How does change occur in psychological therapy?
The key ingredients for change have been debated since the inception of psychological therapy over 100 years ago. Psychologists representing various schools of thought have proposed theories of change revolving around either the technique used in therapy or the quality of the client-therapist relationship, and in recent years there has been a trend toward elevating the importance of the relationship.
In reality, it is possible to identify general principles of change underlying both technique and relationship.
Stepping back and looking at the debate since the middle of the last century, two giants in psychological theory illustrate the extremes of relationship vs. technique in psychological change. Carl Rogers and B.F. Skinner, both writing in the 1950’s, provide examples at the poles of the current debate.
According to Rogers, a pure humanist, the necessary and sufficient conditions for therapeutic change involve, “providing the client with unconditional positive regard and empathy, which are genuinely felt by the therapist.” Skinner, an extreme behaviorist, proposed that human behavior is always determined by external stimuli, and specifically in the therapeutic setting, “the reluctance to acknowledge this may be due to one’s fear of exercising control over another person.”
Over the years, the arguments in each camp have softened, so that today the primary schools of therapy exist along a spectrum acknowledging the importance of both relationship and technique.
So how do these two important forces for change interact to produce positive results for the client? There have been a number of studies demonstrating that the quality of the relationship determines the success of the technique. For example, a study of cognitive therapy in the treatment of depression (Burns & Nolan-Hoeksema, 1992) found that the client’s perception of the therapist’s empathy influenced the outcome. Another study of cognitive techniques in the treatment of depression (Castonguay et al, 1996) found a negative outcome in cases where the client-therapist relationship was “strained.”
Alternatively, the technique used affects the relationship. Several studies have shown that the technique chosen by the therapist can either enhance or strain the relationship. For example, behavioral “directive” techniques used with clients who are strongly self-directed can cause a negative reaction to the therapist. Likewise, certain directive techniques used in dialectical behavioral therapy must be modified to prevent clients from feeling criticized. On the other hand, exploratory techniques can facilitate a bond with the therapist, as can accurate interpretation and reflection.
Given the interplay of technique and relationship, certain general principles of change can be identified operating across the spectrum of the technique-relationship interaction. These are:
- Facilitation of expectations that therapy will help, giving hope to the client
- Establishment of an optimal therapeutic alliance, which includes a personal bond between therapist and client
- Agreement between therapist and client on the goals of therapy
- Agreement between therapist and client on the means (techniques) to achieve these goals
- Offering feedback that increases client awareness
- Encouragement of corrective experiences (positive experience in spite of negative expectations) either within or between sessions
- Emphasis on continued reality testing (reinforcement of awareness through repeated corrective experiences)
These principles of change not only underlie the interplay of technique and relationship, they are specifically the outcome of both technique and relationship. For example, the facilitation of expectations that therapy will help can be fostered by the care and confidence expressed by the therapist that it will work (the relationship), as well as the specific techniques used such as motivational interviewing, educational methods, self-help books, and relaxation techniques.
In general, the association of the technique-relationship interaction and the principles of change is not vague, rather it is causative. Both technique and relationship are key principles of change, and to the extent that positive therapeutic change occurs, both the client-therapist relationship and the specific techniques used are responsible. This is a synthetic outlook that serves to soften the current debate among proponents of humanistic-leaning and behaviorist-leaning theorists.
The full research from Goldfried, M. R., & Davila, J. (2005). The role of relationship and technique in therapeutic change. Psychotherapy: Theory, Research, Practice, Training, 42(4), 421-430. is available at the American Psychological Association’s PyscNET.