the therapy relationship in ipt: elements, functions, and findings gregory g. kolden, ph.d....
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The Therapy Relationship in IPT:Elements, Functions, and Findings
Gregory G. Kolden, Ph.D. Gregory G. Kolden, Ph.D.
University of Wisconsin – MadisonUniversity of Wisconsin – Madison
Department of PsychiatryDepartment of Psychiatry
44thth International Conference on Interpersonal Psychotherapy International Conference on Interpersonal Psychotherapy
Amsterdam, the NetherlandsAmsterdam, the Netherlands
June 23, 2011June 23, 2011
Collaborators
UW Department of PsychiatryPsychology Faculty and Trainees
UW Department of PsychologySara B. Austin
UW Department of Counseling Psychology Bruce Wampold, Ph.D.
AcknowledgementsAcknowledgementsAcknowledgementsAcknowledgements
Dr. Kolden has no industry relationships to disclose. Dr. Kolden has no industry relationships to disclose.
Overview
• Stimulate thoughtful discussion regarding the nature of the therapy relationship in IPT
• Goal: Review of evidence-based relational elements
(i.e., what works in general)
• Goal: Consider relational elements relevant for IPT
(i.e., general as well as treatment-specific nature of the relationship in IPT)
• Goal: Consider therapist practices likely to foster relational elements relevant for IPT
Gelso & Carter (1985, 1994)
“The relationship is the feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed.”
The Therapy Relationship: An Operational Definition
The Therapy Relationship: Functions
Context for change: Relationship makes learning possible
AND
Direct mechanism of change: Relationship events influence biological, psychological and social processes
Kolden et al. (2006)
Culture Warsin Psychotherapy
“The culture wars in psychotherapy dramatically pit the
treatment method against the therapy relationship.”
(Norcross & Lambert, 2011, p. 4)
The therapy relationship operates in concert with interventions, patient characteristics, and therapist qualities in determining outcomes.
(Norcross & Wampold, 2011)
Interdivisional Task Force on Evidence-Based Therapy Relationships
John C. Norcross, Ph.D., Chair
1/2/2011
Norcross, J.C., & Lambert, M.J. (2011). Psychotherapy Relationships That Work II. Psychotherapy, 48/1, 4-8.
Norcross, J.C. (Ed.) (2011). , Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press.
National Registry of Evidence-based Programs and Practices
(www.nrepp.samhsa.gov/)
Conclusions of the Task Force(Norcross &Wampold, 2011)
• The therapy relationship makes substantial and consistent contributions to outcome independent of type of treatment.
• The therapy relationship accounts for improvement (or failure to improve) at least as much as treatment method.
Conclusions of the Task Force(Norcross &Wampold, 2011)
• Efforts to disseminate evidence-based practices without including the relationship are incomplete and potentially misleading.
• Practice guidelines should address therapist behaviors and qualities that promote a facilitative therapy relationship.
The Therapy Relationship and IPT
Can we identify general relational elements and behaviors important for IPT?
Can we identify relational elements and behaviors specific to IPT?
Can we identify relational elements and behaviors
proscribed for IPT?
“Therapeutic Alliance”Borden (1994) - Goals, Tasks, Bonds
Horvath, Del Re, Fluckiger, & Symonds (2011)
190 studies (k); 14,000+ adult participants (N)
Weighted aggregate ES = .275 (p < .0001)
95% CI = .25 to .30
Small to medium ES (Cohen, 1988) accounting for 7.5% variance in outcome
Broad & Inclusive Relational Elements
“Empathy”
Elliott, Bohart, Watson, & Greenberg (2011)
59 studies (k); 3599 participants (N)
Weighted aggregate ES = .31 (p < .001)
95% CI = .28 to .34
Medium ES (Cohen, 1988) accounting for 9% variance in outcome
Specific Relational Elements
“Goal Consensus”patient and therapist agreement on therapeutic goals
Tryon and Winograd (2011)
15 studies 2000-2009 (k); 1302 participants (N)
Weighted aggregate ES = .34 (p < .0001)
95% CI = .23 to .45
Medium ES (Cohen, 1988) accounting for 11.5% variance in outcome
Specific Relational Elements
“Collaboration”patient and therapist actively involved in cooperative relationship
Tryon and Winograd (2011)
19 studies 2000-2009 (k); 2260 participants (N)
Weighted aggregate ES = .33 (p < .0001)
95% CI = .25 to .42
Medium ES (Cohen, 1988) accounting for 11% variance in outcome
Specific Relational Elements
“Positive Regard”
Farber and Doolin (2011)
18 studies (k); 1067 participants (N)
Weighted aggregate ES = .27 (p < .000)
95% CI = .16 to .38
Small to medium ES (Cohen, 1988) accounting for 7% variance in outcome
Specific Relational Elements
“Congruence/Genuineness”
Kolden, Klein, Wang, & Austin (2011)
16 studies (k); 863 participants (N)
Weighted aggregate ES = .24 (p = .003)
95% CI = .12 to .36
Small to medium ES (Cohen, 1988) accounting for 6% variance in outcome
Specific Relational Elements
Summary
ES Variance MagnitudeAlliance .275 7.5% small to medium
Empathy .31 9% medium
Goal Consensus .34 11.5% medium
Collaboration .33 11% medium
Positive Regard .27 7% small to medium
Congruence .24 6% small to medium
Relational elements relevant for IPT
Can we identify relational elements and behaviors specific to IPT?
Can we identify general relational elements and behaviors important for IPT?
Can we identify relational elements and behaviors
proscribed for IPT?
Relational elements relevant for IPT
IPT specific
goal consensus
General
collaboration
empathy
positive regard
congruence/genuineness
Relational elements relevant for IPT
Proscribed
low levels of effective relational elements
excessive focus on transference configurations
ineffective therapist relational behaviors
Therapist Practices
• Explicitly embrace idea of actively cultivating relational behaviors with clients.
• Relational behaviors must be mindfully developed and practiced as complex therapy skills.
• Effective therapists seek awareness of their typical relational style and model healthy relational behaviors.
Therapist Practices
• The maintenance of effective relational behaviors requires therapist awareness of instances when the relationship falters.
• Effective therapists will adjust relational behaviors according to client characteristics, needs, preferences, and expectations (e.g., age, education, culture)
Therapist Practices
Be mindful of “ineffective” therapist relational behaviors!
• Low levels of effective relational behaviors
• Confrontational style
• Negative processes (e.g., hostile, rejecting, blaming, critical comments)
Implications for Training and Supervision in IPT
• Competency-based training in effective elements of the therapy relationship (Norcross & Wampold, 2011)
• Develop criteria for assessing the adequacy of training in effective relational behavior
• Competency-based training in the adaptation of relationship behaviors to the individual patient
Implications for Research on IPT
• Studies demonstrating that relational elements (beyond working alliance) are important for the effectiveness of IPT
• Dissemination research to include an emphasis on IPT interventions AND relational behavior
• Mediators and moderators of relationship element – outcome associations