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In 2009, the American Psychological Association Division of Psychotherapy along with the Division of Clinical Psychology commissioned a second task force on evidence-based therapy relationships to update the research base and clinical practices on the psychotherapist–patient relationship. This chapter begins by tracing the purpose and processes of the interdivisional Task Force. It explicates the need for identifying evidence-based elements of the therapy relationship and means of matching or adapting treatment to the individual. In a tentative way, it offers two models to account for psychotherapy outcome as a function of various therapeutic factors (e.g., patient, relationship, technique). The latter part of the chapter features the limitations of the Task Force's work and responds to frequently asked questions.

Couple and family therapy (CFT) is challenging because multiple interacting working alliances develop simultaneously and are heavily influenced by preexisting family dynamics. An original meta-analysis of twenty-four published CFT alliance-retention/outcome studies (k =17 family and 7 couple studies; N = 1,416 clients) showed a weighted aggregate r = .26. This medium effect size is almost identical to that reported for individual adult psychotherapy. In this chapter, we also summarize the most widely used alliance measures used in CFT research, provide an extended clinical example, and describe patient contributions to the developing alliance. Although few moderator or mediator studies have been conducted, the available literature points to three important alliance-related phenomena in CFT: the frequency of “split” or “unbalanced” alliances, the importance of ensuring safety, and the need to foster a strong within-family sense of purpose about the purpose, goals, and value of conjoint treatment. We conclude with a series of therapeutic practices predicated on the research evidence.

Cohesion is the most popular of several relationship constructs in the group therapy literature. This chapter reviews the most frequently cited definitions and studied measures of group cohesion. This chapter briefly introduces a new measure, the Group Questionnaire, which elucidates group relationships by suggesting two latent factors of cohesion: relationship quality (positive bond, positive work, and negative relationship) and structure factors (member–leader and member–member). To further understand the literature, a meta-analysis was conducted examining the relationship between cohesion and treatment outcome in forty studies. Results indicate cohesion has a moderate relationship with outcome and five moderator variables. Consideration of measures and practices to improve treatment outcome are highlighted.

After defining empathy, discussing its measurement, and offering an example of empathy in practice, this chapter presents the results of an updated meta-analysis of the relation between empathy and psychotherapy outcome. Results indicated that empathy is a moderately strong predictor of therapy outcome (mean weighted r = .30) but revealed considerable nonrandom variability. The empathy–outcome relation held equally for different theoretical orientations. Client and observer perceptions of therapist empathy predicted outcomes better than therapist perceptions of empathic accuracy measures, and the relation was strongest for less experienced therapists. We conclude with practice recommendations, including endorsing the different forms that empathy may take in therapy.

Client preferences are recognized as a key component to evidence-based practice; however, research has yet to confirm the actual influence preferences have on treatment outcome. In this meta-analysis, this chapter summarizes results from thirty-five studies that have examined the preference effect with adult clients. Overall, clients who were matched to their preferred therapy conditions were less likely to drop out of therapy prematurely (OR = .59, p 〈 .001) and showed greater improvements in treatment outcomes (d = .31, p 〈 .001). Type of preference (role, therapist, or treatment type) was not found to moderate the preference effect, but study design was found to be a significant moderator, with RCTs showing the largest differences between preference-matched and nonmatched clients. These results underscore the centrality of incorporating patient preferences when making treatment decisions. Clinical examples and therapeutic practices are provided.

This final chapter reports our research conclusions and practice recommendations from the twenty meta-analyses. This chapter places the meta-analytic evidence on therapy relationships in the context of “treatment effects” and integrate research in the three key contributions: client, relationship, and treatment.

Patients’ expectations have long been considered a contributory factor to successful psychotherapy. Expectations come in different guises, with outcome expectations centered on prognostic beliefs about the consequences of engaging in treatment. This chapter defines outcome expectations and present assessment methods and clinical examples of outcome expectations. The research review includes a comprehensive meta-analysis (N = 8,016 patients across forty-six independent samples) of the association between pre- or early-therapy outcome expectations and posttreatment outcomes. The overall weighted effect size was d = .24, p 〈 .001, indicating a small, but significant positive effect of outcome expectations on adaptive treatment outcomes. This chapter also provides a narrative review of mediators of the expectation–outcome link and patient factors that relate to their outcome expectations. Finally, this chapter discusses limitations of the research base and offer therapeutic practices based on the findings.

This chapter examines via meta-analyses results of recent studies, published from 2000 through 2009, that relate goal consensus and collaboration to treatment outcome. Specifically, fifteen studies with a total sample size of 1,302 yielded a goal consensus–psychotherapy outcome effect size of .34 (SD = .19), indicating that better outcomes can be expected when patient and therapist agree on therapeutic goals and the processes to achieve these goals. The collaboration–outcome meta-analysis based on 19 studies with a total sample of 2,260 patients yielded a mean correlation of .33 (SD = .17), suggesting that psychotherapy outcome appears to be considerably enhanced when patient and therapist are actively involved in a cooperative relationship. We discuss therapeutic practices that follow from these findings.

This chapter reviews the research on the association between therapists’ provision of positive regard and treatment outcome. Rogers’ attempts to define the concept of positive regard are noted, and two examples of positive regard are presented. We conducted a new meta-analysis, focusing on eighteen studies, that yielded an aggregate effect of r = .27, indicating that positive regard has a moderate association with psychotherapy outcomes. Like many other relational factors, it is a significant but not exhaustive part of the process–outcome equation. Notably, the effects of positive regard increased as a function of the racial-ethnic composition in a study. Therapists’ provision of positive regard is strongly indicated in practice; at a minimum, it provides the basis for other mutative interventions.

Congruence or genuineness is a relational quality that has been highly prized throughout the history of psychotherapy, but of diminished research interest in recent years. This chapter defines and provides examples of this attribute of the therapy relationship and present an original meta-analytic review of the empirical literature showing its relation to improvement. Moderators of the association between congruence and treatment outcome are examined, and limitations of the extant research are discussed as well. In closing, this chapter advances several therapist practices that are likely to foster congruence and thus improve psychotherapy outcomes.

This chapter reviews the existing empirical research on the topic of therapeutic alliance ruptures in psychotherapy. Ruptures in the therapeutic alliance are defined as episodes of tension or breakdown in the collaborative relationship between patient and therapist. Two meta-analyses were conducted. The first reviewed studies examining the relation between rupture repair episodes and treatment outcome. The second reviewed the research examining the impact on treatment outcome of training therapists in the use of alliance rupture intervention principles. Both meta-analyses provided promising evidence regarding the relevance of alliance rupture repair processes to therapeutic outcome. The limitations of the research reviewed are discussed, as well as practice implications for repairing the inevitable alliance ruptures in psychotherapy.

Psychotherapists from all professions and perspectives periodically struggle to effectively manage a patient’s resistance to change. This chapter provides definitions and examples of patient–treatment matching applied to patient resistance or reactance. The chapter reports the results from an original meta-analysis of twelve select studies (N = 1,102) on matching therapist directiveness to patient reactance. The findings support the hypothesis that patients exhibiting low levels of traitlike resistance respond better to directive types of treatment while patients with high levels of resistance respond best to nondirective treatments (d = .82). Limitations of the research reviewed are noted, and practice recommendations are advanced.

Attachment theory, developed by Bowlby to explain human bonding, has profound implications for conducting and adapting psychotherapy. This chapter summarizes the prevailing definitions and measures of attachment style. This chapter reviews the results of three meta-analyses examining the association between attachment anxiety, avoidance, and security and psychotherapy outcome. Fourteen studies were synthesized, which included nineteen separate therapy cohorts with a combined sample size of 1,467. Attachment anxiety showed a d of (.46 with posttherapy outcome, while attachment security showed a d of .37 association with outcome. Attachment avoidance was uncorrelated with outcome. The age and gender composition of the samples moderated the relation between attachment security and outcome; a higher proportion of female clients and a higher mean age showed a smaller relation between security and outcome. This chapter discusses the practice implications of these findings and related research on the link between attachment and the therapy relationship.

The fit of patient coping style and treatment focus has been suggested as a factor that improves treatment outcome. This meta-analysis of twelve carefully selected studies tested this hypothesis. A weighted, mean effect size (d) of .55 was found in favor of a fit between externalizing patients and symptom focused-treatment or, alternatively, internalizing patients and insight-focused treatment. This effect is considered to be strong and suggests that nondiagnostic patient factors, like coping style, are important considerations in the selection of effective therapies. Clinical examples and clinical recommendations are provided.

The transtheoretical model in general and the stages of change in particular have proven useful in adapting or tailoring treatment to the individual. This chapter defines the stages and processes of change and then review previous meta-analyses on their interrelationship. This chapter reports an original meta-analysis of 39 studies, encompassing 8,238 psychotherapy patients, to assess the ability of stages of change and related readiness measures to predict psychotherapy outcomes. Clinically significant effect sizes were found for the association between stage of change and psychotherapy outcomes (d = .46); the amount of progress clients make during treatment tends to be a function of their pretreatment stage of change. We examine potential moderators in effect size by study outcome, patient characteristics, treatment features, and diagnosis. We also review the large volume of behavioral health research, but scant psychotherapy research, that demonstrates the efficacy of matching treatment to the patient’s stage of change. Limitations of the extant research are noted, and practice recommendations are advanced.

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 are select studies that illustrate findings from the meta-analyses. Conclusions are that countertransference reactions are related inversely and modestly to psychotherapy outcome, particular therapist qualities and practices are associated with effective countertransference management, and managing countertransference successfully is related to better therapy outcomes. This chapter concludes by summarizing the limitations of the research base and by highlighting the therapeutic practices predicated on that research.

Many clients highly value religious and spiritual (R/S) commitments, and many psychotherapists have accommodated secular treatments to R/S perspectives. We meta-analyzed fifty-one samples from forty-six studies (N = 3,290) that examined the outcomes of religious accommodative therapies and nonreligious spirituality therapies. Comparisons on psychological and spiritual outcomes were made to a control condition, an alternate treatment, or a subset of those studies that used a dismantling design (similar in theory and duration of treatment, but including religious contents). Patients in R/S psychotherapies showed greater improvement than those in alternate secular psychotherapies on both psychological (d = .26) and spiritual (d = .41) outcomes. Religiously accommodated treatments outperformed dismantling-design alternative treatments on spiritual (d = .33) but not on psychological outcomes. Clinical examples are provided and therapeutic practices are recommended.

While highly effective, psychotherapy outcome studies suggest 5%–14% of clients worsen while in treatment and that therapists are unable to identify a substantial portion of such cases. Methods to systematically collect feedback from psychotherapy clients are discussed, and two systems for monitoring treatment response, feeding back this information and assisting in problem solving with such cases, are described. Within these systems, obtaining client ratings of their relationship appear to be highly important. This chapter summarizes an original meta-analysis of the effects of these feedback systems. The number of psychotherapy patients who deteriorate can be cut in half by use of these systems. The chapter concludes with a series of practice implications, including that clinicians seriously consider making formal methods of collecting client feedback a routine part of their daily practice.