CE Corner

CE
APA task force, which was way by, for example, disclosing
co-sponsored by APA Div. 17 their feelings when appropri-
(Society of Counseling Psy- ate and actively inviting feed-
chology) and Div. 29 (Society back from patients about how
for the Advancement of Psy- therapy is going. “It’s about
chotherapy). “We now know making a commitment to be a
that some of these therapeutic partner, in a sense, rather than
elements not only predict but the director or commander in
probably cause improvement,” the relationship,” says Horvath.
he says (see sidebar). Related to mutuality is
A good relationship, the another strong relationship
CONTINUING EDUCATION research finds, is essential builder: collaboration, or work-
BETTER RELATIONSHIPS to helping the client con- ing together to define and
WITH PATIENTS LEAD nect with, remain in and get actualize therapy goals, includ-
TO BETTER OUTCOMES the most from therapy. “It’s ing the direction the therapy
primary in the sense of being relationship is taking.
BY TORI DEANGELIS
the horse that comes before Research supports the
the carriage, with the carriage benefits of both mutual and
being the interventions,” collaborative approaches. For
says Simon Fraser University example, one meta-analysis
emeritus professor Adam O. of 21 studies identified by the

I
n terms of psychotherapy outcomes, the relationship Horvath, PhD, who studies the task force finds that when
between patient and psychologist matters—a lot. therapy alliance. therapists share their feel-
That’s the main takeaway from a new collection of The meta-analyses are ings about the patient or the
meta-analyses released by an APA task force charged reported in the December 2018 therapy relationship—a mutual
with examining the latest evidence on relationship issue of Psychotherapy (Vol. approach known as “imme-
factors in therapy. 55, No. 4) and in two related diacy”—the patient’s mental
Based on its 16 meta-analyses on aspects of the ther- books due out later this year health functioning and insight
apy relationship, the APA Task Force on Evidence-Based (see “Resources”). In addition, improve (Psychotherapy,
Relationships and Responsiveness concludes that a num- APA Div. 29 is hosting 10 webi- Vol. 55, No. 4, 2018). Another
ber of relationship factors—such as agreeing on therapy nars on the findings. meta-analysis of 107 studies
goals, getting client feedback throughout the course of The Monitor explores finds that therapy outcomes
treatment and repairing ruptures—are at least as vital to some of the key findings of are enhanced when the ther-
a positive outcome as using the right treatment method. the meta-analyses and how apist and patient agree and
“Anyone who dispassionately looks at effect sizes psychologists can use them collaborate on patient goals
can now say that the therapeutic relationship is as pow- in therapy to help maximize (Psychotherapy, Vol. 55,
erful, if not more powerful, than the particular treatment treatment outcomes. No. 4, 2018).
method a therapist is using,” says University of Scranton
professor John C. Norcross, PhD, ABPP, chair of the FOSTERING MUTUALITY BEING FLEXIBLE
AND COLLABORATION AND RESPONSIVE
One big shift in psychotherapy Also critical to outcomes is a
CE credits: 1 in recent years is toward therapist’s ability to tailor treat-
Learning objectives: After reading this article, greater mutuality—the notion ment to patients’ individual
CE candidates will be able to: that psychotherapy is a two- characteristics, such as their
1 . Discuss the state of research on relationship factors. way relationship in which cultural background, therapy
WAVEBREAK/GETTY IMAGES

2. Name key areas of new thinking on the therapy relationship. the therapist and client are preferences, attachment
3. Describe ways to apply this thinking in their practice. equal partners in the therapy style, religious or spiritual
For more information on earning CE credit for this article, process. Therapists make this beliefs, gender identity and
go to www.apa.org/ed/ce/resources/ce-corner.aspx. stance apparent in an ongoing sexual orientation—“to select

38 M O N I TO R O N P S YC H O LO G Y ● N OV E M B E R 2 0 1 9
A good relationship,
research finds, is essential
to helping the client connect
with, remain in and get the
most from therapy.

M O N I TO R O N P S YC H O LO G Y ● M O N I TO R O N P S YC H O LO G Y ● APRIL 2019 39
CE Corner

different methods, stances and In a case like this, “taking bert developed an additional
relationships according to the therapy at a slower pace and 40-item measure that assesses
patient and the context,” as periodically checking in with the specific aspects of the alliance,
Norcross puts it. (The topic of patient makes for more attuned the breakdown of which is a key
responsiveness is explored in and effective therapy,” says Tishby. factor in patient deterioration,
nine meta-analyses reported in research also finds. In a meta-
the November 2018 issue of the USING FEEDBACK analysis of 24 studies, Lambert
Journal of Clinical Psychology, Another important way to boost and colleagues found that when
Vol. 74, No. 11.) ABOUT CE the therapeutic relationship—as clinicians used the OQ-45.2 and
Responsiveness is also well as patient outcomes—is by other feedback systems, clients at
“CE Corner” is
related to understanding clients gathering patient feedback and risk for problems were less likely
a continuing-
as individuals—being attuned to education article
incorporating it into treatment. to get worse and twice as likely
their personality traits, conflicts, offered by APA’s A widely studied and validated to experience positive clinical
quirks and motivations, says Orya Office of CE in tool used by psychologists is the change, compared with clients
Tishby, PsyD, a clinical lecturer Psychology. Outcome Questionnaire-45.2 who received treatment as usual
and researcher at The Hebrew (OQ®-45.2), developed by from the same therapists (Psycho-
To earn CE credit,
University of Jerusalem, who after you read this
Brigham Young University therapy, Vol. 55, No. 4, 2018).
co-edited “Developing the Thera- article, complete professor Michael Lambert, Of course, feedback alone
peutic Relationship” (APA, 2018). an online learning PhD. Patients complete the doesn’t mean improvement—
“If the relationship is really exercise and 45-question instrument before therapists must put that feedback
take a CE test.
good, you can tell the difference each session to assess psy- into action. For guidance on
Upon successful
between when your patient might completion of
chological symptoms such as addressing their blind spots and
be acting out or resisting, and the test—a score of depression, anxiety and sub- learning from their mistakes,
when your suggestions aren’t 75% or higher—you stance use, as well as problems some psychologists are turning
working for some other reason,” can immediately in interpersonal functioning and to “deliberate practice.” Taught
print your
Tishby says. social roles. Any score indicating in a variety of training venues,
certificate.
She gives the example of a a propensity toward suicide, deliberate practice entails taking
patient who is being treated for To purchase the violence or substance use is a information from feedback or
social phobia but has difficulty online program visit red flag that calls for immediate supervision and working on prob-
following through with an expo- www.apa.org/ed/ follow-up, while high scores on lem areas with the help of videos,
ce/resources/ce-
sure protocol, such as initiating a one or more of the subscales coaches, mirrors and other tools
corner.aspx.
conversation with a stranger. The The test fee is
suggest key areas for treat- (see the Monitor’s January 2018
patient keeps deferring the task to $25 for members ment focus, Lambert explains. “CE Corner” for more information).
the following week, while telling and $35 for Other psychologists have since Although more research is
the therapist he understands the nonmembers. developed shorter measures for needed, studies show significant
For more
importance of moving forward. the same purpose, notably the improvements in outcomes over
information, call
When the therapist questions (800) 374-2721.
Outcome Rating Scale and the time when therapists incorporate
the patient in an empathic manner, Session Rating Scale, developed feedback and deliberate practice
the patient tells her he’s highly As an APA member, by Scott D. Miller, PhD, Barry L. into their work (see Psychother-
anxious about being rejected by take advantage of Duncan, PsyD, and colleagues. apy, Vol. 53, No. 3, 2016).
your five free CE
a stranger but also feels uncom- Research shows that such
credits per year.
fortable not complying with Select the free
measures are most useful in iden- REPAIRING RUPTURES
treatment. The therapist then sug- online programs tifying patients who are likely to Many factors can break down
gests breaking down the task in a through your drop out of therapy prematurely— the therapy alliance, such as
way that feels more comfortable MyAPA account. between 20 and 40 percent disagreement on treatment goals,
to the patient; they also discuss of therapy clients, according the patient’s misinterpretation of
the patient’s concern about the to research. To guard against something the therapist has said
therapist’s possible reactions to early dropout or the worsening or a mistrust of the therapeutic
his lack of compliance. of a patient’s condition, Lam- process. Research shows that

40 M O N I TO R O N P S YC H O LO G Y ● N OV E M B E R 2 0 1 9
 by recognizing one is occurring,
Muran says. Not surprisingly,
that’s easier when a rupture is
marked by confrontation rather
than withdrawal, so therapists
should watch out for the quieter
forms, he advises. The next step
is to address a rupture by, for
example, providing a rationale for
a task patients may be struggling
KEY POINTS with or renegotiating patients’
goals so they feel more aligned
1 with the direction of therapy.
Sixteen new
meta-analyses A more intensive strategy is
examine links to encourage a mutual discus-
between various sion that addresses the rupture
relationship factors
directly. Facing an uncomfortable
and outcomes, and
nine new meta-
conflict and working through it
analyses examine can aid the patient’s growth—and
factors related the therapist’s, says Muran.
to the best ways
of responding to
HANDLING
patients’ individual
characteristics.
NEGATIVE EMOTIONS
Patients probably wouldn’t be
2 in psychotherapy if they didn’t
Relationship factors
have negative feelings to work
are as or more
important in therapy
through. Unfortunately, it can be
outcomes than the difficult for clinicians to have to
Many factors can break down the therapy particular treatment address patients’ negative states
alliance, such as disagreement on treatment method used. repeatedly. Some therapists
goals or a patient’s misinterpretation of 3 become frustrated, which can be
taken by patients to mean there’s
something the therapist has said. Relationship factors
with the strongest something wrong with them, says
evidence to date Stony Brook University professor
include fostering
Marvin Goldfried, PhD, co-editor
the therapy alliance,
resolving these difficulties, known by patients’ external expressions collaboration,
of “Transforming Negative Reac-
as therapy ruptures, can lead to of anger, such as accusations or goal consensus, tions to Clients: From Frustration
better outcomes (Psychotherapy, sharp questioning of the thera- cohesion in group to Compassion” (APA, 2012).
Vol. 55, No. 4, 2018). pist. Withdrawal ruptures occur therapy, empathy, In such cases, therapists
positive regard
Ruptures fall into two general when patients pull away from the should examine their reactions
and affirmation,
categories, says psychotherapy therapist or from an aspect of and collecting and
and be alert to feelings of dis-
researcher J. Christopher Muran, themselves—for example, when delivering client traction, boredom or the urge to
KATARZYNA BIALASIEWICZ/GETTY IMAGES

PhD, a professor at Adelphi Uni- they fear the therapist’s criticism feedback. end the session. They should also
versity who directs the Mount or are afraid to delve into a pain- be aware that clients pick up on
Sinai Beth Israel Brief Psycho- ful topic. Clues that clients may therapists’ feelings through their
therapy Research Program at be heading toward such ruptures facial expressions, posture, tone
the Icahn School of Medicine at include retreating into silence and of voice and lack of eye contact.
Mount Sinai in New York. Con- not fully engaging in treatment. “We should go from any blame
frontation ruptures are marked Handling any rupture begins to the realization that they are

M O N I TO R O N P S YC H O LO G Y ● NOVEMBER 2019 41
CE Corner

stuck in some uncomfortable way his own parenting ability. He outcomes: having a mutual
of living,” Goldfried says, “and went on to share those reactions discussion about how the therapy
have compassion for that.” with her, and they moved back went, discussing the patient’s
Therapists should also pay into a discussion of her own future functioning and coping,
attention to countertransference RESOURCES parenting issues. helping the patient use new skills
issues, notes psychotherapy Such self-insight can lead beyond therapy, framing personal
researcher and University of Psychotherapy to better outcomes, according development as an ongoing
Maryland emeritus professor Relationships That to the task force report on process, anticipating post-therapy
Work: Vol. 1.
Charles J. Gelso, PhD, author of Evidence-Based three meta-analyses by Jeffrey growth, talking specifically about
“The Therapeutic Relationship in Therapist Hayes, Gelso and colleagues what it means to end this course
Psychotherapy Practice: An Inte- Contributions (Psychotherapy, Vol. 55, No. of therapy, reflecting on patient
grative Perspective” (Routledge, (3rd ed.) 4, 2018). Andrés Pérez-Rojas, gains, and expressing pride in
Norcross, J.C., &
2019) and co-author of “Counter- PhD, Gelso and colleagues have the patient’s progress and in
Lambert, M.J. (Eds.)
transference and the Therapist’s Oxford, 2019 also developed a measure that the mutual relationship (Psycho-
Inner Experience: Perils and helps psychotherapy trainees therapy, Vol. 54, No. 1, 2017).
Possibilities” (Erlbaum, 2007). Psychotherapy cultivate such self-awareness and As with other key moments in
Gelso describes his reaction to Relationships That manage their countertransference therapy, the psychologist should
a client who was talking about the Work: Vol. 2. reactions (Psychotherapy, Vol. 54, discuss termination openly,
Evidence-Based
way she parented her daughter. Therapist No. 3, 2017). even if a patient is simply toying
“All of a sudden I started making Responsiveness with the idea—for example, if
suggestions, which was com- (3rd ed.) PROMOTING the patient actually wants to

MEDIAPHOTOS/GETTY IMAGES
pletely unlike me—I just started Norcross, J.C., & EFFECTIVE ENDINGS stay but is scared to dive into a
Wampold, B.E. (Eds.)
jumping in and being an adviser,” When it’s time to end therapy, difficult topic, Tishby adds. Such
Oxford, 2019
he says. By examining his feel- research by Norcross and col- conversations may include talking
ings, he realized his patient was leagues finds that eight actions about those feelings or about
provoking his ambivalence about tend to promote better patient changing aspects of treatment to

OPTIMIZING THERAPY

WHAT THE EVIDENCE SHOWS

M
embers of the third interdi- causal link between the relationship your patient on the treatment process
visional APA Task Force on behavior and good outcomes. so that you are “on the same page.”
Evidence-Based Relation- Based on those findings, the panel ■ Goal consensus. Fostering agree-
ships and Responsiveness reviewed categorized elements of the therapy ment on the goals and expectations of
the evidence on 16 relationship factors relationship into the following three therapy.
thought to enhance psychotherapy groups. ■ Cohesion in group therapy.
outcomes. Experts conducted meta- Promoting a positive bond between
analyses on each one. A panel then DEMONSTRABLY EFFECTIVE all members of a psychotherapy group
rated the effectiveness of those rela- ■ The alliance (in individual adult by facilitating a climate of openness,
tionship elements using the following psychotherapy, in youth psychotherapy, warmth and egalitarianism.
criteria: the number of studies in a and in couple and family therapy). Build- ■ Empathy. Sensitive understanding of
given area; the consistency of empirical ing an effective working relationship the patient’s feelings and struggles; see-
results; the independence of the with your patient or patients; defined ing them from the patient’s point of view.
supportive studies; the size or strength by the quality and strength of the ■ Collecting and delivering client
of the association; the external validity relationship. feedback. Using feedback systems
of the research; and evidence for a ■ Collaboration. Working together with to gauge how a patient is doing and

42 M O N I TO R O N P S YC H O LO G Y ● N OV E M B E R 2 0 1 9
 better accommodate the patient,
she says.
When it’s clear to both ther-
apist and patient that it’s time to
RESOURCES stop, use the last few sessions to
discuss any issues that have not
Developing the received closure and summarize
Therapeutic
Relationship: the progress that’s been made,
Integrating Case says Tishby. Therapists shouldn’t
Studies, Research, be afraid to share some of their
and Practice own feelings: If you are saddened
Tishby, O., & by the ending of a relationship,
Wiseman, H. (Eds.)
APA, 2018 for example, share that with your
patient and how much you’ve
Psychotherapy valued your work together, she
Relationships advises.
That Work Over time, Tishby has come to
Norcross, J.C.,
& Lambert, M.J. respect patients’ wishes to leave
Psychotherapy, even when she thinks more work
2018 could be done, she adds.
[introduction to “You shouldn’t simply assume
special issue] that if they want to leave, they’re
resisting something,” she says.
“Sometimes therapists and
patients do have gaps in their
Acting on patient feedback also improves treatment outcomes. goals.” ■

using the information to tailor treatment genuineness and seeing each other in emotions as they are stirred up in
accordingly. This relationship factor has realistic terms. relation to your patient.
been shown in controlled trials to cause ■ Emotional expression. Sharing ■ Repairing alliance ruptures. Using
positive outcomes. genuine emotions with your patient in therapy tools such as empathy, collabo-
■ Positive regard/affirmation. Prizing ways that are appropriate to the frame- ration and mutual discussion to address
and supporting your patients, regard- work of therapy. breakdowns in the therapy relationship.
less of their behavior, attitudes or ■ Cultivating positive expectations.
emotions. Supporting patients’ expectations that PROMISING BUT NOT YET
their mental health will improve as a SUFFICIENTLY RESEARCHED
PROBABLY EFFECTIVE result of psychotherapy. ■ Self-disclosure and immediacy. Using
■ Congruence/genuineness. Relating ■ Promoting treatment credibility. the immediate situation to invite your
authentically to your patients without Promoting patients’ belief that psycho- patient to examine what is happening in
hiding behind a professional or personal therapy makes sense, is suited to their the therapy relationship. It may involve
facade. needs and is effective. disclosing aspects of your emotions or
■ The real relationship. Nurturing ■ Managing countertransference. personal life in ways that can feel risky
a therapy relationship marked by Attending to and controlling your own and unfamiliar.

M O N I TO R O N P S YC H O LO G Y ● NOVEMBER 2019 43