perception

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.

all must have prizes

There is the real possibility that practitioners and students in mental health fields accept the Dodo bird verdict simply because it appears to be generally and uncritically accepted by others. - Hunsley & DiGiulio, 2002, p. 13

Wow. How distressing is that idea? Therapists and researchers and students, all eagerly swallowing a particular verdict on a subject, simply because they've heard it repeated enough times, not because they've actually seen a preponderance of empirical evidence to support it.

I have to believe that adherence to the notion of psychotherapy equivalence cannot possibly be all that widespread--even though I heard it declaimed to me as fact during my undergraduate experience. I would certainly doubt that most persons who assent to the notion of psychotherapy equivalence have really thought through what this would mean.

Given that most clinicians (and research groups!) have definite allegiances to particular classes of therapy, such allegiances would suggest a belief that certain types of therapy are more efficacious, effective, and/or efficient than others. I doubt that many who maintained such an allegiance could really bring themselves to wholeheartedly endorse every other possible kind of therapy as well. Hunsley and DiGiulio seem concerned that proponents of "esoteric" therapies might use the Dodo bird verdict to their advantage by "claim[ing] clinical legitimacy for their treatments by relying on the results of research conducted on other forms of psychotherapy" (2002, p. 17). However, anyone promoting their "pet" therapy based on the claim of psychotherapy equivalence would be undermining such a claim in the moment they made it--if all psychotherapies are equivalent, why develop new ones? Why attempt to develop more efficient and effective forms of treatment? If the therapeutic alliance is the only important element, why not just throw all clients in with kindly college professors?

Whether we own up to it or not, I'd say that very few of us actually believe in psychotherapy equivalence. Propagating the myth of equivalence might be more a way of ducking the time- and resource-consuming realities of empirically validating a treatment than anything else.

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Picture from Project Gutenberg.