Quando la relazione psicoterapeutica funziona: la recensione
QUANDO LA RELAZIONE PSICOTERAPEUTICA FUNZIONA
Efficacia ed efficienza dei trattamenti personalizzati John C. Norcross. Roma: Sovera Edizioni; 2012.
ISBN 9788866520351
€ 59,00
La recensione dell'Istituto Superiore di Sanità
a cura di Antonella Gigantesco - Istituto Superiore di Sanità, Rome
According to Norcross and Hill, up to 2000, there were two important omissions in the available evidence-based practices in psychotherapy. First, they neglected the therapist–patient relationship, an interpersonal quality that could make substantial contribution to psychotherapy outcome, independent of the specific type of treatment method used. Second, they ignored the complexity of the patient beyond his or her diagnosis; in other words, they were merely directed toward categorical disorders, ignoring patient’s personal (non-diagnostic) characteristics (Norcross and Hill, 2004).
In that context, in the year 2001, an APA division of psychotherapy task force was established to identify and disseminate information on evidence-based elements of the therapist-patient relationship rather than evidence-based elements of treatment. Specifically, the task force aimed at identifying elements of effective psychotherapy relationship and effective methods of adapting psychotherapy to the individuality of the patient and his or her context (beyond his or her diagnosis).
The task force reviewed an extensive body of empirical research and developed a list of empirically based psychotherapy relationship elements and a list of means for adapting psychotherapy to patient characteristics. For each, the members of the task force judged whether the element could be defined as effective, promising, or insufficiently studied. The main criterion for making these judgements was the relationship between the element and positive mental health outcomes. These lists can be found in the book titled Psychotherapy Relationships That Work, edited by J. Norcross in 2002. The elements of the therapeutic relationship that were classified as effective, that is, related to final outcome, included therapeutic alliance, cohesion in group psychotherapy, empathy, and goal consensus and collaboration. The therapeutic alliance (in individual therapy) and cohesion (in group therapy) refer to the quality of the collaborative relationship between patient and therapist, which is typically measured as agreement on therapeutic goals and treatment assignments. Empathy refers to the therapist’s emotional ability and willingness to understand patients’ thoughts, feelings, and difficulties from their point of view. Goal consensus and collaboration refer to the therapist-patient agreement on treatment objectives and mutual involvement of the participants in the helping relationship, respectively.
The patient characteristics that served as markers for tailoring the therapeutic relationship included resistance (patient’s sensitivity to external persuasion or social influence to change behaviour, thoughts, and feelings that create a perception of limited choices or loss of control) and functional impairment. According to Norcross’ book, patients with high resistance took advantage from self-control methods and a minimally directive therapist. On the contrary, patients with low resistance gained more from a more directive therapist who used an explicit guidance. Patients who had impairment in many areas of functioning (family, social, occupational) were more likely to take advantage from treatment that was longer, more intense, and including medication. In his conclusions, Norcross stated that the book represented an initial step in identifying and codifying available research on the therapeutic relationship in psychotherapy. In fact, in 2009, the American Psychological Association’s Division of Psychotherapy and Division of Clinical Psychology solicited an additional task force to update the findings of the earlier task force. While the aims of the previous and the current task force remained the same, there were some changes in research methodology and in the number of patient characteristics evaluated. In particular, the experts of this second task force were commissioned to utilize relevant meta-analyses for reviewing the size of the associations between psychotherapy outcome and a broader range of patient characteristics.
Initially, the experts proposed more than 200 patient characteristics. In the end, the task force decided to focus on eight of them: resistance level, stages of change, preferences, culture, coping style, expectations, attachment style, and religion/spirituality. Findings of this focus were presented in the book Psychotherapy relationships that work: evidence-based responsiveness (Norcross, 2011) that, substantially, updated the findings of the previous book edited by Norcross (Norcross, 2002).
The present book consists of two volumes, each one representing a monograph in its own right. The first volume examines which psychotherapy styles and relationship behaviours work in general. Each chapter deals with a specific therapist behaviour that could improve treatment outcomes, i.e., alliance in individual psychotherapy, cohesion in group psychotherapy, therapist empathy, consensus and collaboration, therapist provision of positive regard (warm acceptance of the patient experience without conditions), genuineness (being what therapist truly is in the relationship), repairing alliance ruptures (ruptures are episodes of tension in the collaborative relationship between patient and therapist), and managing countertransference problems (therapist’s internal and external reactions that are related to the therapist’s own difficulties and vulnerabilities, rather than to the patient’s personal characteristics and behaviour). With respect to the previous book, other psychotherapeutic styles are analysed, so that new chapters in this book deal with the alliance with children and adolescents, the alliance in couples and family psychotherapy, and with collecting real-time feedback from patients (descriptive and evaluative information provided to therapists from patients about the therapist’s behaviour or the effects of that behaviour). However, the main findings remained fairly consistent with those presented in the previous book. The strong associations between alliance and consensus and collaboration and positive outcomes of treatment were confirmed, while the other relational qualities were moderately correlated with outcome or appeared promising.
The second volume examines which treatment adaptations work better in the presence of particular non-diagnostic patient characteristic, such as resistance level, stages of change (patient progress through a series of stages in both psychotherapy and self-change), preferences, culture, coping style (habitual and enduring patterns of behaviour that characterize the patient when confronting stressful events and situations), patient expectations, attachment style (individual differences in affect regulation and in perceptions of and beliefs about self and close others), and religion (adherence to a belief system and practices associated with a tradition in which there is agreement about what is believed and practiced) and spirituality (feeling of closeness and connectedness to the sacred). Each chapter of this volume offers clinical examples of patients with these characteristics that can potentially affect the outcome of psychotherapy, analyses of the association between each characteristic and treatment outcome, and therapeutic practices for clinicians who want to engage and connect with patients. According to Norcross’ book, there is evidence, primarily from meta- analyses, that four patient characteristics (i.e., resistance, preferences, culture, and religion and spirituality) should definitely be considered for adapting psychotherapy. There is also evidence that stages of change and coping style should probably be considered, whereas expectations and attachment style are related to psychotherapy outcome but their potential to guide treatment adaptation has been insufficiently studied.
The book concludes with a series of recommendations directed toward practice. Evidenced based practices in psychotherapy should explicitly address therapist behaviours and qualities that promote and facilitate the therapeutic relationship. Also, therapists should be encouraged through training and continuing education programs to be more empathic, better listeners, and more supportive.
At the same time, it should be recognized that treatment effectiveness is affected not only by the therapeutic relationship, but also by a number of patient characteristics. Therefore, therapists should be encouraged to become more able to tailor psychotherapy to patient characteristics other than diagnosis in ways found to be effective or promising.
Pubblicato il 06/10/2017
alle ore 14:24
