The Therapy Relationship in IPT: Elements, Functions, and Findings

1. The Therapy Relationship in IPT:Elements, Functions, and Findings Gregory G. Kolden, Ph.D. University of Wisconsin – Madison Department of Psychiatry ggkolden@wisc.edu 4th International Conference on Interpersonal Psychotherapy Amsterdam, the Netherlands June 23, 2011

2. Collaborators UW Department of Psychiatry Psychology Faculty and Trainees UW Department of Psychology Sara B. Austin UW Department of Counseling Psychology Bruce Wampold, Ph.D.

3. Acknowledgements • Dr. Kolden has no industry relationships to disclose.

4. 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

5. The Therapy Relationship: An Operational Definition 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.”

6. 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)

7. 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)

8. Evidence-Based Relational Elements: A Review

9. 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/)

10. 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.

11. 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.

12. 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?

13. Broad & Inclusive Relational Elements “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

14. Specific 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

15. 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

16. 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

17. 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

18. 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

19. Summary ESVarianceMagnitude Alliance .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

20. 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?

21. Relational elements relevant for IPT IPT specific goal consensus General collaboration empathy positive regard congruence/genuineness

22. Relational elements relevant for IPT Proscribed low levels of effective relational elements excessive focus on transference configurations ineffective therapist relational behaviors

23. 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.

24. 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)

25. 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)

26. 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

27. 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

28. Conclusion “Relationship elements and behaviors merit greater attention and consideration as important factors in an elaborated conception of effective change processes in IPT. “