By Garry Cooper
Truly Client-Centered Therapy
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.”