"Maybe if I have this client blink his eyes at an increased speed, while exposing him to his past, and add some cognitive behavioral therapy while sitting next to a waterfall, he may be able to function more effectively in his life!" Yes this is rather exaggerated, however it demonstrates the idea that as professionals in the field of therapy, we often seek complex theories, techniques, and strategies to more effectively treat our consumers. A large amount of our precious time is spent seeking new theories and techniques to treat clients; evidence for this statement is shown by the thousands of theories and techniques that have been created to treat clients seeking therapy.
The fact that theories are being created and the field is growing is absolutely magnificent; however we may be searching for something that has always been right under our nose. Clinicians often enjoy analyzing and making things more intricate that they actually are; when in reality what works is rather simple. This basic and uncomplicated ingredient for successful therapy is what will be explored in this article. This ingredient is termed the therapeutic relationship. Some readers may agree and some may disagree, however the challenge is to be open minded and remember the consequences of "contempt prior to investigation".
Any successful therapy is grounded in a continuous strong, genuine therapeutic relationship or more simply put by Rogers, the "Helping Relationship". Without being skilled in this relationship, no techniques are likely to be effective. You are free to learn, study, research and labor over CBT, DBT, EMDR, RET, and ECT as well as attending infinite trainings on these and many other techniques, although without mastering the art and science of building a therapeutic relationship with your client, therapy will not be effective. You can even choose to spend thousands of dollars on a PhD, PsyD, Ed.D, and other advanced degrees, which are not being put down, however if you deny the vital importance of the helping relationship you will again be unsuccessful. Rogers brilliantly articulated this point when he said, "Intellectual training and the acquiring of information has, I believe many valuable results--but, becoming a therapist is not one of those results (1957)."
This author will attempt to articulate what the therapeutic relationship involves; questions clinicians can ask themselves concerning the therapeutic relationship, as well as some empirical literature that supports the importance of the therapeutic relationship. Please note that therapeutic relationship, therapeutic alliance, and helping relationship will be used interchangeably throughout this article.
Characteristic of the Therapeutic Relationship
The therapeutic relationship has several characteristics; however the most vital will be presented in this article. The characteristics may appear to be simple and basic knowledge, although the constant practice and integration of these characteristic need to be the focus of every client that enters therapy. The therapeutic relationship forms the foundation for treatment as well as large part of successful outcome. Without the helping relationship being the number one priority in the treatment process, clinicians are doing a great disservice to clients as well as to the field of therapy as a whole.
The following discussion will be based on the incredible work of Carl Rogers concerning the helping relationship. There is no other psychologist to turn to when discussing this subject, than Dr. Rogers himself. His extensive work gave us a foundation for successful therapy, no matter what theory or theories a clinician practices. Without Dr. Rogers outstanding work, successful therapy would not be possible.
Rogers defines a helping relationship as , " a relationship in which one of the participants intends that there should come about , in one or both parties, more appreciation of, more expression of, more functional use of the latent inner resources of the individual ( 1961)." There are three characteristics that will be presented that Rogers states are essential and sufficient for therapeutic change as well as being vital aspects of the therapeutic relationship (1957). In addition to these three characteristics, this author has added two final characteristic that appear to be effective in a helping relationship.
1. Therapist's genuineness within the helping relationship. Rogers discussed the vital importance of the clinician to "freely and deeply" be himself. The clinician needs to be a "real" human being. Not an all knowing, all powerful, rigid, and controlling figure. A real human being with real thoughts, real feelings, and real problems (1957). All facades should be left out of the therapeutic environment. The clinician must be aware and have insight into him or herself. It is important to seek out help from colleagues and appropriate supervision to develop this awareness and insight. This specific characteristic fosters trust in the helping relationship. One of the easiest ways to develop conflict in the relationship is to have a "better than" attitude when working with a particular client.
2. Unconditional positive regard. This aspect of the relationship involves experiencing a warm acceptance of each aspect of the clients experience as being a part of the client. There are no conditions put on accepting the client as who they are. The clinician needs to care for the client as who they are as a unique individual. One thing often seen in therapy is the treatment of the diagnosis or a specific problem. Clinicians need to treat the individual not a diagnostic label. It is imperative to accept the client for who they are and where they are at in their life. Remember diagnoses are not real entities, however individual human beings are.
3. Empathy. This is a basic therapeutic aspect that has been taught to clinicians over and over again, however it is vital to be able to practice and understand this concept. An accurate empathetic understanding of the client's awareness of his own experience is crucial to the helping relationship. It is essential to have the ability to enter the clients "private world" and understand their thoughts and feelings without judging these (Rogers, 1957).
4. Shared agreement on goals in therapy. Galileo once stated, "You cannot teach a man anything, you can just help him to find it within himself." In therapy clinicians must develop goals that the client would like to work on rather than dictate or impose goals on the client. When clinicians have their own agenda and do not cooperate with the client, this can cause resistance and a separation in the helping relationship (Roes, 2002). The fact is that a client that is forced or mandated to work on something he has no interest in changing, may be compliant for the present time; however these changes will not be internalized. Just think of yourself in your personal life. If you are forced or coerced to work on something you have no interest in, how much passion or energy will you put into it and how much respect will you have for the person doing the coercing. You may complete the goal; however you will not remember or internalize much involved in the process.
5. Integrate humor in the relationship. In this authors own clinical experience throughout the years, one thing that has helped to establish a strong therapeutic relationship with clients is the integration of humor in the therapy process. It appears to teach clients to laugh at themselves without taking life and themselves too serious. It also allows them to see the therapist as a down to earth human being with a sense of humor. Humor is an excellent coping skill and is extremely healthy to the mind, body, and spirit. Try laughing with your clients. It will have a profound effect on the relationship as well as in your own personal life.
Before delving into the empirical literature concerning this topic, it is important to present some questions that Rogers recommends (1961) asking yourself as a clinician concerning the development of a helping relationship. These questions should be explored often and reflected upon as a normal routine in your clinical practice. They will help the clinician grow and continue to work at developing the expertise needed to create a strong therapeutic relationship and in turn the successful practice of therapy.
1. Can I be in some way which will be perceived by the client as trustworthy, dependable, or consistent in some deep sense?
2. Can I be real? This involves being aware of thoughts and feelings and being honest with yourself concerning these thoughts and feelings. Can I be who I am? Clinicians must accept themselves before they can be real and accepted by clients.
3. Can I let myself experience positive attitudes toward my client - for example warmth, caring, respect) without fearing these? Often times clinicians distance themselves and write it off as a "professional" attitude; however this creates an impersonal relationship. Can I remember that I am treating a human being, just like myself?
4. Can I give the client the freedom to be who they are?
5. Can I be separate from the client and not foster a dependent relationship?
6. Can I step into the client's private world so deeply that I lose all desire to evaluate or judge it?
7. Can I receive this client as he is? Can I accept him or her completely and communicate this acceptance?
8. Can I possess a non-judgmental attitude when dealing with this client?
9. Can I meet this individual as a person who is becoming, or will I be bound by his past or my past?
There are obviously too many empirical studies in this area to discuss in this or any brief article, however this author would like to present a summary of the studies throughout the years and what has been concluded.
Horvath and Symonds (1991) conducted a Meta analysis of 24 studies which maintained high design standards, experienced therapists, and clinically valid settings. They found an effect size of .26 and concluded that the working alliance was a relatively robust variable linking therapy process to outcomes. The relationship and outcomes did not appear to be a function of type of therapy practiced or length of treatment.
Another review conducted by Lambert and Barley (2001), from Brigham Young University summarized over one hundred studies concerning the therapeutic relationship and psychotherapy outcome. They focused on four areas that influenced client outcome; these were extra therapeutic factors, expectancy effects, specific therapy techniques, and common factors/therapeutic relationship factors. Within these 100 studies they averaged the size of contribution that each predictor made to outcome. They found that 40% of the variance was due to outside factors, 15% to expectancy effects, 15% to specific therapy techniques, and 30% of variance was predicted by the therapeutic relationship/common factors. Lambert and Barley (2001) concluded that, "Improvement in psychotherapy may best be accomplished by learning to improve ones ability to relate to clients and tailoring that relationship to individual clients."
One more important addition to these studies is a review of over 2000 process-outcomes studies conducted by Orlinsky, Grave, and Parks (1994), which identified several therapist variables and behaviors that consistently demonstrated to have a positive impact on treatment outcome. These variables included therapist credibility, skill, empathic understanding, affirmation of the client, as well as the ability to engage the client and focus on the client's issues and emotions.
Finally, this author would like to mention an interesting statement made by Schore (1996). Schore suggests "that experiences in the therapeutic relationship are encoded as implicit memory, often effecting change with the synaptic connections of that memory system with regard to bonding and attachment. Attention to this relationship with some clients will help transform negative implicit memories of relationships by creating a new encoding of a positive experience of attachment." This suggestion is a topic for a whole other article, however what this suggests is that the therapeutic relationship may create or recreate the ability for clients to bond or develop attachments in future relationships. To this author, this is profound and thought provoking. Much more discussion and research is needed in this area, however briefly mentioning it sheds some light on another important reason that the therapeutic relationship is vital to therapy.
Throughout this article the therapeutic relationship has been discussed in detail, questions to explore as a clinician have been articulated, and empirical support for the importance of the therapeutic relationship have been summarized. You may question the validity of this article or research, however please take an honest look at this area of the therapy process and begin to practice and develop strong therapeutic relationships. You will see the difference in the therapy process as well as client outcome. This author experiences the gift of the therapeutic relationship each and every day I work with clients. In fact, a client recently told me that I was "the first therapist he has seen since 9-11 that he trusted and acted like a real person. He continued on to say, "that's why I have the hope that I can get better and actually trust another human being." That's quite a reward of the therapeutic relationship and process. What a gift!
Ask yourself, how you would like to be treated if you were a client? Always remember we are all part of the human race and each human being is unique and important, thus they should be treated that way in therapy. Our purpose as clinicians is to help other human beings enjoy this journey of life and if this field isn't the most important field on earth I don't know what is. We help determine and create the future of human beings. To conclude, Constaquay, Goldfried, Wiser, Raue, and Hayes (1996) stated, " It is imperative that clinicians remember that decades of research consistently demonstrates that relationship factors correlate more highly with client outcome than do specialized treatment techniques."
Constaquay, L. G., Goldfried, M. R., Wiser, S., Raue, P.J., Hayes, A.M. (1996). Predicting the effect of Cognitive therapy for depression: A study of unique and common factors. Journal of Consulting and Clinical Psychology, 65, 497-504.
Horvath, A.O. & Symonds, B., D. (1991). Relation between a working alliance and outcome in psychotherapy: A Meta Analysis. Journal of Counseling Psychology, 38, 2, 139-149.
Lambert, M., J. & Barley, D., E. (2001). Research Summary on the therapeutic relationship and psychotherapy outcome. Psychotherapy, 38, 4, 357-361.
Orlinski, D. E., Grave, K., & Parks, B. K. (1994). Process and outcome in psychotherapy. In A. E. Bergin & S. L. Garfield (Eds.), Handbook of psychotherapy(pp. 257-310). New York: Wiley.
Roes, N. A. (2002). Solutions for the treatment resistant addicted client, Haworth Press.
Rogers, C. R. (1957). The Necessary and Sufficient Conditions of Therapeutic Personality Change. Journal of Consulting Psychology, 21, 95-103.
Rogers, C. R. (1961). On Becoming a Person, Houghton Mifflin company, New York.
Schore, A. (1996). The experience dependent maturation of a regulatory system in the orbital prefrontal cortex and the origin of developmental psychopathology. Development and Psychopathology, 8, 59-87.