Video: Dr. John Norcross on Psychotherapy – Relationships that Work
Dr. John Norcross discusses his publication, Psychotherapy – Relationships that Work
LF: So, we’re going to switch over and talk about psychotherapy and treatment and you recently published your second edition of Psychotherapy – Relationships that Work. The results of an APA interdivisional task force that compiled over 20 + meta-analyses, what works in psychotherapy relationships and treatment adaptations. I’d love to hear about that.
JN: Well, it does come in two parts. It’s two books in one. The first part of Psychotherapy – Relationships that Work is about which psychotherapy styles and relationship behaviors do work. And then the second part is what are the treatment adaptations that work? So to simplify that a bit, the first part is what works in general? After 50 years of psychotherapy research, what do we know that therapists can and should be doing to promote more change? And the second part asks, what works for particular patients? How do we adapt being responsive?
Let’s start from the beginning in the first part. Over 50 years, we know the psychotherapy relationship is powerful, curative in all forms of psychotherapy. Occasionally someone will protest and say that, “You know, John, I do exposure therapy or I’m a cognitive behavior therapist.” So the relationship doesn’t matter as much for me. And they’d be absolutely wrong. All the meta-analyses show that it works the same for all therapies. And, in fact, the effect size, the power of the relationship is slightly higher in cognitive behavioral therapy than in psychodynamic and person-centered therapies.
And at first, we were somewhat puzzled and said, “Well, wait a minute. It goes the other way, right?” And then someone pointed out, “No. You’re asking someone to expose themselves to traumatic situations where you’re asking them to undertake new behaviors when they’re anxious, then they better well have a wonderful relationship already established.” So, we do know – this is fact, this is not just a theoretical postulate; this is not just Carl Rogers saying, “I’m pretty sure it’s important.” We literally have thousands of well-conducted, rigorous studies attesting that the therapy relationship predicts and leads to better outcomes. It’s really quite powerful.
Unfortunately, these are not randomized clinical trials so we cannot draw a causal conclusion. Admittedly, that’s a methodological limitation. At the same time, it suggests there is something about the relationship that is so important, so powerful that we can’t randomize it. So I’ve come to think of this a little differently. Yes, the inability to randomize people to empathic vs. un-empathic therapist, supportive vs. unsupportive therapist – we can’t do that. I don’t know an institutional review board on the planet that would possibly allow that.
So while that constrains us from saying these causally lead to change, conceptually, it should lead us all to say, these are the essential mechanisms. The most important things in lives can’t be easily manipulated and randomized.
So my favorite example these days is parental love. Now virtually everyone tries to love their children, nieces, nephews and so forth. But if you think about it, there’s not a single randomized clinical trial that says, “Parental love contributes to better outcome of children.” Well, there can’t be, for ethical reasons. It’s the same thing about the relationship. So it doesn’t trouble me nearly as much as it used to. We know the relationship works.
And that’s the alliance, be it in individual therapy, couples’ therapy, with youth. We know cohesion works in groups. We know support, validation, self-disclosure, a modicum of self-disclosure, humor – all these things contribute to positive psychotherapy. And while we frequently resort to talking about statistics, as we should in these matters, at the end, a good relationship translates into healthier and happier people.
JN: Now Carl Rogers was always fond of saying, “We shouldn’t be training – we ought to be selecting the best therapists.” And unfortunately, we’ve pretty much ignored his advice, particularly getting into the more competitive psychology, psychiatry counseling programs this year, these days, it’s largely about grades and entrance examinations.
But even within those constraints, there are people who can be trained to be more empathic, better listeners, more supportive. They can come up to an acceptable level, may never be the great interpersonally skilled folks, but with decent training and a modicum of commitment on the part of the trainee, I do believe everyone can come up to be good enough in that way. But we also know there’s some therapists, just born to be in the helping professions.
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