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The importance of the client-therapist relationship

Many of us may be unaware of the importance the therapeutic relationship between a psychologist and a client, and the impact this can have on outcomes for the client. In fact, this has been a significant topic of research in recent years.


A recent review released by the APA looked into the different aspects of the therapeutic relationship factors which predict more individualised and enduring outcomes for the client. Let’s explore these now.



Fostering mutuality and collaboration


There has been a greater shift in psychopathology in recent years towards acknowledging that treatment is a mutual relationship between the therapist and the client. With making this a collaborative relationship, the goals of therapy and best approaches to achieve these are decided upon by equal input from both parties.


If we make a commitment to be partners in this process, inviting feedback from clients about how therapy is going, as client you will feel more in control of your own journey to recovery.


Flexibility, feedback and responsiveness


We are all different in our own special way, so we need treatment to be tailored to us. This means accounting for individual characteristics, such as cultural background, therapy preferences, attachment style, religious or spiritual beliefs, gender identity and sexual orientation.


Responsiveness also relates to our individuality and as therapist being attuned to our client’s personality traits, conflicts, quirks and motivations. If we have a well established relationship, as therapists we can tell the difference between our if our client may be resisting to, or our suggestions are not working for some other reason.


For example, John is particularly anxious in social situations and is finding it particularly challenging to follow through with an exposure protocol, such as initiating a conversation with a stranger. John keeps on deferring the task to the following week, while telling the therapist that he understand the importance of moving forward.


If the therapist has a good relationship with John and questions him in an empathetic manner, he tells the therapist that he is highly anxious about being rejected by a stranger but at the same time also feels uncomfortable not complying with treatment. The therapist then suggests breaking down the task in a way that feels more comfortable to John, and also discuss his concern about the therapist’s possible reactions to his lack of compliance. In this case, obtaining feedback and adjusting the pace of therapy to suit John would provide better outcomes for him.


Repairing breaks in therapy


Many factors can break down the therapy alliance, such as disagreement on treatment goals, the client’s misinterpretation of something the therapist has said or a mistrust of the therapeutic process. Research shows that resolving these difficulties, known as therapy ruptures, can lead to better outcomes.


Ruptures fall into two general categories: confrontation and withdrawal. Confrontation ruptures occur when by clients’ may express their angrier externally, such as accusations or sharp questioning of the therapist. Withdrawal ruptures can occur when clients pull away from the therapist or from an aspect of themselves—for example, when they fear the therapist’s criticism, or are afraid to delve into a painful topic. Clues that clients may be heading toward such ruptures include retreating into silence and not fully engaging in treatment.


Handling any rupture begins by recognising one is occurring. The next step is to address a rupture by, for example, providing a rationale for a task clients may be struggling with or renegotiating their goals so they feel more aligned with the direction of therapy. A more intensive strategy is to encourage a mutual discussion that addresses the rupture directly. Facing an uncomfortable conflict and working through it can aid the growth of the client, the therapist and the relationship.


Handling negative emotions


Therapists can sometimes become triggered by ongoing negative emotions when they are discussed repeatedly with clients. Therapists then may need to explore their own reactions and what are the emotions discussed triggering in them, as this can lead to ruptures in the therapeutic relationship if not addressed. Such self-insight then can lead to better outcomes for clients and therapists once the therapist shares those insights with the client and moves back to discussing the clients concerns.


Promoting effective endings


When it’s time to end therapy, eight actions tend to promote better outcomes for clients: having a mutual discussion about how the therapy went, discussing future functioning and coping, helping the client use new skills beyond therapy, framing personal development as an ongoing process, anticipating post-therapy growth, talking specifically about what it means to end this course of therapy, reflecting on gains, and pride in the progress and in the mutual relationship.


As with other key moments during therapy, termination of therapy should be discussed openly. Such conversations may include talking about those feelings or about changing aspects of treatment to better accommodate the client.


When it’s clear to both therapist and client that it’s time to stop, we will use the last few sessions to discuss any issues that have not received closure and summarise the progress that’s been made. I would share some of my own feelings as a therapist, for example if I was saddened by the ending of the relationship and how much I have valued our work together. At other times clients may wish to leave therapy even if we think there may be more work to be done, as sometimes therapists and clients do have gaps in their goals and that is completely okay.


In summary, we can confidently say that the therapeutic relationship is as powerful, if not more powerful, than the particular treatment method used by the therapist.


Therapy is a very special relationship between two people who have purposefully taken the time to get to know each other and build a connection which leads to working towards goals of personal development and building a life that does not need a “clock off time”, but is beautiful through the ups and downs it brings with it.


Article author:

Elica Najdenska

Registered Psychologist

B Psych (Hons), M Prof Psych, MAPS


Elica Najdenska is a Registered Psychologist at Clinical Therapy. Apart from working in private practice, Elica has a keen interest in neuropsychology, early childhood experiences and personality development, as well as generational post traumatic conditions of migrants.


Resources:

Developing the Therapeutic Relationship: Integrating Case Studies, Research, and Practice . Tishby, O., & Wiseman, H. (Eds.) APA, 2018

Psychotherapy Relationships That Work. Norcross, J.C., & Lambert, M.J. Psychotherapy, 2018 [introduction to special issue]

Psychotherapy Relationships That Work: Vol. 1. Evidence-Based Therapist Contributions (3rd ed.). Norcross, J.C., & Lambert, M.J. (Eds.) Oxford, 2019

Psychotherapy Relationships That Work: Vol. 2. Evidence-Based Therapist Responsiveness (3rd ed.). Norcross, J.C., & Wampold, B.E. (Eds.) Oxford, 2019


Content note: Unless otherwise labelled, all blog posts are intended as discussion pieces, and are not academic texts. Articles pertaining to research or making an academic argument will be labelled as such and include supporting evidence/references. All examples (including client names) are fictitious, to illustrate a point, and are not based on actual clients.