Man has been faced with both physical and psychological challenges that have necessitated the provision of appropriate care. Various therapeutic measures, therefore, have been developed to address these medical challenges. Psychotherapeutic intervention is one of the most developed and has helped in taking care of mental or emotional problems. It is the various methods of therapy employed by therapists that have raised concerns among researchers as far as how the clients react to them is concerned. A number of researchers agree that the relationship between the client and the therapist must be at the center of the focus of any therapeutic intervention.
This need has been advocated by the construct of a therapeutic alliance. It is an aspect concerned with the association between the client and the therapist in a psychotherapeutic context. Prominent researchers have formulated three components for the therapeutic alliance. The first one is the need to consider the mutual agreement between the client and the therapist concerning the objectives of the treatment. Secondly, the need to consider the activities that must be performed in the therapeutic encounter and the associated goals. The third component is the emotional bond that must exist between the client and the therapist which is necessary for any meaningful progress in the therapy.
For any significant success to occur in psychotherapy, the therapeutic alliance is paramount. This research paper seeks to critically review the work done by other researchers as far as the therapist-client relationship is concerned in the various fields of therapy. It is evident that the assessment of process-outcome at the beginning of any given therapy helps in ensuring the success of any therapeutic measure.
Several studies have been conducted to evaluate the importance of the therapeutic alliance and its implications on therapeutic practices. Therapists ought to fully understand the impact that their relationships with the clients have on the outcome, especially in psychotherapy. According to a study done by Stein and Lambert (1995), graduate training has a significant impact on the outcome of psychotherapy. In their article, the authors discuss the training efforts that are designed to improve novice therapists’ acquisition of some specific facilitative conditions and other components of “common factors” of therapy.
They also examine the between-group as well as within-group research evaluating the more universal relationship between the level of training of therapists and the outcome of therapy. Additionally, the authors of the article present the results of an updated meta-analytic review of within-study outcome comparisons between the therapists with more graduate training and those with less training.
Stein and Lambert (1995) noted that partial investigation of the impact of training level of therapists can be achieved by examining the outcomes of extensive programs intended to enhance the relationship skills in the therapists who are still undergoing training. Some of the common factors identified in the article include the facilitative conditions, interpersonal skills, or the therapist’s attitudes which may include empathy, warmth, and genuineness.
The investigation of the impact of more or less-trained therapists on the outcome is important than focusing just on training level. The review by Stein and Lambert (1995) was focused on addressing the central issue which is the investigation of client outcomes in relation to the level of therapist’s training. They also conducted both pre- and post-therapy meta-analytic assessment of therapy outcomes.
The authors of the article found out that the training level influences the consistency of treatment and the client’s general improvement. Clients respond more effectively to therapy offered by therapists with advanced training compared to those with less training. Investigations further revealed that premature dropout rates were higher in those therapists without graduate training and working in community mental health centers and less in their colleagues with more training and experience.
This review indicates that the level of training affects the relationship between the therapist and the client. Hence the therapists must acquire the appropriate training if client satisfaction is to be ensured. Training programs must ensure that the skills taught to the therapists lead to quality therapy outcomes among the patients. Further investigations, according to Stein and Lambert (1995), need to be conducted to demonstrate the importance of graduate training on therapy outcomes.
Researchers, as well as clinicians, have embraced the fact that psychotherapists and their clients have varying perceptions of therapeutic sessions. According to research conducted by Eugster and Wampold, the systematic effects of participant role on the evaluation of the therapeutic sessions were investigated (1996). They identified systematic differences between 114 therapists and 119 clients as far as psychotherapy sessions outcomes are concerned.
The Comprehensive Scale of Psychotherapy Session Constructs was used to measure 9 process variables and how they could be used to evaluate therapy sessions from a therapist’s and client’s perspective. The variables used to evaluate the patient’s perception of the sessions were; patient involvement, patient comfort, patient progress, and patient real relationship with the therapist. In the case of the therapist, the following variables were used; therapist involvement, therapist comfort, therapist expertness, therapist interpersonal style, and therapist real relationship with the client. This method of evaluation employed the use of the therapist and patient immediate judgment of a given session.
The study revealed that there are both similarities and significant differences in how patients and therapists evaluate psychotherapy sessions. It also demonstrates that the process components that influence the evaluation of sessions differ systematically as a function of the role. This supports the thesis statement that therapeutic alliance is important and impacts on how therapists interact with their patients.
From both the therapist and patient perspective, patient involvement and patient progress were found to be positive indicators of session evaluation. Client satisfaction was identified to be at the center of session evaluation. On the other hand, therapist expertness was identified as predicting therapist session evaluation while therapist real relationship was the best predictive of patient session evaluation. The most important finding was that the bond that exists between the patient and the therapist determines the success of any therapeutic session. The investigation, however, had some inherent limitations which included the therapist’s bias in choosing the sessions as well as the patients to be evaluated. In order to enhance the reliability of the research findings of this study, further investigation must be conducted to confirm and refine the process constructs, to improve their measurement, and to model relationships without the problem of unreliability.
The challenge in psychotherapy is the accurate evaluation of client satisfaction. Howard, Moras, Brill, Martinovich, and Lutz (1996) conducted a study to investigate the efficacy, effectiveness, and patient progress in psychotherapy. The study focused on the individual’s progress over the course of treatment and feedback of this information to the therapist, supervisor, or the case manager. It concentrated on three fundamental questions on treatment; does it work under special, experimental conditions? Does it work in practice? And, is it working for this patient? They found that psychotherapeutic interventions are efficacious and effective for mental challenges. The dosage and phase models of psychotherapy were identified as the best method for addressing the challenges experienced and ensuring patient satisfaction.
Having discussed the systematic effects of participant role in the evaluation of psychotherapy sessions, it is important to consider the impact of academic training background on practicing marriage and family therapists. A study by Simmons and Doherty (1998) sought to investigate whether academic training background is associated with differences in practice patterns and client outcomes. The study investigated therapists with academic training in psychology, social work, counseling, and marriage and family therapy (MFT). They were compared to a wide range of clinical practice variables and the clients’ satisfaction and outcomes were surveyed.
Two measures examined the client’s perceptions of the treatment they received from their therapist. In one of the instruments, different aspects of the client’s satisfaction with treatment were measured. In another, the clients’ perceptions of the outcomes of treatment were measured. Simmons and Doherty (1998) found highly similar patterns of practice and client outcomes across all the four disciplinary categories. This implies that the training of therapists in different mental health disciplines does not affect the patient outcomes in marriage and family therapy sessions. These results, however, do not disqualify the earlier findings by Stein and Lambert (1995) where the level of training affects the client outcome.
The study by Simmons and Doherty (1998) had some inherent weaknesses that may influence the interpretation of the results. The investigation of treatment outcomes did not take into consideration the impact of race and ethnicity of the therapists and the clients. A follow-up study is recommended to find out the influence of these factors. Secondly, the notably low rate of response prevents any meaningful generalization of the findings. Moreover, the study did not factor in the level of training of those therapists trained in other disciplines other than marriage and family therapy. Advanced training, as concluded by Stein and Lambert (1995) may have helped the non-MFTs to be in line with the MFT-trained therapists.
The findings of this study, however, imply that academic training is not significant in offering MFT services, especially by therapists trained in other disciplines. Therefore, it is evident that therapeutic alliance is what matters in any therapy session and all therapists ought to embrace this fact.
Prior studies recommended further research into the understanding of the relationship between the specific types of skills that beginning family therapists use in therapy and therapeutic outcome. Laszloffy (2000) conducted a study to investigate the implications of client satisfaction feedback for beginning family therapists. She was motivated by the fact that existing literature on this field of therapy has been based on therapist’s instead of client’s experience. Even in situations where client’s experience of therapy is discussed, it is done from a therapist’s, researcher’s, and theoretician’s perspective rather than from a client’s point of view.
The study evaluated client session outcome in terms of extremely satisfied (ES) and extremely dissatisfied (EDS). The findings revealed that clients and therapists had notable congruent perceptions of therapy experience. Therapy outcomes were found to depend on three basic tasks. The first is the cultivation of a positive client-therapist relationship characterized by the “common factors” mentioned earlier in this review. Secondly, the therapist is expected to establish and communicate clear and mutually developed objectives of every therapy sessions. The third task is the actual action by therapists in an attempt to genuinely assist their clients.
The family therapists can learn from the findings that there is need to reinforce their therapy sessions with action oriented behaviour when it comes to dealing with clients. Dissatisfying outcomes leads to reactivity among therapists. The study conducted by Laszloffy (2000) was small and specific to the context and hence generalizations cannot be made. She recommended the use of the three tasks to provide the overall satisfaction rating that can be used to predict therapy outcome.
Every therapeutic session seeks to achieve positive outcome in the case of the client. Researchers have continued to investigate this desire with more emphasize on client perspective of therapy sessions. Fischer and Valley (2000) studied the benefits of family counseling by assessing client satisfaction. They employed the client survey method which usually takes three forms: as an in-process survey while the clients are still undergoing treatment, as a survey at the end of counseling, and as a follow-up survey. In this study, Fischer and Valley preferred the in-process survey due to the high rate of response and hence the ease of collecting information.
Such a method is useful for the therapists in enhancing the services offered to their clients. Still on patient-focused research, Lambert (2001) conducted a study on psychotherapy outcome and quality improvement. The study used the efficacy and effectiveness research approaches which is interested in evaluating individual patient therapy outcomes rather than group outcome.
Overwhelmingly large numbers of researchers have agreed that there is significant importance of positive alliance as one of the best predictors of outcome in therapy sessions. A study by Duncan, Miller, Sparks, Claud, Brown, and Johnson (2003) aimed at investigating the session rating scale. They elaborated on the development and validation of ultra-brief alliance measure known as the Session Rating Scale Version 3 (SRS) (Duncan et al., 2003).
Their study revealed that the psychometric tool represents an unbiased swap between the reliability and validity of the long term research measures. The scale was designed to be used on a session by session basis in the process of therapy. The sample used for this particular study was very small and hence no generalizations can be confidently made. Further research using larger and more diverse clinical samples need to be conducted in order to identify the strengths and weaknesses of the SRS.
Other approaches of assessing professional practice in psychotherapy have been developed by subsequent researchers. Lambert and Hawkins studied the selection and utilization of brief outcome tools for evaluating feedback in professional practice (2004). The study revealed that monitoring patient progress enhances patient therapy outcome, especially for the clients who are at a risk of not responding to treatment. The article by Lambert and Hawkins revealed that there is negligible training in outcome measurement.
This implies that the responsibility of evaluating patient outcome is left to the therapists themselves. The selection of the appropriate measurement instrument is therefore necessary. In their study to investigate consumer response, Nielsen, Smart, Isakson, Worthen, Gregersen, and Lambert (2004) found that psychotherapy is effective and that longer, more intensive therapy is even more effective.
Despite the numerous research efforts done towards the improvement of therapy outcome, the rate of premature dropout is still significantly high. Modern researchers have been challenged by this fact. Anker and Duncan (2009) conducted a study to find out how to use client feedback to improve couple therapy outcomes. They investigated the effects of providing treatment progress and alliance information to clients as well as therapists during couple therapy.
The study concluded that it is important for therapists to use client feedback to enhance their service provision. Another recent study by Reese, Norsworthy and Rowlands (2009) sought to investigate the impact of continuous feedback system on psychotherapy outcome. It was found that clients who used feedback condition demonstrated clinically significant gains compared to those who did not use. The use of this monitoring technique ensures quicker gains resulting in fewer sessions and cutting on cost of patient treatment. Continuous assessment of clients by therapists is therefore very crucial for enhancing client satisfaction.
The review has discussed the findings by several researchers into the broader field of therapy and client satisfaction. From all sections of the review, it is evident that therapeutic alliance is deeply entrenched in any treatment approach and must be cultivated to get positive patient feedback. This fact has significant implications on the therapists and their practice in general. Therefore, the relationship between a client and the therapist is crucial for ensuring the success of any therapeutic intervention.
References
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Duncan, B. L., Miller, S. D., Sparks, J. A., Claud, D. A., Brown, J. & Johnson, L. D. (2003). The session rating scale: preliminary psychometric properties of a “Working” alliance measure. Journal of Brief Therapy. 3(1), 3-12.
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