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21 - Psychotherapy Relationships

Published online by Cambridge University Press:  10 January 2025

By
John C. Norcross  and
Christie P. Karpiak
Edited by
Stephen Hupp  and
David F. Tolin
Stephen Hupp
Affiliation:
Southern Illinois University, Edwardsville
David F. Tolin
Affiliation:
Institute of Living
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Summary

The therapeutic relationship constitutes the heart and soul of the enterprise. Second only to the patient’s contribution, the relationship is the most powerful predictor of, and contributor to, outcome. Its effectiveness cuts across theoretical orientations (transtheoretical) and largely across client problems (transdiagnostic). This chapter reviews evidence-based psychotherapy relationships, primarily with adults in individual treatment. We begin by defining terms and summarizing the meta-analytic evidence on effective relationship behaviors or components (what works). That is followed by a summary of ineffective or discredited relationship behaviors (what does not work). We advance therapeutic and training practices based on this research evidence. The chapter finishes with multiple caveats, concluding thoughts, and useful resources.

Keywords

psychotherapy relationshiptherapy relationshipevidence-based therapy relationshipsevidence-based practicetherapeutic alliancerupture repairclient feedbackemotional expressionscience-based therapy
Type
Chapter
Information
Science-Based Therapy
Raising the Bar for Empirically Supported Treatments
 , pp. 381 - 398
Publisher: Cambridge University Press
Print publication year: 2025

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References

Useful Resources

Norcross, J. C., & Lambert, M. J. (Eds.). (2018). Evidence-based psychotherapy relationship III (special issue). Psychotherapy, 55(4), 303–537.

Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work. Volume 1: Evidence-based therapist contributions (3rd ed.). Oxford University Press.

Norcross, J. C., & Wampold, B. E. (2019). (Eds.). Psychotherapy relationships that work. Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press.

Norcross, J. C., & Karpiak, C. P. (2023). Relationship factors. In Miller, S. D., Chow, D., Malins, S., & Hubble, M. A. (Eds.), Field guide to better results: Individualizing a deliberate practice. American Psychological Association.

Society for the Advancement of Psychotherapy (APA Division of Psychotherapy). (2020). Teaching and learning evidence-based relationships: Interviews with the experts. societyforpsychotherapy.org/teaching-learning-evidence-based-relationships.

References

Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23, 1–33.CrossRefGoogle ScholarPubMed
American Psychological Association Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61, 271–285.CrossRefGoogle Scholar
Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75, 842–852.CrossRefGoogle ScholarPubMed
Barrett-Lennard, G. T. (1981). The empathy cycle: Refinement of a nuclear concept. Journal of Counseling Psychology, 28, 91–100.CrossRefGoogle Scholar
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. (Eds.). (1979). Cognitive therapy of depression. Guilford Press.Google Scholar
Binder, J. L., & Strupp, H. H. (1997). “Negative process”: A recurrently discovered and underestimated facet of therapeutic process and outcome in the individual psychotherapy of adults. Clinical Psychology: Science and Practice, 4, 121–139.Google Scholar
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, 16, 252–260.CrossRefGoogle Scholar
Castonguay, L., & Hill, C. E. (Eds.). (2017). How and why are some therapists better than others? Understanding therapist effects. American Psychological Association.CrossRefGoogle Scholar
Cochrane, A. (1979). 1931–1971: A critical review with particular reference to the medical profession. In Medicines for the year 2000 (pp. 1–11). UK Office of Health Economics.Google Scholar
Cohen, J. (2013). Statistical power analysis for the behavioral sciences. Academic Press.CrossRefGoogle Scholar
de Jong, K., Conijn, J. M., Gallagher, R., et al. (2021). Using progress feedback to improve outcomes and reduce drop-out, treatment duration, and deterioration: A multilevel meta-analysis. Clinical Psychology Review, 85, 102002. https://doi.org/10.1016/j.cpr.2021.102002.CrossRefGoogle ScholarPubMed
Del Re, A. C., Flückiger, C., Horvath, A. O., & Wampold, B. E. (2021). Examining therapist effects in the alliance–outcome relationship: A multilevel meta-analysis. Journal of Consulting and Clinical Psychology, 89, 371–378.CrossRefGoogle ScholarPubMed
Del Re, A. C., Flückiger, C., Horvath, A. O., Symonds, D., & Wampold, B.E. (2012). Therapist effects in the therapeutic alliance-outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32, 642–649.CrossRefGoogle ScholarPubMed
Eisenbruch, A. B., & Krasnow, M. M. (2022). Why warmth matters more than competence: A new evolutionary approach. Perspectives on Psychological Science, 17(6), 1604–1623.CrossRefGoogle ScholarPubMed
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2019). Empathy. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Eubanks, C. F., Muran, J. C., & Safran, J. D. (2019). Repairing alliance ruptures. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Vol. 1 (3rd ed.). Oxford University Press.Google Scholar
Farber, B. A., Suzuki, J. Y., & Lynch, D. (2019). Positive regard and affirmation. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Flückiger, C., Del Re, A. C., Wampold, B. E., Symonds, D., & Horvath, A.O. (2019). Alliance in adult psychotherapy. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Friedlander, M. L., Escudero, V., Welmers-van de Poll, M. J., & Heatherington, L. (2019). Alliances in couple and family therapy. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Gelso, C. (2014). A tripartite model of the therapeutic relationship: Theory, research, and practice. Psychotherapy Research, 24, 117–131.CrossRefGoogle ScholarPubMed
Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling and psychotherapy: Components, consequences, and theoretical antecedents. The Counseling Psychologist, 13, 155–243. https://doi.org/10.1177/0011000085132001.CrossRefGoogle Scholar
Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their inter-action and unfolding during treatment. Journal of Counseling Psychology, 41, 296-306.CrossRefGoogle Scholar
Gelso, C. J., Kivlighan, D. M., & Markin, R. D. (2019). The real relationship. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Vol. 1 (3rd ed.). Oxford University Press.Google Scholar
Greenson, R. R. (1967). Technique and practice of psychoanalysis. International University Press.Google Scholar
Gurman, A. S. (1977). Therapist and patient factors influencing the patient’s perception of facilitative therapeutic conditions. Psychiatry, 40, 218–231.CrossRefGoogle ScholarPubMed
Hardy, G. E., Bishop-Edwards, L., Chambers, E., et al. (2019). Risk factors for negative experiences during psychotherapy. Psychotherapy Research, 29, 403–414.CrossRefGoogle ScholarPubMed
Horvath, A. O., Symonds, D. B., Fluckiger, C., DelRe, A. C., & Lee, E. (2016, June). Integration across professional domains: The helping relationship. Address presented at 32nd conference of Society for the Exploration of Psychotherapy Integration, Dublin, Ireland.Google Scholar
Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. National Academies Press.Google Scholar
Karpiak, C. P., & Norcross, J. C. (2022). Evidence-based therapy relationships. In Asmundson, G. J. G. (Ed.), Comprehensive clinical psychology, Vol. 2 (2nd ed). Elsevier.Google Scholar
Karver, M. S., De Nadai, A. S., Monahan, M., & Shirk, S. R. (2019). Alliance in child and adolescent psychotherapy. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Kolden, G. G., Wang, C.C., Austin, S. B., Chang, Y., & Klein, M. H. (2019). Congruence /genuineness. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Kramer, U., & Stiles, W. B. (2015). The responsiveness problem in psychotherapy: A review of proposed solutions. Clinical Psychology: Science and Practice, 22, 277–295. https://doi.org/10.1111/cpsp.12107.Google Scholar
Lambert, M. J. (2010). Prevention of treatment failure: The use of measuring, monitoring, & feedback in clinical practice. American Psychological Association.CrossRefGoogle Scholar
Lambert, M. J., Ogles, B. M., & Masters, K. S. (1992). Choosing outcome assessment devices: An organizational and conceptual scheme. Journal of Counseling & Development, 70(4), 527–532.CrossRefGoogle Scholar
Lambert, M. J., Whipple, J. L., & Kleinstauber, M. (2019). Collecting and delivering client feedback. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Vol. 1 (3rd ed.). Oxford.Google Scholar
Luborsky, L. (1976). Helping alliances in psychotherapy: The groundwork for a study of their relationship to its outcome. In Claghorn, J. L. (Ed.), Successful psychotherapy. Brunner/Mazel.Google Scholar
Lundahl, B., Moleni, T., Burke, B. L., et al. (2013). Motivational interviewing in medical care settings: A systematic review and meta-analysis of randomized controlled trials. Patient Education and Counseling, 93, 157–168.CrossRefGoogle ScholarPubMed
Miller, W. R. (2018). Listening well: The art of empathic understanding. Wipf and Stock.Google Scholar
Miller, W. R., Wilbourne, P. L., & Hettema, J. E. (2003). What works? A summary of alcohol treatment outcome research. In Hester, R. K. & Miller, W. R. (Eds.), Handbook of alcoholism treatment approaches (3rd ed., pp. 13–63). Allyn & Bacon.Google Scholar
Muran, J. C. & Eubanks, C. F. (2020). Therapist performance under pressure: Negotiating emotion, difference, and rupture. American Psychological Association.CrossRefGoogle Scholar
Norcross, J. C. (Ed.). (2002). Psychotherapy relationships that work. Oxford University Press.Google Scholar
Norcross, J. C. (Ed.). (2011). Psychotherapy relationships that work (2nd ed.). Oxford University Press.CrossRefGoogle ScholarPubMed
Norcross, J. C., & Karpiak, C. P. (2023). Relationship factors. In Miller, S. D., Chow, D., Malins, S., & Hubble, M. A. (Eds.), Field guide to better results: Individualizing a deliberate practice. American Psychological Association.Google Scholar
Norcross, J. C., & Lambert, M. J. (Eds.). (2019). Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Norcross, J. C., & Lambert, M. J. (2019). What works in the psychotherapy relationship: Results, conclusions, and practices. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Vol. 1 (3rd ed.). Oxford University Press.Google Scholar
Norcross, J. C., & Lambert, M. J. (2014). Relationship science and practice in psychotherapy: Closing commentary. Psychotherapy, 51, 398-403. doi: 10.1037/a0037418CrossRefGoogle ScholarPubMed
Norcross, J. C., & Wampold, B. E. (Eds.). (2019). Psychotherapy relationships that work. Volume 2: Evidence-based responsiveness (3rd ed.). Oxford University Press.Google Scholar
Norcross, J. C., Hogan, T. P., Koocher, G. P., & Maggio, L. A. (2017). Clinician’s guide to evidence-based practices: Behavioral health and addictions (2nd ed.). Oxford University Press.CrossRefGoogle Scholar
Norcross, J. C., VandenBos, G. R., & Freedheim, D. K. (Eds.). (2016). APA handbook of clinical psychology (5 volumes). American Psychological Association.Google Scholar
Peluso, P. R., & Freund, R. R. (2019). Emotional expression. In Norcross, J. C. & Lambert, M. J., (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21, 95–103.CrossRefGoogle ScholarPubMed
Rogers, C. R. (1980). A way of being. Houghton Mifflin.Google Scholar
Seewald, A., & Rief, W. (2022). How to change negative outcome expectations in psychotherapy? The role of the therapist’s warmth and competence. Clinical Psychological Science, 11(1), 149–163. https://doi.org/10.1177/21677026221094331.CrossRefGoogle Scholar
Singer, B.A., & Luborsky, L. (1977). Countertransference: The status of clinical versus quantitative research. In Gurman, A. S. & Razin, A. M. (Eds.), Effective psychotherapy: A handbook of research. Pergamon.Google Scholar
Soto, A., Smith, T. B., Griner, D., Rodriguez, M. D., & Bernal, G. (2019). Cultural adaptations and multicultural competence In Norcross, J. C. & Wampold, B. E. (Eds.), Psychotherapy relationships that work, Vol. 2 (3rd ed.). Oxford University Press.Google Scholar
Stiles, W. B., Honos-Webb, L., & Surko, M. (1998). Responsiveness in psychotherapy. Clinical Psychology: Science and Practice, 5, 439–458.Google Scholar
Swift, J. K., & Callahan, J. L. (2010). A comparison of client preferences for intervention empirical support versus common therapy variables. Journal of Clinical Psychology, 66 1217–1231.CrossRefGoogle ScholarPubMed
Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80, 547–559.CrossRefGoogle ScholarPubMed
Totura, C. M. W., Fields, S. A., & Karver, M. S. (2018). The role of the therapeutic relationship in psychopharmacological treatment outcomes: A meta-analytic review. Psychiatric Services, 69, 41–47.CrossRefGoogle ScholarPubMed
Tryon, G. S., Birch, S. E., & Verkuilen, J. (2019). Goal consensus and collaboration. In Norcross, J. C. & Lambert, M. J. (Eds.), Psychotherapy relationships that work, Volume 1 (3rd ed.). Oxford University Press.Google Scholar
Wampold, B. E. (2010). The research evidence for the common factor models: A historically situated perspective. In Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (Eds.), The heart and soul of change: Delivering what works in therapy (pp. 49–81). American Psychological Association.CrossRefGoogle Scholar
Wampold, B. E. (2012). Humanism as a common factor in psychotherapy. Psychotherapy, 49(4), 445–449.CrossRefGoogle ScholarPubMed
Wampold, B. E., & Imel, Z. (2015). The great psychotherapy debate (2nd ed.). Erlbaum.CrossRefGoogle Scholar
Watson, J. C. & Geller, S. (2005). An examination of the relations among empathy, unconditional acceptance, positive regard and congruence in both cognitive-behavioral and process-experiential psychotherapy. Psychotherapy Research, 15, 25–33.CrossRefGoogle Scholar

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