Therapists and Clients Have Different Views About Therapy

A recent article published in the Journal of Clinical Psychology explored differences in perspective between therapists, people receiving therapy (“patients”), and people with no experience of therapy (“lay individuals”) regarding what makes psychotherapy successful. The researchers, Dana Tzur Bitan and Shiran Abayed, found that therapists rated the therapeutic relationship and verbal processing of emotion as most vital. However, patients and lay individuals ranked cognitive/emotional reconstruction and cognitive control as most important.

“Therapists tend to place more importance on the establishment of positive patient–therapist relations and verbal processing of the therapeutic relations, while patients and lay individuals place more importance on the provision of tools for cognitive control,” write Tzur Bitan and Abayed.

Although there has been a significant amount of research exploring what works in psychotherapy, such as the “common factors” model, there has been less work done on what aspects different stakeholders in the mental healthcare system believe to be effective. Feedback about psychotherapy is important, given that many clinicians overestimate their own effectiveness and the progress of their clients. Previous research has explored the perspectives of those who found cognitive-behavioral psychotherapy unhelpful.

Examining which processes are viewed as effective by patients and lay individuals can have important implications for expectation of therapeutic effectiveness, which is one of the “common factors” associated with therapeutic success.

Tzur Bitan and Abayed hypothesized that patients and lay individuals would rank cognitive control as more significant, but that therapists would privilege the therapeutic relationship itself. They asked 107 therapists, 97 patients, and 160 lay individuals to rank different aspects of therapy. The mean age of the total sample was 26, with the majority (83.2%) being female and born in Israel (92.3%).

The researchers used a 32-item self-report questionnaire entitled the “Expectations of the active processes in psychotherapy scale.” The scale measures seven different factors:

• Establishment of positive therapist–client relations (Factor 1)
• Verbal processing of therapist–client relations (Factor 2)
• Exploration of unexpressed contents (Factor 3)
• The ability to share sensitive contents openly and securely (Factor 4)
• Working through specific emotional problems (Factor 5)
• Therapy fosters resilience (Factor 6)
• Therapy provides tools for cognitive control (Factor 7)

After controlling for demographic factors like age and education level, the researchers found that therapists were significantly more likely to vote for Factor 2 (talking about the therapeutic relationship) as most important. Patients and lay people were significantly more likely to rank Factor 7 (tools for cognitive control) as most important.

In another, different type of analysis, the researchers found that therapists also ranked Factor 1 (setting up a therapeutic relationship) significantly higher on their list than did patients and lay individuals.

The biggest limitation to the study is that it was conducted in Israel. The main theoretical approach in Israeli clinical programs is psychodynamic. This differs from the US and other countries, where cognitive-behavioral therapy holds sway. It’s possible that in the US, therapists would also rank Factor 7 very highly.

Another limitation, according to the researchers, is that therapists may have different views about what works in therapy based on the individual with whom they’re working. That is, they may believe that certain aspects of therapy work for some people, but other aspects work for others. This was not captured in the current study.

The researchers write that their results could represent the way public perception of therapy differs from what is taught to therapists.

“Clinical practitioners as well as researchers should take these differences into account, as it is possible that differences in expectations regarding the process of change might account for potential negative responses to therapeutic interventions,” they write.

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Tzur Bitan, D., & Abayed, S. (2020). Process expectations: Differences between therapists, patients, and lay individuals in their views of what works in psychotherapy. Journal of Clinical Psychology, 76(1), 20-30. (Abstract)