g_)bpl t0EMPIRICALLY SUPPORTED THERAPY RELATIONSHIPS: CONCLUSIONS AND RECOMMENDATIONS OF THE DIVISION 29 TASK FORCE

i"i"vmR _m\f g0STEERING COMMITTEE1

d:^f"N5M4? VY!K0'Steven J. Ackerman (student member), Lorna Smith Benjamin (University of Utah), Larry E. Beutler (University of California-Santa Barbara), Charles J. Gelso (University of Maryland), Marvin R. Goldfried (SUNY-Stony Brook), Clara Hill (University of Maryland), Michael J. Lambert (Brigham Young University), John C. Norcross (chair), David E. Orlinsky (University of Chicago), and Jackson Rainer (liaison to Publication Board)

1r[Py"R5O"Rq@0Conclusions of the Task Force

• The therapy relationship (as defined in the opening article) makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment.
• Practice and treatment guidelines should explicitly address therapist behaviors and qualities that promote a facilitative therapy relationship.
• Efforts to promulgate practice guidelines or evidence-based lists of effective psychotherapy without including the therapy relationship are seriously incomplete and potentially misleading on both clinical and empirical grounds.
• The therapy relationship acts in concert with discrete interventions, patient characteristics, and clinician qualities in determining treatment effectiveness. A comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations.
• Adapting or tailoring the therapy relationship to specific patient needs and characteristics (in addition to diagnosis) enhances the effectiveness of treatment.
• The following list embodies the task force conclusions regarding the empirical evidence onGeneral Elements of the Therapy Relationshipprimarily provided by the psychotherapist. Definitions and examples of each element are provided in the respective articles. 

Demonstrably Effective心理学空间g#B!K7I i]Z

Therapeutic Alliance心理学空间MN#]JZO-p

Cohesion in Group Therapy

F^ QF#b0Empathy

%H'EH4iK-H:zJp0Goal Consensus and Collaboration

Promising and Probably Effective心理学空间d4s }(tlZs:a

Positive Regard心理学空间 ly l)V5M7L$Fi](Q

"ZSD0K/qM(WDf0Congruence/Genuineness心理学空间d\Mq?3L

Feedback心理学空间}k wp3U.a][

0~%P0l3pQEy%Q0Repair of Alliance Ruptures 

5l"L_ |I-}5p'H0Self-Disclosure心理学空间 ob7G(le

Management of Counter-transference心理学空间D9?9Yhi Y:})\1o

Quality of Relational Interpretations心理学空间"]%x0@5m'bw2a{

• The following list embodies the task force conclusions regarding the empirical evidence on Customizing the Therapy Relationship to Individual Patients on the basis of patient behaviors or qualities. For example, clients presenting with high resistance have been found to respond better to self-control methods and minimal therapist directiveness, whereas patients with low resistance experience improved outcomes with therapist directiveness and explicit guidance. Definitions and examples of the following patient characteristics are provided in the respective articles. 

Demonstrably Effective as a Means of Customizing Therapy心理学空间{nsb4w

t5d7y i/vy4e0Resistance

n/] W2x*^i5@T0Functional Impairment心理学空间^ b|2BwAu4S9[

Promising and Probably Effective as a Means of Customizing Therapy

r/i}(lf2GL0Coping Style心理学空间BE/j8]){CXh

Stages of Change心理学空间"Qj"E'x^[q

Anaclitic/Sociotropic and Introjective/Autonomous Styles

Expectations心理学空间Vz7@9G8?B

Assimilation of Problematic Experiences心理学空间7X)rN#mO#X%^Q/^3Z

• Current research on the following patient characteristics is insufficient for a clear judgment to be made on whether customizing the therapy relationship to these characteristics improves treatment outcomes. Definitions and examples of the following patient characteristics are provided in the respective articles.

Attachment Style

6l%{9Z,X D;|3Z1Z0Gender

Ethnicity心理学空间2`3k$t7U6[0A1T3}2~

f8S3Zc;v7?1W,[8l%t0Religion and Spirituality心理学空间h&\)fF!i(Ho

6[BY*if0Preferences 

Personality Disorders心理学空间t#Z5]N8[Mwq8c

• The preceding conclusions do not by themselves constitute a set of practice standards, but represent current scientific knowledge to be understood and applied in the context of all the clinical data available in each case.

Recommendations of the Task Force心理学空间 ~M/b+]2{uZ4``

General Recommendations心理学空间 N&[ Xd+? kNI

1. We recommend that the findings and conclusions of this task force be widely disseminated in order to enhance awareness and use of what "works" in the therapy relationship.
2. At the same time, readers are encouraged to interpret these findings in the context of the limitations of the task force's work, as explicated in the opening article of this report.
3. These findings and conclusions represent initial steps in aggregating and codifying available research. We recommend mat future task forces be established periodically to review these findings, include new elements of the relationship, incorporate the results of non-English publications (where practical), and update the conclusions.

a9a:_%c(G#M:U(N0Practice Recommendations

4. Practitioners are encouraged to make the creation and cultivation of a therapy relationship characterized by the elements found to be demonstrably and probably effective in this report a primary aim in the treatment of patients.
5. Practitioners are encouraged to adapt the therapy relationship to specific patient characteristics in the ways shown in this report to enhance therapeutic outcome. 
6. Practitioners are encouraged to routinely monitor patients' responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to repair alliance ruptures, to improve the relationship, to modify technical strategies, and to avoid premature termination. 
7. Concurrent use of empirically supported relationships and empirically supported treatments tailored to the patient's disorder and characteristics is likely to generate the best outcome. 

Training Recommendations

8. Training programs in psychotherapy are encouraged to provide explicit and competency-based training in the effective elements of the therapy relationship.
9. Accreditation and certification bodies for mental health training programs are encouraged to develop criteria for assessing the adequacy of training in empirically supported therapy relationships in their evaluation process.
10. Both graduate training and continuing education programs are encouraged to offer modules on empirically supported therapy relationships and on systematically adapting the therapy relationship to the individual patient.

/iH0nVQ X"^A3N0Research Recommendations心理学空间/o4i)S)`'I7oJ-r+r

11. Researchers are encouraged to examine the specific mediators and moderators of the links between demonstrably effective relationship elements and treatment outcome.
12. Researchers are encouraged to progress beyond experimental designs that correlate frequency of relationship behaviors and outcome measures to methodologies capable of examining the complex associations among patient qualities, clinician behaviors, and therapy outcome.
13. Researchers are encouraged to avoid a "therapist-centric" view of the therapy relationship and to study both patients' and therapists' contributions to the relationship and the ways in which those contributions combine to impact treatment outcome.
14. Although the cumulative research convincingly shows that the therapy relationship is crucial to outcome, relatively little is known about how to create and sustain the relationship and about why the relationship works. These are vital questions for future research.
15. Observational perspective (i.e., therapist, patient, or external rater) is a fundamental consideration that ought to be addressed in future studies and reviews of "what works" in the therapy relationship. Agreement among observational perspectives provides a solid sense of established fact; divergence among perspectives holds important implications for clinical practice.
16. Since many of the important variables reviewed in this report are not subject to randomization and experimental control, we rec-ommend that standard research paradigms include the use of rigorous qualitative methods and statistically controlled correlational designs.

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17. The APA Division of Psychotherapy is encouraged to educate its members and leaders in the benefits of empirically supported therapy relationships.
18. Mental health organizations as a whole are encouraged to educate their members about the improved outcomes associated with using empirically supported relationships along with evidence-based treatments.
19. Finally, we recommend that the APA Division of Psychotherapy and mental health organizations advocate for the research-substantiated benefits of a facilitative and individually responsive human relationship in psychotherapy.