Before beginning psychotherapy, most patients wonder, “Will this counseling really help me with my problems?” Research shows that many factors affect whether treatment is successful, including the severity of the problem(s) being treated, the patient’s belief that the counseling will work and the skill level of the therapist.
However, research over the past fifty years has demonstrated that one factor — more than any other — is associated with successful treatment: the quality of the relationship between the therapist and the patient.
In 1913, Sigmund Freud hypothesized that the relationship between the therapist and patient was a key component of successful treatment. Since that time, research has shown that the quality of this relationship (the “therapeutic alliance,” as it is called) is the strongest predictor of whether or not therapy is successful.
Strikingly, the quality of the therapeutic relationship appears critical to treatment success no matter what type of treatment is studied. Large studies have been conducted of individual, couple and family therapy, using a variety of assessment methods to measure the quality of the relationship (i.e. patient or therapist reports or observational ratings). These studies, which used diverse patient groups (children and adults, in-patients and out-patients) treated for all types of problems (i.e. depression, anxiety, drug abuse, work and social problems), all show the importance of the therapeutic relationship on treatment outcome.
“A little over half of the beneficial effects of therapy accounted for [in previous research] are linked to the quality of the alliance,” according to Dr. Adam Horvath, a professor at Simon Frasier University and a leading expert in research on the patient-therapist relationship. Interestingly enough, patients and therapists often (but not always) agree on the quality of their relationship. However, it is the patient’s perception of the quality of the relationship that is the strongest predictor of treatment success. Patients’ ratings of their relationship with the therapist, even very early in the treatment — after the first session or two — predict their improvement over the course of treatment. However, patients who report poor relationships with their therapists are more likely to drop out of treatment early.
What exactly is a “good” therapeutic relationship?
Since the relationship between the therapist and patient appears so crucial to treatment success, experts have tried to define a “good relationship.” One pioneering expert, Dr. Edward Bordin, defined a good therapeutic relationship as consisting of three essential qualities: an emotional bond of trust, caring, and respect; agreement on the goals of therapy; and collaboration on the “work” or tasks of the treatment.
Qualities of a good therapeutic relationship:
- Mutual trust, respect, and caring
- General agreement on the goals and tasks of the therapy
- Shared decision-making
- Mutual engagement in “the work” of the treatment
- The ability to talk about the “here-and-now” aspects of the relationship with each other
- The freedom to share any negative emotional responses with each other
- The ability to correct any problems or difficulties that may arise in the relationship
A shared sense of ownership for the treatment also appears essential. Do the therapist and patient trust that the other is working hard to contribute to the treatment’s success? Do they collaborate together on decisions that need to be made about the way the treatment is being conducted and what intervention strategies are used?
Every close relationship has problems, difficulties or misunderstandings, and the relationship between the therapist and patient is no exception. However, the manner in which the therapist and patient handle these difficulties together is another crucial component of the success of the relationship. When difficulties arise, can the therapist and patient share any negative feelings, hurt or anger that may have resulted? And, can they work together to resolve any problems that may occur in their work together?
The importance of an expanded conceptualization of the “therapeutic relationship”
Historically, study of the therapeutic relationship has focused solely on the patient’s relationship with the therapist. However, research conducted at The Family Institute at Northwestern University by myself and Dr. William Pinsof demonstrates the importance of expanding this definition to include the influence of significant other people in the patient’s life. For example, in individual therapy, support of the treatment by the patient’s significant others (family members, spouse, close friends) was associated with successful outcome. In couple therapy, the extent to which the couple agreed with each other on treatment tasks, goals and bonds predicted whether therapy would be successful.
What do therapists do to establish a good therapeutic relationship?
Research shows that the ability to form good relationships with patients is not simply a function of therapist training or experience level. Many beginning therapists are as skilled as their more experienced counterparts at forming good therapeutic relationships. However, studies show that experienced therapists are better at forming relationships with those patients who have struggled in past relationships. In addition, experienced therapists are better than novices at identifying and resolving problems in the therapeutic relationship.
Therapists make important contributions to the establishment of a good therapeutic relationship. The therapist’s ability to communicate empathy and understanding to the patient is very important. Another essential component is the therapist’s openness, flexibility and willingness to adapt the treatment to the patient’s needs. Skilled therapists actively solicit patients’ input about the goals and methods of treatment, in order to facilitate collaboration.
What helps patients establish a good therapeutic relationship?
Research shows that patients are more likely to establish a good therapeutic relationship when they have good interpersonal and communication skills. For example, patients are more likely to form good relationships with their therapists when they are open and honest about their needs.
What should I do to try to improve my relationship with my therapist?
If you are having difficulties with your therapist, it is important to talk about that directly with your therapist. If you have questions or concerns about any part of the treatment, do not hesitate to discuss them with your therapist. Open, honest communication is a very healthy strategy for resolving difficulties. In fact, studies show that engaging in this kind of “talking about the relationship” is a very effective therapy strategy for improving the relationship, thus improving your chances of treatment success.
A therapeutic relationship, or therapeutic alliance, refers to the close and consistent association that exists between at least two individuals: a health care professional and a person in therapy.
What is a Therapeutic Relationship?
The purpose of a therapeutic relationship is to assist the individual in therapy to change his or her life for the better. Such a relationship is essential, as it is oftentimes the first setting in which the person receiving treatment shares intimate thoughts, beliefs, and emotions regarding the issue(s) in question. As such, it is very important that therapist provides a safe, open, and non-judgmental atmosphere where the affected individual can be at ease.
Trust, respect, and congruence are major components of a good therapeutic relationship. Therapists are encouraged to show empathy and genuineness. As with any other social relationship, the therapeutic relationship has boundaries which help to define acceptable and unacceptable behaviors.
Why is a Therapeutic Relationship Important?
Establishing a therapeutic relationship is a vital step in the recovery process and for the relationship to be productive, trust is key. A person seeking a therapist must trust that his or her therapist has the knowledge, skill set, and desire to provide appropriate care. Since the balance of power in the therapeutic relationship greatly favors the therapist, a person in treatment must also trust that confidential matters will remain confidential, and that he or she is safe from harm or exploitation at the hands of the therapist.
Once the therapeutic relationship is formed, an individual in therapy might be more inclined to open up emotionally and provide further details about his or her concerns. This, in turn, helps the therapist to better comprehend the affected person’s point of view, feelings, and motives. Equipped with a more complete understanding of the situation, the therapist is then able to provide the most appropriate treatment and employ the most effective strategies in order to address the issue.
What Happens When a Therapeutic Relationship Is Not Healthy?
An unhealthy therapeutic relationship is the consequence of violating the boundaries and ethics of acceptable behavior within the association. In some cases an unhealthy therapeutic relationship can cause significant harm to the person in therapy.
There are many warning signs of inappropriate therapist behavior that a person in therapy can watch out for. Be cautious if your therapist:
- Pays no attention to the changes you want to make and the goals you wish to achieve while in therapy.
- Is judgmental of your conduct, lifestyle, or situation.
- Encourages you to blame friends, family members, or a partner.
- Provides no explanation of how you are supposed to know your therapy is complete.
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- Tries to be your friend outside of therapy or start a romantic relationship with you.
- Tries to touch you without prior consent.
- Talks too much or not at all.
- Attempts to push his or her spiritual beliefs on you.
- Tries to make decisions for you.
Each person has the right to quality mental health care. If you believe you are experiencing a negative therapeutic relationship, you can take steps to address it. Options for resolving an unhealthy therapeutic relationship will vary depending on the unique situation; for example, they can include:
- Discussing your concerns openly with your therapist,
- Terminating therapy with that clinician,
- Meeting with another therapist for a second opinion,
- Filing a complaint with your therapist’s employer and/or licensing board,
- Seeking legal counsel or law enforcement support.
- Ardito, R. B. & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 270. doi: 3389/fpsyg.2011.00270
- de Rivera, J. L. G. (1992). The stages of psychotherapy. European Journal of Psychiatry, 6(1), 51-58.