Journal of Counseling Psychology Copyright 2005 by the American Psychological Association

2005, Vol. 52, No. 4, 640 – 649 0022-0167/05/$12.00 DOI: 10.1037/0022-0167.52.4.640

Measuring the Real Relationship in Psychotherapy: Initial Validation of the

Therapist Form

Charles J. Gelso Frances A. Kelley

University of Maryland Louisiana Tech University

Jairo N. Fuertes Cheri Marmarosh

Fordham University Catholic University of America

Stacey E. Holmes Catarina Costa

University of Maryland Fordham University

Gregory R. Hancock
University of Maryland

The development and initial validation of a therapist-rated measure of the real relationship in psycho-
therapy (the Real Relationship Inventory—Therapist Form [RRI–T]) is reported. Using a sample (n ⫽
80) of practicing psychotherapists and on the basis of prior theory, the authors developed a 24-item
measure consisting of 2 subscales (Realism and Genuineness) and a total score. This 24-item version and
other measures used for validation were completed by 79 additional practicing therapists and 51
counseling graduate students (n ⫽ 130). The RRI–T was found to have high reliability and sound initial
validity. As theorized, the RRI–T correlated significantly with measures of working alliance, session
outcome (depth and smoothness), client intellectual and emotional insight, and client negative transfer-
ence. Discriminant validity was supported by a nonsignificant relation to social desirability.

Keywords: real relationship, therapist measure, therapeutic relationship, validation

The relationship that exists between client and therapist may be
seen as containing several elements (Gelso & Carter, 1985, 1994).
Elements such as working alliance, transference, and countertrans-
ference have been abundantly theorized about for many years (see
Gelso & Hayes, 1998, review). These concepts have also been
empirically investigated to varying degrees (Barber, Foltz, &
Weinryb, 1998; Constantino, Castonguay, & Schut, 2002; Gelso &
Hayes, 2002; Multon, Patton, & Kivlighan, 1996).
Over the years, some theoreticians have also alluded to another
component of the relationship, one that goes beyond the work of
therapy (i.e., the working alliance) and the unconscious projections
and/or distortions of each participant toward the other (i.e.,
transference– countertransference). This component has to do with
Charles J. Gelso, Department of Psychology, University of Maryland;
Frances A. Kelley, Department of Psychology and Behavioral Sciences,
Louisiana Tech University; Jairo N. Fuertes and Catarina Costa, Graduate
School of Education, Fordham University at Lincoln Center; Cheri Mar-
marosh, Counseling Center and Department of Psychology, Catholic Uni-
versity of America; Stacey E. Holmes, Department of Counseling and
Personnel Services, University of Maryland; Gregory R. Hancock, Depart-
ment of Measurement, Statistics and Evaluation, University of Maryland.
We thank Dawn Szymanski for assistance with aspects of the statistical
design.
Correspondence concerning this article should be addressed to Charles
J. Gelso, Department of Psychology, University of Maryland, College
Park, MD 20742. E-mail: gelso@psyc.umd.edu
the personal relationship that exists between therapist and client
from the first moment of contact. Although the personal relation-
ship may be seen as influencing and being influenced by the
working alliance, it has been theorized as being more basic than
the alliance and as existing apart from the work of therapy (Gelso,
2002; Gelso & Carter, 1985, 1994; Gelso & Hayes, 1998). In other
words, whereas the working alliance may be seen as the part of the
total relationship that exists solely for the purpose of the work that
is to be done in therapy, the personal relationship is the relatively
transference-free part of the total relationship that must exist in all
relationships. Following the lead of the psychoanalyst Ralph
Greenson (1967), Charles J. Gelso and his collaborators have
labeled this personal connection or bond the real relationship
(Gelso, 2002; Gelso & Carter, 1985, 1994; Gelso & Hayes, 1998).
The real relationship, although it is interrelated with working
alliance and transference, has been theorized to contribute impor-
tantly and independently to psychotherapeutic process and out-
come across all theoretical approaches (Gelso, 2002, 2004; Gelso
& Hayes, 1998).
The concept of a real relationship has been present in the
literature for many years (e.g., A. Freud, 1954; S. Freud, 1937;
Rogers, 1957). However, the idea has always been a controversial
one (see Beutler & Sandowicz, 1994; Greenberg, 1994). Some
observers have been critical of the construct, claiming that because
everything in therapy is real, the concept of real relationship does
not add anything helpful to theory. Others have challenged the

640
 MEASURING THE REAL RELATIONSHIP
concept on the grounds that even if there is a reality, we cannot
ever know it fully. Still others have raised the question of who, in
the final analysis, is the arbiter of what is real. In responding to
these criticisms, Gelso (2002) has commented that, first, although
in a certain sense everything that happens in any relationship is
real, the construct real relationship captures elements in therapy
that other relationship elements fail to capture. Second, the fact
that what is real is not fully knowable in no way negates the
concept of real relationship. Last, the merit of a concept such as
real relationship does not depend on one or another member of the
therapy being the total arbiter of what is real. Instead, what is real
may be seen as constructions of both members of the dyad. In sum,
despite the controversy, the present research is based on the
argument that real relationship is a theoretically useful and empir-
ically measurable construct that can help in understanding the
process and outcome of treatment.
What is the real relationship? Gelso (2004) has defined it as “the
personal relationship existing between two or more people as
reflected in the degree to which each is genuine with the other and
perceives the other in ways that befit the other” (p. 6). Thus, real
relationship is seen as consisting of two key, interrelated elements:
genuineness and realism. Genuineness, a key concept in virtually
all humanistic– experiential systems, may be defined as “the ability
to be who one truly is, to be nonphoney, to be authentic in the here
and now” (Gelso, 2002, p. 37). Realism, conversely, is seen as “the
experiencing or perceiving of the other in ways that befit him or
her, rather than as projections of wished for or feared others (i.e.,
transference)” (p. 37). Realism is often seen as an important
element in the more psychodynamic systems.
Although genuineness and realism are the two general defining
features of the real relationship, to make sense of this construct two
other aspects are needed: magnitude and valence. Magnitude refers
to just how much genuineness and realism exist. Gelso (2002) has
theorized that an ebb and flow occurs in the magnitude of the real
relationship. The magnitude or degree of genuineness should in-
crease linearly as the work progresses, whereas the magnitude of
realism may be greater at the beginning and end phases of treat-
ment. Valence, conversely, refers to how positive versus negative
the participants’ feelings are toward the realistically experienced
other. Such feelings may range from highly positive to highly
negative. Positive feelings may take the form of liking, caring,
respect, or even nonromantic loving. Negative reactions, too, may
occur within the real relationship, and in some instances the real
relationship may even be largely negative. A negative real rela-
tionship, especially early in the therapy, may in fact be responsible
for many so-called premature terminations (Gelso, 2002, 2003,
2004).
Despite the fact that the real relationship has been discussed for
many years (see Couch, 1999), next to no empirical research has
been done on it. Studies have looked at elements of the real
relationship (e.g., genuineness), but we could locate only one study
that directly examined real relationship (Eugster & Wampold,
1996), and that study strongly supported the importance of the
client-rated real relationship in the outcomes of treatment. Gelso
and Hayes (1998) have suggested that the most fundamental rea-
son for the lack of research has been the absence of a reliable,
valid, and economical measure. The main purpose of the present
study is to develop such a measure and to provide beginning
reliability and validity data on the measure.
641
The real relationship may be assessed from various perspec-
tives—therapist, client, supervisor, outside raters. In the present
study, we seek to develop a measure from the therapist’s perspec-
tive. In sum, we developed and validated items tapping the con-
cepts of genuineness and realism as well as the subconcepts of
magnitude and valence under each of the two main defining
features. Thus, therapists were asked to rate themselves, their
clients, and the therapy relationship on items representing genu-
ineness and realism (and magnitude and valence within genuine-
ness and realism).
In seeking to validate our measure, we focus on constructs to
which it theoretically ought to relate. Such constructs reflect rela-
tional and process variables as well as session-outcome variables.
First, we hypothesized that the real relationship would relate
positively to the working alliance between therapist and client. The
basis for this hypothesis is that the alliance has been theorized as
stemming from and resting on the real relationship (Greenson,
1967; Safran & Muran, 1998). The alliance represents the human
bond that is part of the work of therapy, whereas the real relation-
ship reflects the human bond that exists in all relationships and that
underlies a working bond.
Because the real relationship is theorized to represent, to an
extent, the realistic and nondistorted aspect of the relationship, it
ought to be negatively related to aspects that are distorted by the
client’s defenses, wishes, fears, and so forth. That is, a stronger
real relationship ought to be indicative of less distortion. Because
the latter is what ordinarily is seen as indicative of transference
(Gelso & Hayes, 1998), our second hypothesis was that there is a
negative relation between real relationship and transference. It
should be noted that the type of transference that has been found
to be especially predictive of other relational, process, and out-
come variables is negative transference (Gelso, Hill, & Kivlighan,
1991; Gelso, Wine, Kivlighan, Jones, & Friedman, 1997; Wood-
house, Schlosser, Crook, Ligiero, & Gelso, 2003). Positive trans-
ference relates to such variables in the same manner as does
negative transference, but the correlations are consistently of lower
magnitude. Thus, we particularly expected a relation between real
relationship and negative transference. Furthermore, because we
expected client self-insight to allow for the working through of
transference and in this way to foster realistic perceptions, we
hypothesized that there would be a positive relation between
therapist-rated client self-insight and real relationship. We ex-
pected this relation to be most salient for the kind of insight often
referred to as emotional insight rather than intellectual insight (see
definitions under Measures). This expectation was based on the
finding that emotional insight more powerfully influences the
therapeutic process than does intellectual insight (Gelso & Hayes,
1998; Gelso et al., 1991, 1997).
A thread running through the literature on real relationship over
the decades is that a good or positive real relationship leads to
more effective psychotherapy. At the level of the therapy session,
this effect of the real relationship should be manifested in terms of
session outcome. That is, the stronger and more positive the real
relationship is, the more positive should be the outcomes of any
given therapy session. Thus, we posited that there would be a
positive relation between session outcome and real relationship.
The elements of session outcome that we examined are depth and
smoothness (Stiles, 1980; Stiles, Gordon, & Lani, 2002).
The relations discussed so far have pertained to convergent
validity. Theoretically, they reflect constructs to which a valid
642 GELSO ET AL.
measure of real relationship ought to relate. However, a valid
measure of real relationship also should not relate to certain
constructs, thus reflecting discriminant validity. The construct
chosen to assess discriminant validity in the present study is social
desirability. In developing a therapist measure of the real relation-
ship, we sought to write items that would not pull for impression
management and socially desirable responses. However, in any
value-laden measure, such as the one we created, the relation to
social desirability must be assessed. It was hypothesized that real
relationship would be unrelated to social desirability.
The theorized elements of the real relationship, genuineness and
realism, are seen as interrelated. A question may be raised about
the degree to which they are correlated and whether, in fact, the
two may be empirically separable. Thus, we sought to determine
whether the two theorized factors were empirically separable. The
research question was as follows: Does a two-factor solution
including genuineness and realism provide a better fit to the data
than a one-factor model?
Method
Participants
Two different samples were used in the present study: a professional
sample (n ⫽ 159) and a sample of graduate students (n ⫽ 51). The graduate
sample was included to enhance external validity, as a significant amount
of therapy is conducted during graduate education. The professional sam-
ple was randomly selected from the 2000 membership directory of Divi-
sions 29 (Psychotherapy) and 42 (Independent Practice) of the American
Psychological Association (APA). The graduate student sample consisted
of students from master’s and doctoral programs in counseling and coun-
seling psychology at two universities in the northeastern United States.
It should be underscored that the professional sample was divided into
two subsamples. One of these (n ⫽ 80) was used in the item development
phase of the study, whereas the other subsample (n ⫽ 79) was used in the
validation phase. The graduate student sample, conversely, was used only
in the validation phase. These phases and subsamples are further clarified
in the Item Development and Procedure sections.
Regarding the professional sample, 155 of the 159 participants had a
PhD, 1 had an MD, and 3 had master’s degrees. Sixty-five (41%) were
female, and 94 (59%) were male. Regarding race/ethnicity, of those who
completed this index, 147 (96%) were White/Caucasian, 3 were Asian
American, 3 were Latino, and 3 were of other ethnicities; 3 did not reply.
The sample was highly experienced, with an average of 22.0 years (SD ⫽
8.9) of practice experience since their last degree. The mean age was 55.0
years (SD ⫽ 8.8).
Most of the therapists in the professional sample worked with the client
used for the current study (see Procedure) in an independent practice
setting (n ⫽ 140; 88%), although a few saw the client in a university
counseling center (n ⫽ 3) or a mental health center (n ⫽ 6). When
therapists were asked to rate their belief in and adherence to three general
theory clusters on a 5-point scale (1 ⫽ low and 5 ⫽ high), the following
mean ratings emerged: cognitive– behavioral ⫽ 3.90 (SD ⫽ 0.98), human-
istic– existential ⫽ 3.20 (SD ⫽ 1.07), and psychoanalytic–psychodynamic
⫽ 3.06 (SD ⫽ 1.21). Thus, the professional sample favored cognitive–
behavioral therapy over humanistic– existential and dynamic–analytic ap-
proaches, although it appears that the sample was highly diverse
theoretically.
Regarding the graduate student sample, 45 of the 51 (94%) had a
master’s degree, 4 had not yet attained the master’s, and 2 had already
earned a doctoral degree. Twelve (24%) were male, 38 (75%) were female,
and 1 did not indicate gender. Regarding ethnicity, 35 (69%) were White/
Caucasian, 8 (16%) were Black, 2 were Asian American, 4 were Latino,
and 2 were multiethnic. As expected, this sample had limited clinical
experience (M ⫽ 1.98 years of experience since last degree). The mean age
was 31.60 years (SD ⫽ 9.10). About half (49%) saw their designated client
at the counseling center of the university at which these graduate students
were studying, whereas the remaining half saw their client in a range of
other settings (inpatient settings, mental health clinics, etc.). In terms of
theoretical orientation, on the same 5-point ratings scale as the profession-
als used (1 ⫽ low and 5 ⫽ high), the following means emerged: cognitive–
behavioral ⫽ 3.69 (SD ⫽ 1.03), humanistic– existential ⫽ 3.78 (SD ⫽
1.09), and psychoanalytic–psychodynamic ⫽ 2.96 (SD ⫽ 1.11). Thus, the
graduate student sample was also theoretically diverse, although these
students favored a humanistic orientation more than did the professional
sample.
It should be noted that demographic data were not gathered on the clients
on whom the therapists based their ratings. However, the therapist and
setting data as well as the client selection method (see Procedure) strongly
suggest that the large majority of clients were White and that most were
female.
Item Development
Each member of our research team wrote items believed to be reflective
of the real relationship. An effort was made to write items in theoretically
neutral language, and items that seemed slanted toward a particular theory
(e.g., psychoanalysis) were either deleted or reworded during the item
development process. All team members were familiar with the writing of
Gelso and his collaborators on this topic (Gelso & Carter, 1985, 1994;
Gelso & Hayes, 1998), and the writing of items followed the conceptual-
ization of these authors. Three of the six team members were doctoral-level
counseling psychologists with 6 to 30 years of postdoctoral clinical expe-
rience. The remaining three were postmaster’s-level doctoral students in
counseling psychology.
Items were written to capture realism and genuineness as two funda-
mental elements of the real relationship. Furthermore, both realism and
genuineness were subdivided into valence (degree of positive vs. negative
feelings and perceptions) and magnitude (how much real relationship
existed). Finally, each item was written so that it pertained either to the
therapist, to the client, or to the relationship. Thus, all real relationship
items rated by therapists refer to the therapists, their clients, or the rela-
tionship between the therapists and their clients.
Initially, 130 items were generated by the research team members. Four
members from the research team then sought to eliminate items that were
repetitive, unclear, or not consistent with theory on the real relationship.
This process reduced the item pool to 99. At this point, these four members
designated each item as belonging to 1 of 12 categories (genuineness or
realism ⫻ valence or magnitude ⫻ self, other, or relationship). The 99
items were submitted to the two remaining team members to classify into
the categories of realism or genuineness and then valence or magnitude.
Items were kept only if the two subgroups agreed on their classification
into categories of realism and genuineness. On the basis of this procedure,
along with further elimination of redundancy, the measure was reduced to
44 items (23 reflecting the realism dimension and 21 reflecting
genuineness).
The 44-item version was then mailed to 200 randomly selected members
of either Division 29 or Division 42 of APA. Two mailings and a postcard
reminder yielded usable returns from 80 participants. (Specifics of the
return rate are reported in the Procedure section.) Therapists were asked to
select the most recent client they had seen during the past week with whom
they had worked for at least five sessions. Our aim in asking therapists to
use the most recent client was to eliminate the potential confound of
therapist self-selection, for example, of their most rewarding client. Ther-
apists were then asked to “use the following scale to evaluate your
relationship with the designated client over the last five sessions.” Items
were rated on a 5-point Likert scale ranging from 1 (strongly disagree) to
5 (strongly agree). Results from the 80 participants, referred to subse-
quently as our item-development subsample, were used to reduce the Real
Relationship Inventory—Therapist Form (RRI–T) to its final number of 24
 MEASURING THE REAL RELATIONSHIP
items (12 realism and 12 genuineness). The item reduction procedure is
described below.
In determining the final items for the measure, we paid particular
attention to (a) item–total correlations within the two subscales, Realism
and Genuineness, and (b) the reduction in Cronbach’s alpha when an item
was deleted within the two subscales. We decided a priori to reduce these
two subscales to 12 items each. This number permitted sound reliability
while also enhancing ease of usage. The rules we followed in reducing the
scale from 44 to 24 items were (a) no item–total correlation (within the
subscale the item was in) would be less than .40 if an item were to be
maintained, (b) an item would be subject to elimination if the alpha was not
reduced when the item was eliminated, and (c) items with the highest
item–total correlations would be maintained provided that there was at
least one item in each of six cells per subscale. These six cells were
determined by ratings of magnitude and valence ⫻ self (therapist), other
(client), and relationship. It should be noted that if items initially among the
top 12 for a subscale had to be eliminated to fill cells, we used redundancy
as the decisive factor in determining what item to eliminate. This occurred
only for the Realism subscale, in which we eliminated two magnitude–
other items to fill magnitude–self and valence–self cells. The two added
items did have item–total correlations that were lower than .40 (rs ⫽ .34
and .37), but we believed this a worthwhile trade-off. The alpha coeffi-
cients for the subscales were as follows: Realism ⫽ .89, Genuineness ⫽
.87. The correlation between the two subscales was .75, suggesting a great
deal of overlap between them (in fact, when taken together, the final 24
items exhibited an overall Cronbach’s alpha of .93).
At the same time that the 44-item measure was mailed to members of
APA’s Divisions 29 and 42, a back-translation (Dawis, 1987) of these
items was conducted. The raters were five doctoral students in clinical
psychology from a university in Washington, DC. These raters were given
clear written and verbal definitions, descriptions, and examples of realism
and genuineness. They were then asked to place all items into the catego-
ries of either realism or genuineness. Of the 24 items that had been arrived
at through the above psychometric analysis, 19 were correctly categorized
by at least four of five raters, and only 1 item was correctly categorized by
less than three of the five. Because that item had a very high item–total
correlation, made theoretical sense, and was not redundant with other
items, we decided to maintain it in the final form.
The final 24-item version of the RRI–T is presented in the Appendix. As
can be seen, 6 items reflect therapists’ ratings of their own reactions, 11
reflect their ratings of their clients’ reactions, and 7 reflect their ratings of
the client–therapist relationship. For the final 24 items, the means tended to
be high (overall mean for the 24 items ⫽ 3.75), and 3 items had means over
4.25. Although from a psychometric perspective it would have been
preferable to develop items or scales yielding lower scores, we maintained
the current items and scales because of the view that, on the average, real
relationship in actual therapy practice should be on the positive or stronger
side. In addition, the 3 items with the highest scores contained content that
was desirable and behaved satisfactorily psychometrically—for example,
satisfactory standard deviations and item–total correlations that were ac-
ceptable. (Copies of a table containing item means, standard deviations,
and item–total correlations for the final 24 items are available from Charles
J. Gelso.)
Measures
Working Alliance Inventory (WAI; Horvath & Greenberg, 1986, 1989).
The WAI is composed of 36 items and contains three subscales (12 items
each) measuring client–therapist agreement on goals, agreement on tasks,
and bond (Bordin, 1979). Parallel forms exist for therapists and clients, and
participants rate items on a 7-point scale anchored by 1 (never) and 7
(always). This measure has been rigorously studied over the years and has
been found to be highly reliable (Kivlighan & Shaughnessy, 2000). It has
also been soundly validated through the demonstration of its relation to
treatment outcomes, client characteristics, and therapist technical activity
(see Constantino et al., 2002; Kivlighan & Shaughnessy, 2000). In the
643
present study, the short form of the WAI (WAI–S) was used. This is a
12-item version, with 4 items per subscale. Therapists rated items in
reference to the overall evaluation of the last five sessions with a desig-
nated client (see Procedure). The WAI–S was originally proposed by
Tracey and Kokotovic (1989), who provided initial reliability and validity.
Since that initial investigation, several studies have provided further sup-
port for the WAI–S. Most recently, Busseri and Tyler (2003) have sup-
ported the interchangeability of the short and original forms for both the
therapist and the client versions for the total and subscale scores. In the
present study, the therapist version (total score) of the WAI–S was used.
For our combined validation sample of doctoral-level professionals who
completed the WAI–S (n ⫽ 41; see Procedure for clarification of different
samples sizes for different measures) and graduate student counselors (n ⫽
51), the internal consistency estimate (Cronbach’s alpha) was .85.
Transference and insight. Therapists rated their designated client’s
insight and transference. Transference was rated for the last session and the
last five sessions, whereas insight was rated for only the last session. For
transference, three single items were used that asked therapists to rate their
client’s positive transference, negative transference, and transference
amount. For insight, two items were used, one requesting that therapists
rate intellectual insight, and the other asking them to rate emotional insight.
The transference items were initially used by Graff and Luborsky (1977) in
their study of the process of psychoanalysis, and the insight items were
developed by Gelso et al. (1991) in their study of session outcome.
Therapists were provided a definition of each of these two constructs
(transference and insight) and asked to use these definitions in their ratings.
Ratings were on a 5-point scale, where 1 ⫽ none or slight and 5 ⫽ very
much. Definitions were as follows.
Transference: The degree to which the client is dealing with material
that is overtly or covertly related to the therapist. This material must
be a manifestation of or displacement from an early important rela-
tionship(s). The previous person (or transference source), however,
need not be mentioned; he or she may be inferred because of, for
example, the presence of distortion, strong affect, inappropriate affect,
and so forth. Positive transference may be seen as positive reactions
to or perceptions of the therapist that are transference based, whereas
negative transference is reflected in negative reactions to or percep-
tions of the therapist that are transference based.
Insight: The extent to which the client displays accurate understand-
ing of material being explored. Understanding may be of the relation-
ship, client’s functioning outside of counseling, or aspects of the
client’s dynamics and behavior. Intellectual insight reflects an under-
standing of cause– effect relationships but lacks depth because it does
not connect to affect underlying the client’s thoughts. Emotional
insight connects affect and intellect; the client is thus connected
emotionally to his or her understanding.
Although single-item measures can be problematic psychometrically,
they have the advantage in field research of being highly practical and
economical. More important, these particular items on transference and
insight have been used in a series of studies, and in each case, they have
behaved in theoretically sensible ways, which thus supports their construct
validity (Gelso et al., 1991, 1997; Graff & Luborsky, 1977; Kivlighan,
1995; Multon et al., 1996; Woodhouse et al., 2003). In the initial studies,
Luborsky and his colleagues (Graff & Luborsky, 1977; Luborsky,
Crabtree, Curtis, Ruff, & Mintz, 1975; Luborsky, Graff, Pulver, & Curtis,
1973) provided evidence for moderate interjudge agreement between ther-
apist ratings of transference and those of outside raters. Subsequent studies
found the transference items to relate (a) interactively with insight in
affecting session (Gelso et al., 1991) and treatment (Gelso et al., 1997)
outcome, (b) to a multi-item measure of transference (Multon et al., 1996),
and (c) to clients’ pretherapy schema ratings for their mother and father
(Patton et al., 1995). Counselor and supervisor ratings of transference on
these items have also been found to be highly intercorrelated (Kivlighan,
644 GELSO ET AL.
1995). As noted, the insight items, too, have received sound support in
terms of their interactive effects with transference on session and treatment
outcome.
Session outcome. Two of the subscales of the Session Evaluation
Questionnaire (SEQ; Stiles & Snow, 1984), Depth and Smoothness, were
used as measures of session outcome. The SEQ consists of 24 bipolar
adjective pairs that tap four constructs: depth, smoothness, positivity, and
arousal. However, Depth and Smoothness are the two that are most often
used and the subscales that have received the greatest empirical support.
Therapists rated their last session with a designated client. Each item
requires a rating on a 7-point semantic differential scale, where higher
scores reflect greater depth and smoothness. The Depth subscale taps
respondents’ perceptions of sessions as deep, powerful, valuable, full, and
special; the Smoothness subscale taps perceptions of sessions as smooth,
relaxed, pleasant, easy, and comfortable. Counselors often equate depth
with good sessions, whereas clients give more equal weight to smoothness
(Stiles et al., 2002). Internal consistency estimates for both subscales are
consistently in the vicinity of .90, and construct validation has been
extensively supported through documented relations of both Depth and
Smoothness to a wide range of counseling process and outcome measures
(Stiles et al., 2002). In the present study, the values of coefficient alpha for
our validation sample of graduate students (n ⫽ 51) and professionals who
completed the SEQ (n ⫽ 39; see Procedure for clarification of sample
sizes) were .82 for Depth and .83 for Smoothness.
Social desirability. The Marlowe–Crowne Social Desirability Scale
(SDS; Crowne & Marlowe, 1960; Reynolds, 1982) is a 13-item self-report
short version of the 33-item SDS. The short version was used to enhance
therapist cooperation and because it has received sound support in terms of
reliability and validity. The SDS uses a true–false format and aims to
identify individuals who describe themselves as possessing culturally sanc-
tioned characteristics considered rare in the general population to obtain
approval from others. This measure has been used extensively to assess
social desirability as a response tendency in studies implementing self-
report formats. High scores are indicative of more socially desirable
responding, reflecting both impression management and self-deception
(Paulhus, 1991). The 13-item version developed by Reynolds (1982) has an
acceptable level of internal consistency, a very strong relation with the
longer version of the SDS (i.e., greater than .90), and a significant relation
with the Edwards Social Desirability Scale (O’Grady, 1988). For the
present study, the internal consistency estimate based on the graduate
student sample (n ⫽ 51) was .80.
Procedure
As indicated, the sample consisted of both professionals and graduate
students. Below we describe the procedure for the professional sample first
and then for the graduate students.
Using the 2000 membership directory of the APA, we randomly selected
200 names from Division 29 (Psychotherapy) and 200 from Division 42
(Independent Practice). When we encountered individuals who had mem-
bership in both divisions or had international addresses, we selected the
name immediately following the name that was to have been selected. Each
potential participant was assigned a number for confidentiality purposes.
One week prior to the survey mailing, we sent out a postcard to all 400
individuals notifying them that they would be receiving a mailing within a
few days. The survey mailing consisted of a personalized cover letter
explaining the purposes of the study and giving directions for completing
and mailing the survey back to us; a self-addressed, stamped envelope; and
the surveys, which were also coded on the front page with a number from
1 to 400. In the cover letter, participants were asked to consider their
relationship with the last client they saw during the past week and with
whom they had worked for a minimum of five sessions. They were asked
to complete the measures with that client in mind. All cover letters were
personally signed by the three doctoral-level investigators. The pool of
professionals was divided into two subsamples, an item development
subsample and a validation subsample, each consisting of 200 individuals.
Item development subsample. Two hundred of the 400 recipients were
randomly selected to receive the cover letter and only the 44-item RRI–T.
Those from this pool who completed our measures were used to reduce the
measure to 24 items.
Validation subsample. The 200 remaining professionals in the pool
formed the validation subsample, which was used to validate the 24-item
measure. The research plan for the validation study was to ask potential
participants to complete only a portion of the measures. We took this
approach to ask less of the participants and thus increase return rate and
external validity. One hundred of the remaining 200 professional partici-
pants were sent the cover letter and the RRI–T as well as the WAI and the
Transference and Insight Questionnaire. A second group of 100 received
the cover letter, the RRI–T, and the SEQ along with the Transference and
Insight Questionnaire.
Ninety-five respondents of the 400 returned the packet after the first
mailing. Three weeks after this mailing, a reminder postcard was sent to all
participants who had not yet returned their surveys. This reminder yielded
an additional 51 surveys over the next 4-week period. At this point, we also
received 52 surveys that were undeliverable. A second mailing of the
packets was sent to the remaining 202 recipients, along with a bookmark
as a gift. The second mailing yielded a return of 44 surveys, for a total of
190 completed packets. Thus, the return rate for the study was 55%, or 190
out of 348 packets that were delivered. Of the 190 packets, however, 31
were not usable. Approximately 85% of these were from recipients who
reported not having seen a client during the last week, as specified in the
instructions. Thus, usable returns were obtained from 159 of those who
were surveyed.
Data were also collected over a 3-week period from master’s and
doctoral students in counseling and counseling psychology programs at
two northeastern universities. Students who were enrolled in counseling
practicum classes were invited to participate in the study. They were
informed of the criterion for inclusion (having seen a client during the last
week) and assured that participation was voluntary and confidential. These
students were asked to complete the questionnaires with respect to the last
client they interviewed during the past week for at least five sessions or the
latest client with whom they had worked for a minimum of five sessions.
Students were given a packet of measures along with a self-addressed,
stamped envelope in which to return the completed questionnaires. Of the
73 students surveyed in class, 51 (70%) agreed to participate and com-
pleted all measures, including the Marlowe–Crowne SDS, which was not
completed by the professional sample. Responses from the graduate stu-
dent sample were used only in the validation (not the item reduction) phase
of the study.
Results
Reliability
Earlier we reported reliability estimates based on the item de-
velopment subsample of professionals (n ⫽ 80). For the validation
subsample of professionals (n ⫽ 79) and for the graduate students
(n ⫽ 51) on whom the following validity analyses were performed,
the coefficient alpha values were as follows: Realism ⫽ .79,
Genuineness ⫽ .83, total score ⫽ .89. The differences in internal
consistencies between the professional and graduate samples were
minuscule, with the exception of the Realism subscale. On that
subscale, the alpha for the professional sample was .81, whereas
for the student sample it was .72. It should be noted that because
real relationship has been conceptualized as fluid over the course
of treatment, stability analysis (e.g., test–retest coefficients) did
not seem called for or appropriate theoretically.
Validity Analysis
The bivariate correlation coefficients between the RRI–T and
the measures against which the RRI–T was validated are presented
 MEASURING THE REAL RELATIONSHIP
in Table 1. We maintained the subscale analyses for Realism and
Genuineness and present correlations for both these subscales as
well as for the total score. Note also that, because therapist expe-
rience level (years of therapy experience), as indicated on the
demographic questionnaire, was only negligibly related to the
main variables in the study, the professional and graduate student
samples were combined.
As can be seen in Table 1, consistent with expectations, the
RRI–T total score and one or both subscale scores correlated
significantly ( p ⬍ .05) with the WAI, the SEQ Depth and Smooth-
ness subscales, emotional insight, intellectual insight, and negative
transference for the last session and the last five sessions. How-
ever, the RRI–T did not correlate with positive transference when
rated in either the last or the last five sessions. Finally, as pre-
dicted, the RRI–T did not correlate with the measure of social
desirability.
Confirmatory Factor Analysis (CFA)
Our research question focuses on whether a model consisting of
two factors, Genuineness and Realism, represents the best fit to the
data. We used a CFA to test the underlying factor structure of the
RRI–T for the validation subsample of 80 professionals (the 79
noted earlier plus 1 respondent who completed only the RRI–T)
and 51 graduate students. However, rather than using the 24
individual items as indicator variables of the two factors, which
can be quite taxing with somewhat smaller samples, we followed
the recommendation of Bagozzi and Heatherton (1994) to create
aggregated variables or item parcels within each factor. Specifi-
cally, we randomly parsed the 12 Realism items into three subsets
of 4 items, each forming a new indicator variable consisting of a
subtotal of the 4 items. We repeated the same process for the
Genuineness items, which thus yielded three indicators of each of
the two factors of interest. The three resulting Realism composites
had alpha coefficients of .63, .51. and .53, whereas the three
resulting Genuineness composites had alpha coefficients of .69,
.62. and .53.
Prior to conducting the CFA, we used the structural equation
modeling software EQS 6.1 (Bentler, 2004) to assess the distribu-
tional characteristics of the data. Specifically, using the data for the
validation subsample, we computed the normalized estimate of
Table 1
Pearson Correlations of the Real Relationship Inventory—Therapist Form (RRI–T) (Realism, Genuineness, and Total) With Validation
Measures
Measure n Realism
Working Alliance Inventory 92
Session Evaluation Questionnaire—Depth 90
Session Evaluation Questionnaire—Smoothness 90
Emotional insight 130
Intellectual insight 130
Negative transference—last session 130
Negative transference—last five sessions 130
Positive transference—last session 130
Positive transference—last five sessions 130
Social Desirability Scale 51
* p ⬍ .05. ** p ⬍ .01.
645
Mardia’s (1970) coefficient of multivariate kurtosis to be 1.5822.
This estimate was well below the recommended threshold of
3.0000, making normal-theory maximum likelihood estimation a
reasonable choice for method of estimation. Sample size recom-
mendations for maximum likelihood CFA are highly varied, in-
cluding 5–10 cases per variable (e.g., Bryant & Yarnold, 1995), 5
cases per model parameter (Bentler & Chou, 1987), and potentially
considerably more liberal recommendations on the basis of loading
strength (Marsh, Hau, Balla, & Grayson, 1998). The CFA models
tested use six variables, and the oblique model specifically requires
the estimation of 13 parameters; by any of the above sample size
guidelines, the current validation sample of 131 is more than
adequate.
Two primary models served as the focus of the CFA analyses,
a two-factor oblique model (i.e., with factors allowed to covary)
and a one-factor model. Other potential alternatives to CFA mod-
els include so-called higher order models, the most common of
which posit that the covariation between Realism and Genuineness
is itself the result of another factor that has no measured indicator
variables itself; however, in the current case, such a model is
locally underidentified given that there are only two first-order
factors (i.e., Realism and Genuineness). A second type of higher
order CFA model, a bilevel CFA model, has a general factor
influencing all measured indicators and then specific factors af-
fecting the subsets of theoretically related variables (i.e., Realism
variables and Genuineness variables). Such a bilevel model was
actually attempted with the current data but suffered from multiple
irreparable offending estimates (specifically, Heywood cases). As
a result, the one-factor and two-factor oblique models remained
our primary focus.
All analyses were executed via EQS 6.1 (Bentler, 2004), and
data-model fit was evaluated with multiple fit indices, as per the
recommendations of Hu and Bentler (1999). These authors found,
on the basis of their extensive simulation study, the standardized
root-mean-square residual (SRMR), the comparative fit index
(CFI), and the root-mean-square error of approximation to be
particularly useful. These values as well as the model chi-square,
degrees of freedom, and EQS’s version of the Akaike information
criterion are reported for both models in Table 2. According to one
of Hu and Bentler’s recommended joint criteria guidelines, SRMR
RRI–T scales
Genuineness Total
.32** .55** .47**
.30** .38** .36**
.42** .40** .43**
.21* .31** .28**
.18* .20* .21*
⫺.27** ⫺.26** ⫺.29**
⫺.16 ⫺.21* ⫺.20*
.13 .09 .12
.09 .05 .08
.06 .10 .08
646 GELSO ET AL.

Table 2
Confirmatory Factor Analysis Results

Model ␹2 df AIC SRMR RMSEA(90% CI) CFI

One-factor model 21.459 9 3.459 .043 .103(.047, .160) .966

Two-factor oblique model 21.324 8 5.324 .043 .113(.056, .172) .964

Note. AIC ⫽ Akaike information criterion; SRMR ⫽ standardized root-mean-square residual; RMSEA ⫽ root-mean-square error of approximation; CI ⫽
confidence interval; CFI ⫽ comparative fit index.

should be .10 or less, and CFI should be at least .96. As seen in
Table 2, for both models, the fit is deemed acceptable by these
modern (and quite rigorous) criteria. The standardized loadings for
the one-factor model, all of which were statistically significant
( p ⬍ .05), were .799, .732, and .664 for the Realism indicators and
.810, .762, and .710 for the Genuineness indicators. The standard-
ized loadings for the two-factor oblique model differed only by
thousandths: .805, .734, and .666 for the Realism indicators and
.814, .763, and .713 for the Genuineness indicators (all with p ⬍
.05). Further, for the two-factor model, the Realism–Genuineness
interfactor correlation was a statistically significant .986.
Because a hierarchical relation exists between the two models,
with the one-factor model nested within the two-factor oblique
model, their fit may be compared statistically by a likelihood ratio
(chi-square difference) test. The difference in the models’ chi-
square values was a minuscule 0.135 with one degree of freedom,
which is not statistically significant ( p ⫽ .713). The inference,
then, is that the additional complexity of distinguishing between
Realism and Genuineness is not actually necessary, as one might
surmise from their interfactor correlation of .986 in the two-factor
oblique model. Thus, we retained the one-factor model as a highly
satisfactory and simpler explanation of the relations among the six
indicator variables.
Additional Analyses
Correlation coefficients were computed among the 12 main
variables, other than the RRI–T total or subscale scores. Included
in this analysis were therapist experience level, theoretical orien-
tation, working alliance, SEQ Depth and Smoothness subscales,
positive and negative transference scores for the last session, client
emotional and intellectual insight, and social desirability. Because
predictions were made about these relations and given the large
number of analyses conducted, we set the alpha level (error rate)
conservatively at .01. In Table 3, we present the means and
standard deviations for each of the variables as well as the inter-
correlations among the variables.
Discussion
It appears that the RRI–T has sound reliability and beginning
validity. It correlates as it should with therapists’ ratings of the
working alliance, the depth and smoothness of sessions with the
client who was rated, and therapists’ ratings of both the intellectual
and emotional insight displayed by the client. In addition, the
RRI–T, as theorized, was negatively associated with negative
transference. Thus, the stronger the real relationship was over the
last five sessions in a given therapy, the lower was the amount of
negative transference during both the last session and the last five
sessions. The RRI–T also displayed beginning evidence of dis-
criminant validity in that it did not correlate with social
desirability.
Each of the relations just noted is theoretically crucial in vali-
dating a real relationship measure. For example, because the
working alliance has been theorized as emerging from the real
relationship (Greenson, 1967), a fairly strong relation should exist
between the two. However, these two constructs ought to be
empirically distinguishable from one another. The correlation be-
tween real relationship and working alliance that emerged (r ⫽
.47) appears to fit this expectation of both overlap and distinguish-
ability. In addition, given the close theoretical link between real
relationship and working alliance, with the latter seen as emerging

Table 3
Sample Sizes, Means, Standard Deviations, and Interconnections for and Among Major Variables

Measure n M SD 1 2 3 4 5 6 7 8 9 10 11 12

1. Experience 129 14.34 12.99 — .09 ⫺.11 .11 .02 ⫺.25 .18 .15 .17 .15 ⫺.05 .04
2. Psychoanalytic 131 2.95 1.19 — .12 ⫺.38** ⫺.17 .18 .07 .29** .25** .11 ⫺.04 ⫺.09
3. Humanistic 130 3.59 1.06 — ⫺.10 .14 .12 ⫺.00 .00 ⫺.02 ⫺.06 ⫺.10 .00
4. Cognitive–behavioral 131 3.87 1.00 — .07 ⫺.10 .10 ⫺.15 ⫺.03 ⫺.01 .01 ⫺.04
5. Working alliance 92 5.37 1.09 — .14 .16 ⫺.25 ⫺.00 .13 .39** ⫺.02
6. SEQ—Depth 89 5.22 0.76 — ⫺.01 .02 ⫺.07 .30** .26 ⫺.22
7. SEQ—Smoothness 88 4.45 1.25 — ⫺.35** ⫺.00 ⫺.01 .19 .18
8. Negative transference 131 1.82 0.95 — .28** .06 ⫺.11 ⫺.10
9. Positive transference 130 2.82 1.21 — .10 .15 ⫺.01
10. Intellectual insight 131 3.52 0.90 — .41** .00
11. Emotional insight 131 2.94 1.01 — .01
12. Social desirability 51 7.75 3.37 —

Note. SEQ ⫽ Session Evaluation Questionnaire.

** p ⬍ .01.
 MEASURING THE REAL RELATIONSHIP
from the former for the purposes of the work of therapy, it remains
to be seen whether each of the two possesses incremental validity
in relation to the other in predicting therapy-relevant criteria. For
example, does real relationship predict aspects of process and
outcome beyond the predictive power of working alliance? This
key question must await future empirical scrutiny.
With respect to transference, the real relationship theoretically
reflects lack of or at least low levels of transference, especially
negative transference. Thus, a valid measure of real relationship
must be associated with lower levels of negative transference,
which is precisely what was found in the present study. It should
be noted that the negative correlations between real relationship
and negative transference were not high, with each accounting for
between about 4% and 9% of the variance in the other, a small to
medium effect size. However, a high correlation between the two
should not, in theory, be expected. That is because transference
and real relationship are seen not as the opposites of each other but
rather as existing on two separate dimensions that are negatively
related to one another (Gelso, 2004; Gelso & Hayes, 1998).
The degree of insight exhibited by the client seems to be crucial
to real relationship in the sense that such insight ought to allow
clients to appreciate the real relationship and prevent transference
distortions from damaging or eroding the real relationship. Also, a
strong real relationship ought to foster insight because of the sense
of safety engendered by a good relationship. Finally, stronger real
relationships ought to lead to better sessions, and vice versa. Thus,
the fact that a substantial relation was found between the RRI–T
and session outcome (depth and smoothness of sessions) is seen as
a vital source of validation.
Despite the high correlation between the two subscales of the
RRI–T (Realism and Genuineness) and the fact that the CFA did
not support a two-factor solution, we believe it wise to maintain
two subscales (Genuineness and Realism) at this time. The ratio-
nale for this is twofold. First, the theory from which the measures
emanated is embedded in this dual notion of real relationship, and
it seems premature to eliminate subscales after these initial anal-
yses. Second and perhaps more important, we can envision situa-
tions in which the two subscales would behave differently from
one another, that is, correlate differentially with certain constructs.
In fact, this phenomenon occurred in the current analyses when the
subscales of the RRI–T were correlated with working alliance,
where post hoc analysis revealed that the correlations of working
alliance with the Realism (r ⫽ .32) and Genuineness (r ⫽ .55)
subscales of the RRI–T were significantly different from one
another, t(89) ⫽ 5.13, p ⬍ .01. We also uncovered differential
correlations in preliminary analyses of an in-process study of the
relation of real relationship to various therapy process and out-
come variables (Marmarosh, Gelso, Markin, Doschek, & Majors,
2004).
As is often the case with relational constructs, one might ask just
what aspect of real relationship is being measured and what term
best captures that aspect. Is it valence? Or is it amount? Because
the RRI–T deliberately contains items tapping both valence (pos-
itive vs. negative) and magnitude (how much), both of these
qualities must be incorporated into any term used to describe the
aspect being measured. We see the RRI–T as measuring the
strength of the real relationship, where strength is a result of both
valence and magnitude.
It should be noted that participants in the professional sample
were asked to complete the RRI–T with respect to the last five
647
sessions combined that they had with the designated client. We
believed that such a rating provides a more stable estimate of real
relationship than would ratings of, for example, one session and a
more precise estimate than would assessments of real relationship
without the mention of a session number. It is our expectation that
the findings derived under this method will hold up when partic-
ipants are asked to rate the last session, the therapy in general, or
any other particular cluster of sessions. However, further research
is required to empirically test this expectation.
A key limitation of the current work resides in the exclusive use
of therapist ratings. Because our aim was to develop the therapist
version of the RRI, naturally we sought therapists’ ratings of real
relationship items. However, in the future it will be important to
determine how therapists’ ratings of the real relationship correlate
with clients’ and outside raters’ evaluations of aspects of the
relationship—for example, client insight, working alliance, and
session outcome. A second limitation is that a very small percent-
age of the professionals sampled were members of racial/ethnic
minority groups (6%, or 9 of 156 who indicated race/ethnicity).
This figure increased, however, when the graduate student sample
was added, given that 31% of those participants were racial/ethnic
minorities. Thus, 12% (25 of 207 who indicated race/ethnicity) of
our total sample were minorities. Future research might profit from
examining how cultural variables interact with the real relationship
and its role in therapy.
Although additional work is needed to provide further validation
of the RRI–T, the existence of such a measure should finally open
the door to research on the real relationship. As Gelso and Hayes
(1998) have pointed out, “When a measure is at once reliable,
valid, and convenient, it stirs the minds and hearts of researchers”
(p. 27). We hope that the RRI–T serves this function. Numerous
questions await empirical scrutiny. Key among them are the fol-
lowing: How do therapists’ perceptions of the real relationship
relate to clients’ and others’ perceptions? How does the real
relationship unfold over the course of brief and longer term ther-
apy; for example, is it stable or fluid? How does it differ according
to therapists’ theoretical orientation? How does real relationship at
various points in treatment relate to outcome, and is the connection
to outcome direct or mediated, for example, by working alliance?
How does it interact with other relational constructs, such as
working alliance, transference, countertransference, therapist em-
pathy, and both therapist and client attachment styles, in affecting
process and outcome? Last but certainly not least, what client,
therapist, and treatment factors contribute to the formation and
maintenance of a strong real relationship?
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 MEASURING THE REAL RELATIONSHIP 649

Appendix

The Real Relationship Inventory—Therapist Form

Please complete the items below in terms of your relationship with your client or patient. Use the following
1–5 scale in rating each item, placing your rating in the space adjacent to the item.

Strongly Agree Neutral Disagree Strongly

Agree Disagree
5 4 3 2 1

1. My client is able to see me as a real person separate from my role as a therapist.

2. My client and I are able to be genuine in our relationship.
3. My client feels liking for the “real me.”
4. My client genuinely expresses his/her positive feelings toward me.
5. I am able to realistically respond to my client.
6. I hold back significant parts of myself.
7. I feel there is a “real” relationship between us aside from the professional relationship.
8. My client and I are honest in our relationship.
9. My client has little caring for who I “truly am.”
10. We feel a deep and genuine caring for one another.
11. My client holds back significant parts on him/herself.
12. My client has respect for me as a person.
13. There is no genuinely positive connection between us.
14. My client’s feelings toward me seem to fit who I am as a person.
15. I do not like my client as a person.
16. I value the honesty of our relationship.
17. The relationship between my client and me is strengthened by our understanding of one another.
18. It is difficult for me to express what I truly feel about my client.
19. My client has unrealistic perceptions of me.
20. My client and I have difficulty accepting each other as we really are.
21. My client distorts the therapy relationship.
22. I have difficulty being honest with my client.
23. My client shares with me the most vulnerable parts of him/herself.
24. My client genuinely expresses a connection to me.

Note. Realism subscale items ⫽ 1, 3, 5, 7, 9, 12, 14, 15, 17, 19, 20, 21; Genuineness subscale items ⫽ 2, 4,
6, 8, 10, 11, 13, 16, 18, 22, 23, 24. Reverse scored items ⫽ 6, 9, 11, 13, 15, 18, 19, 20, 21, and 22.

Received August 31, 2004

Revision received January 19, 2005
Accepted January 20, 2005 䡲