Do therapists assess the quality of the therapeutic relationship accurately?
Perhaps surprisingly, the research seems to suggest that we are not that good when it comes to accurately estimating how our clients experience us. Orlinsky et al. (1994) for example, found that therapist assessment of the quality of the therapeutic alliance bore little relationship to the outcome of therapy. Therapists tended to rate the strength of the alliance as much higher than that of their clients. Furthermore, when the alliance was rated by clients, it was strongly related to the outcome of therapy.
Does it matter that as therapists we may frequently inaccurately assess the quality of the alliance? I would say yes definitely given the central role of the alliance in treatment success and that studies have shown poor alliance scores to be predictive of premature termination of therapy. It is worth asking therefore what factors might be contributing to therapist inaccurate perception of the alliance quality and what can be done to improve these skills?
It seems to me that as therapists we like to think we are doing a good job, and this might lead to some biases in how we perceive our clients perceive us. It can be unsettling or feel awkward to think that something we have said has triggered the client. We are human after all. Previous research has suggested that in a fair number of cases therapists did not attend to a rupture even when the client directly commented on the relationship. This suggests we may be a bit avoidant or unsure of how to make the alliance the focus of collaborative enquiry. I think we need to bring a healthy vulnerability to our work to be able to adopt a genuine position of curiosity in relation to how our clients experience us in any given moment. This may mean having to stay present and empathic when faced with responses that feel attacking or that challenge our ideas of ourselves as good therapists.
There are easy to use client alliance rating scales that can easily be incorporated into your clinical work. I have used these from time to time and they have helped me develop my capacities to accurately assess the alliance, become more familiar with my own biases and vulnerabilities in doing so, and crucially aid my awareness when the alliance is unsatisfactory and needs attention. I think this has been particularly helpful when the rupture has been a withdrawal rather than confrontation event. I think we tend to think of ruptures as confrontation events involving the expression of angry feelings – often they are withdrawal events marked by subtle signs that can be easily missed.
Cognitive analytic therapy (CAT) offers us many useful approaches which can be integrated usefully into other therapeutic models to help therapists work better to accurately assess the quality of the alliance. CAT can also help us to formulate and make the focus of collaborative enquiry any tensions within the alliance. So please do consider joining this ACAT workshop in London on Thursday 4th April, designed to help therapists work better when the therapeutic relationship gets stuck .
Dr Robert Watson, Clinical Psychologist, Accredited CAT Supervisor and Therapist, Vice-Chair Association for Cognitive Analytic Therapy.