Can you see what I see? A comparison of client and observer perspectives of the alliance and group cohesion in CBT

Cognitive behaviour therapy (CBT) is an effective treatment for many mental health disorders, but not everyone benefits from therapy. While some studies have shown over 80% respond to treatment, others have observed rates as low as 38%. Why does CBT work for some, but not others?

People who try therapy often say that one of the most important parts of treatment is their relationship with the therapist. Finding the “right match” is routinely touted as key to successful treatment. In the case of group treatments, it is also argued that having a good relationship with the other group members is essential to the success of treatment. In CBT, therapy relationships characterised by mutual understanding, support, and team work creates the necessary environment to make treatment effective.

To test this theory, researchers have tried to examine the link between therapeutic relationships and treatment outcomes. But first, figuring out if, how, and to what extent therapeutic relationships work in therapy ultimately relies on knowing how best to measure the relationship in treatment.

Traditionally, therapeutic relationships are measured by asking the clients themselves to rate their experiences. This makes sense, as it is convenient, cost-effective, and provides a client’s subjective perception of therapy.  

But what about using an objective, third-person to measure the relationship? Independent observers can be trained to focus on specific aspects of treatment, they can practice and build a large database of what constitutes “strong” versus “weak” relationships for more consistent ratings, and they can be less vulnerable to biases such as social desirability – that is, the tendency for people to hide their true experiences in favour of giving a more socially preferable response e.g., clients pretending to like a therapist to be “polite”.  

Our research aimed to answer the question – when measuring the alliance and cohesion in CBT, is it worth getting both client and observer perspectives? To test this, we asked clients enrolled in a group CBT program for anxiety disorders to rate their relationship with their therapist (alliance) and with other group members (cohesion) after a treatment session. We then asked trained graduate psychology students to watch video recordings of these sessions and rate the alliance and cohesion for each client.

When we compared these two perspectives, we found some interesting results. First, client ratings of alliance and cohesion did not relate to their observer rated counterparts. Second, for the alliance, we found that only client ratings predicted treatment outcomes, and not observer ratings. In contrast, for group cohesion, it was found that both client and observer perspectives uniquely predicted treatment outcomes.

Taken together, these findings suggest that client and observers are measuring different aspects of therapy relationships, each of which operate uniquely in treatment. While the benefits of obtaining observer ratings of the alliance remains uncertain, this study shows that both client and observer-rated cohesion likely contain important, meaningful, and distinct information about how relationships work in CBT.

Read full Read the full paper: Luong, H. K., Drummond, S. P. A., & Norton, P. J. (in press). Can you see what I see? A comparison of client and observer perspectives of the alliance and group cohesion in CBT. Cognitive Behaviour Therapy. doi:10.1080/16506073.2021.1898463

Photo by: dankueck

Pictured: Peter Norton
Pictured: Hoang Luong
Pictured: Sean Drummond

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