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Therapeutic Relationships

Therapeutic Relationships

Therapeutic Relationships

Psychotherapy has been described as a dance, with “mind-body synchronicity that occurs between therapist and client” (Schore, 2014, p. 388).

Psychotherapy and counseling, in general, are settings for clients and therapists to engage in authentic, intimate, and one-of-a-kind interactions.

There are a few key points that all counseling methods share, even though there are over 200 different approaches to counseling (Rivera, 1992).

Every type of therapy necessitates an interpersonal relationship in order to assist a client in healing or relieving distress. Thus, anyone in a helping position should strive to understand this sacred relationship.

We call this incredible and one-of-a-kind relationship the therapeutic Alliance, and we explain its four stages in this article.

Before you continue, we thought you might be interested in downloading our three free Positive Relationships Exercises. These detailed, scientifically based exercises will assist you or your clients develop healthy, life-enriching relationships.

This article contains the following information: What Is the Therapeutic Alliance in Psychology?
3 Components of the Therapeutic Relationship Model Explained
The Alliance has four phases and stages.
4 Real-World Examples
A Look at Therapeutic Boundaries
Social Relationships vs. Therapeutic Relationships
Resources on
References for a Take-Home Message

In Psychology, What Is the Therapeutic Alliance?
According to research on the outcomes of psychotherapy and counseling, only 15% of treatment success can be attributed to the type of therapy or the techniques used (Hubble, Duncan, & Miller, 1999).

Therapist qualities and the overarching therapeutic Alliance are more important than technique or therapy.

For the past 80 years, psychotherapists have argued that common nonspecific factors are to blame for their work’s success (Groth-Marnat, 2009). The therapeutic Alliance is central to these everyday factors in psychology.

The therapeutic alliance concept can be traced back to Freud’s (1913) concept of transference, which was initially thought to be entirely negative. Later, rather than simply labeling it as a problematic projection, Freud considered the idea of a beneficial attachment between therapist and client.

Later, Zetzel (1956) defined the therapeutic Alliance as a non-neurotic, non-transferential relationship between a patient and therapist that allows the patient to understand the therapist and the therapist to understand the client’s experience interpretations.

Rogers (1951) is best known for emphasizing the therapist’s role in the relationship, which led to the development of what is now known as client-centered therapy. According to Rogers (1951), the active components of a therapeutic relationship are empathy, congruence, and unconditional positive regard.

The therapeutic relationship is also known as the therapeutic Alliance, the helping Alliance, and the working Alliance, all of which refer to the relationship between a healthcare professional (counselor/therapist) and the client or patient.
Therapeutic Relationships
It is the collaborative relationship between these two parties engaged in a typical battle to overcome the patient’s suffering and self-destructive thoughts and behaviors and effect positive change.

Over 1,000 studies have been conducted on the therapeutic relationship’s ability to predict adherence, compliance, concordance, and outcomes across various diagnoses and treatment settings (Orlinsky, Ronnestad, & Willutski, 2004).

3 Components of the Therapeutic Relationship Model Explained
Model of Therapeutic Relationship
It is no secret that relationships have an impact on personal healing.

The therapeutic Alliance is a one-of-a-kind relationship; the interactions, bonds, and purpose contribute to a client’s healing, treatment progress, and outcome success.

Transference was first described by Freud (1905) as the repetition of an old relationship. It happens when feelings from an old significant object/event trigger feelings and impulses in the therapist.

Transference is based on unconscious and regressive distortions rather than the actual relationship. A new definition of transference describes it as an interactive communication in which the client-therapist symmetry is the actual engine of treatment and change (Lingiardi, Holmquist, & Safran, 2016).

Simply put, transference is the ‘transfer’ of emotions from previous relationships onto the therapist. This can make room for reflection, healing, and healthier patterns of relating to others.

Collaboration in the workplace
The therapeutic relationship includes the working Alliance. It is the union of a client’s good side, and the therapist’s analyzing side.

Bordin (1979) is well-known for breaking down the working Alliance into three components: tasks, goals, and the bond.

Tasks are the steps, methods, and techniques that must be followed to achieve the client’s objectives.
Goals are what the client hopes to gain from therapy and are determined by the presenting issue.
The bond between the therapist and the client is formed through trust and confidence that the tasks chosen will help the client achieve their goals.
Genuine connection
The genuine relationship consists of the client and therapist’s interpersonal attraction and compatibility.

According to Gelso (2011), the concept of the actual relationship in therapy is divided into two parts: genuineness and realism.

Genuineness is the desire to avoid deception, including deception of oneself. The therapist must be aware of their own identity and present an accurate picture of who they are in the relationship.

Realism is having an experience with the client that benefits them. Within the relationship, realism includes both empathy and understanding.

The Alliance has four phases and stages.
The therapeutic Alliance is a living thing. Throughout the stages of therapy, a healthy alliance will include ruptures and repairs.

Luborsky (1976) differentiated two broad stages of the therapeutic Alliance. The client’s perception of the therapist’s support and empathy drives the early stages of therapy.

A collaborative relationship develops later in therapy to overcome or address the client’s problems. During the second phase, there is a shared responsibility for achieving goals.

Rivera (1992) defined the therapeutic relationship as having four stages.

1. Dedication
Initially, the patient and therapist agree to devote time and energy to achieving specific goals. The therapist’s perception, the intensity of the client’s motivation, and the compatibility of personalities/experiences are all crucial factors at this stage.

The Miracle Question Worksheet is an excellent tool for determining what goals the client and therapist will work toward together. The client’s ability to commit to working for their ideal life/world/emotional state improves as they write and draw it. It clarifies the client’s ideals further, allowing the therapist and client to move in the same direction.

2. Procedure
This is the most difficult stage because it contains the treatment and the relationship. This is the stage at which the therapist looks for patterns, gathers information, and consolidates it.

The therapist will look for triggers, cycles, and repetitive interactions in the client. This is also the stage at which the therapist will gather additional information and attempt to implement change.

Various therapeutic tasks, techniques, and approaches may be used during the process stage.

3. Modification
This stage represents the treatment plan’s completion and success. The client can accept their mental or emotional state and develop habits that will improve their overall well-being.

4. Discontinuation
The client “graduates” at this point. The therapist and the client can recognize one another as autonomous and self-sufficient individuals.

This point has resolved positive transference and regressive forms of dependence. The client has been given permission and rights to live on their terms.

The Preventing Mental Health Relapse Worksheet is an excellent tool during the treatment termination stage. This worksheet highlights potential red flags and triggers the client should be aware of as they leave treatment. It is also an excellent way for the client to take responsibility for their therapy work and future mental health.

4 Case Studies of Therapeutic Alliance

It is critical to identify specific examples of therapy components and phases.

The client’s impression of the therapist is critical in the first commitment stage to deepening the relationship and moving to subsequent successful phases.

Here are some helpful practices that therapists can use to optimize the therapeutic process, as well as some to avoid.

Empathic reaction
Empathetic responses are critical in the early stages of therapy for establishing a solid therapeutic alliance.

Client response to treatment has been monitored explicitly in research using “client feedback” to measure the therapist’s level of empathy and the client’s rating of the therapeutic Alliance, compliance, and retention in therapy. Therapists with the highest levels of empathy had the highest client feedback and client success ratings (Duncan, 2010).

Empathetic responses reflect the client’s content and feelings about it. Here is an example of such a debate.

Therapist: So, what exactly are you feeling?

Client: I am apprehensive about school.

Therapist: Could you elaborate?

Client: My parents constantly nag me about my grades, which are never good enough.

Therapist: Do I understand that your parents’ nagging about your grades never being good enough makes you anxious about school?

Client: That is right. It is challenging.

Transference and countertransference become essential aspects of the therapeutic Alliance during the process stage of therapy.

Transference occurs in therapy when clients project their feelings (or those of another person in their life) onto the therapist. In this case, the client is projecting their rage at their parents onto the therapist.

Therapist: You mentioned being hurt by your father when you were young.

Client: I did not say that! You never listen to or hear me correctly. You, like my parents, misunderstand everything I say.

This video shows another clear example of transference in action by examining past relationships and current actions.

Transference can occur in any relationship, but therapists must be aware of it in a session to foster a healthy relationship (Shimokawa, Lambert, & Smart, 2010).

When therapists can identify transference and create healthier responses, the therapeutic Alliance is strengthened, and clients learn healthier ways to interact with others.

When the therapist projects their feelings onto the client, this is known as countertransference. This can be harmful to the therapeutic Alliance as well as the client’s progress. The therapist’s awareness of countertransference is integral to the process and professional development.

In the following example, the therapist gives advice rather than listening to the client, providing space, and creating an environment where clients can find solutions or process emotions.

Client: My husband expects me to work full-time while doing all the housework. I cannot do it all; it feels impossible, and he is highly demanding.

Why don’t you hire a maid to do your housework? You both make enough money to be able to afford it.

Other forms of countertransference include the therapist’s attraction to the client and becoming overly or underly involved in the situation.

If a client is sexually assaulted and the therapist blames the victim, this is an example of under-involvement. Instead of listening to the client, the therapist sympathizes with the perpetrator and discourages the client from filing charges. This is an example of negative countertransference (Jorgenson, 1995).

Making a commitment
This brief video depicts the difficulties many new counselors face in establishing a solid therapeutic alliance during the first session or in the early stages of therapy.

A Look at Therapeutic Boundaries
While emphasizing the therapeutic relationship’s importance, it is also critical to address the issue of boundaries in professional relationships. Setting healthy boundaries at the start of therapy helps to create a healthy therapeutic environment, which leads to effective therapy.

Appropriate self-disclosure is required to establish trust and a connection with the client (Zur, 2018). Self-disclosure can assist clients in feeling accepted and normalizing their situation.

Other methods for establishing healthy boundaries include rules and rituals (Zur, 2018).

Within a session, rules provide clients with parameters to explore themselves, their thoughts, and their emotions. Limiting cell phone use or not allowing derogatory or harmful language are examples of rules.

Rituals help the client maintain stability and consistency from session to session. They can be developed in conjunction with the client. A ritual could include beginning each session with a mindfulness exercise or ending with a final thought or a word of gratitude.

Boundary violations are always unethical and, in most cases, illegal and occur when a therapist crosses the line of integrity by abusing power to exploit the client (Lazarus & Zur, 2002).

However, when therapists cross boundaries with the client’s best interests in mind, the therapeutic Alliance is likely to improve. It can be a valuable tool in establishing, maintaining, and repairing the therapeutic relationship.

The following are examples of beneficial boundary crossing, and none of them are examples of “dual relationships” (unethical relationships):

To overcome a fear of kites, I walked with a client in an open space outside the office to fly a kite.
Appropriate self-disclosure to provide a different point of view, build authentic connections, or level the playing field
Attending a client’s performance to show support for their hobbies or interests
Attending a 12-step meeting with an addict
“Boundaries, like fences, are man-made and intended to separate. Because they are man-made, they can be built or dismantled, raised or lowered, and made more or less permeable.”

(Zur, 2018, p. 29)

Crossing boundaries should be approached with two things in mind: the client’s welfare and the technique’s goal/effectiveness. It should be part of a well-designed treatment plan that considers the presenting problem, personality, environment, culture, history, and therapeutic setting/context of the individual client.

More interventions for using mindfulness in counseling are discussed in this article.

Social Relationships vs. Therapeutic Relationships
Relationships that are therapeutic versus those that are social
This definition of psychotherapy emphasizes the distinction between a therapeutic relationship and a nonprofessional social relationship:

“A purposeful and willing relationship between at least two people, one who is supposed to know what he is doing and the other who wants help to improve his life.”

Rivera (Rivera, 1992, p. 52)

Dedicated to a specific purpose or goal
This definition emphasizes the importance of therapy as a relationship with a specific goal. It is not by chance, and objectives are set for the duration of the relationship. It is a willing and formal relationship that necessitates consent and a commitment to working toward mutually agreed-upon goals.

Dependent on the time
The therapeutic relationship should ideally have a clear beginning and end point. It goes through the four stages described above: commitment, process, change, and termination.

The power dynamic
The therapeutic relationship has an apparent power dynamic, which is why ethics, boundaries, and dual relationships are essential components of psychotherapy training and certification.

Therapist wields power because of their professional skills and abilities. The therapist knows the techniques and interventions required for change and can interpret the client’s data.

It is a one-sided relationship in which the therapist serves the client’s needs with no emotional/mental reciprocation.


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