In the psychotherapeutic professions, increasing attention is being paid to the therapies carrying the distinction of an "evidence based practice." But what does that really mean? And does the literature actually reveal that cultivating a strong therapeutic relationship is more important than any specific practice or intervention? Delivered at the University of Southern Indiana Addiction Studies Conference, May 2015

1. It’s The Relationship That Heals:
A New Spin on “Evidence-Based Practice”
Jamie Marich, Ph.D., LPCC-S, LICDC-CS
Founder, Mindful Ohio & The Institute for
Creative Mindfulness
www.mindfulohio.com

2. About Your Presenter
• Licensed Supervising Professional Clinical Counselor
• Licensed Independent Chemical Dependency Counselor
• 14 years of experience working in social services and counseling;
includes three years in civilian humanitarian (Bosnia-
Hercegovina)
• Specialist in addictions, trauma, EMDR, dissociation,
performance enhancement, grief/loss, mindfulness, and pastoral
counseling
• Author of EMDR Made Simple, Trauma and the Twelve Steps, Trauma
Made Simple, and Dancing Mindfulness (forthcoming)
• Creator of the Dancing Mindfulness practice

3. From the American Psychological
Association (2006)
An evidence-based practice in psychology is
“the best available research with clinical
expertise in the context of patient
characteristics, culture, and preferences”

4. From Irvin Yalom
 Therapyshouldnotbetheorydriven, butrelationshipdriven(The Gif t of
Ther apy, 2001)
 The EveryDayGetsaLittleCloserexper iment (Yalom &
Elkins, 1974)

5. What does empathy mean t o you?

6. Empathy
• Coined by the German philosopher Rudolf Lotze in
1858
• The German word, Einfühlung, translates as “in” +
“feeling”
• Derives from the Greek empatheia, meaning “in” +
“pathos” (feeling)
• Pathos is also the root of “passion” and “pain”

7. Empathy
Directidentificationwith, understandingof, andvicariousexperienceof
anotherperson'ssituation, feelings, andmotives.
St edman’s Medical Dict ionary (2002)

8. The Rogerian View of Empathy
“Being empat het ic ref lect s an at t it ude of prof ound int erest in
t he client ’s world of meanings and f eelings. The t herapist
receives t hese communicat ions and conveys appreciat ion and
underst anding, assist ing t he client t o go f urt her or deeper.
The not ion t hat t his involves not hing more t han a repet it ion of
t he client ’s last words is erroneous. I nst ead, an int eract ion
occurs in which one person is a warm, sensit ive, respect f ul
companion in t he t ypically dif f icult explorat ion of anot her’s
emot ional world. The t herapist ’s manner of responding should
be individual, nat ural, and unaf f ect ed. When empat hy is at it s
best , t he t wo individuals are part icipat ing in a process
comparable t o t hat of a couple dancing, wit h t he client leading
and t he t herapist f ollowing.”
(Raskin & Rogers, in Corsini, 2014)

9. The Imperative of the
Therapeutic Alliance
• Using a collect ion of empir ical research
st udies and chapt er s f rom t he
psychot herapeut ic pr of essions, Nor cross
(2002) demonst r at ed t hat a combinat ion of
t he t her apy r elat ionship, t oget her wit h
discret e met hod, is crit ical t o t reat ment
out comes.
• Norcr oss f ur t her concluded t hat r elat ional
skills can be honed by t herapist s, and t hat it
is t he t her apist ’s responsibilit y t o t ailor
t hese skills t o t he needs of individual client s.

10. The Imperative of the
Therapeutic Alliance
Norcr oss’ cont ent ions also support ed by t he
massive lit erat ur e r eviews t hat appear in TheHeart
andSoulofChange: DeliveringWhatWorksinTherapy(Duncan, Miller,
Wampold, & Hubbard, 2009)

11. The Common Factors
• Client & ext r at her apeut ic f act or s
• Techniques t hat engage and inspire t he
part icipant s
• The t herapeut ic alliance
• The clinician

12. The Common Factors
• The common f act ors are a list ing of f our qualit ies
t hat all successf ul psychot herapeut ic approaches
have in common
• Developed by psychiat rist Saul Rosenzweig (1936), in
response t o t he numerous philosophies of t herapy
assert ing t heir superiorit y in his era
• A review of over sixt y years of lit erat ure on
psychot herapy and t herapeut ic change support s t he
common f act ors hypot hesis (Duncan, Miller, Wampold,
& Hubbard, 2009)

13. What Works for Trauma Processing?
• A meta-analysis examining all studies on bona
fide treatments for PTSD (e.g., desensitization,
hypnotherapy, PD, TTP, EMDR, Stress Inoculation,
Exposure, Cognitive, CBT, Present Centered, Prolonged
exposure, TFT, Imaginal exposure) conducted
between 1989-2007 found no statistical
significance amongst the treatments (Benish,
Impel, & Wampold, 2008).
• The only factor leading to any statistically
significant impact was therapist allegiance.

14. What Works for Addiction
Treatment?
• A meta-analysis examining all studies on bona
fide treatments for alcohol dependence and
abuse (e.g., CBT, 12-steps, PDT, Relapse
Prevention therapy) conducted between 1960-
2007 found no statistical significance amongst
the treatments (Imel, Wampold, Miller, &
Fleming, 2008).
• The only factor leading to any statistically
significant impact was therapist allegiance.

15. The Common Factors
• Client & ext rat herapeut ic f act or s
• Techniques t hat engage and inspir e t he
par t icipant s
• The t her apeut ic alliance
• The clinician

16. From the American Psychological
Association (2006)
An evidence-basedpractice in psychology is “t he
best available research wit h clinical
expert ise in t he cont ext of pat ient
charact erist ics, cult ure, and
pref erences”

17. Partners for Change Outcomes
Management System (SAMHSA: 2012)

18. For More Information on Client
Outcomes Research & Tracking:
www.cent erf orclinicalexcellence.com
www.myout comes.com

19. Marich (2012)
• Ther e ar e several qualit ies of goodt her apist s
t hat must be examined t o under st and what
client s most value in EMDR Therapy.
• These qualit ies, as def ined by f ormer client s,
include t herapist per sonalit y, an abilit y t o
empower client s, f lexibilit y, int uit ion, a sense
of ease and comf or t in working wit h t r auma,
and a commit ment t o t he small measur es of
caring t hat client s ident if y as helping t hem
f eel saf er.

20. Cindy & JoElle: Description of
Negative Experience with Their
First EMDR Therapist
• rigid
• script ed
• det ached
• anxious
• unclear
• uncomf ort able wit h t rauma

21. According to Cindy
(Regarding 2nd
Therapist):
“My EMDR t her apist played a ver y signif icant
part in knowing exact ly what she needed t o say
t o me t o eit her br ing st uf f out or t o move ont o
somet hing else or t o f ocus on t his. And I t hink
it was huge, act ually, in making t hat connect ion
t hat was so impor t ant .
[EMDR] is somet hing t hat ’s ver y personal and
ver y involved and I t hink it t akes a special kind
of counselor t o pull st uf f out of you.”

22. According to JoElle
(Regarding 2nd
Therapist):
“She was a nat ural f or t his j ob. I could t hink
somet hing and she would say it . She was j ust
amazing and she knew so much…she j ust
knew a lot about me and she was really easy
t o t alk t o. She used, t o me, a lot of common
sense along wit h counseling. That ’s not
always done. She was t he great est .”

23. Now It’s Your Turn…
• Write up a brief case, typical for your clinical
setting (5-7 characteristics):
- An actual client (using a pseudonym)
- A composite client
- A “famous” example
- A fictitious case

24. Break Time

25. ParticipationExercise

26. Reactions/DiscussionFrom
EmpathyExercise

27. The Case of Anna: Qualities of a
Good Therapist (Marich, 2014)
• To know and understand a client’s diagnosis.
• To get to know you, where you're at (are you externally
and internally safe???), where you've come from
(historical context; triggers, traumas, what to be aware
of), and where you want to go (short- and long-term
goals).
• To be a person who believes in TEAMWORK. Both the
professional and the client do work, lots of it. There is
not an aggressor in the equation, ever. When/if it
happens, stop.

28. The Case of Anna: Qualities of a
Good Therapist (Marich, 2014)
• To have compassion and empathy—NOT PITY, ever. I
have seen pathological psychiatrists who don't like
humans. Pity is just destructive to what is supposed to
be happening: growth and healing. Pity is never a
foundation for that.
• To have a sense of connectedness. For people without
a diagnosis, when they're going through a hard time, the
baseline is to find someone you connect with.
• To never, never, never put their own moral thing (e.g.,
Christianity) above the code of treatment. Ever!!!!! No
dogma at all should be in the way of the client finding her
way.

29. The Case of Anna: Qualities of a
Good Therapist (Marich, 2014)
“Bad therapy is worse than no therapy.
I have learned this experientially.”
-Anna

30. Best Practices for
Assessment & Interactions
with Clients• Do not re-traumatize!
• Do ask open-ended questions
• Do be genuine, build rapport from the first greeting
• Do consider the role of shame in addiction, trauma,
and grief
• Do be non-judgmental
• Do avoid the “you need to” language
• Do make use of the stop sign when appropriate
• Do assure the client that they may not be alone in
their experiences (if appropriate)
• Do have closure strategies ready

31. Principles of Trauma-Informed
Care (SAMHSA, 2014)
• Promote trauma awareness and understanding
• Recognized that trauma-related symptoms and behaviors
originate from adapting to traumatic experiences
• View trauma in the context of individuals’ environments
• Minimize the risk of retraumatization or replicating prior
trauma dynamics
• Create a safe environment

32. Principles of Trauma-Informed
Care (SAMHSA, 2014)
• Identify recovery from trauma as a primary goal
• Support control, choice, and autonomy
• Create collaborative relationships and participation
opportunities
• Familiarize the client with trauma-informed services
• Incorporate universal routine screenings for trauma
• View trauma through a socio-cultural lens
• Use a strengths-based perspective: Promote resilience

33. Principles of Trauma-Informed
Care (SAMHSA, 2014)
• Foster trauma-resistant skills
• Demonstrate organizational and administrative commitment
to trauma-informed care
• Develop strategies to address secondary trauma and
promote self-care
• Provide hope—recovery is possible

34. Read the entire SAMHSA Treatment
Improvement Protocol:
•Substance Abuse and Mental Health
Services Administration (2014). A treatment
improvement protocol: Trauma-informed care in
behavioral health services. Washington, DC:
Author.
•Available online:
http://www.ncbi.nlm.nih.gov/books/NBK2072

35. Mindfulness & Self Care
• Promoting mindfulness in psychotherapists-in-training could
positively influence the therapeutic course and treatment
results in patients (randomized, double-blind controlled study;
Grepmair, Mitterlehner, Loew, et al, 2007)
• Health care professionals participating in a mindfulness-based
stress reduction program (MBSR) were able to more fully
identify their own themes of perfectionism, the automaticity of
“other focus,” and their tendencies to always enter “fixer”
mode; this recognition led to numerous changes along
personal and professional domains (grounded theory; Irving,
Park-Saltzman, Fitzpatrick, et al., 2014); a similar study that
exclusively studied nurses yielded similar findings (Frisvold,
Lindquist, McAlpine, 2012)

36. Mindfulness & Self Care
• In an extensive mixed methods research study with working
psychotherapists from a variety of theoretical backgrounds,
Keane (2013) concluded that personal mindfulness practice
can enhance key therapist abilities (e.g., attention) and
qualities (e.g., empathy) that have a positive influence on
therapeutic training.
• Mindfulness practice could provide a useful adjunct to
psychotherapy training and be an important resource in the
continuing professional development of therapists across
modalities.

37. Beutler, et al. (2005)
On the Connection Between Therapist Traits &
Client Outcomes
• Effective therapists are interested in people as
individuals
• Have insight into their own personality characteristics
• Have concern for others
• Intelligent
• Sensitive to the complexities of human motivation
• Tolerant
• Able to establish warm and effective relationships with
others

38. Charman (2005)
• mindful
• not having an agenda
• having concern for others
• intelligent
• flexible in personality
• intuitive
• self-aware
• knows own issues
• able to take care of self
• open
• patient
• creative

39. References
Amer ican Psychological Associat ion Pr esident ial Task For ce on Evidence-Based Pr act ice. (2006).
Evidence-based pr act ice in psychology. AmericanPsychologist, 61, 271–285.
Benish, S., Imel, Z., & Wampold, B. (2008). The relative efficacy of bona fide psychotherapies for
treating post-traumatic stress disorder: A meta-analysis of direct comparisons. Clinical
Psychology Review, 28(5), 746–758.
Beutler, L., Malik, M., Alimohamed, S., Harwood, T., et al. (2005). Therapist variables. In M. Lambert
(ed.). Bergin and Garfield’s Handbook of Psychotherapy and Behavior Change (5th
ed.,pp. 227–306). New York: Wiley.
Charman, D. (2005). What makes for a “good” therapist? A review. Psychotherapy in Australia, 11(3),
68–72.
Duncan, B.L., Miller , S.D., Wampold, B.E., & Hubble, M.A. (Eds.) (2009). Theheartandsoulof change:
Deliveringwhatworksintherapy. (2nd
ed.) Washingt on, D.C.: Amer ican Psychological Associat ion.
empat hy. (2002). Stedman’sMedicalDictionary. Ret r ieved Febr uar y 18, 2012, f r om Dict ionar y.com websit e
ht t p:/ / dict ionar y.r ef er ence.com/ br owse/ empat hy
Frisvold, M. H., Lindquist, R., & McAlpine, C. P. (2012). Living life in balance at midlife: Lessons
learned from mindfulness. Western Journal of Nursing Research, 34, 265-278.
Grepmair, L., Mitterlehner, F., Loew, T., Bachler, E., Rother, W., & Nickel, M. (2007). Promoting
mindfulness in psychotherapists in training influences the treatment results of their
patients: A randomized, double-blind controlled study. Psychotherapy and
Psychosomatics, 76, 332-338.
Imel, Z., Wampold, B., Miller, S., & Fleming R. (2008). Distinctions without a difference: Direct
comparisons of psychotherapies for alcohol use disorders. Psychology of Addictive
Behaviors, 22(4), 533-543.

40. References
Irving, J.A., Park-Saltzman, J., Fitzpatrick, M., Dobkin, P.L., Chen, A., & Hutchinson, T. (2014).
Experiences of health care professionals enrolled in mindfulness-based medical practice:
A grounded theory model. Mindfulness, 5, 60-71.
Keane, A. (2013). The influence of therapist mindfulness practice on psychotherapeutic work: A
mixed-methods study. Mindfulness. DOI: 10.1007/s12671-013-0223-9.
Marich, J. (2012). What makes a good EMDR therapist?: Exploratory clients from client-centered
inquiry. Journal of Humanistic Psychology, 52(4), 401–422.
Marich, J. (2014). Trauma made simple: Competencies in assessment, treatment, and working with
survivors. Eau Claire, WI: PESI Publishing & Media.
Nor cr oss, J . (2002). Psychotherapyrelationshipsthatwork: Therapistcontributionsand responsivenesstopatients. New Yor k:
Oxf or d Univer sit y Pr ess.
Raskin, N.J ., & Roger s, C.R. (2014). Per son-cent er ed t her apy. I n R.J . Cor sini & D. Wedding (Eds.),
Currentpsychotherapies(pp. 133-167). Belmont , CA: Thomson Wadswor t h.
Rosenzweig, S. (1936). Some implicit common f act or s in diver se met hods of psychot her apy.
American JournalofOrthopsychiatry, 6, 412-415.
Substance Abuse and Mental Health Services Administration (2014). A treatment improvement protocol:
Trauma-informed care in behavioral health services. Washington, DC: Author.
Yalom, I . (1973). Everydaygetsalittlecloser: Atwice-toldtherapy. New Yor k: Basic Books.
Yalom, I . (2001). Thegiftoftherapy: Reflectionsonbeingatherapist. London: Piat kus Books.

41. To contact today’s presenter:
Jamie Marich, Ph.D., LPCC-S, LICDC-S
jamie@jamiemarich.com
www.jamiemarich.com
www.drjamiemarich.com
www.mindfulohio.com
www.dancingmindfulness.com
www.traumamadesimple.com
www.traumatwelve.com
Phone: 330-881-2944