A Special Feature on Collaboration in Psychotherapy

Abstract

Collaboration between a psychotherapist and a patient occurs at the intersection of the therapeutic relationship and treatment method. Many methods contribute to collaboration, which is then experienced as a respectful, mutual, cooperative relationship. Despite its noble history and its empirical evidence as an important attribute in psychotherapy, collaboration has rarely been operationalized and illustrated in ways that might concretely guide clinical practice. This article introduces an issue of the Journal of Clinical Psychology: In Session designed to describe and illustrate the role of the psychotherapist in facilitating collaboration. Expert practitioners present case examples of collaboration in psychodynamic psychotherapy, cognitive-behavioral therapy, experiential therapy, family therapy, mindfulness-based cognitive therapy, multicultural therapy, and in the context of pharmacotherapy. In the final article, a practitioner-friendly review of empirical research on collaboration is offered.

For over 100 years, our professions have debated the issue of genetics versus environment in attempting to understand the cause, maintenance, and treatment of various health and mental health problems. As with many things in life, the answer is not (a) or (b), but rather (c) all of the above. How often can we say that things are just one way or another? How often does it happen that when we look at dichotomies, we appreciate their connectedness? Perhaps the same is true in psychotherapy.

Psychotherapy researchers have long debated the efficacy of therapeutic relationship versus treatment method, with many advocating either (a) or (b). Some empirical reviews have valiantly attempted to determine the proportion of outcome variance because of either the particular treatment method or the relationship. As concluded by a recent Task Force of the American Psychological Association on evidence-based therapy relationships, it is very difficult to separate relationship from technique, because they are inextricably bound and interdependent processes (Norcross, 2010; Norcross & Lambert, 2011). A therapeutic technique rarely sits in a consulting room by itself. A method or technique needs its therapist and its client and is rooted in the relationship.

Collaboration between a psychotherapist and a patient occurs at the intersection of the therapeutic relationship and treatment method. It is certainly both in some sense, but not quite either. Many methods contribute to collaboration, which is then experienced as a respectful, mutual, cooperative relationship.

The technical and relational blend that characterizes collaboration has long been recognized as a curative mechanism of multiple systems of psychotherapy (Bachelor, Laverdiere, Gamache, & Bordeleau, 2007; Orlinsky, Rønnestad, & Willutzki, 2004). Effective psychotherapies nurture and support patient involvement and participation in an open and participatory context. Such contexts feel “safe” for self-disclosure, behavior change, authentic engagement, trialing different strategies, and making mistakes. Collaboration has been subject to comprehensive review in meta-analysis and is considered a demonstrably element of the therapy relationship (Ackerman et al., 2001; Tryon & Winograd, 2011a, 2011b).

Despite its noble history and its empirical evidence as an important attribute in psychotherapy, collaboration has rarely been operationalized and illustrated in ways that might concretely guide clinical practice. Nor has guidance been offered to the practitioner on how this attribute might be effectively implemented in different psychotherapy systems.

Accordingly, this issue of the Journal of Clinical Psychology: In Session was designed to describe and illustrate the role of the psychotherapist in facilitating collaboration with patients in multiple psychotherapy approaches.

This Issue

Prominent psychotherapists were invited to deconstruct and illustrate collaboration in their respective treatments. To maintain its practical focus, each author was asked to (a) outline the role of the therapist in promoting and maintaining collaboration, weaving in select research findings; (b) present a case study to illustrate the mechanisms of collaboration, emphasizing means of developing, maintaining and ending relationships within their specific therapeutic approach; and (c) conclude with a summary of the clinical practices for fostering collaboration.

Hadas Wiseman, Orya Tishby, and Jacques Barber provide the first contribution to this issue with an historical overview and a contemporary account of collaboration in psychodynamic psychotherapy. Frank Dattilio and Michelle Hanna follow with a description of collaborative empiricism as a defining feature of the therapeutic relationship in cognitive-behavioral therapy. Lucia Berdondini, Robert Elliot, and Joan Shearer then present a piece on collaboration in experiential therapy, followed by Elena Tuerk, Michael McCart, and Scott Hengeller's description of collaboration in the newer brand of evidence-based family therapies.

Reflecting comparatively recent developments in the psychotherapy literature, Jennifer Felder, Sona Dimidjian, and Zindel Segal present on collaboration in mindfulness-based cognitive therapy as an approach to assisting with depressive relapse. The issue proceeds with contributions by Anu Asnaani and Stefan Hofmann on collaboration in multicultural therapy. Moving from purely psychotherapy, Gregoris Simos reviews collaborative methods and processes in pharmacotherapy for mental disorders.

In the final article, Michael Lambert and Kara Cattini provide a practitioner-friendly review of empirical research on collaboration. Specifically, they review the meta-analytic research on the efficacy of collaboration, goal consensus, and homework adherence and then present the impressive results of monitoring patient progress as part of ensuring collaboration in routine practice.

Final Thoughts

At the outset, we considered the debates that have characterized our understanding of the human condition, and our understanding of the human interaction in psychotherapy. We reflected that our existing operationalizations of therapeutic relationships were oversimplified. We argued that collaboration is inseparable from both the treatment method and the therapeutic relationship.

What will future generations of psychotherapy practitioners and researchers conclude from the expert contributions to this issue of the Journal of Clinical Psychology: In Session? How will our current perspectives be viewed in 50, even 25, years from now?

The articles in this issue take us an important leap forward. Collectively, they highlight that the therapeutic model and the ways in which the therapist formulates the development and maintenance of emotional, cognitive, physiological, behavioral, and interpersonal experiences are the foundation for understanding collaboration. The excellent contributions and case illustrations in this issue also demonstrate that this complex array of elements in the consulting room is static only for a brief moment.

Our current research methodologies involve session-based assessments at specific points for a prediction of some fixed final result. Yet the interaction that occurs in a therapy session is fluid and constantly changing on a moment-by-moment basis. Therapeutic interactions push and turn, and have patterns observable when viewed only in context and over time. Our efforts to understand the therapeutic encounter, to make explicit the changes and movements of the individuals in the room, and to quantify ideal movement and potential for change require more sophisticated methodologies. Any moment in a therapy session is complex, and our science is taking important steps forward in understanding and defining that complexity. Our ultimate goal is to enhance the quality of human services and our training and supervision of therapeutic interactions.

Our journey has only just begun.