Kolden G.G., Wang C-C., Austin S.B. et al.
Psychotherapy: 2018, 55(4), p. 424–433.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Kolden at email@example.com.
Research findings amalgamated for the American Psychological Association show 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 [Though not specific to clients with drug and alcohol problems, the principles derived from this review of psychotherapy studies are likely to be applicable, partly because severe substance use problems generally form part of a complex of broader psychosocial problems. Addictions work may not necessarily best be conceptualised as psychotherapy, but there is a therapeutic element to it which makes these findings relevant to keyworkers and counsellors. This review updates an earlier version by some of the same authors.]
For the American Psychological Association, this review amalgamated findings relating psychotherapy outcomes to the therapist’s character integration, personal awareness and authenticity (‘congruence’) or the closely related quality of conveying ‘genuineness’.
The overall link between congruence/genuineness and outcomes was moderate but statistically significant, and in individual studies almost uniformly in the direction of greater congruence/genuineness being associated with better outcomes.
Though causality cannot be established by the types of studies included in the analysis, it is probable, and the safest stance for trainers, supervisors, therapists, and counsellors is to presume that conveying genuineness and authenticity is an important way therapists underpin an effective therapeutic relationship.
The featured review is one of several in a special issue of the journal Psychotherapy devoted to features of the therapist–client relationship related to effectiveness, based on the work of a task force established by the American Psychological Association. This particular review synthesised findings on the links between outcomes of therapy and the degree to which therapists behave in a way ‘congruent’ with their feelings and understandings.
Congruence was described by the seminal psychotherapist Carl Rogers as the therapist being “freely and deeply himself, with his experience accurately represented by his awareness of himself”, highlighting the importance of personal awareness, authenticity, and the integration of the therapist’s internal and external experiences and actions. Therapeutically effective congruence also involves conveying this quality to the client by words and actions. Thoughtful reflection and measured judgment are required; congruence precludes both indiscriminate self-disclosure and deception, behaviours seen as barriers to progress. In Rogers’ formulation, clients are disabled by their own incongruence – a disjunction between actual experiences and how they see themselves which distorts those experiences and prevents them seeing themselves as they are.
This quality was one of three posited in 1957 by Rogers in a classic paper as “necessary and sufficient” for therapy to work. The other two – positive regard and empathy – are reviewed in other papers in this series. Congruence is central to this framework, because it is seen as a prerequisite for the transmission of empathy and positive regard. Later theorists stressed that rather than the therapist’s qualities as such being related to outcomes, the client’s perception of congruence was the determining factor.
‘Genuineness’ is a closely related but much broader and more inclusive concept – “the ability to be who one truly is, to be non-phoney, to be authentic in the here and now” – which forms a major part of the ‘real relationship’ between therapist and client simply as people.
In psychotherapy, congruence/genuineness means that therapist and patient are accessible, approachable, and sincere, rather than hiding behind professional roles or holding back feelings that are obvious in the encounter; transparency is paramount, but not unbridled. They are aware of themselves, accept themselves as they are, and behave accordingly. The client’s experience of the highly congruent therapist is that they are fully at ease within the relationship and openly themselves, not avoiding discussion of uncomfortable feelings and impressions important to therapy. Congruence is not necessarily fully formed at the start of therapy, but is promoted by the therapy process as fear and avoidance retreat. In turn, congruence furthers safe and open experiencing, deepening security in the therapy relationship, resulting in more immediate contact with feelings, thoughts, and urges.
To test whether these qualities really are associated with better outcomes for clients, analysts sought studies of individual or group therapy with adults or adolescents which measured both patient outcomes and congruence/genuineness, and reported on their relationship in a way which enabled this to be aggregated with findings from other studies. The result was 21 findings of the strength of the relationship among a total of 1,192 clients, whose outcomes were variously assessed as symptom-reduction (eg, anxiety), improved psychosocial functioning (eg, coping), well-being, general change, and various measures of life satisfaction and psychological health, usually from the perspective of the patient. Findings were amalgamated in a meta-analysis to provide estimates of the overall strength of the link between congruence/genuineness and outcomes, and to explore possible influences on the strength of the link. Strength was calculated as a correlation coefficient, an expression of the degree to which outcomes co-varied with the therapist’s degree of congruence/genuineness. The chosen metric ranges from -1 (perfect negative co-variation, meaning that as one side of the link gets larger the other diminishes to the same degree) to +1 (perfect positive co-variation, meaning that as one side of the link gets larger so does the other, and to the same degree). Correlation coefficients were also converted to effect sizes. Effectively these metrics indicate how influential congruence/genuineness had been if causally linked to outcomes.
Some of best recognised and validated measures of congruence/genuineness are derived from the Real Relationship Inventory, which has client and therapist versions in longer and shorter formats. These questionnaires generate a total score and subscale scores for realism and genuineness by asking respondents to rate statements from strongly disagree to strongly agree. Items scored on genuineness include:
• “I am able to be myself with my therapist.”
• “My therapist and I had an honest relationship.”
• “I was holding back significant parts of myself.”
• “It was difficult for me to express what I truly felt about my therapist.”
• “My therapist was holding back his/her genuine self.”
• “My therapist seemed genuinely connected to me.”
The other best recognised and validated measure is incorporated in the Barrett-Lennard Relationship Inventory, whose questions are based on the concepts promoted by seminal therapist Carl Rogers (1 2). Parallel therapist and patient forms of the inventory ask each to describe how they felt towards the other during the session, for example:
• “I am willing to tell him my own thoughts and feelings.”
• “He is willing to tell me his own thoughts and feelings.”
The 21 estimates of the relationship between therapist congruence/genuineness and outcomes amalgamated to a correlation of 0.23, equating to a small-to-medium effect size of 0.46. This statistically significant links indicates that better outcomes can be expected when the therapist is seen as congruent/genuine by their client and/or (in a few studies) by themselves or observers. If this link was causal, it would account for about 5% of the difference in outcomes seen among the clients. Despite six new studies, these figures were very similar to those found in the previous version of the featured analysis. Moreover, these was little indication that studies missed by the analysts’ searches would have affected the results.
The strength of the congruence/genuineness–outcomes relationship significantly varied across the studies. Factors were sought which might have affected the strength of this relationship and which had been documented in at least five studies. Strength did not significantly vary depending on how congruence/genuineness was measured or from whose perspective, or with the types of outcomes these measures were related to. However, the link was stronger when congruence had been assessed several times during therapy rather than only towards the end or after therapy had been completed. The older the therapist or the longer they had been in clinical practice, the stronger the link between congruence/genuineness and outcomes, which was also stronger when therapists were fully qualified or licensed than among trainees, but not significantly different depending on the type of licence (psychologist/counsellor v. others) or the therapist’s sex. Neither was the theoretical orientation (psychodynamic v. eclectic, client-centred, or interpersonal) of the therapy a significant factor, though the link may have been stronger in group therapies. Therapist congruence/genuineness did not seem significantly more or less influential depending on the client’s educational level or sex, but was more strongly associated with outcomes among younger clients – perhaps why school counselling centres registered a significantly stronger association than mixed settings or outpatient mental health settings; for the latter, across four studies the correlation was just 0.06.
Although these characteristics could not be included in the analysis, it seems likely that patients differ in their abilities to themselves be congruent and in their needs for and reactions to a therapist who is open, honest and informally ‘human’, as opposed to formal, directive, and authoritative. Cultures too may differ in the role of congruence. For example, the value placed by Western psychotherapy on ‘being yourself’ may not hold true for patients from collectivist cultures more oriented to inter-dependence than independence.
The findings provide evidence for congruence/genuineness as an essential element in psychotherapy relationships, though this implication of the findings must be tempered by methodological limitations of the studies, considered further below. However, the consistent pattern of positive findings is unlikely to be explained by study flaws, and probably reflects a real link between congruence/genuineness and outcomes.
Limitations of the research include variation in ways of measuring congruence, and the relative lack of recent studies. No randomised trials have been conducted which might establish that congruence/genuineness is not just associated with outcomes, but actually affects them. 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/genuineness and seeing it as an important influence on outcomes, raising the possibility of researcher bias.
Congruence/genuineness may be a potent change process only in certain circumstances, for example when therapists are more experienced or clients younger, and rather than being influential in itself, may be an essential platform for qualities such as empathy or positive regard to effect positive change.
commentary On the issue of causality (considered further below) research findings are far from definitive. Nevertheless, the safest stance for trainers, supervisors, therapists, and counsellors is to presume that conveying genuineness and authenticity – the impression they give that at least during therapy, they are being and giving of themself as an integrated, authentic human being – is one way therapists underpin an effective therapeutic relationship. The recommendations in the featured review aimed to help therapists and counsellors in this task, though research to back the recommendations seems sparse.
The main weakness in drawing practice implications from the reviewed studies is that they were not designed to establish whether congruence/genuineness actually does contribute to better outcomes. Studies which observe the natural course of therapy are generally unable to eliminate the possibility that (for example) clients who are going to do well in any event, or are already doing well, encourage therapists to feel safer about being themselves, or that therapists more capable of generating feelings of genuineness are also more competent in other ways which affect outcomes. In these scenarios, congruence/genuineness would remain associated with better outcomes, but not because it helped cause them. Without effectively random allocation of patients to more or less congruent/genuine therapists, alternative explanations of a link between these qualities and outcomes cannot be eliminated. However, ethical considerations would seem to rule out deliberately allocating troubled clients to a therapy marked by inauthentic falsehoods to see whether this really does prevent them getting better.
Despite the lack of research confirmation, for at least two reasons a causal link between congruence/genuineness and outcomes seems likely. First is the consistency of the association between these variables. Though sometimes very small and non-significant, in only two of the 21 estimates amalgamated by the review was this relationship negative; in neither was the finding statistically significant, and in one it was marginal. Second is the plausibility of the proposition that modelling congruence and being congruent helps clients debilitated by incongruence become more integrated characters. For seminal therapist Carl Rogers, the coming together of the incongruent client and the congruent therapist is central to effective therapy. Imagining the opposite makes this proposition look self-evident; a scenario where both client and therapist are conflicted and inauthentic, unable to see themselves or act as they are, seems unlikely to generate a state of congruence in the client.
The strength of the congruence/genuineness–outcomes link was virtually identical to that found in the earlier version of this analysis, suggesting that further studies are unlikely to fundamentally alter the picture, an implication reinforced by the fact that there was no evidence that studies missed by the analysis would appreciably affect its results. If given current evidence we accept – or doubt – an effect of congruence/genuineness on outcomes, future research is unlikely to change our minds.
Both the featured analysis and its predecessor found that the congruence/genuineness–outcomes link was stronger when therapy was conducted by more experienced therapists. The earlier version offered an explanation of this finding: “Congruence appears to be especially apparent in psychotherapy with more experienced (often older) practitioners. Perhaps therapists come to relax the pretence of role bound formality and give themselves permission to genuinely engage their clients as they gain experience, confidence, and maturity. Moreover, experienced therapists may recognise and more carefully discern a client’s need for relational congruence.”
In the substance use sector, significant findings on genuineness emerged from two US studies. The first had recruited an unusually diverse (in terms of initial proficiency) set of addiction counsellors and clinicians who applied for training in motivational interviewing. The second evaluated a two-day motivational interviewing workshop for parole officers. In both, audiotaped sessions with clients were analysed to assess the impact of the training.
The implications of these studies have been explored for the Effectiveness Bank and briefly discussed in the Drug Treatment Matrix. They seemed to reveal some of the consequences of the potential conflict between following motivational interviewing’s ‘rules’ whilst also appearing genuine to clients. Normally for therapists who naturally take to or have absorbed motivational interviewing’s principles, there would presumably be no conflict, but even for them, being genuine can occasionally demand breaching the approach’s mandates to make naturally caring but ‘proscribed’ responses such as issuing warnings or uncalled for advice, or adopting a directive stance more in tune with the reality of the relationship with the client.
In the first study, when the counsellor’s general social skills were taken into account, how often they contravened motivational interviewing’s rules was significantly and quite strongly related to client engagement, but in the opposite direction to that expected: the more the counsellors broke the rules, the better their clients engaged. Moreover, when socially skilled counsellors acted in these ways, they actually enhanced the effect their skills had on client engagement.
The interpretation was that within (and only within) the kind of empathic, caring context these socially skilled counsellors generated, doing things such as warning and expressing uncalled for advice and concern deepened the client’s engagement with therapy. Socially skilled counsellors tended to avoid these risky manoeuvres, but also had the wherewithal to carry them off without alienating their clients – in fact, the reverse; they strengthened engagement.
To the authors, genuineness seemed the explanation for this conundrum. Therapists who honestly and openly expressed the concerns they were feeling and gave advice they felt the client needed without holding their tongues, or trying to manipulate the client into doing the expressing for them, would have rated higher on being genuine, and perhaps also come across this way to the clients.
In the second study, the surprise came when the parole officers’ glowing accounts of their improved proficiency in motivational interviewing were checked against observers’ ratings of audiotapes of how they actually behaved at three stages: before the workshop with an offender client; at the end with someone acting as a client; and with a real offender-client four months later. Especially when the raters were assessing overall adherence to motivational principles rather than specific techniques, improvements were slight and left trainees far short of expert practice, largely because they were unable to suppress their previous interactional styles. On one dimension which attempted to reflect how genuine the officers were, things had even got worse. By four months later even the post-workshop boost in use of specific techniques had eroded. Clinching this negative picture was the fact that, compared to pre-workshop tapes, their clients did not evidence greater commitment to positive change versus resistance.
It seems likely that the natural way a parole officer relates to offenders is quite far removed from motivational interviewing, and reversion to type was the dominant trend. Being trained to go against the grain simply meant that after the workshops raters felt officers had become less genuine in their interactions with clients. Told about this finding, the officers explained that this new approach felt unnatural. It does not take much imagination to realise that within the undeniably unequal and coercive context of the criminal justice system, motivational interviewing’s ‘It’s up to you’ stance might feel false to the officers themselves and also to observers and offenders.
Listed below are analyses of the other reviews commissioned by the American Psychological Association task force.
Overall conclusions based on the other 16 reviews
The ‘real’, person-to-person relationship
Alliance in couple and family therapy
Alliance in child and adolescent therapy
Cohesion in group therapy
Goal consensus and collaboration
Therapist self-disclosure and ‘immediacy’
Therapist and client emotional expression
Repairing ruptured alliances between therapists and clients
Treatment outcome expectations
Feeding back client progress data therapists
Thanks for their comments on this entry in draft to Asna Ahmed, counselling psychologist with special interest in addiction, England. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 28 March 2019. First uploaded 10 February 2019
REVIEW 2018 Cohesion in group therapy: a meta-analysis