Updated: Jul 5, 2021
TITLE: THE POTENTIAL BENEFITS OF USING A VALUES CLARIFICATION EXERCISE IN PSYCHOTHERAPY IN TERMS OF THERAPEUTIC ALLIANCE AND PATIENT ENGAGEMENT
Author: Belinda Lau @The Lighthouse Counselling
Therapeutic alliance is considered an important aspect of the therapeutic process, with research suggesting that the quality of the therapeutic relationship is a strong predictor of positive clinical outcome, independent of the variety of psychotherapies and outcome measures. One of the aims of therapeutic alliance is to work with patients’ own personal values and to help them assess their values so as to integrate them in a less neurotic and conflictual life adaptation. This is promoted through understanding the patient's authentic self and the full range and implications of both ego and superego functioning, as well as the organization and integration of his inner psyche (Meissner, 1996). In this paper, I am going to inquire into the literature to identify the place of the values clarification exercise. I am also going to provide some initial clinical illustrations in order to discuss the potential benefits that the values clarification exercise might bring in relation to therapeutic alliance and patient engagement. A potentially new way in improving therapeutic alliance through engaging patients with a values exploration exercise will be discussed. I will also discuss this with relevance to the context of mutuality, authenticity, learning, self-reflexivity and self-empowerment in addition to some pre-existing theories and definitions.
KEYWORDS: therapeutic alliance, personal values, values clarification exercise, patient engagement
Therapeutic alliance is considered as an important aspect of therapeutic process with previous research (Ardito & Rabellino, 2011) suggesting that the quality of the therapeutic relationship is a strong predictor of positive clinical outcome, independent of the variety of psychotherapies and outcome measures. A recent study (Daniels et al., 2017) also revealed that client engagement (ie. attendance, contributing, contracting, working, etc.) is significantly correlated to client-rated alliance. Nonetheless, ‘engagement’ is a concept that lacks a clear definition, yet the term has been used in a number of ways including accessing services, retention within services, enthusiasm and self-management, service provision and the interaction between the patient and healthcare provider” (Fisher et al, 2020). Consequences of patient engagement included cognitive benefits such as greater understanding and awareness through learning and communication on the part of the patient, and job satisfaction on the part of care providers through more meaningful interaction and collaboration with patients...making explicit the meanings expressed by the concept will improve communication between healthcare entities through a shared understanding of the core aspects and variations of patient engagement. (Higgins et. al, 2017). Furthermore, this lack of a precise consensual definition [alliance] has, on one hand, made it easier for researchers and clinicians of diverse theoretical frameworks to embrace the term and integrate it within their respective conceptualisations (Flückiger et. al, 2018).
Nowadays, many psychotherapeutic approaches are anchored to the three key components conceptualised by Bordin (1979) in order to achieve a strong alliance - agreement on therapeutic goals, agreement on interventions and effective bond between the therapist and patient. Although it sets a very clear framework for therapists to engage effectively with the patients, it also depends on the ability of the patients to have clarity of what they were looking to achieve in the sessions. Through the observations during my psychotherapy work, I noticed that some patients came into therapy feeling lost and not all of them really knew their purposes of coming into therapy. Many of them might not have capacities to understand the tasks or interventions in the therapy sessions. Not all the patients attend therapy sessions only to discuss their issues, either. For instance, after having achieved their therapeutic goals and feeling back on track, some of them enjoyed staying in therapy on a regular basis and continued their self discovery journey. I took opportunities to engage with some of my patients with a values clarification exercise during our sessions. Such exercise aims to explore ‘personal values’ with the patients with the objective of self-discovery and personal growth, adopting the value items under the Schwartz Value Survey (Schwartz, 1992) (see Appendix 1). Schwartz viewed that value types as an integrated system fits the conception that attitudes and behavior are guided by tradeoffs among relevant competing values. The Schwartz Value Survey has 56 items (values) grouped into eleven subscales - Conformity, Universalism, Tradition, Benevolence, Self-Direction, Achievement, Security, Stimulation, Hedonism, Power and Spirituality. This motivational value system is a combination of terminal and instrumental values set by Schwartz. For instance, ‘pleasure’ and ‘enjoying life’ are grouped under the subscale of ‘Hedonism’; ‘exciting life’, ‘varied life’ and ‘daring’ are grouped under the subscale of ‘Stimulation’. During his research he had patients rate these values according to the importance, as a ‘guiding principle in my life’ on a 9-point scale (ie. extreme importance to not important and opposed to my values). The mean of the score ratings are aggregated into their respective eleven value types in order to be weighted against each other. Through finding out value priorities Schwartz was able to evaluate the correlation with cultural background, attitude and behaviour variables.
During my psychotherapy sessions, I asked some of my patients to choose their top six values from the item list and explain to me why they are the most important to them based on their personal experiences and stories. I initiated this value clarification exercise with some of my patients intending to give them autonomy to express and discuss what they value, eventually discovering their own guiding principles and moral compass. Meissner (1996) also reinstated that therapeutic alliance aimed at working with patient’s own personal or cultural values and to help him assess them so as to integrate them in a less neurotic and conflictual life adaptation. This is promoted through understanding the patient's authentic self and the full range and implications of both ego and superego functioning, as well as the organization and integration of his psychic self.
Although there was no proper collection of any feedback from the patients (ie. patient-rated alliance measures), I may outline preliminarily on the positive impact that I personally perceived from a therapist’s perspective (ie. therapist-rated alliance). Referencing the Therapist-Patient Alliance inventory (Langhoff et al., 2008), the key components in this therapist-patient alliance assessment are Empathy, Cooperation, Transparency, Focusing, and Assurance of Progress. To elaborate this - I felt that the patients felt understood in the session (Empathy); the patient and I cooperated with one another (Cooperation), the patient understood the therapeutic procedure (Transparency); the patient and I talked about something important for the patient (Focusing); the patient achieved their goals and made great progress in the session (Progress). These were reflected through various cues such as more involvement (ie. active responses, reciprocal questions) and more engagement (ie. ongoing attendance even after their original therapeutic goals were achieved).
Based on my observations, the values clarification exercise appeared to be positively received by most of my patients. The aim of this paper is to inquire into the literature to explore how applying the values clarification exercise may potentially be a new way in improving therapeutic alliance. I will provide some initial clinical illustrations in order to discuss the potential benefits that the values clarification exercise might bring in relation to therapeutic alliance and patient engagement. I will also discuss this with relevance to the context of mutuality, authenticity, learning, self-reflexivity and self-empowerment in addition to some pre-existing theories and definitions.
During my private psychotherapy practice in the past, I asked some of my patients to choose their top values from the list of 56-item Schwartz Value Survey (Schwartz, 1992), also to explain why they are the most important to them based on their personal experiences and stories. Some anonymised feedback from the patients will be addressed in this paper in order to explore the potential improvement and transformation in therapeutic relationships. Identities of the patients and context of our discussions are to remain confidential. None of these patients reported any psychiatric or mental health conditions, or in midst of receiving any medical treatment before taking the values clarification exercise. Some of the verbal feedback on their therapeutic experiences after taking the values clarification exercise in our psychotherapy sessions will be addressed later in this paper.
THERAPEUTIC ALLIANCE & THE LITERATURE
The concept of the therapeutic alliance has its roots in psychoanalytic theories and the importance of a robust collaborative therapeutic relationship is not a new concept. It began with Freud (1912) from believing that it was a transference when patients project their repressed wishes onto the therapists, to elaborating the possibilities of a beneficial attachment between patient and therapist in a form of positive transference. Since then, the concept of therapeutic alliance was developed and expanded by many scholars. Beginning with the term therapeutic alliance firstly used by Zetzel (1956) who described a trusting bond between patient and therapist as a dyadic relationship that summarises the mother-child union. Thereafter, Rogers (1957) elaborated six conditions that a therapeutic relationship should embody in his Client-Centered Theory: 1. psychological contact between the therapist and the patient; 2. the therapist’s unconditional positive regard; 3. the patient’s state of incongruence; 4. the therapist’s congruence; 5. the therapist’s empathic understanding; 6. the patient’s reception of the therapist’s empathic understanding and unconditional positive regard. Rogers believed that these conditions enable the patient to move towards a more harmonious state of congruence between self and experience. Greenson (1965) also coined the term ‘working alliance’ such that the real relationship between the therapist and patient is the vital ingredient of success or failure in psychoanalytic treatment. He believed that such collaborative relationships are important for the patient to work purposefully in analysis. Therapeutic alliance was later elaborated into a tripartite model by Bordin (1979) which consists of the tasks, therapeutic goal and emotional bond between therapist and patient.
From a psychoanalytic point of view, transference neurosis developed into an unconscious therapeutic alliance (Freud, 1914). Freebury (1989) also suggested that alliance development is an interpersonal experience which depends on the therapist’s ability to listen to the patient’s narrative and to empathetically experience the meaning of their stories. Responses to the patient must act in such a way to support the patient’s core sense of self. Essentially, the patients often seek new developmentally needed experiences so it is happening unconsciously in the sessions all the time when the patients hope this new therapeutic relationship will offer them such new developmentally needed experiences to repair those past experiences or that they never had. From a therapist’s perspective, it is important to ensure that the sessions are conducted in the best interests of their patients (BPC Code of Ethics, 2011). A recent study (Liou, 2018) also revealed that learning is an important and influential element in psychotherapy when it provides time, space, safety and attention, it potentially allows people to pause, observe and reflect. During such reflection-on-action, the participants in the study also presented a ‘blueprint’ of the kind of relationships and attitudes they would like to have with their family, friends, and those in need in our local society. Through being genuinely empathic and deepening a patient's experiences, it allows a patient access to their inner subjective experiences, identify and address their hidden or subconscious issues, and potentially reconstruct their memories in order to promote positive changes in patients. Liou also addressed that a learning activity also promotes personal growth and change, and helps people become aware and get in touch with their emotional experiences. In this case, the values clarification exercise may serve as an experiential learning activity for the patients that promotes reflexivity and an organic learning experience.
Since transference is a redirection of one’s unconscious feelings and thoughts from their original object to a new object, it is meaningful to help the patient to identify their transferences so that they have an opportunity to develop healthy relationships in the future without carrying their past with them. Transference is a fundamental aspect of every therapeutic relationship and awareness of it by both patient and therapist is helpful to effective work. Developing a therapeutic alliance requires therapist and patient being connected, and being connected requires the therapist to allow the patient to express their emotions. Ulvenes et al. (2004) addressed that therapist-patient interactions that were followed by an affective response in the patient, as well as having the therapist orient and focus the patient toward their affect (ie. through clarification of their emotions) were highly correlated with a positive therapeutic outcome. Besides, the more the patient is aware of their own affect the more it increases their own sense of self as a result. The study found out that this process would be moderated by the patients’ own sense of self (ie. improving one’s capacity of affective self-regulation, promoting one to initiate effort in making psychological changes, etc.). Ulvenes et al. also emphasised that in many schools of therapy, strategies for increasing sense of self are central therapeutic interventions. As a person who is affirming their own needs and sees themselves as an active co-creator of their interpersonal world will have an adaptive interpersonal sense of self.
Kinsella (2019) viewed that a collaborative therapeutic alliance is essential to completing didactic and directive strategies, as such it is helping to mobilise patient’s intrinsic values and stimulate behaviour change. Expressing interpersonal recognition via a client-practitioner dyad can foster autonomy and such autonomy is believed to be the catalyst of the patient’s personal growth. As both parties uncover the patient’s capacities, it then contributes toward their therapeutic growth, both within and beyond the therapeutic alliance. Holmes (1996) also viewed that psychotherapy should be seen as a discipline that requires moral development. He emphasised autonomy as one of the central goals of therapy, and to be autonomous is to discover one’s own set of values. The values clarification provides an opportunity to the patients to elaborate the meanings and definitions of their chosen values and essentially self-define their own identities by themselves.
Such conscious affiliation and collaboration is crucial in order to reinforce the patient’s ability to use their healthy part of ego to accomplish the therapeutic tasks (Flückiger et al., 2018). Some patients might come to therapy feeling helpless and lost, which could be caused due to depressive moods, negative thoughts, struggles and dilemmas in life, etc. It felt as though they were hoping to find a sense of purpose for their lives. Identifying their core values might help them to create a framework to guide themselves to an authentic life they longed for. This framework might offer a sense of direction to the patients such that it fuelled themselves with self-worth and sense of identity at the same time. I noticed that through the values clarification exercise, the patients were given opportunities to express themselves authentically, in turn I was also given opportunities to respect and learn about them. In a conventional therapy setting, the therapist aspires to empathise and understand the patients in order to nurture and develop trust and therapeutic alliance. Through using a values clarification exercise, it creates an opportunity for the patients to self-reflect and learn, leading themselves to feel assured and empowered by themselves. It creates a channel for the patients to connect through expressing their beliefs instead of being the passive role in the consultation room. It transforms the understanding and trusting therapeutic relationship into an elevated therapeutic relationship of mutual recognition and respect.
Based on Attachment Theory and Klein’s object relations theory, Erskine et al. (1999) derived eight primary relational needs which include the need to feel validated and affirmed; to be accepted; confirmation of personal experience; self-definition, etc. Through narrating their own experiences and stories, the patients in return get the sense of validation and affirmation through having their personal experiences acknowledged and heard. It offers a sense of emotional sharing that gives the patients their own voices with a sense of self, just like the ‘gleam in the mother’s eye’ as Heinz Kohut described. Such exchange is critical in one’s developmental phase as this response reflects back to the child a sense of self-worth and value. It resonates with a child’s need for affirmation and acceptance being fulfilled through their caretakers.
Knox (2019) emphasised the importance of relational interaction between the patient and therapist as we intuitively find it so rewarding that it is therefore the activation of these processes that has positive therapeutic effects. These interactions co-construct a shared set of meanings via a dynamic process of ‘turn-taking’. Such sequences of turns contribute to the overall coherence of the therapeutic alliance by shifting from conflict to collaboration. She viewed psychotherapy as a ‘conversation’, emphasising that a strong alliance enables normal developmental processes including self-exploration. She also addressed that the sequences of turns facilitate the moment-to-moment interaction of two subjects, resonating the intersubjectivity between subject and object (patient and therapist). Such turn-taking moments promote the patients to begin sharing responsibility for co-creating this communicative and therapeutic alliance. As I mentioned, the values clarification exercise provides a space for the patients to make inferences so as to respond from their own perspectives, which develop the capacity to relate to another person’s perspective. Habermas (2006) viewed that the perspective taking process of another or self-mentalisation increases the patient’s awareness of their motives, emotions and intentions. He emphasised that turn-taking narratives in psychotherapy encourage patients to share responsibility through a communicative and introspective alliance. As the psychotherapy sessions progress, the values clarification exercise can be viewed as an engaging interim exercise in an overall therapy journey. This exercise which promotes the patients to express themselves through personal stories and experiences, resembles a turn-taking interaction to some extent hence the overall therapeutic narratives thus become one in which the patient’s perspective is equal in value to that of the therapist. It is this interactional intelligence that makes language possible. It is also the interactional collaboration at this turn taking moment where the mental and emotional experience of intersubjectivity develops, where the patient and therapist are co-constructing a shared narrative together (Knox & Lepper, 2014). Such turn-taking echoes the intersubjectivity idea that interactions between the two are mutually influencing each other. Kinsella (2019) also expressed that a healthy dialogue can act as a catalyst in fostering autonomy through self-recognition and self-realisation. As a relationship underpinned by the experience of recognition, the therapeutic alliance is a space in which the self-transcendence that underpins dialogue can paradoxically act as a catalyst for progressing toward self-definition.
Békés & Hoffman (2020) studied the role of the Authentic Relational Moments in psychotherapy sessions. They are the positive relational episodes of patients' experiences which are especially strong, deep and genuine connections, which are argued to be the fundamental part of the relational learning process for the patients. The moments often signify the point of time when the patients felt that the therapeutic relationship is fundamentally (ie. positively) transformed, indicating these moments may potentially improve therefore elevate the therapeutic alliance and real relationship. The study elaborated the three core aspects of Authentic Relational Moments - Authenticity, Understanding and Witnessing. The first core element ‘Authenticity’ refers to the genuineness in the real relationship of both parties. What helps a patient sense an authenticity in the alliance is when they experience an emotional closeness with the therapist through being encouraged to be honest and open. The downplay in analysis or interpretation offers the patient a sense of personal connection in the moment with another human rather than a professional or analyst. The second core element ‘Understanding’ refers to a deep level of attunement to the patient’s affective states and relational longings. Through listening to the patient’s narratives of personal stories and experiences, it might make the patients feel deeply understood and that the therapists could personally relate to their experiences. Békés & Hoffman also described that it is a state where the patients feel ‘in sync’ in a shared intersubjective state. Sharing a memorable personal story can be a very vulnerable and intimate experience. When the patients do that they are allowing the therapists to enter their inner world. Such moments could possibly create a sense of being immersed in the patient’s intersubjective space. The third core element ‘Witnessing’ carries the function of acknowledging. Through understanding how the values meant meaningfully to the patients via storytelling, it creates a virtual moment of bringing the therapist back to the patient’s experiences just like a ‘witness’. This ‘witnessing’ role also offers a sense of affirmation to the patients, truly acknowledging and empathising why they are who they are today. Correspondingly, Békés & Hoffman also mentioned the idea of ‘at-one-ness’ which is the therapist’s ability to become immersed in the patient’s psyche and experience, allowing both to live the experience together.
Barrett-Lennard (1998) defined the concept of Authenticity through a tripartite Person-Centered model consisting of a person’s primary experience, their symbolized awareness and their outward behaviour and communication. Wood et al. (2008) then developed the Authenticity Scale, a measure of dispositional authenticity based on Barrett-Lennard’s tripartite model. In this scale, the first component of authenticity, ‘self-alienation’, means the difference between people’s actual experiences and the perception of their experiences. The second component, ‘authentic living’, means the congruence between the people’s perception of their internal experiences and explicit behaviours, whether they are expressing and behaving as a true self in terms of emotions, beliefs, cognitions, intentions, etc. The third component, ‘accepting external influences', means the extent of a belief that one has to conform to the expectations of another and when one accepts the influence of another. A recent study (Bayliss-Conway et al., 2020) had initial findings that Rogers’ Client-Centered (1957) elements of therapeutic alliance (ie. congruence, empathy, unconditional positive regard) are positively correlated to the patient’s authenticity, by using the Authenticity Scale. It implies that the three components in the Authenticity Scale potentially help to improve the quality of therapeutic alliance. As such, referencing the three factors, people are authentic to the extent that they have insight into their internal experiences. The values clarification exercise seemed to help the patients connect their experiences and beliefs together. It helped to ‘make sense’ for them and such experience resonates through a sense of personal discovery and insight. People are also authentic to the extent of how much they behave according to their internal experiences. The patients had the autonomy to behave and align their actions according to their own core values. It appears that the therapist also acts as a witnessing / supervisor role to acknowledge the patient’s (future) behaviours once they have clarified the values in the sessions. Through this process, it may give the patients the affirmation and recognition that they unconsciously needed therefore enhance the therapeutic alliance as a result. Furthermore, people are authentic to the extent of how much they resist external influences and conform to the expectations of others. The patients were encouraged to genuinely select their top values and ensured that they would not be judged. As such, a sense of authenticity is nurtured and promoted. The patients should not feel that they were acting in any particular way under preset expectations but on the contrary.
Mack (1994) discussed the notion of empowerment in psychotherapy, addressing that patients often felt overwhelmed, powerless and oppressed outside like having forces inside of themselves that they could not manage. Mack suggested that emphasis or purpose in psychotherapy should turn increasingly to empowerment and enabling, to the means of enhancing a sense of agency in the self. Patients should be enabled to exercise their capacity in building positive connections with other people in a mutually satisfying way, such that we varyingly call the will, self-assertiveness or personal strength. A sense of personal power and self-worth can hardly exist in isolation from others, either. Therefore, a dyadic psychotherapy provides a medium for this to flourish. He also addressed that an essential communication and therapeutic alliance is an active process of engagement and dialogue, a bringing forth of new possibilities from within the other person out of the freedom and support fostered in the therapeutic interaction and conversation. Therefore, it allows the patients to explore, recognise and acknowledge their own experiences in the therapeutic relationship and in the patient’s previous life can be incredibly valuable for enabling them to discover their own inner strength and power.
Thiry (2020) suggests the five domains of therapeutic alliance (neuroticism, extraversion, openness to experience, agreeableness and conscientiousness) have become one of the evaluation tools to assess the quality of the therapeutic alliance. The study suggested that factors supposed to hamper therapeutic alliance would primarily be relational while elements that facilitate therapy would be more ‘‘intellectual’’. For instance, patients with more willingness to attend the session, to engage and question, including emotional authenticity but also respect the commitment in the therapeutic framework proposed by the therapist have a particularly high score of therapeutic alliance rating. This implies that such a group of patients shows their need to learn and grow, and would become an ideal audience for the values clarification exercise as they are also prone to perceive and engage better. In turn, this might serve as a guide as an ideal target audience / research participants for future study.
During my private practice psychotherapy work, I requested some of my patients to pick six values out of the 56 Schwartz Values inventory that mean the ‘most important to them’. They would then describe to me why the chosen values were particularly important to them, through narratives of personal stories and experiences. Such approach may constitute a preliminary idea of how the values clarification exercise can be applied in clinical practice. Three clinical examples from my psychotherapy practice will be illustrated below together with some of their verbal feedback during the sessions, based on my personal experiences and observations from my private practice work.
Patient A described that after sharing her core values with me, she felt that the dynamics between us have become ‘more collaborative and more equal’. She also described it as ‘like any relationship building, part of that is about sharing, moving beyond acquaintance and to something else’. ‘More equal’ suggests a sense of mutuality and reciprocity. In such, Tierney (2018) emphasised the importance of mutuality as it allows both persons to see and be seen together, individually and as a dyad, permitting mutual recognition and self-expression. She also pointed out that mutuality is essential to our well being because every person’s brain has the capacity to change which provides the hope to develop empathy and experience healthy, connected relationships. It was addressed that through mutual empathy and mutual empowerment, the patient and therapist allow each other to matter. This process in terms of relational psychotherapy nurtures a growth-enhancing therapeutic relationship. Just as Patient A described, there was a sense of transformation (ie. ‘moving beyond’) in the standard therapeutic relationship, implying a deep connection and reciprocity in the alliance.