Patients’ Group
Perceptions of the Therapy Outcome
BY
S. GURMAN,
ALAN
PH.D..
AND
Therapeutic
JAMES
P.
Relationship
GUSTAFSON.
The ait/iorS review the empirical literature examining the hypothesized relationship between the patient’s perception o.ft/ie therapeutic relations/up and treatment outcome in group therapy and describe studies ofhoth inpatient and outpatient group therapy. Their review indicates that, in contrast to tile ot’erwizelming evidence in support ofthe perceived relationship-outcome hypothesis in individual psychotherapy, there is no persuasive evidence in favor oft/ie proposed relations/zip between the therapist-patient relations/zip and the efficacy of’group treatment. The authors discuss the clinical and theoretical differences between individual and group therapy that i’ould contribute to this result.
M.D.
psychotherapy their necessity,
The
ALL
MAJOR
SYSTEMS
of
psychotherapy
have
empha-
Strupp
(8) argued
that
the
parent-child
relationship
es-
tablished in dynamic psychotherapy is the key source of the therapist’s influence. The most emphatic statement of the necessity of a facilitative therapeutic relationship for positive personality change has been made by Rogers (9), who went so far
as to argue
for
the
sufficiency
of the
conditions
of empathy, warmth, and genuineness for effective psychotherapy. Nearly two decades of research have now made it clear that such relationship dimensions are rarely sufficient for patient change in individual
predominant
1290
Am
J Psychiatry
133:/I,
Nove,nber
/976
it seems difficult as preconditions
mode
mere offering not sufficient titudes
the
of assessment
to impugn for change.
of the therapeu-
or
of therapeutic conditions to a patient for positive change (9). Rather, these
styles
patient,
i.e.
change to occur. Evidence has apeutic conditions change in group
of relating
the
,
must
patient
be communicated
must
also
been adduced are generally psychotherapy
paper
is at-
perceive
to
them
for
that tape-rated therpredictive of patient (12). The purpose of
is to evaluate
the empirical
and
theo-
retical status of Rogers’ (9) perceived-conditions-outcome hypothesis in group therapy in light of the fact that data from research in this domain are clearly more consistent with the theoretical underpinnings of the relationship construct than are those based on the perceptions of external judges.
More
than
technical
issues
arise
in applying
Rogers’
hypothesis to group therapy. Rogers himself suggested that in the group situation leader acceptance may be less important than acceptance and understanding
from
peers
(13).
Hence,
the
correlation
with desired leader qualities may results. Yalom’s outcome study therapy (13) supports this idea: he ity with other group members and
group
were
outcome.
the only Even
attributes
The
factors
successful
leader
with
good
characteristics
ofempathy, warmth, a part of the necessary
group
ofencounter
of outcome
not yield significant of outpatient group found that popularcohesiveness of the
associated
consider
that the variables represent only
of the
study
two
if we
alone, it seems and genuineness
groups
leader.
by Lieberman
and as-
sociates (14) demonstrated that the successful leader must provide a clear cognitive framework for group members to be able to make good use of their affective
experiences.
Yalom
tripartite
therapy pist,
Dr. Gurman is Assistant Professor and Director of the Outpatient Clinic. and Dr. Gustafson is Assistant Professor and Director of Group Therapy Training, Department of Psychiatry. University of Wisconsin Medical School, 427 Lorch St. . Madison, Wis. 53706.
(10), but at least
tic relationship has been the rating of tape-recorded therapy interactions by trained nonparticipant judges. Thus, as Howard and Orlinsky (11) noted, most research in this area has been misguided on theoretical grounds, in that Rogers stated unambiguously that the
the present sized the importance of the therapist-patient relationship, although their explanatory languages for the centrality ofthe relationship construct clearly vary. Social psychological theories highlight the mediational role of the relationship in arguing that the patient’s attraction to the therapist heightens the therapist’s ability to influence the patient toward therapeutic ends (1-3). Social learning approaches emphasize the therapist’s role in the relationship as that ofa salient source for modeling and reinforcement of new patient behavior (4). The neoanalytic writings of Fromm-Reichmann (5), Menninger (6), and Sullivan (7) support the common observation that analytically oriented therapists view the resolution of the neurotic distortions of the relationship as the cornerstone of their work. More recently,
and
analogy
(13) suggested to the
is the patient’s to the
whole.
That
ly one
of the
action that A further
other
good
relationship
group
aspects
in a group
and
with of the
the
of individual
to his group
members,
is, the relationship critical
that
relationship
to the
the therapist group
can influence outcome. difficulty with the client-centered
thera-
group
therapy
as a
is oninter-
hypothe-
ALAN
sis in group therapy is that many schools ofgroup therapy systematically attempt to influence the group members through variables other than the leader’s empathy, warmth, and genuineness. The obvious examples of this are schools of group therapy that emphasize a group-centered rather than a leader-centered approach. Yalom’s technique, for example, although it also attempts to use the leader-patient relationship, relies heavily on the “social engineering” ofthe group situation. Another technique ofthis type is that recommended by Whitaker and Lieberman (15), which attempts to help the group find less restrictive solutions to its shared conflicts.
At the
other
end
of the
continuum
are
schools
of
group therapy that rely almost entirely on an intense pairing relationship between therapist and patient and use the group as a chorus. The outcomes of such leader-centered groups would seem to depend more heavily on the personal qualities of the leader and thus be more likely to confirm the client-centered hypothesis. Examples of this type are many Gestalt, transactional analysis, and psychoanalytic group therapies. Of course, most contemporary schools are both leadercentered and group-centered, at least in some aspects.
A clearly
intermediate
strategy
is that
recommended
by Foulkes (16), in which the leader permits the group to be leader-centered in the beginning, gradually helping the group to shift toward a more democratic peeroriented style as the group masters its relationship with the authority of the leader. Hence, in that kind of group we might expect to fInd the client-centered hypothesis confirmed in the early stages of the group but
not
in the later stages. With these important
reservations
in mind,
we exam-
inc the existing data that focus solely on the relationship between the patient’s perception of therapist empathy, warmth, and genuineness and outcome in group therapy.
tween warmth,
23
nificant.
OF THE THERAPY
THERAPEUTIC
Because
can
be
of empirical therapeutic-conditions--outcome therapy is presented in table
the hypothesis
in question
of the perceivedhypothesis in group I . Only I 1 studies testing
conducted
under
actual treatment conditions, 6 with outpatients and 5 with inpatients. The patient’s perception of the therapist-patient relationship was assessed by either the Relationship Inventory of Barrett-Lennard (RI) (28) or the Truax Relationship Questionnaire (22), both of which have been found to share a good deal of com-
mon factor Among
variance (29). the outpatient
studies
(17,
19-21,
27)
only
those of Truax and associates (27) and Hansen and associates (19) found even tenuous support for the proposed positive relationship between patient-perceived
therapeutic sociates’
conditions study,
of
and the
69
outcome. correlations
GUSTAFSON
would
be expected
sis.
as
providing
only
very
to
weak
for the perceived-conditions-outcome All
but
tamed
I of these
on MMPI
significant
change
The a
first
study
significant
correlations
measures,
group
by Hansen
were
and only
and
rank-order
members’
therapeutic
associates
correlation
perceptions
conditions
of their
and
cvi-
hypotheob-
1 of the
conditions-Q-sort correlations-was significant. addition, the obtained significant correlations quite low (range, .23-.3 1), and over a third of the lations were of zero-order magnitude.
15
In were corre-
(19) found (.83)
between
group
leader’s
self-concept
change
based
on a Q-sort. The authors’ data analysis was based on the mean perceived conditions and mean self-concept change within each of their treatment groups, yielding an
N of 6. The
and
the
only
more
one
appropriate
that
would
statistical
have
allowed
analysis,
direct
test-
ing of the Rogerian hypothesis, would have involved Pearson’s product-moment correlation of individual members’ scores on these two measures. Unfortunately, therefore, the authors’ inappropriate data analysis obscures the meaning of their finding and may explain why this result failed to be replicated in a later study by Hansen and associates (20), in which the appropri-
ate correlational
analysis
was
performed.
Further support of the lack of evidence for the perceived-conditions-outcome hypothesis in outpatient group therapy is derived from the overwhelmingly negative results obtained in the study with the soundest
methodological vided change
quality
by these scores
and
(17).
authors (positive
below
We used
the raw data
to compare composite versus negative) and
the group
differences
Studies
been
P.
median).
according
to
pro-
overall RI scores
We found chi-square
nonanaly-
515.
studies
have
JAMES
4 correlations
interpreted
dence
testing
talized A summary
AND
change measures and therapist empathy, and genuineness, only 9 were statistically sig-
significant PERCEPTIONS IN GROUP
GURMAN
reach statistical significance (p
Perceptions of the Therapy Outcome
BY
S. GURMAN,
ALAN
PH.D..
AND
Therapeutic
JAMES
P.
Relationship
GUSTAFSON.
The ait/iorS review the empirical literature examining the hypothesized relationship between the patient’s perception o.ft/ie therapeutic relations/up and treatment outcome in group therapy and describe studies ofhoth inpatient and outpatient group therapy. Their review indicates that, in contrast to tile ot’erwizelming evidence in support ofthe perceived relationship-outcome hypothesis in individual psychotherapy, there is no persuasive evidence in favor oft/ie proposed relations/zip between the therapist-patient relations/zip and the efficacy of’group treatment. The authors discuss the clinical and theoretical differences between individual and group therapy that i’ould contribute to this result.
M.D.
psychotherapy their necessity,
The
ALL
MAJOR
SYSTEMS
of
psychotherapy
have
empha-
Strupp
(8) argued
that
the
parent-child
relationship
es-
tablished in dynamic psychotherapy is the key source of the therapist’s influence. The most emphatic statement of the necessity of a facilitative therapeutic relationship for positive personality change has been made by Rogers (9), who went so far
as to argue
for
the
sufficiency
of the
conditions
of empathy, warmth, and genuineness for effective psychotherapy. Nearly two decades of research have now made it clear that such relationship dimensions are rarely sufficient for patient change in individual
predominant
1290
Am
J Psychiatry
133:/I,
Nove,nber
/976
it seems difficult as preconditions
mode
mere offering not sufficient titudes
the
of assessment
to impugn for change.
of the therapeu-
or
of therapeutic conditions to a patient for positive change (9). Rather, these
styles
patient,
i.e.
change to occur. Evidence has apeutic conditions change in group
of relating
the
,
must
patient
be communicated
must
also
been adduced are generally psychotherapy
paper
is at-
perceive
to
them
for
that tape-rated therpredictive of patient (12). The purpose of
is to evaluate
the empirical
and
theo-
retical status of Rogers’ (9) perceived-conditions-outcome hypothesis in group therapy in light of the fact that data from research in this domain are clearly more consistent with the theoretical underpinnings of the relationship construct than are those based on the perceptions of external judges.
More
than
technical
issues
arise
in applying
Rogers’
hypothesis to group therapy. Rogers himself suggested that in the group situation leader acceptance may be less important than acceptance and understanding
from
peers
(13).
Hence,
the
correlation
with desired leader qualities may results. Yalom’s outcome study therapy (13) supports this idea: he ity with other group members and
group
were
outcome.
the only Even
attributes
The
factors
successful
leader
with
good
characteristics
ofempathy, warmth, a part of the necessary
group
ofencounter
of outcome
not yield significant of outpatient group found that popularcohesiveness of the
associated
consider
that the variables represent only
of the
study
two
if we
alone, it seems and genuineness
groups
leader.
by Lieberman
and as-
sociates (14) demonstrated that the successful leader must provide a clear cognitive framework for group members to be able to make good use of their affective
experiences.
Yalom
tripartite
therapy pist,
Dr. Gurman is Assistant Professor and Director of the Outpatient Clinic. and Dr. Gustafson is Assistant Professor and Director of Group Therapy Training, Department of Psychiatry. University of Wisconsin Medical School, 427 Lorch St. . Madison, Wis. 53706.
(10), but at least
tic relationship has been the rating of tape-recorded therapy interactions by trained nonparticipant judges. Thus, as Howard and Orlinsky (11) noted, most research in this area has been misguided on theoretical grounds, in that Rogers stated unambiguously that the
the present sized the importance of the therapist-patient relationship, although their explanatory languages for the centrality ofthe relationship construct clearly vary. Social psychological theories highlight the mediational role of the relationship in arguing that the patient’s attraction to the therapist heightens the therapist’s ability to influence the patient toward therapeutic ends (1-3). Social learning approaches emphasize the therapist’s role in the relationship as that ofa salient source for modeling and reinforcement of new patient behavior (4). The neoanalytic writings of Fromm-Reichmann (5), Menninger (6), and Sullivan (7) support the common observation that analytically oriented therapists view the resolution of the neurotic distortions of the relationship as the cornerstone of their work. More recently,
and
analogy
(13) suggested to the
is the patient’s to the
whole.
That
ly one
of the
action that A further
other
good
relationship
group
aspects
in a group
and
with of the
the
of individual
to his group
members,
is, the relationship critical
that
relationship
to the
the therapist group
can influence outcome. difficulty with the client-centered
thera-
group
therapy
as a
is oninter-
hypothe-
ALAN
sis in group therapy is that many schools ofgroup therapy systematically attempt to influence the group members through variables other than the leader’s empathy, warmth, and genuineness. The obvious examples of this are schools of group therapy that emphasize a group-centered rather than a leader-centered approach. Yalom’s technique, for example, although it also attempts to use the leader-patient relationship, relies heavily on the “social engineering” ofthe group situation. Another technique ofthis type is that recommended by Whitaker and Lieberman (15), which attempts to help the group find less restrictive solutions to its shared conflicts.
At the
other
end
of the
continuum
are
schools
of
group therapy that rely almost entirely on an intense pairing relationship between therapist and patient and use the group as a chorus. The outcomes of such leader-centered groups would seem to depend more heavily on the personal qualities of the leader and thus be more likely to confirm the client-centered hypothesis. Examples of this type are many Gestalt, transactional analysis, and psychoanalytic group therapies. Of course, most contemporary schools are both leadercentered and group-centered, at least in some aspects.
A clearly
intermediate
strategy
is that
recommended
by Foulkes (16), in which the leader permits the group to be leader-centered in the beginning, gradually helping the group to shift toward a more democratic peeroriented style as the group masters its relationship with the authority of the leader. Hence, in that kind of group we might expect to fInd the client-centered hypothesis confirmed in the early stages of the group but
not
in the later stages. With these important
reservations
in mind,
we exam-
inc the existing data that focus solely on the relationship between the patient’s perception of therapist empathy, warmth, and genuineness and outcome in group therapy.
tween warmth,
23
nificant.
OF THE THERAPY
THERAPEUTIC
Because
can
be
of empirical therapeutic-conditions--outcome therapy is presented in table
the hypothesis
in question
of the perceivedhypothesis in group I . Only I 1 studies testing
conducted
under
actual treatment conditions, 6 with outpatients and 5 with inpatients. The patient’s perception of the therapist-patient relationship was assessed by either the Relationship Inventory of Barrett-Lennard (RI) (28) or the Truax Relationship Questionnaire (22), both of which have been found to share a good deal of com-
mon factor Among
variance (29). the outpatient
studies
(17,
19-21,
27)
only
those of Truax and associates (27) and Hansen and associates (19) found even tenuous support for the proposed positive relationship between patient-perceived
therapeutic sociates’
conditions study,
of
and the
69
outcome. correlations
GUSTAFSON
would
be expected
sis.
as
providing
only
very
to
weak
for the perceived-conditions-outcome All
but
tamed
I of these
on MMPI
significant
change
The a
first
study
significant
correlations
measures,
group
by Hansen
were
and only
and
rank-order
members’
therapeutic
associates
correlation
perceptions
conditions
of their
and
cvi-
hypotheob-
1 of the
conditions-Q-sort correlations-was significant. addition, the obtained significant correlations quite low (range, .23-.3 1), and over a third of the lations were of zero-order magnitude.
15
In were corre-
(19) found (.83)
between
group
leader’s
self-concept
change
based
on a Q-sort. The authors’ data analysis was based on the mean perceived conditions and mean self-concept change within each of their treatment groups, yielding an
N of 6. The
and
the
only
more
one
appropriate
that
would
statistical
have
allowed
analysis,
direct
test-
ing of the Rogerian hypothesis, would have involved Pearson’s product-moment correlation of individual members’ scores on these two measures. Unfortunately, therefore, the authors’ inappropriate data analysis obscures the meaning of their finding and may explain why this result failed to be replicated in a later study by Hansen and associates (20), in which the appropri-
ate correlational
analysis
was
performed.
Further support of the lack of evidence for the perceived-conditions-outcome hypothesis in outpatient group therapy is derived from the overwhelmingly negative results obtained in the study with the soundest
methodological vided change
quality
by these scores
and
(17).
authors (positive
below
We used
the raw data
to compare composite versus negative) and
the group
differences
Studies
been
P.
median).
according
to
pro-
overall RI scores
We found chi-square
nonanaly-
515.
studies
have
JAMES
4 correlations
interpreted
dence
testing
talized A summary
AND
change measures and therapist empathy, and genuineness, only 9 were statistically sig-
significant PERCEPTIONS IN GROUP
GURMAN
reach statistical significance (p
