One theme arose repeatedly in both of our articles today--and it wasn't "it's the relationship, stupid!" No, what I heard was, "it's the perceived relationship, stupid!"
Given that the client's perception of the therapeutic relationship seems more predictive of outcome than "objective" measures of therapist and alliance qualities, I wondered about the degree to which variables like therapist empathy and collaboration in the therapeutic relationship affect clients whose perception of the world is in some way disordered. In many situations the difficulties clients are encountering in daily living may be directly related to the way in which they interpret others' social cues. Clients' affective states may also contribute to their "read" on their interpersonal relationships in general as well as their relationship with their therapist specifically. This is part of what really irks me with the "common factors" argument, which we saw rearing its head in the Kirschenbaum & Jourdan article--such an argument, which has alliance quality and the Rogerian core conditions doing all the heavy lifting, completely fails to take into account the fact that many clients may present for treatment with conditions that bias their perceptions. It is possible that in some cases the link between perceived alliance quality (or perceived therapist empathy, positive regard, or congruence) and positive outcome may occur because clients who successfully learn to interpret cues from their environment (particularly their social environment) in a more "realistic" manner are both doing better at recognizing positive elements of the therapeutic relationship and are using their newfound skills to achieve a higher level of overall functioning. This does not indicate that the effective elements of psychotherapy are essentially equivalent; indeed, different clients may require very different treatment approaches to help get to this point.
This is not to say that I do not believe empathy and positive regard and affectively positive, collaborative alliances are not extremely important. Indeed, I believe that treating patients/clients in this manner is our ethical obligation--such practices demonstrate respect for the dignity of all persons. However, we cannot ignore client factors that influence their perception of the therapeutic situation--and the empirically supported strategies that best help patients with particular constellations of factors--if we wish to help them achieve the best possible outcomes.
1 comment:
"it's the perceived relationship, stupid!"
Excellent points, as usual. I sometimes wonder not only about the perceptual biases clients bring to their sessions, but also, and more specifically, the client's ability to notice change as a function of therapy, and then to retrospectively imbue their therapeutic relationship with positive qualities as a result. In other words, what is the degree to which positive working alliances follow rather than precede therapeutic change. We know already that memory for past events is strongly colored by current affective states, for example.
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