The Therapy Relationship in IPT: Elements, Functions, and Findings Gregory G. Kolden, Ph.D. University of Wisconsin – Madison Department of Psychiatry.

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

[email protected]

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)

Evidence-Based Relational Elements: A Review

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

ConclusionConclusion