachment styles that are
fearful, anxious, dismissive, or preoccupied; and, borderline and other personality
disorders.
Clients who have difficulty forming intimate relationships have stronger alliances
with experienced psychotherapists, while less relationally handicapped clients do not
respond differentially. Experienced psychotherapists appear better able than less
experienced psychotherapists at identifying deteriorating or poor alliances.
Psychotherapists who form alliances that tend to be hostile, distant, challenging,
controlling, or competitive have poorer outcomes. Collaboration is one of the key
features of the alliance concept, and most alliance measures seek information on the
degree of felt collaboration from psychotherapist and client. Preliminary evidence links
collaboration and better alliance.
Psychotherapeutic Practices. A stronger alliance is fostered when
psychotherapists convey an understanding and appreciation of clients perspective
through empathy, openness, and flexibility. The alliance is impeded by the
psychotherapists relational control, i.e., needing to take control of a session. In the
early phases of treatment, developing the alliance takes precedence over technical
interventions. Psychotherapists actively solicit clients perspectives on various aspects of

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the alliance and negotiate both the goals of treatment and the content of sessions to secure
clients active engagement. Close attention is important early in treatment with clients
who have relational problems, personality disorders, poor object relations, or dismissing
attachment style. These clients are difficult to engage in any intimate relationship and are
likely to elicit negative or rejecting responses from the psychotherapist.
The link between positive alliances and psychotherapist flexibility and
willingness to negotiate suggests a need to think carefully about the potential limiting
effects of strict adherence to treatment manuals. The larger lesson learned from reviewing
the literature is that the traditional idea of the therapy relationship plus technique, may
need to be replaced with a model in which the alliance is understood as one perspective
of clinical practice, whereas techniques are the same phenomena viewed through a
different lens.
EMPATHY (Greenberg, Watson, Elliot, & Bohart, 2001)
Carl Rogers defined empathy as the psychotherapist's sensitive ability and
willingness to understand the client's thoughts, feelings, and struggles from the client's
point of view. Empathy has been operationally defined in terms of three different
components: (a) the psychotherapist's experience (empathic resonance), (b) the observers'
view (expressed empathy), (c) and the client's experience (received empathy). Observerrated empathy measures have raters decide if a psychotherapists responses detract from
the clients response or enhance it by responding to its feeling components. The most
frequently used client-rated and psychotherapist self-report measure of empathy is the
Barrett-Leonard Relationship Inventory.

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Research. A review of 47 studies on the association between empathy and
psychotherapy outcome yielded an effect size of .32. The relation between empathy and
outcome did not vary as a function of theoretical orientation but was greater for less
experienced psychotherapists than for more experienced psychotherapists. Two
explanations for this finding are, first, less experienced psychotherapists vary more in
their levels of empathy than more experienced psychotherapists whose ratings fall in a
restricted range or have a ceiling effect, and, second, more experienced psychotherapists
may have developed additional skills so that clients are more forgiving of lapses in
empathy. Empathy is more predictive of improvement with non-specific measures of
outcome, such as global improvement or client satisfaction, than with more specific,
problem-focused measures. Some studies suggest that empathy is not solely a
psychotherapist-determined, but may be a function of the mutually created climate
between psychotherapist and client.
Four factors have been identified to explain the positive association between
empathy and outcome. Empathy as relationship condition: Feeling understood increases
client satisfaction with ones psychotherapist and thereby increases compliance and
decreases premature termination. Feeling understood increases feelings of safety,
facilitates self-disclosure, and the willingness to discuss difficult personal areas. Empathy
as a corrective emotional experience: An empathic relationship may break isolation and
help clients learn that they are worthy of respect and being listened to, and that their
thoughts and behaviors make sense. Empathy and cognitive-affective processing:
Empathy has been found to promote exploration and meaning creation, help clients think
more productively, raise levels of productive experiencing, and facilitate emotional

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reprocessing. Empathy and the client as active healer: Empathy contributes to promoting
clients self healing by creating a space for client involvement and openness to the
clinical process. It helps the psychotherapist choose interventions compatible with the
client's frame of reference, which also promotes the clients active participation.
Psychotherapeutic Practices. Psychotherapists are advised to make efforts to
respond to their clients through responses that address a clients needs as the client
perceives them on an ongoing basis. Empathic responses that add to or carry forward the
meaning of the clients communications are useful. Empathic psychotherapists do not
parrot their clients words or reflect only the content of words, but strive to understand
and respond to overall goals and moment-to-moment experiences at explicit and implicit
levels meaning. Some clients have a negative response to expressions of empathy, and
some fragile clients may find empathic responses intrusive. Highly resistant clients may
find empathy too directive, while other clients may find an empathic focus on feelings
too foreign. Psychotherapists therefore need to know how to time empathic responses.
Throughout the treatment, they need to determine when and how to communicate
empathic understanding and at what level to focus their empathic responses on a
moment-to-moment basis. Empathic psychotherapists assist clients to articulate their
experience and track their emotional responses, so that clients can deepen their
experience and examine their own feelings, values, and goals. To this end, they need to
attend to what is not said, or what is at the periphery of awareness, as well as what is said
and is figural in awareness.

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COHESION IN GROUP PSYCHOTHERAPY (Burlingame, Fuhriman, & Johnson,
2001)
The therapeutic relationship in group psychotherapy refers to group cohesion. It is
defined as including all the relationships emerging from the group, namely, (a) memberto-leader, (b) member-to-member, and (c) member-to-group relationships. Processes of
group cohesion include both intrapersonal components, that is, a group member's sense
of belonging and acceptance and a personal commitment and allegiance to the group, and
intragroup components, including attractiveness and compatibility felt among group
members.
Research. The review of studies on the association between group cohesion and
psychotherapy outcome found a positive association in 80% of the studies. The
experience of individual members in the group, an aspect of the member-to-group
cohesion, is related to outcome in terms of how the group member felt understood,
protected, and comfortable in the group. Perception of group leaders, the member-toleader dimension, was associated with outcome in terms of how group member felt
warmth, understanding, hope, and being personally valued by the group leader. Group
processes that affect cohesiveness include high and positive emotional relatedness among
group members that leads to self-disclosure, ability to tolerate conflicts in the work
phase, and focus on the welfare of the group rather than the leader or individual
members.
Psychotherapeutic Practices. The following six principles have strong empirical
support and can guide the clinician in managing group cohesiveness:

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1. Pregroup preparation sets treatment expectations, defines group rules, and
instructs members in appropriate roles and skills needed for effective group participation
and group cohesion. Pregroup training may be one of the most powerful factors in
creating a cohesive group. Pregroup preparation should include setting treatment
expectations (rationale, discussion of fears), establishing group procedures (time, fees,
etc.), engaging in role preparation, building skills, and setting process norms.
2. The group leader should establish clarity regarding group processes in early
sessions since higher levels of structure probably lead to higher levels of disclosure and
cohesion. Group members experience discomfort when they enter the group. Unless the
leader deals effectively with this anxiety, it can lead to client attrition and poor
cohesiveness.
3. Leader modeling real-time observations, guiding effective interpersonal
feedback, and maintaining a moderate level of control and affiliation may positively
impact cohesion. The leader can explicitly set norms and reinforce interactional patterns
that can lead to more interactions. Leadership styles that are moderate in directiveness
and affiliation have been related to increased levels of cohesion.
4. The timing and delivery of feedback should be pivotal considerations for
leaders as they facilitate this relationship-building process. Positive feedback should
predominate in early sessions, and corrective feedback should occur in later sessions. The
latter is best received when preceded by positive feedback focusing on specific and
observable behaviors. Corrective feedback requires careful consideration of the readiness
of the receiver with leader providing instruction and modeling of useful feedback.

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5. The group leader's presence not only affects the relationship with individual
members, but all group members as they vicariously experience the leader's manner of
relating, and thus the importance of managing one's own emotional presence in the
service of others. Positive outcomes are associated with group psychotherapists who are
warm, accepting, empathic, and convey a positive regard for the individual client member
and the group. Positive relationship-building attitudes and behaviors early in the group
prevent early client dropout.
6. A primary objective of the group leader should be facilitating group members'
emotional expression, the responsiveness of others to that expression, and the shared
meaning derived from such expression. The leader characteristics that contribute to the
emotional climate of the group are also useful characteristics in group members, namely,
empathy, support and caring, acceptance, and trust. The basic skills of listening and
conveying that one has heard and understands are important client factors in creating a
healthy emotional climate.
GOAL CONSENSUS AND COLLABORATION (Tryon & Winograd, 2001)
The concepts of goal consensus and collaboration involvement apply to all
psychotherapies regardless of theoretical orientations and practice settings. Goal
consensus is one aspect of the working alliance and is defined as psychotherapist-client
agreement on goals and expectations. Collaborative involvement is the mutual
involvement of client and psychotherapist in the helping relationship. Both goal
consensus and collaborative involvement are elements of the therapeutic contract,
referring to how the client understands his or her role for engaging with the
psychotherapist.

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Research. Of 25 studies, 68% found a positive relation between goal consensus
and psychotherapy outcome. These studies evaluated how goal consensus functioned in
the treatment relationship in terms of (a) client-psychotherapist agreement on goals; (b)
the extent to which a psychotherapist explains the nature and expectations of
psychotherapy, and the client's understanding of this information; (c) the extent to which
goals are discussed, and the client's belief that goals are clearly specified; (d) client
commitment to goals; and (e) client-psychotherapist congruence on the origin of the
client's problem, and congruence on who or what is responsible for problem solution.
Of 24 studies, 89% found a positive relation between collaborative involvement
and psychotherapy outcome. The studies examined how collaborative involvement
functioned in the treatment relationship in terms of client cooperation, role involvement,
and homework compliance. Withdrawn and psychotic clients were less likely to
cooperate and showed less involvement. Clients contributed to a collaborative
relationship by completing homework assignments, which was positively related to
psychotherapy outcome.
Psychotherapeutic Practices. It is difficult to assess goal consensus, since client
and psychotherapist may be working on the same goals but talking about them in
different ways. Psychotherapists and clients should frequently discuss and agree upon
goals in a shared decision-making process. When psychotherapists address topics of
importance to clients and resonate to their concerns, clients feel understood, which leads
to greater collaboration. When clients are given clear explanations of the treatment plan
and how it relates to their presenting complaints, they are more satisfied with
psychotherapy sessions and more willing to work on their problems.

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Research suggests that positive outcome is associated with collaborative
involvement that includes cooperation and affiliation on the part of both client and
psychotherapist. Clients achieve better outcomes when they are actively involved in the
treatment process, and discuss their concerns, feelings, and goals rather than resisting or
passively receiving them. Clients who resist have poorer outcomes. Although,
psychotherapists who assign and review homework have better outcomes, it is not the
quantity of assigned homework but the quality of completed homework that leads to
better outcomes.
PROMISING AND PROBABLY EFFECTIVE
POSITIVE REGARD (Farber & Lane, 2001)
Positive regard, or unconditional positive regard, refers to a psychotherapist
treating a client in a consistently warm, totally accepting, and highly regarded manner. It
has been characterized as prizing, nonpossessive warmth, and affirmation. The
correlation between psychotherapists ability to communicate positive regard and
psychotherapy outcome were modest in research studies. Associations were most robust
when outcome was assessed by clients ratings rather than psychotherapist ratings or by
an objective measure.
Nevertheless, the psychotherapists ability to provide positive regard appears to
be significantly related to outcome and, therefore, is indicated in clinical practice. It
creates an interpersonal context for other interventions and may, in some cases, be
sufficient in itself to effect change. It is the clients perception of a psychotherapist
positive regard that is most robustly associated with good outcome. This indicates that
psychotherapists cannot rely on merely feeling good about their clients, but make sure

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that they communicate those positive feelings in the form of caring and respect that
affirms the clients sense of self-worth.
CONGRUENCE/GENUINENESS (Klein, Michels, Kolden, & Chisolm-Stockard, 2001)
Therapist congruence, in addition to empathy and positive regard, are Carl
Rogers core conditions for psychotherapeutic change. Congruence and genuineness refer
to both the psychotherapists personal integration, that is, the ability to freely and deeply
be him/herself, and the psychotherapists ability to communicate his or her personhood to
the client. In the 20 studies reviewed, 34% of the results found a positive relation
between psychotherapist congruence and treatment outcome, and 66% reported
nonsignificant associations. The proportion of positive findings increased to 68% when
congruence was tested in connection with empathy and positive regard. This supports the
notion that the facilitative conditions work together and cannot be easily distinguished.
Psychotherapist characteristics associated with higher congruence include more
self-confidence, good mood, increased involvement or activity, responsiveness, and
smoothness of speaking exchanges. Client congruence was associated with higher levels
of self-exploration/experiencing and absence of severe disorders, suggesting that these
may mediate or moderate the relationship between congruence and outcome, such that it
is easier for a psychotherapist to communicate congruence with more expressive and
higher functioning clients.
Congruent responses include self-disclosure of personal information, articulation
of thoughts and feelings, and feedback on client behavior. These responses are honest,
respectful, sincere, and not intellectualized. They serve as a vehicle for communicating

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empathy and regard. Psychotherapists need to be aware that clients have differing needs
and expectations with respect to congruence.
FEEDBACK (Claiborn, Goodyear, & Horner, 2001)
Feedback is descriptive or evaluative information provided by the psychotherapist
to the client about the clients behavior or its effects. It has been called praise,
reinforcement, immediacy, and confrontation. Since feedback can be motivational, the
psychotherapist needs to manage how information is presented such that the clients
emotions do not distort the information or elicit resistance. The effects of feedback have
not been extensively researched; of 11 studies, 73% found a positive association with
outcome and 27% were nonsignificant.
Clients usually accept positive feedback that affirms their self-perception.
Negative feedback serves to correct client attitude and behavior and is more acceptable in
the context of a safe and trusting relationship and when preceded by positive feedback.
Clients processing of feedback is attenuated by low self-esteem and negative mood. A
collaborative relationship is the context for the exchange of feedback, which, especially
with positive feedback, helps to establish and strengthen that relationship. A structure for
feedback is created by the psychotherapist describing the feedback process and goals to
the client, by training clients in giving and receiving feedback, and allowing clients to
work through feedback.
REPAIR OF ALLIANCE RUPTURES (Safran, Muran, Samstag, & Stevens, 2001)
Research on the therapeutic alliance, as reviewed earlier, consistently finds that a
strong therapeutic alliance is associated with positive treatment outcome. Therefore, it
follows that breakdowns in the relationship alliance ruptures are an important part of

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the treatment process. Even experienced psychotherapists have considerable difficulty
discerning when there are problems in the relationship, for example, secrets and things
left unsaid. The small body of research indicated that the frequency and severity of
alliance ruptures was associated with more defensive psychotherapist behavior, such as
greater adherence to treatment manuals or increased concentration on transference
interpretations, both of which resulted in poor outcomes. When psychotherapists attend to
ruptures as they occur and adjust their behaviors, not only does the alliance improve but
these moments may also be an intrinsic part of the change process. The limited research
suggests that poor outcome cases are characterized by attack-and-defend patterns of
communication between psychotherapist and client. It is difficult to train
psychotherapists to deal constructively with these patterns of communication.
Since clients are typically reluctant to articulate their negative feelings about
psychotherapy and the treatment relationship, psychotherapists need to be attuned to
ruptures in the alliance and take the initiative in exploring these. Clients benefit from the
opportunity to express negative feelings and assert differing perspectives. It is important
for psychotherapists to respond in a non-defensive manner when criticized and take
responsibility for their contribution to the interaction. Exploring clients fears about
discussing negative feelings contributes to the process of resolving alliance ruptures.
SELF-DISCLOSURE (Hill & Knox, 2001)
Therapist self-disclosures, one of the most controversial interventions, are
statements that reveal something personal about the psychotherapist. It is important to
distinguish self-disclosures, which reveal non-immediate personal information, from
immediacy statements, which reveal immediate feelings about the client.

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Analogue research (designs involving simulations of psychotherapy rather than
actual psychotherapy) suggests that nonclients generally have positive perceptions of
psychotherapists who self-disclose and like psychotherapists who moderately selfdisclosed personal information. Research of actual psychotherapy suggests that
psychotherapists disclose infrequently and disclose mostly about their professional
background. Psychotherapists try to avoid self-disclosure when it gratified their own
needs and distracted the clients work Disclosures were perceived as helpful in terms of
the immediate outcomes of the therapy, although their effects on the longer term
outcomes remain unclear. Humanistic-existential psychotherapists disclose more than
psychoanalytic psychotherapists
Psychotherapists should disclose infrequently and, when they do, strive to validate
reality, normalize, model, strengthen the alliance, or offer alternative ways of thinking.
The most appropriate self-disclosures involve professional boundaries and the least
appropriate are sexual beliefs and practices. They should avoid disclosures that are used
for their own needs, distract from the client, or blur the treatment boundary.
Psychotherapists should observe carefully how clients respond to disclosures and use that
information in deciding how to proceed in the future. Self-disclosures may be especially
important with clients who have difficulty forming treatment relationships.
MANAGEMENT OF COUNTERTRANSFERENCE (Gelso & Hayes, 2001)
First described by Freud, countertransference refers to a psychotherapists
reactions to clients based on the psychotherapists conscious and unconscious conflicts.
The conventional view is that countertransference that is not understood or controlled

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injures the psychotherapeutic process, and, conversely, countertransference that is
understood and managed facilitates the process.
There have been few empirical investigations of countertransference and
psychotherapy outcome. These studies focused on immediate effects of
countertransference, that is, effects observed in a given hour, or countertransference as a
mediating factor. These studies support the idea that unmanaged countertransference
adversely affects outcome. Although there has been a paucity of research on the effects of
countertransference on distal outcomes, the available research suggests that
countertransference weakens the therapeutic alliance.
Effective psychotherapists work to prevent countertransference acting out and
manage countertransference reactions in a manner that facilitates the treatment process.
Countertransference management involves five interrelated skills: self-insight, the
psychotherapists ability to understand their own reactions to the client; self-integration,
the ability to maintain a healthy boundary between self and client; anxiety management,
the ability to experience and tolerate anxiety without acting-out; empathy, the ability to
climb into the clients world; and, conceptualizing ability, the ability to conceptually
grasp client and treatment dynamics.
RELATIONAL INTERPRETATIONS (Crits-Christoph & Gibbons, 2001)
Interpretations are defined in the psychoanalytic literature as interventions that
bring material to consciousness that was previously out of awareness. Relational
interpretations address the psychotherapeutic relationship and include transference
interpretations. Operational definitions of relational interpretations emphasize

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psychotherapist statements that go beyond what the client has overtly recognized and
pointing out themes in the clients behavior or personality.
Research has focused on the association of treatment outcome to the frequency of
transference interpretations and the quality of these interpretations. The association
between frequency of interpretations and psychotherapy outcome has yielded mixed
results, but converge towards the conclusion that high rates of transference interpretations
lead to poor outcomes, particularly for clients with low quality object relations. Studies of
the quality of transference interpretations suggest that positive outcomes are associated
with a psychotherapist accurately addressing central features of a clients interpersonal
dynamics.
Three main implications for clinical practice are, first, avoid high levels of
transference interpretation, second, interpretations should focus on the central
interpersonal themes, and, third, psychotherapist should strive to make these
interpretations accurate.
PRACTICE RECOMMENDATIONS
Decades of empirical research, despite the inevitable limitations, point to the
following practice recommendations:

Practitioners are encouraged to make the creation and cultivation of a

psychotherapy relationship as characterized by the demonstrably and probably
effective elements a primary aim in the treatment of patients.

Practitioners are encouraged to routinely monitor patients responses to the

therapy relationship and ongoing treatment in order to repair alliance ruptures, to

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improve the relationship, to modify technical strategies, and to avoid premature
termination.

Concurrent use of empirically supported relationships and empirically supported

treatments tailored to the patients disorder and characteristics is likely to generate
the best outcomes.

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