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Kolden G.G., Klein M.H., Wang C-C. et al.
Psychotherapy: 2011, 48(1), p. 65–71.
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This meta-analytic review commissioned by the American Psychological Association finds that in the (mainly Western) cultures where these studies have been done, outcomes improve the more therapists are seen as genuine by their clients and relating to them human to human rather than as an authority figure.
Summary Editor's note: Though not specific to patients with drug and alcohol problems, many of the studies in the analyses described below will have included such patients, and the principles are likely to be applicable to these disorders among others, not least because substance use problems generally form part of a complex of broader psychosocial problems.
This review is one of several in a special issue of the journal Psychotherapy devoted to evidence-based, effective therapist-client relationships. It reports on a research synthesis of the links between outcomes of therapy and the degree to which therapists behave in a way 'congruent' with their feelings and understandings, described by the seminal psychotherapist Carl Rogers and colleagues as openly "being the feelings and attitudes which at the moment are flowing within" rather than hiding behind a professional role or holding back feelings that are obvious in the encounter. A closely related concept is 'genuineness,' described as "the ability to and willingness to be what one truly is in the relationship". Genuineness is related to authenticity, openness, honesty, and non-phoniness.
This dimension (referred to here as 'congruence/genuineness' or just 'congruence') was one of three therapist qualities posited in 1957 in a classic paper by Carl Rogers. The other two, positive regard and empathy, are reviewed in other papers in this special issue. Rogers' paper fostered the view that the therapist-client relationship per se was the critical determinant of therapeutic success, rather than the therapist's technical expertise in, for example, choice and timing of interventions.
The featured review incorporated meta-analyses A study which uses recognised procedures to combine quantitative results from several studies of the same or similar interventions to arrive at composite outcome scores. Usually undertaken to allow the intervention's effectiveness to be assessed with greater confidence than on the basis of the studies taken individually. synthesising results from relevant studies to provide estimates of the overall strength of the link between client progress and congruence/genuineness, and to be able to probe for influences on the strength of the link. Strength was expressed as effect sizes A standard way of expressing the magnitude of a difference (eg, between outcomes in control and intervention groups) applicable to most quantitative data. Enables different measures taken in different studies to be compared or (in meta-analyses) combined. Based on expressing the difference in the average outcomes between control and experimental groups as a proportion of how much the outcome varies across both groups. By convention, in the behavioural sciences an effect size of the type used in the featured analyses is considered a small effect at 0.10, a medium effect at 0.30, and a large effect at 0.50. using the 'r' metric, which can be squared to calculate how much of the difference in outcomes can be attributed to differences in the therapy dimension being investigated. The assumption was made that there is no single, true strength of the link between outcomes and regard which appears to vary only because of methodological differences, but that instead strength really might vary across the studies included in the analysis.
The analysis included studies of individual or group therapy with adults or adolescents which measured both patient progress and congruence/genuineness, and reported on their relationship in a way which enabled results to be aggregated with those from other studies. Progress was variously assessed as symptom reduction (eg, anxiety), improved psychosocial functioning (eg, coping), well-being, general change and various measures of satisfaction and psychological health, usually from the perspective of the patient.
Across the resulting 16 studies, the strength of the link between congruence/genuineness and therapy outcomes equated to a small to medium effect size of 0.24, a statistically significant link which accounted for 6% of the variance in outcomes, indicating that better outcomes can be expected when the therapist is seen as genuine by (in most studies) their client and/or by themselves or observers.
The strength of this relationship varied across the studies more than would be expected by chance. Several factors appeared to influence this. When progress was rated by the client rather than the therapist, the relationship with congruence/genuineness (effect size 0.29) was stronger, probably because in these studies congruence/genuineness too was usually assessed by the client. The longer the therapist had been in clinical practice, the stronger the congruence-outcome link. Therapist congruence also seemed relatively influential in achieving good outcome with less rather than more educated clients, adolescents rather than adults, and in more present-oriented, problem-focused therapies in contrast to psychodynamic approaches. For reasons difficult to understand, congruence/genuineness had a negligible relationship with outcomes when therapy was conducted in outpatient mental health settings.
Although patient characteristics could not be included in the analysis, it seems likely that patients differ in their needs for and reactions to a therapist who is open, honest and informally 'human' as opposed to formal, directive, and authoritative. Cultures differ in what they expect from therapists and personalities differ in their need for an authority figure as opposed to someone who approaches them as one human being to another.
Conclusions advanced on the basis of the meta-analysis must be tempered by the methodological limitations of the studies and of the methods used to combine their results. Apart from variations in samples and ways of measuring congruence, there have been few recent studies, and no randomised controlled trials which might establish a causal role for congruence. Also, positive findings for congruence/genuineness have derived mainly from studies of client-centred, eclectic, and interpersonal therapies. Researchers who choose to study these approaches may also lean towards valuing congruence and seeing it as an important influence on outcomes. Congruence may be important only when other conditions are met. For example, rather than being influential in itself, it may be an essential platform for empathy or positive regard to effect positive change.
Many of these limitations can be expected to have diluted the aggregated relationship between congruence and client progress. That nevertheless a small to medium link emerged suggests that the evidence is likely more strongly support this link than it seems at first glance; a consistent pattern of positive findings is unlikely to be explained by study flaws.
Therapists must first embrace striving for genuineness with their clients. This involves acceptance of and receptivity to experiencing with the client and a willingness to use this information in their interactions with clients. The congruent therapist is responsible for their feelings and reactions and makes this clear, for example, by thinking out loud why they said or did something, a stance which promotes bonding as well as helping steer the therapy relationship.
Though complex and perhaps difficult, therapists can mindfully develop the intrapersonal quality of congruence. Seeking feedback from colleagues, supervisors, peers, and perhaps clients, might help.
Therapists can foster the experience of congruence in their patients by modelling congruence through considered disclosure of personal information and life experiences and expressing thoughts, feelings, opinions, pointed questions, and feedback about how clients behave. Congruent responses are honest and neither disrespectful, overly intellectualised, nor insincere, though they may involve irreverence. They are authentic and consistent with the therapist as a real person with likes, dislikes, beliefs, and opinions, as well as a sense of humour. Genuine therapist responses are cast in the language of personal pronouns (eg, "I feel ...", "My view is ...", "This is how I experience ...").
Maintaining congruence requires therapists to be aware when congruence falters (marked by feelings of being 'false' in some way), and to use this as a cue for self-examination and a return to a more genuine and direct way of relating.
It is important for therapists to identify and become aware of their congruence style and to discern and adjust to the differing needs, preferences, and expectations clients have for congruence.
Congruence may be especially important in younger, less educated, and perhaps less sophisticated clients. The congruent therapist communicates acceptance and the possibility of an authentic relationship, something needed but unexpected from the often formal and authoritarian adults in their lives.
More experienced (often older) practitioners come across as more genuine and congruent. Perhaps as they have gained experience, confidence, and maturity, they have come to relax the pretence of role-bound formality and give themselves permission to genuinely engage with their clients. Moreover, experienced therapists may recognise and more carefully discern a client's need for relational congruence.
commentary This article was in a special issue of the journal Psychotherapy devoted to effective therapist-client relationships. For other Findings entries from this issue see:
Evidence-based psychotherapy relationships: Psychotherapy relationships that work II
Evidence-based psychotherapy relationships: Alliance in individual psychotherapy
Evidence-based psychotherapy relationships: The alliance in child and adolescent psychotherapy
Evidence-based psychotherapy relationships: Alliance in couple and family therapy
Evidence-based psychotherapy relationships: Cohesion in group therapy
Evidence-based psychotherapy relationships: Empathy
Evidence-based psychotherapy relationships: Goal consensus and collaboration
Evidence-based psychotherapy relationships: Positive regard
Evidence-based psychotherapy relationships: Collecting client feedback
Evidence-based psychotherapy relationships: Repairing alliance ruptures
Evidence-based psychotherapy relationships: Managing countertransference
Evidence-based psychotherapy relationships: Research conclusions and clinical practices
The special issue which contained the article featured above was the second from the task force. The first was a special issue of the Journal of Clinical Psychology. While the second aimed to identify elements of effective therapist-client relationships ('What works in general'), the first aimed to identify effective ways of adapting or tailoring psychotherapy to the individual patient ('What works in particular'). For Findings entries from this first special issue see this bulletin. Both bodies of work have also been summarised in this freely available document from the US government's registry of evidence-based mental health and substance abuse interventions.
Last revised 30 May 2011
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