The Therapeutic Relationship- Part I
The Therapeutic Relationship

There are many pieces to the interpersonal interactions of patient and therapist. Typically, all therapies involve the following:
1) constancy of therapist's interest no matter how disturbing the subject
2) suspension of moral judgment
3) therapist's empathy, insight, understanding, and acceptance
4) patient's opportunity to speak the unspeakable now
5) reliability of therapist in keeping appointments, the duration of the session, the attempt to put patient's welfare first, the safe environment that the therapist's structure provides in which the patient can regress
6) the therapist allowing him/herself to be used as a transference object without the interference of counter-transference

The hallmarks of analysis are making the unconscious conscious and the regressive transference neurosis. To understand the transference neurosis, you have to keep in mind that the patient's experience in therapy approximates early experiences in the present; past traumas feel as if they were actually happening now. The "observing ego," or the part of us that watches what we do and say in some objective manner, watches all this and tolerates the anxiety that is produced. Since the therapist may not meet needs of the patient (the therapist can not be perfect and know all of the client's needs and wishes), and since the therapist does not act like the object of the transference (the therapist is not judgmental like the critical parent, or uncaring like the neglecting parent), frustration results, promoting more regression. This allows for the examination of these feelings, and exploration of the differences between fantasies and wishes versus acts. The observing ego learns more and more about what the whole person does. This is what makes analysis of transference so powerful.

In short term therapy the idea is similar. The patient becomes increasingly able to adopt an attitude of self-observation, therapeutic interest, and therapeutic alliance. Each time the "therapist passes the test," that is, meets some need of the patient, this process is strengthened. This process is circular and continuous. In the analysis of transference during short term therapy, the therapist tends to be more active, direct, confrontive, interpretive, and corrective of the patient's transference distortions, which provides multiple experiences for the "corrective emotional experience." The idea of the Corrective Emotional Experience is that you re-experience the problem relationships with the therapist and solve them. The patient also begins to introject or identify with the therapist, to act and think like the therapist does. Think of this as building a little therapist in your head that helps you calm down, figure out what you are doing, why you are doing it, and what else you could do. The identification with the therapist has important maturational and developmental impact on the ego and superego.

So there are two experiences here - the regressive transference relationship, and the new experience with the therapist of a new relationship. If the two experiences are not different, you strengthen the neurosis because the therapist acts just like the traumatic people in the client's life.

Originally, the proponents of behavioral therapy explained the results of therapy as solely a function of the treatment, stating that the therapist is simply a "social reinforcement machine," an "engineer of behavior." Due in part to this, behavioral therapists have been viewed as cold and aloof. Today, modern behaviorism has called attention to the relationship, or at least to "non-specific factors in therapy," and asked "what percentage of the variance in therapy is accounted for by relationship factors?"

Impact of the Therapeutic Relationship
There are 3 main studies in this area;

Sloane et al. 1975 (the Temple study)
Behavioral therapists were rated significantly higher than psychodynamic therapists on their level of interpersonal contact, empathy, and self-congruence (genuineness). They talked more and for longer periods of time, directed the sessions more, and gave more information and advice than did psychodynamic therapists. Clients in psychodynamic therapy who were liked by the therapist were more likely to improve; this was not shown for behavioral therapists.

Truax-Carkhuff measures (named for the authors who first measured them all together, these are ratings of the therapist's empathy, warmth, concreteness, and genuineness, as well as an overall score across the four areas) showed no significant differences for behavioral and psychodynamic therapists, though there was a slight tendency for behavioral therapists to score higher on all five scales. Analogue studies (using "fake" patients) failed to show significant differences.

Both real and analogue patients rated the personal interaction with the therapist as the single most important factor in their treatment. A two year follow up showed patients rated the points reflecting a good personal relationship as very or extremely important in their treatment.

Alexander et al. 1976
They investigated interpersonal skills and found that two major factors, relationship variables (such as warmth) and structuring variables (such as directiveness and self-confidence), together accounted for 60% of the variance. This has been explained by noting the more effective the therapist is as a social reinforcer, the more effective he or she is at causing change in the client.

Ford 1978
Ford evaluated Client's Perception of the Therapeutic Relationship (CPTR). Of 48 behaviors, he found that individual therapists had a significant effect on CPTR ratings. Some therapists were better than others. Specific therapeutic behaviors only accounted for 15-30% of the variance. Focus on the patient's significant others was negatively correlated with outcome.

Thus there are four conclusions from all this -

1) behavioral therapists are perceived as having good therapeutic relationships
2) the relationship is not sufficient for change, but is important
3) the therapeutic relationship is an elusive construct that doesn't depend solely on the therapist's behavior
4) some therapists are better than others.

Specific Relationship Factors
Therapy length or time of sessions appears to have little or no effect on smoking cessation, nail biting, or enuresis. It does appear to have some effect on obesity. Home based treatment programs and self-help manuals suggest that the relationship may be minimally relevant to change with phobias, alcohol abuse, and sexual problems. In fact, using different therapies in a patient treatment program may help prevent the therapist from becoming a discriminative stimulus for behavioral change, and may help decrease dependency on one person.

Live vs. Taped Treatment- Analogue research has found that 1) a tape of the therapist talking to you is better than no treatment; 2) the presence of a therapist is better than the absence of a therapist; 3) the therapist's presence is not statistically different from memorex.

Social Reinforcement, Praise, and Feedback could enhance treatment with some clients, but praise by itself had little effect. The conclusion was that exposure plus feedback were the crucial variables, and not just social reinforcers. The research in this area is plagued by poor methodology.

Therapist Experience has been rarely studied. No difference in efficacy was observed between PhDs and paraprofessionals according to some studies. However, better designed studies found that paraprofessionals can make a difference, but professionals make more of a difference. Tall and Ross showed that age and experience are confounders.

Manipulation of Expectancy - Frank and Wilkins are the big names here. The idea here is that expectations of improvement are what make therapy effective, not the therapy or therapist. The problems with this line of research are several.. First, how do you manipulate expectations? Tell people that you are a bad therapist? Second, expectancy of improvement can be manipulated by altering the expectations you have of the time you will spend in treatment, the expertise of the therapist, or the faith of the client that therapy in general is helpful.

Studies on Relationship Factors - There has been little research in this area. There are 3 good studies though.
1) Rabavilas et al. 1979 found that obsessive compulsive clients when asked one year after terminating therapy, attributed change to two therapy variables - the therapist's general attitude (respect, understanding), and manner of conducting treatment (demanding, encouraging, challenging), both of which were positively related to outcome. Meeting dependency needs was negatively related to outcome.
2) Mathews et al. 1976 stated that agoraphobics attributed important effects to the therapist's encouragement and sympathy, and to a lesser degree the practice component and learning to cope with panic.
3) In other studies, therapist warmth and fear reduction were important variables to patient change.

No definitive answers are available, but a tentative conclusion can be made. The therapeutic relationship interacts with the "technology" or specific strategies of therapy either to enhance or hinder the attainment of client goals. The relationship is likely just as important to effective therapy as the actual techniques used. The client's perception of therapy is also important.