The therapeutic alliance is often characterized as the heart and soul of therapy. A strong and trusting relationship between the therapist and client is essential for disclosure, adherence, and ultimate treatment success. In fact, therapist-level alliance, which is a client’s evaluation of the therapeutic alliance, is seen as a robust indicator of treatment efficacy. But does this type of measurement accurately assess a therapist’s performance? To answer this question, Zac E. Imel of the University of Utah’s Department of Educational Psychology recently conducted an analysis to determine if client ratings provided the best view into therapists’ effectiveness.
Imel reviewed data from two samples clients, including over 3,000 ratings of 72 Health Maintenance Organization (HMO) therapists, and over 1,600 ratings of 93 independent practice (IP) therapists. In general, Imel found that there were few differences in the alliance ratings. However, the results did raise some concerns. For instance, therapists with less than 10 ratings had their results scaled to fit the larger model. This generalization of data could suggest that some therapists need additional training when in fact, if their ratings were examined independently, it would be revealed that they are well within satisfactory levels.
Also, Imel noticed a slight difference between HMO therapists and IP therapists, with client evaluations being more varied among IP therapists. Although factors such as type of treatment, training, and client base were not evaluated fully in this study, these are all conditions which can dramatically skew client evaluations. Future studies should look at the diversity of therapists in HMO settings compared to IP settings. Perhaps the HMO therapists, who are more stringently monitored than IP therapists, aim to work within specific HMO-mandated guidelines and offer a narrower range of treatment methods than private practice therapists. “Outstanding performance may be sacrificed in order to homogenize patient experience,” said Imel. However, one common finding was that therapists who were highly rated by the first half of their cases tended to have high ratings throughout the remainder of their cases, regardless of practice environment. Imel believes that although therapists with few client evaluations may benefit from a more focused alliance review, the majority of client evaluations do provide a relatively accurate picture of therapist performance.
Imel, Z. E., Hubbard, R. A., Rutter, C. M., and Simon, G. (2012). Patient-rated alliance as a measure of therapist performance in two clinical settings. Journal of Consulting and Clinical Psychology. Advance online publication. doi: 10.1037/a0030903
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