Without the therapeutic relationship there can be no effective or meaningful therapy. This applies to all forms of counselling and psychotherapy. Within my psychotherapy training I soon learnt that in counselling and psychotherapy the therapeutic relationship is, what Jung called, “the. Outcome research analyses the results of the therapy, whereas of therapeutic alliance in group psychotherapy follows Bordin's theory.
In addition to that, as McLeod suggested, when discussing counselling, it is easier to use a language that involves techniques and methods than a language that involves relational context. However, removing the interpersonal for the instrumental could divert the attention from one of the most important aspects of therapy. The different approaches to therapy use different paradigms to understand the therapy process and ultimately the therapeutic relationship.
Person-centred approach understands therapeutic change as a process that happens inside an accepting and empathetic client-counsellor relationship Barrett-Lennard, For feminist therapy, the focus is not only on the interpersonal, but also on the socio-political aspects of the therapeutic relationship.
The focus is on female clients since, on the one hand, women constitute the majority of counselling and psychotherapy clients and, on the other hand, their experiences are often excluded from traditional psychological theories Matlin, Thus, gender in the present study plays a role only in that the clients of the study are women and they share their experiences as women. Lambert and Barleyin their research review, concluded that the different aspects of the therapeutic relationship are related, to a larger degree, with the therapeutic outcome when compared to specialized therapeutic techniques.
Also, the effectiveness of each approach is bound to the relational context between the counsellor and the client Norcross, In the study of Barber et al. Whereas, for clients who did not experience a strong therapeutic alliance, an average level of technique was related to better results. In spite of the evidence that considers the therapeutic relationship as an important factor for the effectiveness of therapy, a challenge in researching this relationship is the difficulty of specifying the different relational elements Cooper, In order for the healing qualities of the therapeutic relationship to be determined, the American Psychological Association APA appointed a task force aiming at the empirical investigation of the counsellor-client relationship.
Clients found the therapeutic relationship effective when counsellors displayed characteristics such as being understanding, unbiased, friendly, trustworthy, gentle, non-judgmental, caring, open and supportive. When illustrating the type of relationship, most participants likened it to friendship, while also noticing the differences and all participants noted the importance of trust and comfort.
They also found helpful the explanations or interpretations provided by the counsellors, the positive feedback and the ability to self-disclose personal information. Likewise, Oliveira, Sousa, and Pazo Piresin their phenomenological study with three ex-clients of psychotherapy, found that the participants preferred a collaborative, nonjudgmental therapeutic relationship with a knowledgeable and competent counsellor. Thus, having an understanding counsellor who they could trust and open up to was imperative for the clients.
Finally, in a similar qualitative study of 16 participants, Sackett and Lawson found that clients valued a substantial and authentic bond with their counsellors, where they felt trust and, also, understood and accepted. Women as Clients in Therapeutic Relationships [ TOP ] Women constitute the vast majority of clients seeking help from counselling and psychotherapy e.
Indeed, researchers and authors call for a gender inclusive therapeutic process and relationship, emphasizing the need for awareness in areas such as: For example, Bhati addressed the role of gender in therapeutic dyads and pointed out that across all stages of therapy, female clients who worked with a female therapist reported higher therapeutic alliance ratings in comparison to female clients who worked with a male therapist.
Likewise, Landes, Burton, King, and Sullivan researched the preferences of female college students and found that the participants reported higher levels of anticipated comfort self-disclosing to a female therapist. Concerning the therapeutic process, Ogrodniczuk, Piper, Joyce, and McCallum found that female clients who were randomly assigned to either interpretive or supporting therapy had better outcome in supportive therapy, which was less challenging and encouraged a more collaborative and trusting relationship.
More specifically, female clients preferred counsellors who were supportive when dealing with emotional issues, whereas on relationship issues, women tended to like a more directive approach, in which the counsellor advised them on what to do. Thus, listening to female clients and the way that they construct relationships in therapy was a main goal of the study. The therapeutic relationship is a relationship that happens outside of the everyday social context of each person involved.
Therefore, the descriptions generated by the clients are usually overlooked.
On the grounds of listening to the clients, aiming to study their lived experiences and exploring their point of view of the counselling relationship, the study was approached by using interpretative phenomenological analysis Smith, In this way, the focus is on exploring individual, subjective experiences and on understanding the patterns that form when clients share the ways that they relate to their counsellors.
A second theoretical approach that informed the present study was feminist research. Thus, the main goals of the present study were: Participants [ TOP ] The participants of the study were 27 counselling and psychotherapy female clients.
The duration of the sessions was between 2 months and 5 years, with a prerequisite of at least 8 sessions. The goal of this choice was to allow the participants to form and develop a therapeutic relationship that could be properly discussed and analysed Thompson, Seventeen of the clients visited a female counsellor and 10 a male one.
Women as Counselling and Psychotherapy Clients: Researching the Therapeutic Relationship
The study had no restrictions concerning the issues discussed in therapy. Some of the most prominent issues defined by the clients were anxiety and anxiety-related problems, depression, interpersonal relationships, self-awareness and specific events that needed sorting out.
In terms of their occupation, 11 participants were employees of the private or the public sector, six were self-employed, five were university students and five were unemployed.
Thirteen of the participants were single, eight were married, two were engaged and four separated or divorced. Nine of them had children.
Participants were recruited through an invitation letter that was sent to counselling services and counsellors and psychotherapists in private practice.
The letter invited participation in the study and the purpose of the study and the anonymous character of the research were fully explained. Interviews [ TOP ] The data for the present study was collected with the use of individual, semi-structured interviews.
The interview question regarding the present study was the following: An informed consent letter explaining the goals of the study and its anonymous character was distributed and signed by all participants. All the interviews were conducted by the first author of the article, while the digital records were transcribed verbatim according to Smith For the purpose of the present article, back translation was used for every extract included. While analysing the data, the first author repeatedly read the transcripts, made notes and then transformed the notes into specific themes, which were confirmed by the other two authors.
The themes were examined in relation to one another and grounded within the transcripts. After this circular process, the super-ordinate themes and the subthemes were produced. The criteria used, in order for the methodological rigour of the study to be determined, were the systematic consideration of the themes, investigator triangulation, and reflexivity.
The triangulation was carried out with the help of two independent researchers who analysed the data and produced similar results. Results [ TOP ] The three super-ordinate themes that originated from the data analysis were the following: Comparing the Therapeutic Relationship [ TOP ] This super-ordinate theme focused on the definition that 17 participants gave to the unique relationship with their counsellor. In their attempt to define this relationship, the participants did not engage with terms used in the literature but, maybe in loss of a structured definition, they compared the therapeutic relationship to other interpersonal relationships.
These comparisons were not part of an interview schedule but were generated by the participants themselves. The comparisons included similarities, differences or analogies that the participants found with friendship, family relationships or other professional relationships. Thus, the three subthemes that were produced addressed the comparison of the counselling relationship to friendship, to family relationships or to other professional relationships.
Comparing the Therapeutic Relationship to Friendship [ TOP ] The most common comparison that 11 participants used in order to define the therapeutic relationship was that of friendship.
An example is that of Ioanna, who hesitantly proceeded to liken the relationship with her therapist to friendship: We discuss so naturally. For example how does it feel when you are with a friend of yours and you chat about your news, and the discourse is very natural, it has a very natural flow, without you pressuring yourself to say or not to say things?
Did you understand what I mean? Although Ioanna hesitated to name her therapist her friend, maybe because she was well aware of the boundaries that are drawn in the therapeutic context, she described a relationship that is like a friendship, where she felt comfortable to talk.
Another participant who seemed ambivalent about the definition of her relationship to her counsellor was Antonia. For Antonia, initially, there was a negotiation whether or not to characterize this relationship as friendship, but she ended up accepting this definition because of the equality and the comfort that she experienced: But you cannot name it friendship.
I think it is friendship. Although, you cannot open up yourself like this to a friend… But I would consider it friendship because we are equals, because we can comfortably discuss with each other. The reason why Antonia did not actually define her therapeutic relationship as friendship did not seem to be because of the boundaries, like in the experience of Ioanna, but because she could open up more freely to a counsellor than to her friends.
Nevertheless, she accepted friendship as the closest definition. In the following examples, the participants used the comparison in order to offer an analogy between the two types of relating, while also noting the differences. For instance, Danai seemed to experience the therapeutic relationship as the best version of friendship.
As she stated in the following extract: I can talk very comfortably. Not friendly, not with that sense. This is something very freeing. Danai, like Antonia, talked about the best qualities of the therapeutic relationship in comparison to friendship, but instead of linking the two, she emphasized the differences. In this contrast, the counselling relationship was the one that appeared to be more favoured.
In the same vein, Kaiti contrasted the two kinds of relationship and found the therapeutic relationship to be better, although, similar to friendship: My relationship… I would say friendship. Something more than friendship. She is a person that I feel very close to, to whom I could say my inner truths and this is very important. For most people who are very busy with their problems it is very important to be able to discuss your inner truths with a stranger.
What is interesting in the above extract is that Kaiti simultaneously considered the therapeutic relationship to be better than friendship because of the closeness that she experienced, and also characterized her counsellor as a stranger. Another example of the way that the counselling relationship is likened and contrasted to friendship was the experience of Aliki. She expressed that in this situation, she was the one who was the center of attention and her problems were the priority, whereas, in other friendships, her issues might be disregarded and the focus would soon be elsewhere: When you talk with your friend, you will sit down and talk about your problems and she will say: Then she will start talking about herself.
Here it is a little like an egotistical friendship [laughs]. This is the nature of this profession. The psychologist will not say that I have no reason to worry. Why did this happen? Thus, she certainly did not experience her counsellor as her friend: There are boundaries [in the relationship with the counsellor], which means that she is not your friend.
Almost all of the participants that attempted to define their relationship to their counsellor as a friendly one described characteristics such as closeness, equality, being able to talk easily, self-disclosure and being listened to and also the sense of an informal environment when it comes to sharing.
Comparing the Therapeutic Relationship to Family Relationships [ TOP ] Another way that participants illustrated the type of relationship that they experienced with their counsellor was by comparing the counselling relationship to family relationships.
More specifically, for eight participants the counselling relationship was compared to a relationship with a parent or a sibling. For example, Theano appeared to be saying that her counsellor provided the necessary support and acted like a person on whom she could lean on, like she would do with a father: I was feeling that he had a strong presence, where I could feel relaxed, where I could lean on to, where I could ask for his support.
According to Horvath and Symondsthe extent of the relationship between alliance and outcome was not a direct function of time: The results of these studies have led researchers to consider the existence of two important phases in the alliance. The first phase coincides with the initial development of the alliance during the first five sessions of short-term therapy and peaks during the third session.
During the first phase, adequate levels of collaboration and confidence are fostered, patient and therapist agree upon their goals, and the patient develops a certain degree of confidence in the procedures that constitute the framework of the therapy. The deterioration in the relationship must be repaired if the therapy is to be successful. This model implies that the alliance can be damaged at various times during the course of therapy and for different reasons.
The effect on therapy differs, depending on when the difficulty arises. In this case, the patient may prematurely terminate the therapy contract. According to Safran and Segalmany therapies are characterized by at least one or more ruptures in the alliance during the course of treatment. Randeau and Wampold analyses the verbal exchanges between therapist and patient pairs in high and low-level alliance situations and find that, in high-level alliance situations, patients responded to the therapist with sentences that reflected a high level of involvement, while in low-level alliance situations, patients adopted avoidance strategies.
Although some studies are based on a very limited number of cases, the results appear consistent: While recent theorists have stressed on the dynamic nature of the therapeutic alliance over time, most researchers have used static measures of alliance. There are currently several therapy models that consider the temporal dimension of the alliance, and these can be divided into two groups: Few studies have analyzed alliance at different stages in the treatment process.
According to the results proposed by Traceythe more successful the outcome, the more curvilinear the pattern of client and therapist session satisfaction high—low—high over the course of treatment.
When the outcome was worse, the curvilinear pattern was weaker. Kivlighan and Shaughnessy use the hierarchical linear modeling method an analysis technique for studying the process of change in studies where measurements are repeated to analyses the development of the alliance in a large number of cases. According to their findings, some dyads presented the high—low—high pattern, others the opposite, and a third set of dyads had no specific pattern, although there appeared to be a generalized fluctuation in the alliance during the course of treatment.
In recent years, researchers have analyzed fluctuations in the alliance, in the quest to define patterns of therapeutic alliance development. Kivlighan and Shaughnessy distinguish three patterns of therapeutic alliance development: They based their analysis on the first four sessions of short-term therapy and focused their attention on the third pattern, in that this appeared to be correlated with the best therapeutic outcomes. In further studies of this development pattern, Stiles et al.
Unlike Kivlighan and Shaughnessy, these authors considered therapies consisting of 8 and 16 sessions, using the ARM to rate the therapeutic bond, partnership, and confidence, disclosure, and patient initiative.
Why the therapeutic relationship matters - Counselling Directory
No significant correlation was observed between any of the four patterns and the therapeutic outcome. However, the authors observed a cycle of therapeutic alliance rupture—repair events in all cases: On the basis of this characteristic, the authors hypothesize that the V-shaped alliance patterns may be correlated with positive outcomes.
In particular, Stiles et al. The results of the study by De Roten et al. According to De Roten et al. De Roten et al. According to Castonguay et al. This has supported the idea that therapeutic alliance may be characterized by a variable pattern over the course of treatment, and led to the establishment of a number of research projects to study this phenomenon. Discussion and Conclusion According to their meta-analysis based on the results of 24 studies, Horvath and Symonds demonstrate the existence of a moderate but reliable association between good therapeutic alliance and positive therapeutic outcome.
More recent meta-analyses of studies examining the linkage between alliance and outcomes in both adult and youth psychotherapy Martin et al. Thus, it is not by chance that in their meta-analysis, Horvath and Luborsky conclude that two main aspects of the alliance were measured by several scales regardless of the theoretical frameworks and the therapeutic models: This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants.
In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended.
From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop.
Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.
So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects.
Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist.
Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Acknowledgments The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article. A Research Handbook, eds Greenberg L. Guilford Press;— Bibring E. On the theory of the results of psychoanalysis.
The generalizability of the psychoanalytic concept of the working alliance. Clinical Applications of Attachment Theory. Routledge and Kegan Paul Budman S. Cohesion, alliance and outcome in group psychotherapy. Psychiatry 52, — [ PubMed ] Burlingame G.
It can be especially valuable to clients who may have struggled forming relationships in their past, and those who experienced traumatic events in their early years, leading them to find it difficult to form relationships in adulthood. Therapy allows clients the chance to explore their relational attachments, bonds and experiences through their relationship with their therapist, which is why this relationship is so important.
What makes the therapeutic relationship so different? The therapeutic relationship is unique in that for many clients, it may be one of the first times they have formed an intimate connection with another person, where the feelings, thoughts or ideas have been allowed to be heard, understood and valued, and where they have not had to censor themselves.
Why do you need to see a therapist? It is a relationship that is impartial, not based in the past or does not carry the judgements, feelings or dynamics that can be associated with our external relationships. What are the characteristics of the therapeutic relationship? The therapeutic relationship has many components and varies between each individual relationship.
However there are some common themes and characteristics which I have listed below: They must be a real person who can relate to another genuinely. This is the basis and foundation for a therapeutic relationship because it establishes a personal connection between the therapist and client, allowing the client to see their therapist hears them, values and understands their needs. Trusting and a non-judgemental attitude For a therapeutic relationship to develop, grow and flourish, it is crucial a client feels their therapist is trustworthy.
For clients who find it difficult to open up or explore their feelings due to worrying that it is not safe for them to do so, it matters greatly that they can feel confident that their therapist will not judge them.