How important is the therapeutic relationship—the relationship between a person in therapy and his or her therapist—to the change process? Is the relationship itself the primary source of healing or are techniques the mechanisms for positive outcomes? And where does “love” fit in to all of this?
Out with the Old
My career in social work began with a full-time psychotherapy position in a rural town at a small mental health clinic. I was convinced my recent academic instruction had taught me everything under the sun, but also that I was clinically inept to practice as a therapist. Fortunately, the thoughtful, compassionate, and experienced supervisors at the clinic reined in my earnest energy.
I met with a clinical social worker on a weekly basis for supervision. She was a former nun with a wicked proclivity for curse words and an extreme disdain for computers. The topics that arose in the supervision hour varied. We talked about my personal issues, people who got under my skin in the therapy setting, and even her recollection of the days when people in therapy—as well as therapists—smoked cigarettes throughout sessions. What I remember most from our time together was her insistence that the beginning and end-all goal of psychotherapy was the same: you want the people you help in therapy to love you.
She did not mean love in the romantic sense, nor was she veering from any ethical boundaries. This was not a trick or gimmick. She believed that the person in therapy improved based on the degree of emotional connection, including shared trust and belief in the therapeutic relationship. I immediately dismissed the idea. My graduate school never talked about love, and I didn’t know of any research to back what my supervisor was saying.
I was trained to understand psychology as a series of universal principles. These principles are translated cross-culturally. I was clinically oriented and meticulously uniform with many of the therapeutic modalities I applied. The rigid stance I took on this disallowed vulnerable feelings from surfacing within the therapeutic relationship. It was easier for me to sit back and diagnostically judge than to truly join with people in therapy.
The Role of Therapeutic Alliance
My supervisor at the time was describing (and to some degree going beyond) the concept of the therapeutic alliance. Simon Goldberg of the University of Wisconsin-Madison has conducted research on this concept. It is an emotional bond between the therapist and the person in therapy, which includes a shared agreement regarding the goals to work on as well as the form of psychological intervention used (Goldberg et al., 2013).
Goldberg brought up a related construct—the real relationship (Gelso & Carter, 1994)—which involves the “actual, non-transferential relationship between a client and a therapist” which he feels most accurately reflects what we might call love in therapy. The real relationship is theorized to operate in tandem with the therapeutic alliance, combining the emotional bond of therapist and person in therapy with agreement on the tasks and the goals of where the therapy work is headed. “Love has something major to do with effective therapy,” he adds.
Part of the therapeutic alliance includes a positive attachment contracted around the mutually defined treatment plan for therapy. The role of the therapeutic alliance is central to psychotherapy, and the effect is independent of the type of therapy used. The quality of the therapeutic alliance accounts for approximately 30% of the clinical outcome, while the guiding theory or model used accounts for 15% (Walsh, 2013).
In other words, therapists are all different, but the methods or theories they use are far less important in terms of a person feeling better (Germer et al., 2005). This means that the alphabet soup of therapy acronyms (e.g., EMDR, CBT, DBT, ACT, etc.) are relatively minor ingredients to what really fills the therapeutic bowl: a person’s individual characteristics (participation, motivation, problems, background) and the therapeutic alliance (Walsh, 2013).
However, many therapists swear by their affiliated or credentialed techniques. So, what accounts for the change that occurs in therapy?
Phases of the Therapeutic Alliance
Goldberg states that the theory and technique offer a “rationale on some ritual that the client and therapist engage in.” This collaborative partnership with mutual agreements as to the problem and solution is the predominant factor for change in psychotherapy.
For alliance to build, the therapist needs to be flexible and not hold tightly to an agenda. Priority is placed on collaborating with the person in therapy to establish and maintain the therapeutic relationship.
Past research looked at this alliance as developing from two phases. Phase one sees the person in therapy believing in the therapist as the desirable source of assistance. With warm regard and support from the therapist, the caring relationship commences. Therapy begins on this foundational level. In phase two, the alliance involves the person in therapy buying into the process of therapy via commitment to the procedure (i.e., shared understanding of the problem, value of the examination of the problem) as well as each person’s responsibility for the process (Horvath et al., 2011).
For alliance to build, the therapist needs to be flexible and not hold tightly to an agenda. Priority is placed on collaborating with the person in therapy to establish and maintain the therapeutic relationship (Horvath et al., 2011). The quality of the relationship can be assessed based on the “level of mutual and collaborative commitment to the ‘business of therapy’ by therapist and client” (Horvath et al., 2011; p. 15). This is the “collaborative enterprise” of psychotherapy. Essentially, the question and answer comes down to how well the person in therapy and the therapist work together in sessions.
Collusion Versus Confrontation
Specific variables and behaviors can be assessed for each role of the enterprise. The therapist’s non-reactivity to comments or overall antagonism of the person in therapy is reflected in the therapeutic alliance. My work centers on the conceptual space between collusion and confrontation. It is essential for the therapist to hear—not ignore—criticisms, but this must be done by threading the needle between colluding with the person in therapy or confronting his or her ideas. This perspective requires a dance between total agreement or affirmation and a scared-straight challenge or proverbial wrestling match.
For example, a person might say, “Am I a bad patient?” The therapist’s collusion with this statement might come across as, “Let’s talk about something else,” or, “You can be difficult at times.” The other end of the spectrum is confrontation. A therapist says, “No, no, no. You are not a ‘bad patient.’ ” Or the therapist could say, “Where did you get that idea?” in direct opposition to the statement. A middle-ground response finds the therapist replying, “What would it mean to you to be a ‘bad patient’?” This is the essence of non-defensive but attuned responsiveness.
The therapist does not personalize or absorb any statements, but also does not ignore or avoid emotional comments (Horvath et al., 2011). This is the narrow window or divide between collusion and confrontation that fosters alliance. This is an attuned, appropriate, and nonjudgmental response. Isn’t that love?
- Gelso, C. J., & Carter, J. A. (1994). Components of the psychotherapy relationship: Their interaction and unfolding during treatment. Journal of Counseling Psychology, 41, 296–306.
- Germer, C. K., Siegel, R. D., & Fulton, P. R. (2005). Mindfulness and psychotherapy. New York: Guilford Press.
- Goldberg, S. Personal communication, December 5, 2015.
- Goldberg, S.B., Davis, J.M., & Hoyt, W.T. (2013). The role of therapeutic alliance in mindfulness interventions: Therapeutic alliance in mindfulness training for smokers. Journal of Clinical Psychology, Vol. 69(9), 936–950.
- Horvath, A. O., Del Re., A. C., Fluckiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9–16.
- Walsh, J. (2013). Theories for direct social work practice (2nd). Belmont, CA: Thompson Brooks/Cole.
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