7. It is the relationship not the therapy (II)
It is all about relationships
Reflections on how common factors theory makes us think differently about responding to disadvantage
It is the relationship not the therapy. It is the connection between practitioner and client, not the intervention. It is the bond between family members, not the help that is offered. I can formulate this argument in many ways, but at its core is the proposition that the components of relating- of listening, asking questions, or acting as a mirror to the other- that these and other ingredients of a healthy relationship, are more likely to resolve human suffering than any techniques being used as a part of the relationship.
There must be limits to this hypothesis. For example, the challenges faced by some people in life require simple, practical solutions, like advice about a legal problem, or money to get them through the week, or a break to give themselves time to gather themselves up. Does a healthy relationship multiply the impact of such interventions? Possibly not.
It is the relationship not the therapy. It is the connection between practitioner and client, not the intervention. It is the bond between family members, not the help that is offered.
Still the possibility remains that for many challenges the relationship matters more than the therapy. But testing this premise is going to be fearsomely difficult. How to tease apart the relational capability of say a therapist or social worker or volunteer from the simple act of helping another human being in need from ordinary dynamics, such as do the two parties like each other? The common factors theory identifies the relationship as one of several influences on outcomes found in most therapies, so how to take account of the non-relational components?
And then there is the problem of measurement. There is a lot to be said for the Working Alliance Inventory, not least because it conceptualises the components of an effective relationship into bond, task and goals, and particularly because it requires both helper and helped to rate their connection.
The 3HAdvisor app asks questions like Head- My worker helps me achieve my goals; Heart- My worker understands me; and Hands- My worker helps me get things done.
Then again, I am also drawn to the simple subjective rating by the person being helped. The studies that sparked my interest in relationships had me working with young people facing more than most of us will face in a lifetime. They affirmed the importance of relationships and developed an app for young people in similar circumstances as themselves to capture the strength of their connection to those charged with helping them. The 3HAdvisor app asks questions like Head- My worker helps me achieve my goals; Heart- My worker understands me; and Hands- My worker helps me get things done.
Even then there is the problem of knowing when to measure. The best of relationships go through bad times. Can we trust one rating, good or bad?
Then we have the issue of direction of effect I mentioned in my previous intervention. It is noticeable that therapists who feel they have a strong bond with their clients tend to over-rate how much progress the client is making. Does the progress we make as a result of any intervention make us think more of the relationship we have with the person leading that intervention -not so encouraging- or does the quality of relationship we have with the therapist help us to make more progress?
So, not an easy research problem to solve but, nonetheless, a problem worth solving. Much public policy over the last 30 years has put the intervention before the people involved in that intervention.
Fortunately for me I have an opportunity to begin to untangle the various parts of this puzzle. The Lankelly Chase Foundation, which has supported this writing, has also funded me to re-analyse data from the large Canadian trial of the At Home/Chez Soi programme that offered housing to people facing multiple disadvantage in Vancouver, Toronto, Montreal, Moncton, and Winnipeg. There is good data on the intervention -providing housing- and on the quality of relationship between the person managing and the person on the receiving end of that intervention.
Much public policy over the last 30 years has put the intervention before the people involved in that intervention.
Then there is the idea that Michael Little described in the previous contribution to this series. He has been working with colleagues in Spain and the United States to mount a different kind of test into the effectiveness of evidence based programmes like Functional Family Therapy, one that estimates the contribution of the relationship between therapist and programme recipient.
I am also working to get more organisations to further develop and test the app described above, which was designed to get young people to give a simple subjective rating of how they get along with the people assigned to help them.