The Real Relationship

Although writing about the real relationship has existed from the beginnings of the talking cure,” it is only in recent years that empirical research has focused on this phenomenon. The real relationship is the personal relationship between patient and therapist marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that are realistic. The strength of the real relationship is determined by both the extent to which it exists and the degree to which it is positive or favorable. In this chapter, a meta-analysis is presented on the association between the real relationship and the outcome of psychotherapy. Summed across 16 studies, this meta-analysis revealed a moderate association with outcome (r =.38, 95% confidence interval [.30, .47], p<.001, d = 0.80, N = 1,502 participants). This real relationship–outcome association was independent of the type of outcome studies and of the source of the measure. We also present frequent measures of the real relationship, limitations of the research, and patient contributions. The chapter concludes with diversity considerations and practice recommendations for developing and strengthening the real relationship.

Positive Regard and Affirmation

This chapter meta-analytically reviews the research on the association between therapist positive regard and treatment outcome. The history of the construct of unconditional positive regard in client-centered theory, as well as the efforts to operationalize and measure this construct, are reviewed. Several clinical examples are presented. The meta-analysis, which features 64 studies, yielded a small positive association between positive regard and treatment outcome, g = 0.28. To control for the repeated use of data sets and study samples within the database, a multilevel meta-analysis was adopted that indicated a stronger relation between positive regard and clinical outcome, g = 0.36. These analyses support positive regard’s standing as a significant component of the therapy relationship that leads to improved clinical outcomes. The chapter concludes with limitations of the research, patient contributions, diversity considerations, and practice recommendations.

Empathy

Empathy refers to understanding what another person is experiencing or trying to express. The chapter begins by discussing definitional issues and presenting an integrative definition. It then reviews measures of therapist empathy, including the conceptual problem of separating empathy from other relationship variables. Clinical examples illustrating different forms of therapist empathy and empathic response modes are then presented. The core of the review is a meta-analysis of research on the relation between therapist empathy and client outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome: mean weighted r = .28 (equivalent of d = .58) for 82 independent samples and 6,138 clients. In general, the empathy–outcome relation held for different theoretical orientations and client presenting problems. The chapter considers the limitations of the current data and concludes with diversity considerations and practice recommendations, including endorsing the different forms that empathy may take in therapy.

Alliances in Couple and Family Therapy

This chapter reviews meta-analytic evidence for the alliance-outcome relation in couple and family therapy (CFT). The authors describe the unique features of CFT alliances and their measurement, followed by case descriptions. A meta-analysis of 48 studies (Ns = 2,568 families, 1,545 couples, and 491 effect sizes) found r = .297. In another analysis with 7 independent samples and 31 effect sizes, the split alliance–outcome association was also significant, r = .316, indicating that the more split or unbalanced the alliance, the poorer the outcome. Moderator analyses showed that alliance–outcome associations did not differ for couple versus family therapy, but correlations were significantly stronger in samples with younger problem children, older adults, proportionally more male youth and adults, and when the families voluntarily sought help (as compared to involuntary or mandated families). The chapter concludes with research-informed strategies for building and sustaining strong alliances in CFT.

What Works in the Psychotherapy Relationship: Results, Conclusions, and Practices

This chapter concludes the first volume of the third edition of Psychotherapy Relationships That Work. The authors present the formal conclusions and the 28 recommendations of the Third Interdivisional Task Force. Summaries of the meta-analytic associations between the relationship elements and psychotherapy outcomes are provided. Those statements, approved by the 10 members of the Steering Committee, refer to the work in both this volume on therapy relationships and the second volume on treatment adaptations or relational responsiveness. These statements reaffirm and, in several instances, extend those of the earlier task forces. The chapter concludes with final thoughts on what works, and what does not, in the therapy relationship.

Collecting and Delivering Client Feedback

This meta-analysis examines the impact of measuring, monitoring, and feeding back information on client progress to clinicians while they deliver psychotherapy. It considers the effects of the two most frequently studied routine outcome monitoring practices: the Partners for Change Outcome System and the Outcome Questionnaire System. Meta-analyses of 24 studies produced effect sizes from small to moderate. Feedback practices reduced deterioration rates and nearly doubled clinically significant/reliable change rates in clients who were predicted to have a poor outcome. Clinical examples, diversity considerations, and therapeutic advances are provided.

Emotional Expression

Although emotion has long been considered important to psychotherapeutic process, empirical assessment of its impact has emerged only recently. This chapter reports two meta-analyses on the association between therapist expression of emotion and psychotherapy outcome and client expression of emotion and psychotherapy outcome. A significant medium effect size was found between impact of therapist emotional expression and outcomes (d = 0.56, 13 studies) and a significant medium-to-large effect size client emotional expression and outcomes (d = 0.85, 43 studies). Third-party rating of emotional expression emerged as a significant moderator of outcomes. Limitations of the research, diversity considerations, and therapeutic practices conclude the chapter.

Managing Countertransference

This chapter reviews the history and definition of countertransference, as well as empirical research on countertransference, its management, and the relation of both to psychotherapy outcome. Three meta-analyses are presented, as well as studies that illustrate findings from the meta-analyses. The first meta-analysis indicated that countertransference reactions are related inversely and modestly to psychotherapy outcomes (r = –.16, d = –.33, k = 14 studies, N = 973). A second meta-analysis supported the notion that countertransference management factors attenuate countertransference reactions (r = –.27, d = –.55, k = 13 studies, N = 1,065). The final meta-analysis revealed that successful countertransference management is related to better therapy outcomes (r = .39, d = .84, k = 9 studies, N = 392 participants). The authors conclude by summarizing the limitations of the research base, noting diversity considerations, and highlighting the therapeutic practices predicated on research.

Promoting Treatment Credibility

Patients’ perception of treatment credibility represents their belief about a treatment’s personal logicality, suitability, and efficaciousness. Although long considered an important common factor bearing on clinical outcome, there have been no systematic reviews of the credibility–outcome association. In this chapter, the authors first discuss the definitions of credibility and similar constructs, common measures of credibility, clinical examples of treatment credibility perception, and several landmark studies. The chapter then presents a meta-analysis of the association between patients’ credibility perception and their posttreatment outcomes. The meta-analysis was conducted on 24 independent samples with 1,504 patients. The overall weighted effect size was r = .12, or d = .24. Next, the authors present moderators and mediators of the treatment credibility–outcome link (the former in the context of the meta-analysis), evidence supporting causality in the association, patient factors contributing to their treatment credibility perception, and limitations of the research base. Finally, the chapter reviews diversity considerations, training implications, and therapeutic practices with regard to patient-perceived treatment credibility and its association with therapy outcome.

Alliance in Child and Adolescent Psychotherapy

In youth treatment, the alliance has been defined and measured as a consensual or collaborative bond. This chapter reviews varied definitions of the alliance, enumerates its frequent measures, and presents clinical examples. The authors provide a meta-analytic review on the relation between the therapeutic alliance and treatment outcome in child and adolescent psychotherapy. The meta-analysis of 43 studies revealed a weighted random effect size of r = .20, which is a small to medium effect consistent with the adult alliance literature and with prior youth meta-analyses. Multiple moderators of the alliance–outcome association were found, including diagnosis class, study design, and outcome rater. Research limitations, patient contributions, and diversity considerations follow. The chapter concludes with research-informed practices for building and maintaining the therapeutic alliance with youth.