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The Working Alliance is Not Mechanical
The relationship that psychologists develop with their clients/patients is known as a working alliance. Bordin (1979) was the first psychologist to define the working alliance in terms of goals, tasks, and bond. Both the therapist and patient must agree on: a) what the goals of therapy are, b) the tasks that are expected to help realize these goals, and c) form an emotional bond characterized by empathy and genuine interest. Considerable research has demonstrated that the working alliance is a common factor across all empirically supported psychotherapies regardless of the theoretical orientation from which they were derived.
The working alliance is therapeutic in and of itself apart from anything else that the therapist does. It is beyond the scope of this blog to review the extensive literature that conclusively demonstrates the positive therapeutic effects of a good working alliance. I am not questioning either the association of a good working alliance with positive outcomes nor am I questioning the causal status of the working alliance. I fully accept that a good working alliance is a necessary condition for a positive therapeutic outcome and that it can be a sufficient condition for a good therapeutic outcome.
What I object to is the claim made by authors such as Burns et al. (2014) that the working alliance and associated patient expectations are general mechanisms that explain psychotherapy outcome. These authors are not alone in making this claim. They are not the first nor will they be the last to claim that the working alliance is a psychotherapy mechanism. The problem that I have is that the working alliance is a relationship and there is nothing mechanical about it. Hence, the working alliance is not a mechanism of any kind.
Mechanisms entail causal links that necessitate the effects that they generate. Mechanisms reveal how and why effects are caused. There is nothing about the working alliance that constitutes a natural science explanation in the form of causal steps that explain how and why positive results derive from psychotherapy. Treated this way, the working alliance becomes a psychological/cognitive black box where two people enter a relationship and beneficial psychotherapeutic results occur. No information is provided about what happens inside the psychological/cognitive black box. This psychological/cognitive black box is just as uninformative as the Skinnerian black box where stimuli go in and behaviors come out without any explanation.
Some readers may feel that I have misunderstood these authors as they may never have meant that the working alliance is mechanical even though the word mechanism derives from the word mechanical. It can be argued that what they meant to say was that the working alliance is a psychological mechanism in the same way that we commonly understand repression, denial, etc. to be psychological defense mechanisms. The psychodynamic orientation within clinical psychology has long accepted an explanatory role for defense mechanisms. Closer examination of such claims reveals a major problem that I discuss at length in the first chapter of my book, Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory, where I make the following observation.
The Google command ‘define:mechanism’ returned the following definition: ‘(1) A system of parts working together in a machine; a piece of machinery. (2) A natural or established process by which something takes place or is brought about’. This second meaning is more relevant to psychology than the first but reveals that defense mechanisms are not mechanisms at all because they do not inform us about the ‘process by which something takes place or is brought about’. Defense mechanisms specify a functional effect, but not the causal steps by which that effect is brought about. Defense mechanisms assert that something happens but fail to explain how that effect occurs by specifying the chain of causal steps that clarifies why the functional effect occurs. For example, denial describes that a person refused to acknowledge some fact or event, but does not provide causal details sufficient to explain how this result actually occurs. The same analysis pertains to all other defense mechanisms. None of them inform us about the ‘process by which something takes place or is brought about’. Hence, they are not real mechanisms. One can say that they are ‘psychic mechanisms,’ but that approach removes them from natural science, the scope of this book, and moves them to the realm of metaphor and literature (p. 25, bold font in the original)
The three components of the working alliance identified by Bordin (1979) above do not inform us about the ‘process by which something takes place or is brought about’. They provide no causal mechanism information and consequently should not be called mechanisms. To do so implies that psychologists know much more than they do. While this illusion may enhance the self-esteem of psychologists, it only serves to further disillusion the public when they discover that metaphor has been presented as scientific mechanism. See Lilienfeld (2012) for additional reasons why the public is skeptical about psychological science. The subtitle of his article is “why many people perceive the study of human behavior as unscientific”.
Warren’s book, Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory is available for purchase on the Elsevier Store.
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About the Author
Warren W. Tryon received his undergraduate degree from Ohio Northern University in 1966. He was enrolled in the APA approved Doctoral Program in Clinical Psychology at Kent State University from 1966 – 1970. Upon graduation from Kent State, Dr. Tryon joined the Psychology Department faculty at Fordham University in 1970 as an Assistant Professor. He was promoted to Associate Professor in 1977 and to Full Professor in 1983. Licensed as a psychologist in New York State in 1973, he joined the National Register of Health Service Providers in Psychology in 1976, became a Diplomate in Clinical Psychology from the American Board of Professional Psychology (ABPP) in 1984, was promoted to Fellow of Division 12 (Clinical) of the American Psychological Association in 1994 and a fellow of the American Association of Applied and Preventive Psychology in 1996. Also in 1996 he became a Founder of the Assembly of Behavior Analysis and Therapy.
In 2003 he joined The Academy of Clinical Psychology. He was Director of Clinical Psychology Training from 1997 to 2003, and presently is in the third and final year of phased retirement. He will become Emeritus Professor of Psychology in May 2015 after 45 years of service to Fordham University. Dr. Tryon has published 179 titles, including 3 books, 22 chapters, and 140 articles in peer reviewed journals covering statistics, neuropsychology, and clinical psychology. He has reviewed manuscripts for 45 journals and book publishers and has authored 145 papers/posters that were presented at major scientific meetings. Dr. Tryon has mentored 87 doctoral dissertations to completion. This is a record number of completed dissertations at the Fordham University Graduate School of Arts and Sciences and likely elsewhere.
His academic lineage is as follows. His mentor was V. Edwin Bixenstein who studied with O. Hobart Mowrer at the University of Illinois who studied with Knight Dunlap at Johns Hopkins University who studied with Hugo Munsterberg at Harvard University who studied with Wilhelm Wundt at the University of Leipzig.
Cognitive Neuroscience and Psychotherapy: Network Principles for a Unified Theory is Dr. Tryon’s capstone publication. It is the product of more than a quarter of a century of scholarship. Additional material added after this book was printed is available at www.fordham.edu/psychology/tryon. This includes chapter supplements, a color version of Figure 5.6, and a thirteenth “Final Evaluation” chapter. He is on LinkedIn and Facebook. His email address is firstname.lastname@example.org.
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