Psychotherapy Relationships That Work: Therapist Contributions and Responsiveness to Patients [Hardcover]

"Psychotherapy Relationships That Work" is a much-needed balance to our current near-exclusive focus on psychotherapy "treatments". Research, frankly, shows that relationships are at least, if not more effective than specific treatments for specific disorders. (See, for example, research summaries in the 2nd edition, 2010, The Heart and Soul of Change: Delivering What Works in Therapy.)

"Psychotherapy Relationships That Work" gives excellent in-depth summaries for four crucial aspects of client/therapist relationships. First, what works in the relationship "in general" -- what works with all client/therapist relationships. This includes the client/therapist alliance, therapist empathy, and therapist/client goal consensus & collaboration.

Second, what research shows that doesn't work in the client/therapist relationship: confrontations, negative process, unchecked assumptions, therapist centricity, rigidity, "ostrich behavior" (ignoring "the elephant in the living room") and "procrustean bed" -- forcing the client into the treatment or into a type of relationship.

Third, what research shows that works in individualizing client/therapist relationships. This includes how to adjust/respond to client "resistance" or "reactance", i.e., clients who seem easily provoked or oppositional to therapist in-puts. And it includes adjusting the relationship to the client's functioning level - for DSM folks, the client's Axis V: General Assessment of Functioning or GAF levels. Note: there's far less research on individualizing relationship factors than on generalized relationship factors.

Fourth, what relationship factors research suggests are "promising", both "in general" -- across all client/therapist relationships -- and "in particular" -- individualizing client/therapist relationships. Promising "in general" characteristics include the therapist's positive regard or prizing the client; the therapist's genuineness or congruence, the therapist giving feedback to the client (and seemingly more important per recent research, is the client giving regular feedback to the therapist); detecting and repairing the "therapeutic alliance" when the relationship ruptures, the working relationship between client and therapist; limited & targeted therapist self-disclosure; managing the therapist's counter-transference, roughly the therapist's own triggers or hooks; and interpreting or commenting on the client/therapist relationship.

Promising aspects to customizing or individualizing include using Prochaska's "stages of change", i.e., the readiness of clients to change; the therapist meeting client relationship expectations and preferences; the therapist meeting the client's basic "attachment style", that is, the way clients bond in important relationships (based on Bowlby, Ainsworth and other attachment researchers & theorists); incorporating client religious and spiritual beliefs; and the therapist incorporating client cultural, gender and age/stage of life characteristics, as well as meeting different "personality disorders".

Obviously, and as is stated openly throughout the book, there's a lot of overlap between these relationship aspects. For example, research suggests that Rogers, in his classic 1957 article, "The Necessary and Sufficient Conditions of Therapeutic Personality Change" (which is in "The Carl Rogers Reader") -- empathy, congruence/genuineness and positive regard/prizing -- are really aspects of one whole relationship and must be considered together.

Curiously, the best introduction to "Psychotherapy Relationships that Work" is in another book. Norcross, a long-time therapist/client relationship researcher & clinician, has written an updated 30-page research summary, "The Therapeutic Relationship", in Barry Duncan, et al., eds., The Heart and Soul of Change: Delivering What Works in Therapy, 2nd ed. (American Psychological Association, 2010). Norcross's summary is a beautiful, well-balanced & well-reasoned introduction. I recommend not only buying "Psychotherapy Relationships That Work", I also recommend buying "The Heart and Soul of Change". As Norcross points out in his "Heart and Soul" article, the relationship cannot be isolated from such aspects of psychotherapy as client characteristics and the treatment procedures. These other aspects are also covered in "Heart and Soul". Indeed, Norcross, in his 2010 summary, and the researchers/clinicians in "Psychotherapy Relationships that Work" constantly emphasize the inter-relations between all these factors. This is a major strength, both in the 2010 summary and the 2002 book.

So why buy & read the 2002 book, a book now 8 years behind what's most current?

Two very good reasons. First, the research hasn't changed that much. "Psychotherapy Relationships that Work", the 2002 book, analyzes & summarizes literally thousands of psychotherapy effectiveness research studies. Most of this hasn't changed in the past 8 years, for a good reason & a sad reason. The good reason: a lot in this research has proved robust -- demonstrated over & over for more than half a century, since Carl Rogers led psychotherapy research in the 1950's. The sad reason: most academic psychology departments, especially the larger ones - the ones who get the most money -- are committed to researching specific treatment modalities for specific DSM disorders. More & more, effectiveness research in areas such as client characteristics, therapist characteristics and the therapeutic relationship, have been economically shoved aside. This bias has affected how we do and don't train our graduate students, our next-generation psychotherapists.

A second good reason for reading this 2002 book: the added detail in each section. This is, after all, a 450-page book. For example, "Stages of Change" , in Norcross's 2010 summary, has maybe a page. In the 2002 book, it's given 10 pages, an entire chapter, including a page-long bibliography for learning more. The 2002 chapter was not only written by Norcross, but also by Prochaska, the founder of Stages of Change. Another example is "Empathy" -acrucial for all psychotherapy relationships. In Norcross's 2010 summary, it receives slightly over a page. In the 2002 book, empathy has almost 20 pages, and it's co-written by four of the most distinguished empathy researchers in the field.

But does a good therapist really need to read this book? If they're a good therapist, aren't they already doing these things?

Yes & no. Disclosure: of the seven genius therapists with whom I've studied, the earliest five, the five with whom I've most intensively & continually studied, for over 25 years now, were all students of Carl Rogers. Their emphasis on client/therapist relationship is comprehensive. I have many years of closely-supervised training in client/therapist relationship, in general and how it's expressed, in particular through "listening". Listening, I hasten to add, is not "reflection of feelings", which I rarely do. Listening is extremely complex, and it's the foundation of making sure that I stay with my client, moment-to-moment. Norcross and the other researchers/clinicians repeatedly emphasize that this is the key to effective client/therapist relationships, as well as the key to living both the general and the individualizing aspects of the client/therapist relationship.

With all that, did I benefit from reading "Psychotherapy Relationships That Work"?

Definitely. There were very few chapters where I didn't get useful insights and suggestions for adjusting my relating style to become more effective with more clients. (My clinical specialty is difficult, complex, multi-problem and often relationship-impaired clients, including children & teens. With these clients, no one EVER is good enough in building effective therapist/client relationships.)

My only complaint - serious, but sadly predictable: the assumption of individual therapy. Not nearly enough space is devoted to working in families and couples. BOTH maintaining my relationship with all the clients in the room, and enhancing relationships BETWEEN clients in AND out of the room is often my most challenging relationship issue. Perhaps the most important healing is building-up, evolving/developing, healing, strengthening and enriching relationships BETWEEN clients - husband & wife, parent & child. These relationships, I believe, are a lot more important & on-going than the clients' relationship with me. In other words, the most important relationship in the therapy room is NOT client/therapist, but couple/family.

"Psychotherapy Relationships" has an excellent article on facilitating "cohesion" in group therapy. Their suggestions, in my experience, translate well into families & couples. So do many aspects of the therapist/client relationship. But much more specificity is needed. In fairness, I suspect that this comes from the little and/or poor research into therapist/family relationships. But I hope that future editions will correct this omission.

The best article I know about therapist/family relationships is also in "Heart & Soul". See Sparks' and Duncan's article, "Common Factors in Couple and Family Therapy: Must All Have Prizes?", Chapter 12, in the 2nd edition. (2010).

And I found "Psychotherapy Relationships That Work" well-worth reading. Indeed, it gave me a few steps with some of my most difficult clients. I recommend it whole-heartedly

A multitude of studies and meta-analyses indicate that most, if not all, psychotherapy systems are equivalent in efficacy. This repeated finding suggests that emphasis on research and clinical thinking needs to shift toward what psychotherapies have in common, and how interpersonal processes in the psychotherapeutic relationship contribute to outcome.

Most therapy texts seem to ignore these trends, and focus on a particular psychotherapy approach (e.g., CBT, psychodynamic, schema), without recognizing that they are all likely to have similar effect.

This text fills a needed gap by focusing on "common factors" in different psychotherapies, and processes in the therapeutic relationship that contribute to psychotherapeutic efficacy. The chapters base discussion on empirical research findings without neglecting clinical implementation. Discussion is apppropriately focused on the interpersonal processes contributing to outcome, rather than any theory of change per se.

A highly recommended text for anyone seeking to understand the process of what actually happens in the practice of psychotherapy.

the organization of the topics in the book with the research + statistical methods and designs plus critical narrative on how the samples were gathered, pros and cons of the research and conclusions on counseling theory and specifically the therapeutic alliance concept is excellent and an easy read. Very disappointed I couldn't get Norcross
subsequent book - expanding to evidence-based responsiveness, 2 ed. (2011) on my Kindle also. Crazy about the kindle and expansive range of books and topics available on this device.
Kathryn L.