Handbook of Psychotherapy and Behavior Change: Starting in March 2013 I will review one chapter a month from the Handbook of Psychotherapy and Behavior Change in addition to reviewing psychotherapy research articles. Book chapters have more restrictive copy right rules than journal articles, so I will not provide author email addresses for these chapters. If you are interested, the Handbook table of content and sections of the book can be read on Google Books.
Bohart, A.C. & Wade, A.G. (2013). The client in psychotherapy. In M. Lambert (Ed.) Bergin and Garfield’s handbook of psychotherapy and behavior change (6th ed.), pp. 219-257. Hoboken, NJ: Wiley.
Last month I blogged about the section in Bohart and Wade’s (2013) chapter that focused on client symptom severity and motivation. This month I focus on differences between clients and therapists on their perceptions of therapy processes and outcomes. In a previous blog (see June 2013), I reviewed a meta analysis that showed that given two equally effective treatments, clients should be given their preference in order to improve outcomes. Clearly, client perceptions and preferences are important, and perhaps more important than the therapist’s perceptions. Bohart and Wade (2013) reviewed a number of studies that demonstrated this. For example, studies show that client ratings of the therapeutic alliance predicted which therapists had better than average outcomes, whereas therapist ratings of the alliance did not predict outcomes. In three other meta-analyses, client perceptions of therapist genuineness, empathy, and therapeutic presence were each more predictive of outcomes than the respective therapists’ assessments of their own genuineness, empathy, and therapeutic presence. Clients also value different outcomes compared to therapists and researchers. Most research on outcomes tends to focus on symptom reduction, but clients appear to have a broader view of good outcomes. In a qualitative study, clients focused on healthier relationship patterns, an increase in self-understanding that led to freedom from and avoidance of self-destructive behaviour, and stronger valuing of the self, in addition to symptom reduction. Others report that clients define good outcomes as reengaging in meaningful work and social roles, and restoring their self respect.
Clients are more finely attuned to the therapeutic alliance than therapists, and perhaps are better at detecting relevant and helpful therapist stances. If you are interested in assessing therapeutic alliance or a therapist’s empathy, don’t ask the therapist, ask the client. This has implications for training therapists in helpful therapeutic relationship stances. Helping trainees find areas for continued development as a therapist (i.e., in terms of improving their empathy, genuineness, and therapeutic presence) may require asking their clients’ opinions. Client perceptions of therapist qualities are more relevant than therapist perceptions when assessing effective therapist relationship stances. Therapists should monitor client preferences, particularly if the client is having difficulty engaging in the therapy. If possible and reasonable, therapists should alter their relationship approach to a client based on client feedback. Regarding outcomes, therapists, researchers, and agencies should consider broader definitions of outcomes that are more aligned with what clients want and value. Improved self concept, improved relationships, and better social and work functioning may be just as important as symptom reduction for most clients.