7. It is the relationship not the therapy (I)
It is all about relationships
A good chunk of the contributions in the last few weeks have been about therapy. Freud and psychoanalysis. Rogers and humanistic therapy. Beck and CBT. So many therapies, so much abstract language to describe them.
Are they all different? Is one better than the others? Or maybe they are all the same? A person who wants to help sitting alongside somebody who needs help. Maybe no therapy is better than another, it is more that each shares the same active ingredients that make a difference.
These intriguing possibilities are not new. Saul Rosenzweig was writing in 1936 about the common elements of different therapies. Freud was a fillip for all kinds of competing schools of thought about the workings of the mind and the resolution to its faulty functioning. Futile wars blew up between the different proponents. The controversy continues to this day, but is no longer newsworthy.
Maybe no therapy is better than another, it is more that each shares the same active ingredients that make a difference.
These were false battles said Rosenzweig. His work sponsored a raft of researchers, people like Frank Jerome, Michael Lambert and others who picked up, ran with and developed what became known as common factors theory.
Their ideas have been widely tested. Tests of the theory show that success isn’t explained by any one method of intervention. Success is explained by shared elements of all interventions. One shared element is the client. Some are more amenable to recovery than others, those with greater resilience and those with more ability to engage with and reflect on what the therapist says. Another common element is the space in which the therapy takes place. It should have healing qualities. The theory also finds that individual therapists explain more of the variance in outcomes than the therapy itself. This is called therapist effect.
Think about that a little more. Jane and John are psycho-analysts. Helen and Henry are skilled CBT practitioners. Susan and Stanley are followers of the humanistic tradition. Vera suffers from depression and anxiety. According to common factors theory her recovery depends more on whether she sees Jane, Henry or Susan -the therapists with the extra zing- than whether she gets any one of the three types of intervention. The person trumps the intervention.
Common factors theory finds that individual therapists explain more of the variance in outcomes than the therapy. This is called therapist effect.
And what qualities do Jane, Henry and Susan have? The research is still not clear on this matter. Back in 1960s psychologist Stanley Strong was interested in the role of charisma, clearly not a factor susceptible to training.
So one common factor is the therapist effect. Another is the quality of relationship between helper and helped. Because common factors theory is focused on therapy, this factor is labelled the therapeutic relationship.
The potential for variation in relationship quality to explain client outcomes can be traced back to the work of Francis Robinson in the 1940s. But it was Edward Bordin in the late 1970s that really got a hold of the shared relational elements of therapy putting it all under the headline of working alliance.
Bond, goals and tasks, the three elements of an effective working alliance.
Bordin observed and recorded the relationship between therapist and client in a range of therapeutic models and concluded that success was attributable to three types of connection between the two parties. First, good outcomes occur when there is a bond between the two. Second, progress is more likely when there are shared objectives for the therapy. Third, agreement on how best to achieve those objectives also matters. Bond, goals and tasks, the three elements of an effective working alliance.
Out of this work came a measure, the Working Alliance Inventory. It is unusual in that the items in the inventory are completed by both therapist and client. The quality of relationship is measured not just on how the questions are answered but also on whether there is concord on selected items.
The results suggest a modest but robust association between relationship quality and client outcomes. On some readings of the data the quality of relationship seems to matter more than the type of therapy. So the way Jane gets on with Vera, or Henry gets on with Vera matters more than the fact that Jane is a psychoanalyst or that Henry delivers CBT. (The lack of clarity partly comes from the inability to determine the direction of effect. Is Vera’s improvement explaining the quality of her relationship with Jane, or is Jane and Vera’s bond the explanation for Vera’s reduced anxiety and depression).
So the way Jane gets on with Vera, or Henry gets on with Vera matters more than the fact that Jane is a psychoanalyst or that Henry delivers CBT.
I have shorn away much complexity in the research about common factors and the therapeutic alliance, and also much of the ambiguity in findings from studies to test the theories.
When I take all that complexity away, three ideas worth testing emerge from this brief review of the literature:
- the type of therapy or intervention matters less than a small number of core elements common to most work by the helping professions
- the qualities of the therapist who delivers the intervention matter more than the type of therapy or intervention
- the quality of relationship between helper and helped, heavily influenced by the qualities of the therapist, matters more than the intervention