More than a ‘nice to have’ philosophical approach, true collaboration with our clients makes a substantial difference to their engagement in therapy and their outcomes. We profile a paper that sets out the evidence for the power of collaboration and what it can look like in practice.

If I were to ask you “Do you work collaboratively with your clients?” I’d expect you to fix me with a raised eyebrow and a look that suggests that it was a monumentally daft question. Of course you work collaboratively with your clients. Don’t we all?

If I were to ask a hundred therapists, however, a different question, for example “Tell me in what ways you work to foster a collaborative approach with your clients”, I suspect I’d get a hundred different answers. There would be some overlap, but I imagine also, considerable divergence.

A recent paper explores the theme of collaboration in therapy. Unlike many papers, this one not only presents the theoretical underpinnings of the concept, it also presents a case example showing what elements of a collaborative approach might look like in practice. I love this type of paper, and we profiled a similar example recently on the theme of therapist responsivity to patients’ early treatment beliefs and psychotherapy process.

As the paper highlights, developing a collaborative approach to therapy with clients is not just a ‘nice to have’. Rather, it is a cornerstone of successful therapy. On average, around 20% of clients drop out of therapy. Understanding and practising the elements of a collaborative approach will help to lessen the likelihood that our clients will end prematurely and increase the chances of a positive outcome.

 

Components of a collaborative framework

While the paper acknowledges the importance of the collaborative relationship across different theoretical orientations, it also suggests that its role may differ somewhat between them.

Within a psychodynamic framework, for example, a strong collaborative relationship will ‘provide clients with the opportunity to explore and evaluate their relationship patterns in the present moment.’ From a cognitive-behavioural perspective, collaboration may be seen more as a ‘stepping stone’ so that clients will be more receptive to specific intervention strategies integral to the approach (e.g. cognitive restructuring, exposure or completing homework.)

It’s perhaps the client-centred framework that places the most significant emphasis on collaboration in therapy.

From this perspective, a collaborative relationship promotes ‘a positive and meaningful alliance, which, in and of itself, serves as a source of healing for the client.’

Congruent with person-centred perspective, the paper’s authors see collaboration as a hope-building process in which the client’s voice and perspectives are valued, and their resources and capacity for change recognised. Given that most drop out occurs in the early stages of therapy, efforts to facilitate a collaborative framework may be most effective in the early sessions of therapy.

What does the research say about collaboration?

Within the paper the authors bring together three distinct strands of research that support the value of establishing a collaborative relationship in therapy. Each is outlined briefly below.

1. The power of a strong working alliance

Recall that two of the three theoretical elements of the working alliance, namely agreement on goals and agreement on the means or methods by which they may be achieved, require purposeful collaboration between client and therapist. As we’ve highlighted in previous blogs, the alliance accounts for a larger proportion of the variance in therapy outcome than any other relationship factor.

2. Accommodating client preferences

Research clearly demonstrates that accommodating clients’ preferences (also the subject of a previous blog) positively impacts levels of client satisfaction, retention and outcomes. As the authors of this paper highlight, the process of negotiating client treatment preferences and sharing treatment decisions is central to the idea of collaboration in therapy.

In addition to research which focuses specifically on the working alliance and accommodation of client preferences, there is also a significant body of research which examines the impact of collaboration on therapy outcomes. The paper highlights the findings of Tryon and Winograd [i] drawing on data from 19 studies, of a significant correlation between the level of collaboration and the outcomes of therapy.

Collaboration in practice

The research clearly supports collaborative approaches, but what does collaboration look like in practice?

The paper offers a case study illustrating three distinct techniques employed by the therapist for fostering collaboration in the initial session of her work with her client ‘Craig’.

1. Recognising the client's expertise

How many times has a client referred to you as ‘the expert’ and seemed to look to you for the answers to their problems? When, within the case study, Craig does exactly that, the therapist responds by suggesting that no-one knows his experience better than he.

“You are the expert for your own life; you know your experiences, thoughts, and feelings in detail, better than anyone else. Because of this, I think that you can really bring a lot to the table as we problem-solve some of the difficulties you’ve been having. You can bring your expertise and insight about your life, and on my end, I will make sure to contribute any ideas or strategies that might be helpful. How does that sound?”

She gently challenges his rather passive view of his role within their relationship and invites him to recognise his own expertise and enter into a more balanced and collaborative approach to their work.

Whatever specific hopes or goals the client may have for therapy, developing greater agency and capacity for choice invariably underpin the work. Rather than seeing these as endpoints or destinations, we can begin to lay the foundations for their development at the very start.

2. Enquiring about client preferences

Just as we need to avoid allowing clients to disown or outsource to us their capacity for choice, so we should also encourage their involvement in key decisions about the direction of therapy.

In the case study the therapist presents Craig with two options for approaching their work. When Craig asks her to make a recommendation, she responds by asking for his thoughts about the two options that she has outlined.

“Craig: Hmm, I definitely do not want to make the wrong decision on this, what do you recommend?”

“Therapist: Both options have their advantages and both have research-support behind them, so there really is no wrong decision here…………Still, I recognize that it can be hard to make a decision about something you’ve never done before………..Maybe we can start by having you tell me what you like and do not like about both of the options I presented.”

As we’ve highlighted previously, there are many ways in which we can elicit client preferences.

One approach I’ve often found fruitful and tried to cultivate in the past two or three years is to ask clients how they understand their problems or struggles. Put another way: “How do you make sense of your experience and where you find yourself now?”

I don’t know if this chimes with your experience, but my sense is that clients can find it tremendously powerful to understand that their erstwhile ‘irrational’ patterns make perfect sense when they understand the context in which they first arose.

If we ask the right questions, clients will often have a felt sense of what may lie at the heart of their stuckness. In terms of eliciting their preferences about how these might be approached, one way is simply to ask them “Do you think it might be helpful for us to explore that a bit further?”

3. Recognising that the therapist may make mistakes

To err is human. To err in therapy, especially early in therapy, can be fatal to the relationship. The sad fact is that, as we sit staring at the empty chair where our client should be, we may not even realise that we have erred.

In the case study initial session Craig expresses his anxiety about the process and about saying ‘something stupid or irrelevant in here’. The therapist responds by reassuring him that it’s OK to make mistakes. She goes further by venturing the possibility that she will make mistakes of her own and invites Craig to tell her when her approach isn’t helpful. Writing this is serving as a reminder to me that I need to do this more consistently, and not just when I remember.

I had a recent powerful reminder of the importance of the client being able to able say, in effect, ‘Ouch!’ A client with whom I have been working for two years was able to tell me how painfully she had responded to something I had said at the end of the previous session. Imagine this scenario with a newer client who has not been explicitly invited to tell the therapist they’ve got something wrong. It’s probably game over.

And how about you?

Whether your experiences chime with anything above, or whether you have a different perspective entirely, we’d love to know. Leave a comment below, and thanks!

References

[i] Tryon, G. S., & Winograd, G. (2011). Goal consensus and collaboration. Psychotherapy, 48, 50–57. http://dx.doi.org/10.1037/a0022061

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Posted by:Barry McInnes

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