Ever since 1996, when the APA’s Division 12, the Society of Clinical Psychology, first assembled its list of what are now called empirically supported treatments (ESTs)—specific treatments that research appeared to show were effective for specific disorders—the idea that the match between a given therapeutic approach and a particular presenting problem was the key to successful therapy has gained currency. Yet, critics of the EST approach have steadily produced empirical evidence demonstrating that a specific treatment is a relatively minor factor in effective psychotherapy. Years of studies and metanalyses showing the greater importance of what psychotherapy researcher John Norcross has coined “evidence-based relationship” (EBR)—the connection between client and therapist that cuts across treatment methods—have alerted therapists to the importance of the healing relationship. However, even therapists who endorse the centrality of the relationship often don’t realize that EBRs have moved well beyond the vague construct of therapy alliance to a more fine-grained way of thinking about and managing the therapeutic relationship.


The EBR, says Norcross, incorporates such specifics as clients’ choices, expectations, and readiness for change. Two recent journal issues, both with introductions by Norcross—the February 2011 Journal of Clinical Psychology and the March 2011 Psychotherapy—present more than 20 studies and articles featuring metanalyses that will help therapists quickly establish evidence-based relationships. The data supporting EBRs is now so compelling, says Norcross, that the standard of therapeutic competency should be expanded from using empirically supported treatments to also establishing and maintaining therapy relationships.

According to Norcross, it’s been shown that matching the relationship to at least five transdiagnostic client-characteristics produces better treatment outcomes:

-Reactance/resistance: Clients who are easily provoked and are oppositional toward external demands benefit more from therapy that stresses self-control and uses minimal direction and paradoxical interventions. Clients with low reactance benefit more from directive therapy and explicit guidance.

-Preferences: Accommodating clients’ choices about style of treatment, how long they’d prefer therapy to last, and what they don’t want improves the therapeutic relationship and reduces dropout rates by 33 percent.

-Religion/spirituality: Therapists who adapt therapy to clients’ spiritual beliefs and religion by honoring their belief systems experience more success.

-Stages of Change: Knowing how ready (or unready) a client is for change and adapting your style to each stage reliably predicts therapy outcome. For example, if a client isn’t sure he wants to change, being a directive, supportive coach isn’t likely to work as well as supporting his current feelings and explorations.

-Coping Style: Clients who internalize respond better to interpersonal and insight-oriented therapy; clients who externalize do better with symptom-focused and skills-building therapy.

In addition, metanalyses attest that clients’ expectations and attachment styles affect outcome, but there isn’t enough research on this yet to match these characteristics to therapists’ methods.

These findings corroborate what many therapists have long believed about effective therapy: the relationship with a client is more important than providing a specific type of treatment. They also provide a clearer understanding of how to achieve truly client-centered therapy. “The creation and cultivation of a therapy relationship should be a therapist’s primary aim,” says Norcross. “And that involves creating a new therapy for each client.”

Can We Trust Studies?

It took years for psychology to move from being perceived primarily as a soft science to being viewed as one built upon the bedrock of empiricism. Now an article by Jonah Lehrer in the December 13, 2010, New Yorker hearkens back to that earlier view by suggesting that psychology findings may be more ephemeral than we thought. In “The Truth Wears Off,” provocatively subtitled, “Is There Something Wrong with the Scientific Method?” Lehrer examines the well-known phenomenon of diminishing effect sizes in psychology research: studies that attempt to replicate original studies yield smaller and smaller results over time.

Lehrer’s article focuses on social psychologist Jonathan Schooler, whose landmark 1990 study discovered the concept of verbal overshadowing. Schooler found that people who are asked to describe an event immediately after it occurs have poorer recall of it later. The study overturned the prevailing notion that talking about something immediately would enhance recall. But each time he tried to replicate his original study, he found that the effect size kept shrinking, eventually by about 60 percent. “It was,” says Schooler, “as if nature gave me this great result, and then tried to take it back.”

Lehrer examines several reasons for the phenomenon of diminishing effects. Confirmatory bias frequently plays a role, influencing researchers to find what they expect or want to find. For instance, numerous studies showing that optimism protects against cancer are slowly melting in the face of more hard-eyed research. Exaggerated results are also a problem. Some studies have exaggerated results because their sample size is too small to support the conclusions they draw, so replication is less likely. In fact, in the July 13, 2005, Journal of the American Medical Association, epidemiologist John Ioannidis concludes that in the scientific literature, 25 percent of the most frequently cited clinical trials had findings that were exaggerated because of small sample groups.

However, Lehrer attributes much of the diminishing effect phenomenon to randomness. Case in point, researchers simultaneously conducted tests of the effects of cocaine on mice under rigorously controlled, identical conditions in three cities, and yet one city’s results significantly varied. That’s because in any experiment, Lehrer says, no matter how rigorously controlled, the possibility of outliers exists—people or other organisms who, for some indiscernible reason, end up at the far ends of the bell curve. Only large or multiply replicated studies can correct for this.

So can we discern incontrovertible facts from psychology research? Lehrer doesn’t seem very positive about that question. “The declining effect,” he concludes, “is troubling. . . . We like to pretend that our experiments define the truth for us. [But] when the experiments are done, we still have to choose what to believe.”

Although the phenomenon of diminishing effect is well-known to researchers, Northwestern University psychologist Jay Lebow, a frequent contributor to the Networker on psychotherapy research, points out that Lehrer ignored the many studies that don’t have diminishing effect sizes. “There are endless examples of well-established findings in the social sciences where something is found and the effect is regularly replicated,” Lebow says. Numerous replicable studies prove there’s a strong association between individual distress and relationship problems, and that psychotherapy has a steady, beneficial effect.

Lehrer’s article, which created a huge buzz among researchers and the public, is a valuable reminder to read studies more carefully and not to rely on abstracts or media accounts of the findings.

Responding to Suicidal Clients

When a therapist suspects a client is contemplating suicide, one of the commonest interventions is a procedure called suicide prevention contracting (SPC), either a formally written contract or a firm verbal assurance or agreement. Although the research has been clear for years that SPC isn’t very effective at preventing suicides, many therapists figure it might work, and, if worst comes to worst, SPC could afford some legal protection. But in the November 2010 Crisis: The Journal of Crisis Intervention and Suicide Prevention, social worker Stephen Edwards points out that these are both serious miscalculations. Edwards cites studies showing that insisting on SPC may actually increase the likelihood of suicide, and, given the research demonstrating its ineffectiveness, SPC won’t prove due diligence or clinical competence either.

Therapists, says Edwards, coauthor with Christopher Goj of the forthcoming book Suicide Prevention Contracting, need to know about a “deadly dangerous paradox” of SPC, especially because a survey of 420 therapists conducted by Edwards and social worker Mark Sachmann found that about 80 percent of them believed SPC causes no harm. Although therapists believe that SPC communicates their concern and compassion, research finds that many clients, especially those with histories of suicide attempts, see SPC as an attempt by therapists to protect themselves. Suicidal clients who feel that a therapist’s primary concern is self-protection may mask their feelings of rage, despair, or abandonment and agree to SPC, leaving the therapist feeling safer, but in no way helping to protect the potentially suicidal client.

So what should therapists do when a client appears to be suicidal? Noting that, “The strength of any suicide contract rests only on the strength of the therapy relationship,” Vancouver, B.C., psychologist Michael Mandrusiak advocates using a treatment agreement instead of SPC in the February 2006 Journal of Clinical Psychology. “From suicidal clients’ perspectives,” says Mandrusiak, “suicide isn’t their problem, it’s their solution.” Insisting on SPC backs them into a corner and is as likely to shut down treatment as enable it.

Instead, Mandrusiak says, therapists should try to get clients’ agreement to give treatment a chance, implicitly or explicitly leaving the suicide option on the table. Talking about a treatment agreement serves as a preliminary assessment of the seriousness of the suicidal intent: clients who won’t agree at least to discuss a treatment agreement are likely at higher risk. That’s the kind of information you won’t get out of SPC.

Part of the treatment agreement should include a safety plan. Clients who participate in drawing up their own plans are already engaging in treatment. Mandrusiak advises therapists to enlist clients’ creativity. Which friends and family members can clients call on when they’re desperate? How will they discuss with them their inclusion in the safety plan?

As the dialogue proceeds using this approach, the therapy relationship is likelier to open up, replacing the negative energy of don’ts with collaboration and hope. “Persuading clients to promise not to kill themselves makes them passive and puts clinicians in the driver’s seat,” notes Mandrusiak. “Effective change occurs when clients are active participants.”

Better or Worse Times for Therapists?

In January 2010, the long-awaited Mental Health Parity and Addiction Equity Act went into effect. Sponsored by New Mexico Senator Pete Domenici, whose adult daughter suffers from schizophrenia, and the late Minnesota Senator Paul Wellstone, the law is intended to ensure that Americans who seek mental health treatment receive the same level of insurance benefits that they do for any medical condition. It eliminates separate tiers of deductibles, out-of-pocket costs, and benefit limits, and would seem to be a great boon to therapy and therapists. But under intense lobbying from insurance companies, it ends up covering only group policies issued by businesses employing more than 50 people. It doesn’t require plans without mental health coverage to add it; it says only that if a plan offers mental health benefits, the coverage must be equivalent.

While helping thousands of people get better mental health coverage, the law has had some unintended consequences. In a paper currently under review for publication, psychologists Michael Hoyt of San Rafael, California, and Alan Gurman, coeditor of the classic Clinical Handbook of Couple Therapy, note that therapy sessions treating relational problems or involving an identified client’s family or peer support system are now triggering more denials of payment by insurance companies. Insurers are taking this action despite clear research showing that bringing a depressed client’s partner or a troubled adolescent’s friends into sessions can help significantly. Another development, says Hoyt, is that some HMOs are narrowly invoking “medical necessity” as a way to restrict coverage to brief cognitive therapies. Both Hoyt and Gurman consider this part of a movement to replace forms of evidence-based psychotherapy with psychopharmacology. Because medical necessity often equates only to “the most appropriate level of service,” this may herald a return to the old days of restricting coverage to briefer forms of therapy.

Ironically, parity has resulted in some loss of mental health coverage. A report by the Kaiser Foundation notes that 9 percent of firms with more than 50 employees that had previously supplied mental health coverage dropped the coverage as a result of what they said were increased premiums brought on by parity. However, parity isn’t the real cause of the higher premiums: it’s merely the excuse put forward by insurance companies to disguise their power play to increase profits. The Congressional Budget Office estimated that parity would increase premiums by less than 1 percent. Yet, since January 2010, insurance companies have raised their premiums by 8 to as much as 20 percent. This has yielded the logical result: in 2010, WellPoint, UnitedHealth, Aetna, Humana, and Cigna aggregately netted $3.2 billion, a 31-percent profit increase over 2009, according to Health Care for America Now, a nonprofit consumer advocacy group.

Will the Affordable Health Care Act, popularly known as healthcare reform, help remedy the situation? After all, it’s intended to lower premiums and bring insurance coverage to millions of Americans, mandating that most Americans have health insurance by 2014. Moreover, beginning in 2011, insurance companies are required to spend at least 80 percent of all premium dollars on healthcare—not on salaries, dividends, or administrative costs. But the same forces that cut away at parity may whittle down the new law’s intended benefits. Many therapists are already reporting increasing denials and payment delays.

People who run billing services for therapists, however, are just beginning to see changes. “A lot of policies have changed,” says Jean Thoensen of PsychBiller, LLC. “Many have dropped preauthorization requirements, for example, but some have added them.” For instance, she notes that Anthem Blue Cross of California now requires preauthorization after the 12th visit for most policies. She’s also seen policies that only allow 10 visits per year, and require preauthorization.

Social worker Susan Frager, who runs Psych Administrative Partners, hasn’t seen any noticeable roadblocks yet, but expects that more preauthorization requirements or back-end audits are coming soon. With back-end audits, therapists may have to produce their treatment notes and be subject to refunding insurance payments.

Frager’s wake-up call for therapists includes a prediction that parity and insurance reform will give cover for insurance companies to insist that therapists prove medical necessity before or after providing treatment. In addition to requiring “appropriate levels of care,” medical necessity calls for treatment that meets accepted standards of medical practice. So this is probably an excellent time for clinicians to become proactive about ensuring that their practices maintain appropriate standards.

All insurance companies are obligated to post their codes outlining what they define as a medical necessity, usually on their websites, Frager explains. So doing this bit of research is a good start. “Most therapists’ practices probably do meet these standards,” she adds, “But it’s the documentation of it that’s the key.”



Client-Based Therapy:

Journal of Clinical Psychology 67, no. 2 (February 2011): 127-214

Psychotherapy 48, no. 1 (March 2011)

Trusting Studies:

New Yorker (December 13, 2010): 52-57

Journal of the American Medical Association 294, no. 2 (July 13, 2005): 218-28


Crisis: The Journal of Crisis Intervention and Suicide Prevention 31, no. 6 (November 2010): 290-302

Journal of Clinical Psychology 62, no. 2 (February 2006): 243-51

Garry Cooper

Garry Cooper, LCSW, is a therapist in Oak Park, Illinois.


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