The Therapeutic Relationship - Part II
The Therapeutic Relationship - Research and Theory

The client-therapist relationship is important both as a primary element of therapy (an effective element of therapy in and of itself) and as a supportive or secondary element of therapy (an effective element of therapy through secondary effects).

Various studies (e.g. Smith & Glass, Shapiro & Shapiro) have indicated that psychotherapy is effective. While these studies are based on meta-analytic reviews which have their own limitations, the findings seem solid. Psychotherapy is effective for approximately 2/3s to 3/4s of the people that seek it.

The question of "Which is the more important, the technique or the relationship?" in psychotherapy has been debated over the years (e.g. Strupp, 1972; Garfield, 1972). Bowers and Clum (1988) attempted to form some answer to this question by reviewing studies which compared therapies with a technique focus, therapies with a relationship focus (placebo therapy), and therapies with both. Overall they found that therapy with both relationship and technique focus had an effect size of .76, while therapy with technique focus only had an effect size of .55. Thus, they concluded, that the non-specific factors of therapy, the relationship focused therapy, contributes .21 to the effect size, while technique contributes .55 to the effect size, giving the obtained effect size of .76 overall. Thus, the question of "Which is the more important, the technique or the relationship?" in psychotherapy has been answered to some extent, because empirical data supports that both contribute to the effectiveness of psychotherapy. The therapeutic relationship has effectiveness at least as a primary element of therapy; it contributes a unique piece of variance to the effectiveness of therapy.

The therapeutic relationship also has effectiveness as a secondary element of therapy. Many (Strupp, 1992; Van Denberg & Van Denburg, 1992) note that the relationship may be involved in a client's feelings about therapy and his/her decisions to terminate therapy. Van Denburg & Van Denburg (1992) note that Kohut believed that often premature termination resulted from empathic breaches, or failures in empathy. They notes that others have suggested that premature termination occurs from too strong negative transference (Blanck & Blanck), fears of abandonment by and separation from the therapist (Mahler), and too strong feelings regarding dependence on the therapist (transference resistance - Freud). Thus, according to these theorists, the therapeutic relationship has at least secondary or preventative effects in therapy as a factor that is involved in client's beliefs and feelings about the effectiveness of therapy as well as maintenance of therapy services.

The Therapeutic Relationship in Cognitive-Behavioral Therapy

Beck and Freeman (1990), in their brief review cognitive-behavioral treatment, note that cognitive-behavioral therapy is based on therapist and client collaboration in guided discovery. Both the client and therapist work to determine goals, homework assignments, terms for success, and means for maintenance of success. The therapist is open and honest with the client, sends clear and explicit messages to the client, and gives honest feedback.

The cognitive-behavioral therapist works with schemas. These are, simply put, peoples' collections of beliefs, experiences, and rules for behavior regarding themselves, others, and the world. Beck and Freeman note that the person may well have schematic beliefs that people in general can not be trusted, that they themselves are worthless and/or bad at the core, that bad things will happen to the client and there is nothing the client can do about it, and that they themselves can not live without help from someone else such as the therapist.

While the primary goal of cognitive-behavioral treatment is the change/reorganization in old schemas and the creation of new schemas, the client's current schemas about self and others may interfere with the work of therapy. Given this, the cognitive-behavioral therapist must be sensitive to relationship issues and work towards building a trusting relationship early in therapy. Further, change may become frightening for the client if it happens too fast, has negative consequences in the client's eyes, and/or is incompatible with core ideas about the self ("I'm a failure, so all this is pointless as I will screw it up anyway"). Thus, the relationship must be attended to as therapy progresses as schemas about the self will continually effect the client's progress at schema change.

Thus, the cognitive-behavioral therapist effects change primarily through therapeutic techniques, such as guided discovery of schema beliefs, relaxation training, graded anxiety hierarchies, dysfunctional thought recording, in vivo and imaginal exposure … but also understands the importance of relationship issues as they effect these primary goals and the effectiveness of these techniques. Cognitive-behavioral therapists see the relationship as a secondary factor of therapy. There has been ample literature on the effectiveness of cognitive-behavioral therapy (e.g. Smith & Glass; Shapiro & Shapiro), often over psychodynamic and humanistic models of therapy, and thus perhaps this model of the therapeutic relationship is supported empirically.

The Therapeutic Relationship in Humanistic Therapy

Rogers (69) holds that the therapist's primary effectiveness is through the therapeutic relationship. The therapist must show empathy to the client, be genuine with the client, and have unconditional positive regard for the client. Showing empathy requires understanding the client's feelings and reflecting them back to the client to help them understand these feelings as well. Being genuine involves being open and honest with the client and sometimes self-disclosing to help the client feel the therapist has empathy. Having unconditional positive regard for the client means valuing them as people, without conditions of worth. Rogers holds these therapist characteristics and behaviors, along with the client's ability to perceive these characteristics, as the necessary and sufficient elements of therapeutic change. Various studies (such as those by Truax & Carkuff) empirically support the importance of these therapist characteristics.

While Roger's acknowledges that techniques may be helpful to the client, they are helpful only as the help the client gain a greater sense of self-efficacy. However, this end is mostly accomplished by unconditional positive regard of the client by the therapist. Insight may also be helpful to the client. The therapist does not help the client gain insight by leading them along a road towards the final goal of an insight the therapist has known all along;, but rather, the therapist helps the client gain insight by reflecting back the client's feelings and thoughts so that s/he can learn insight on their own and teach the therapist. Thus, the therapeutic relationship is important as a primary factor in psychotherapy.

Indeed, Frank (19XX) has argued that the relationship is the most important part of therapy. It is through the relationship that the therapist provides the three critical elements of therapy: 1)an explanation of the problem, 2)a relationship which focuses on emotions and feelings to work out the problem, and 3)hope for change. In fact all therapy, some would argue (Strupp, 1972), gains its effectiveness through the relationship.

Understanding Negative Transference

The cognitive-behavioral therapist would see the idea of "negative transference" as resulting from either/both


1)failure to attend to the client's underlying schema about themselves and others ("Others are dangerous and will take advantage of you if you aren't careful", "Others are critical of you if you make mistakes or don't live up to their expectations");

2)failure to keep the client as an equal partner in the"guided discovery" of therapy.

Such negative transference would be handled by acknowledging the client's difficulty trusting the therapist, examining what specifically was involved in this incidence of mistrust, and gently challenging these beliefs. Further, the therapist could review with the client the goals and homework assignments on which the pair are working as well as the speed at which the therapist and client are currently working. This would help alleviate the "negative transference."

A humanistic therapist would see the "negative transference" as resulting from the client's past experiences with others' demands and expectations of the client. In other words, the client is not used to having relationships that carry unconditional positive regard. Past relationships must have carried high conditions of worth. Thus, the therapist would help the client feel valued unconditionally, reflect back their feelings or anger and hurt, and help them to understand the effects these past experiences of conditioned worth have had on the client.

Brief Treatment

Brief psychotherapy has been referred to by many as short term anxiety provoking psychotherapy (STAPP), as time limited therapy, as brief therapy, and as problem-focused therapy. Several questions need to be reviewed, such as what brief therapy is, what it isn't, can it work, who it is for, and who it is not for.

Brief therapy usually lasts 20 sessions or less: sometimes as few as six sessions and sometimes as many as 40 sessions are termed brief therapy. Such therapy may;

1)have a specific problem as the therapy focus,
2)be more directive and active therapy,
3)make use of positive transference to effect change,
4)use the time pressure to create anxiety to motivate the client
5)may use such techniques as suggestion, cathartic experiences, modeling, and/or homework assignments,
6)be applied to individuals or to marital couples.

Brief therapy usually does not focus on past relationships and childhood experiences or analyze (negative) transference.

Howard and Kopta (1986) studied the "dose effect" of therapy to see how much of it is needed in order to be successful, and found that approximately 50% of clients are rated as significantly improved after 8 sessions, and 75% after 26 sessions. Client ratings of improvement and therapist ratings of improvement were similar for most disorders. Most benefit occurred early in therapy. Thus, as perhaps most people benefit from the early sessions of therapy, maybe a therapist could provide only the early sessions of therapy and be very effective.

Sifneos (1981) and Mann (1984) review these criteria for STAPP and note that appropriate clients usually;

1)have high ego strength
2)have high initial anxiety which is important for motivation
3)have an initial problem focus to keep the therapy focused
4)have the ability to form a trusting relationship with the therapist
5)have the ability to access feelings and experiences

Clients who do not meet these criteria are assumed to be inappropriate for brief therapy. Therapists who foster dependence by their clients, who have difficulty maintaining a focus in therapy, and who require detailed exploration of childhood experiences and past relationships are also assumed to be inappropriate to conduct brief therapy (Mallon, 19XX). Garfield and Bergin (1986) note that there is some evidence for the effectiveness of brief therapy when such criteria as those above are used to select clients.

Criteria for brief marital therapy may be drawn from this as well. Certainly an appropriate couple needs to have good boundaries and a committed relationship, the ability to form a positive relationship with the therapist(s), motivation to change, an initial problem on which to focus, and the ability to access their own feelings and experiences, as well as the ability to hear and understand partner's feelings and experiences.

It should be noted that there are some individual therapists, such as more psychoanalytically oriented psychodynamic therapists, argue that brief therapy isn't helpful as it fosters symptom substitution, fails to address core identity issues, and doesn't provide real insight. Likewise, there are some family oriented therapists who believe that families and couples must change the structure of their family, a difficult task which usually can not be addressed in short term therapy.

As over 50% of clients report improvement after 8 sessions (Howard & Kopta, 1986), some might argue that most anyone is appropriate for brief therapy as most people can gain at least some benefit from brief therapy. The unanswered question, however, is how much can the specific anyone benefit from brief therapy? It is possible that inappropriate clients may gain some benefit in brief therapy, but do they benefit enough from therapy to warrant treating them, both from the client, the therapist, and the HMO or PPO perspectives? It is also possible that brief therapy could be harmful to some, possibly because the client gained little benefit or because s/he may have become worse in brief therapy. A client who gains little benefit from brief therapy may feel the need for more therapy, but also feel that therapy has been "tried and it didn't work." They may not seek services again and be denied help. While some clients will deteriorate in therapy (about 12% according to Smith and Glass), clients may deteriorate in brief therapy due factors brief therapy can not handle, such as psychosis, strong and overwhelming feelings as a result of therapy, conscious memory of previously repressed traumatic events…. These clients may need further services, which the HMO or PPO may be unwilling to provide. Such clients may be harmed by being released from brief therapy.

Thus, an understanding of clients for who brief therapy is not helpful and potentially harmful is important. Sifneos (1981) and Mann (1984) note that some clients, such as borderline clients, may not be appropriate for brief therapy as they may have impaired objects relations effecting their ability to form ego strength and positive transferences. Certainly other clients with low ego strength or poor self-schemas, such as chronic mentally ill clients, may have difficulties working in brief therapy.

Others, such as Beck and Freeman (1990), note that borderline clients may have very strong dysfunctional and maladaptive schemas and require 1½ to 2½ years to effect change. Thus, there are a great number of issues/problems that must be dealt with in therapy. Other clients facing a large number of issues/problems, such as a very personality disordered client or a terminally ill client, may have difficulty working in brief therapy as well. The requirement for access to feelings and experiences may preclude certain clients, such as an adult who was sexually abused as a child and/or a person diagnosed with PTSD, from in brief therapy as well.

Not mentioned in Sifneos and Mann's criteria, however, is physical/life safety. A suicidal client or physically abused spouse may need immediate hospitalization, followed by more time-open-ended therapy to deal with such issues and monitor their safety.

Children must be considered separately, as they may or may not be able to benefit from brief therapy, depending upon the view of the problem. Some family theorists (e.g. Minuchin) argue that the presenting problem for a child, for example a school based behavior problem, is most likely a family problem (for example distressed marital relations due to a chronically depressed partner/parent) which needs family or marital treatment. Coyne (87) notes that children of depressed parents are at an increased risk for poor mental health (such as depression). An "inoculative" or compensating factor is a stable relationship with a supportive adult.

Strategic therapists would address the referral problem alone and not address other family problems unless asked to, and thus conduct brief family therapy. The child would be expected to improve, as the behavior at school would be changed, perhaps providing a more structured environment at school and a stable relationship with a school social worker, a teacher, or a school counselor. Structural therapists would address the family's underlying structure and problem (the depressed parent and marital dysfunction), and thus conduct more time-open-ended family therapy. The child would be expected to improve as the family would improve its ability to help the child and meet the child's needs. Individual child therapists might conduct individual therapy with the child and not focus on the family's problems (except perhaps through parenting skills) and thus provide that stable and supportive relationship in the framework of more time-open-ended individual therapy. Thus, brief treatment of children is more serious and must be carefully evaluated, with sensitivity to the presenting problem, the family's functioning, and the theory and focus of treatment.

In summary, brief therapy may clearly be very effective with some adults. However, the adult client's functioning and potential for harm in brief therapy must be assessed.