Psychotherapy

© 2018 American Psychological Association 2018, Vol. 55, No. 4, 434 – 444
0033-3204/18/$12.00 http://dx.doi.org/10.1037/pst0000183

The Real Relationship and Its Role in Psychotherapy Outcome:

A Meta-Analysis

Charles J. Gelso and Dennis M. Kivlighan Jr. Rayna D. Markin

University of Maryland, College Park Villanova University

Although writing about the real relationship has existed from the beginnings of the “talking cure,” it is
only in recent years that empirical research has focused on this phenomenon. The real relationship is the
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

personal relationship between patient and therapist marked by the extent to which each is genuine with
This document is copyrighted by the American Psychological Association or one of its allied publishers.

the other and perceives/experiences the other in ways that are realistic. The strength of the real
relationship is determined by both the extent to which it exists and the degree to which it is positive or
favorable. In this article, a meta-analysis is presented on the association between the strength of the real
relationship and the outcome of psychotherapy. Summed across 16 studies, this meta-analysis revealed
a moderate association with outcome (r ⫽ .38, 95% confidence interval [.30, .44], p ⬍ .001, d ⫽ 0.80,
N ⫽ 1.502). This real relationship⫺outcome association was independent of the type of outcome studied
(treatment outcome, treatment progress, and session outcome) and of the source of the measure (whether
the client or the therapist rated the real relationship and/or treatment outcome). We also present
commonly used measures of the real relationship, limitations of the research, and patient contributions.
The article concludes with diversity considerations and practice recommendations for developing and
strengthening the real relationship.

Clinical Impact Statement

Question: What is the meta-analytic association between the strength of the real relationship from
therapists’ and patients’ perspectives and the outcomes of psychotherapy? Findings: Computed
across 16 studies, there is a statistically significant and moderate relationship (r ⫽ .37, p ⬍ .001)
between the strength of the real relationship and outcome, and this association is not dependent upon
who made the ratings (therapists or patients) or type of outcome (session outcome, treatment
progress, pretest to posttest change). Meaning: Therapists should pay close attention to the strength
of their real relationships with patients and seek to cultivate and strengthen it during treatment. Next
Steps: More quantitative and qualitative studies are needed on the real relationship and distal
treatment outcomes, as well as on what factors moderate and mediate this relationship.

Keywords: real relationship, psychotherapy relationship, therapy outcome, meta-analysis, process-

outcome research

The idea of a real relationship between therapists and patients
has been written about since the inception of the “talking cure.”
This element of the therapeutic relationship emerged from psycho-
analysis, and Freud (1919, 1937) referred to it when he remarked
that “not every relation between an analyst and his subject during
and after analysis was to be regarded as transference; there were
also friendly relations which were based on reality and proved to
be viable” (1937, p. 222).
Other early psychoanalysts also commented on a personal, non-
work connection between the analyst and analysands. Perhaps the
most incisive comment from these early psychoanalysts was of-
fered by Anna Freud (1954, p. 372), when she wrote as follows:

Charles J. Gelso, Department of Psychology, University of Maryland,
College Park; Dennis M. Kivlighan Jr., Department of Counseling, Higher
Education, and Special Education, University of Maryland, College Park;
Rayna D. Markin, Department of Education and Counseling, Villanova Uni-
versity.
This article is adapted, by special permission of Oxford University
Press, by the same authors in J. C. Norcross & M. J. Lambert (Eds.)
(2018), Psychotherapy relationships that work (3rd ed.). New York,
NY: Oxford University Press. The Interdivisional APA Task Force on
Evidence-Based Psychotherapy Relationships and Responsiveness was
cosponsored by the APA Division of Psychotherapy/Society for the
Advancement of Psychotherapy and the Society for Counseling Psy-
chology/APA Division 17.
We thank Ms. Erin M. Hill and Ms. Jillian Lechner for their editorial and
research contributions to this chapter.
Correspondence concerning this article should be addressed to Charles J.
Gelso, Department of Psychology, University of Maryland, College Park,
MD 20742. E-mail: gelso@umd.edu

434
 REAL RELATIONSHIP AND OUTCOME
With due respect for the necessarily strictest handling and interpreta-
tion of the transference, I still feel that somewhere we should leave
room for the realization that patient and analyst are two real people,
of equal status, in a real relationship with each other. I wonder
whether our at times complete neglect of this side of the matter is not
responsible for some of the hostile reactions we get from our patients
and which we are apt to ascribe to “true transferences” only.
Anna Freud’s comment was typical of analysts’ views in the
sense that the real relationship was seen as the counterpoint to
transference. In other words, the word “real” was taken to mean
“realistic” in that the real relationship involved each participant
perceiving and experiencing the other in ways that befit the
other, rather than through the lenses of transference. By con-
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trast, the latter would involve a displacement of past unresolved
This document is copyrighted by the American Psychological Association or one of its allied publishers.
conflicts with significant others onto the present therapeutic
relationship. Thus, when transference was happening, the ther-
apeutic relationship was experienced in a distorted way,
whereas the real relationship represented the realistic, nondis-
torted element of the relationship.
A second key element of the real relationship was highlighted
by the psychoanalyst Greenson (1967). This aspect concerned the
participants in the analytic dyad being genuine with each other,
that is, being themselves in the relationship rather than holding
back or being artificial. In this way, the real relationship is con-
nected to the humanistic/experiential therapies that placed genu-
ineness or congruence as the centerpiece of treatment (Perls, 1969;
Rogers, 1957). Greenson’s conceptualization focused both on re-
alism and genuineness as the key elements of the real relationship.
This two-part conception has been a fundamental element of
current thought and empirical research on the real relationship
(Gelso, 2014; Wampold & Budge, 2012).
Although the real relationship has its roots in psychoanalysis,
the current literature focuses on the real relationship as transtheo-
retical, applying to all theoretical orientations in psychotherapy
(Gelso, 2009, 2011; Gelso & Carter, 1985, 1994; Gelso & Silber-
berg, 2016; Wampold & Budge, 2012). Theoretically, the strength
of the real relationship should not vary according the therapist’s
theoretical orientation, and existing empirical evidence supports
this expectation (Gelso, 2011).
Definitions and Measures
Clarifying and extending Greenson’s (1967) psychoanalytic
conceptualization, the modern definition of the real relationship is
“the personal relationship between therapist and patient marked by
the extent to which each is genuine with the other and perceives/
experiences the other in ways that befit the other” (Gelso, 2009, p.
119). Thus, the real relationship consists of two fundamental
elements: realism, or realistic perception/experience of the other,
and genuineness. The more realistically the participants experience
and perceive each other, and the more genuine they are with each
other, the stronger is the real relationship within the overall ther-
apeutic relationship.
These two elements, realism and genuineness, may be further
divided into what has been termed magnitude and valence. Mag-
nitude refers to how much realism and genuineness exist in the
therapeutic relationship, both overall and on a moment-to-moment
basis. Valence is a bit more complicated. The real relationship
varies on a positive versus negative dimension. Thus, one’s gen-
435
uine and realistic feelings toward another may be negative. For
example, the therapist may not like the patient with whom s/he is
genuine and who s/he perceives/experiences realistically. In other
words, one may have a high magnitude of realism and genu-
ineness vis-à-vis another but may still feel negatively toward
the other. Naturally, however, in what may be considered a good
or strong real relationship (see below), the participants’ feelings
for one another would be largely positive. The additive combina-
tion of realism and genuineness, including their valence and mag-
nitude, yields the strength of the real relationship. This construct
of strength has been its main measure in research studies.
The Who and When
The real relationship is a bipersonal phenomenon, and as such,
it is contributed to by both the therapist and patient. The therapist
contributes directly by self-disclosures of thoughts, feelings, and
information, while contributing indirectly as well. For example,
the therapist reveals who s/he is not only by what s/he says to the
patient but also by his/her sense of humor, attire, office décor,
facial expressions, body posture, and the like. All these enable the
patient to build an image of the therapist as a person. The therapist
also contributes to the strength of the real relationship by being
genuine and nonphony with the patient, as well as by experiencing/
perceiving the patient as he or she is rather than as a projection
based on the therapist’s unresolved conflicts.
From the patient’s side, the enactment of his or her role con-
tributes to the formation and development of the real relationship.
That is, the real relationship is built and strengthened by the
patient’s getting in touch with inner experiences and through both
verbal and nonverbal self-exploration and communication that
share who s/he is. These communications are a part of the patient’s
genuineness. In addition, the patient contributes to the real rela-
tionship through experiencing and perceiving the therapist in ways
that befit the therapist. This is not to say that misperceptions, often
referred to as transference, will not occur.
The real relationship manifests itself and unfolds from the first
moment of contact between the therapist and the patient. Each
participant perceives and experiences the personhood of the other
immediately, although probably to varying degrees. It has been
theorized that as the therapeutic relationship deepens, the strength
of the real relationship increases (Gelso, 2014). At least two
studies on the unfolding of the real relationship support this
suggestion (Fuertes, Gelso, Owen, & Cheng, 2013; Gelso et al.,
2012).
Interrelated Constructs
Probably all relational constructs are connected to one another.
However, for the real relationship, three related constructs—the
working alliance, patient transference, and patient and therapist
attachment—are especially relevant. As for the association be-
tween the real relationship and the working alliance, these have
been theorized to be highly interrelated, to the point of being
viewed as sister concepts (Gelso, 2014). Still, they are also seen as
being separate and contributing separately to the treatment process
and its outcomes. The real relationship may be thought of as the
personal or person-to-person, nonwork connection between the
therapist and the patient, whereas the working alliance is the work
 436 GELSO, KIVLIGHAN, AND MARKIN
connection. The working alliance, as typically conceptualized,
consists of the bond between the patient and the therapist, the
extent of their agreement on the goals of therapy, and the degree
of agreement on the tasks that will facilitate the attainment of those
goals (Bordin, 1979). The bond part of the working alliance is
particularly overlapping with the real relationship. However, the
bond part of the working alliance may be seen as a working
bond—the connection between therapist and patient that directly
reflects their therapeutic work (Gelso, 2011, 2014). For example,
when the patient communicates confidence in the therapist’s skills
and competence, or feels a connection with the therapist as an
effective professional, that may be seen as part of the working-
alliance bond. When the therapist expresses liking for the patient
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as a patient, this reflects more working alliance than the real
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relationship. On the other hand, when either the therapist or the
patient feels a connection to the other as a person, and feels liking
or caring for the person of the other, the bond is more in the realm
of the real relationship.
Given the substantial overlap between the real relationship and
the working alliance, it has been important to examine if the two
contribute independently to the treatment process and outcome. A
review by the first author (Gelso, 2014) indicates that, although
studies indicate that the two constructs are clearly interrelated, as
theorized (rs typically in the range of .50 to .60), they are also
separate and contribute separately to outcome. For example, when
Bhatia and Gelso (in press) used a simultaneous regression to
predict session outcome, therapists’ ratings of the working alliance
and real relationship were the best predictors, and both contributed
independently and significantly to the prediction of session out-
come.
As indicated, other relational constructs to which the real rela-
tionship is theoretically expected to relate are transference and
therapist and patient attachment patterns. Both of these constructs
have been found to relate as theoretically expected. For example,
in Gelso’s tripartite model of the therapeutic relationship, trans-
ference is expected to relate modestly and negatively to the real
relationship, and this has been supported in four separate studies
(Gelso, 2014).
In addition, both therapist self-disclosure and patient self-
disclosure are related to the real relationship (Gelso, 2014). The
person-centered concept of therapist congruence is, in certain
ways, synonymous with the therapist genuineness element of the
real relationship. The associations of the strength of the real
relationship with working alliance, transference, and attachment
are beyond the scope of the present article but are explored in the
corresponding book chapter (Gelso, Kivlighan, & Markin, 2018).
Measures
Only in recent years has empirical research been conducted on
the real relationship. A major reason for this slow development is
that no reliable measures had been created prior to the mid-1990s.
The first measure of the real relationship was developed by Eug-
ster and Wampold (1996), who created patient-rated, eight-item
scales of both the therapist’s and the patient’s contributions to the
real relationship. These scales assessed patients’ feelings and re-
actions toward their therapists, as well as patients’ perceptions of
their therapists’ feelings and reactions to them. Parallel therapist-
rated scales were identical to the patient-rated measures, except
they tapped the therapist’s views. The items mostly pertain to the
genuineness and liking elements of the real relationship, with little
attention to the realism element.
Two studies (Eugster & Wampold, 1996; Kelley, Gelso,
Fuertes, Marmarosh, & Lanier, 2010) found rather modest internal
reliability of these measures, with Cronbach’s ␣ coefficients rang-
ing from the .60s to the mid-.70s. Still, the measures did correlate
significantly with several other measures to which it theoretically
should relate, providing support for its construct and convergent
validity. Despite its psychometric limitations, the Eugster and
Wampold measure represents a brief, convenient assessment of the
real relationship in terms of genuineness and mutual liking.
Virtually all of the quantitative research on the real relationship
since that 1996 study has used two subsequent measures: the Real
Relationship Inventory–Therapist Version (RRI-T; Gelso et al.,
2005) and the Real Relationship Inventory–Client Version
(RRI-C; Kelley et al., 2010). As implied by their names, the RRI-T
taps the therapist’s perceptions of the real relationship, whereas the
RRI-C assesses the client’s perceptions. Both measures consist of
a total score and subscale scores for Realism and Genuineness.
Within the subscales, items assess the subelements of magnitude
and valence as defined earlier. Furthermore, both the RRI-C and
RRI-T examine the rater’s assessments of self, other, and the
relationship. For example, in the RRI-C, the client rates real-
relationship items pertaining to him/herself, the therapist, and their
relationship. The valence and magnitude of realism and genuine-
ness combine to yield scores for the strength of the real relation-
ship. Solid evidence of reliability and validity of these measures
has accumulated since their initial appearance.
The RRI-T and RRI-C have been abbreviated to 12-item mea-
sures, with six items in each of the two subscales, Realism and
Genuineness (Hill et al., 2014). Items were derived by the authors
selecting the 12 items that they believed best represented the two
components within the longer measures. The abbreviated versions
correlated .91 and .94 with the longer RRI-C and RRI-T, respec-
tively. The shortened RRI has been used in several studies, and
support has been found for its reliability and validity (Kivlighan,
Kline, Gelso, & Hill, 2017). This measure would appear to be a
good choice when ease of usage is crucial and when the total score
is what is being assessed, rather than subscale scores. Examples of
items from both the full-length and abbreviated versions of the
Client Form are as follows: (a) “I had a realistic understanding of
my therapist as a person” and (b) “My therapist did not see me as
I really am” (negatively stated item). Examples of items from the
Therapist Form are as follows: (a) “There is no genuinely positive
connection between us” (negatively stated item) and (b) “My
client’s feelings toward me seem to fit who I am as a person.”
Clinical Examples
What does the real relationship look like, or how does it man-
ifest, in the psychotherapy hour? The real relationship shows itself
at three levels, independent of the therapist’s theoretical orienta-
tion. At the first level, the real relationship exists in the back-
ground of patient⫺therapist transactions:
It shows itself through the participants’ ongoing sensing and under-
standing of one another and in their feelings toward each other . . .
These inner states simply exist as the therapist and patient explore the
 REAL RELATIONSHIP AND OUTCOME
patient’s inner conflicts and outward behavior about matters other
than the relationship. (Gelso, 2011, p. 88)
However, the real relationship is expected to come into the fore-
ground when there is a rupture in some aspect of the relationship,
when disruptive transferences occur, and when the patient needs
the support of a strong real relationship.
At the second level, the real relationship may manifest itself in
the behaviors of the participants that reflect realism and genuine-
ness, and the valence of these. At the third level, the real relation-
ship can show itself in each and every communication between the
participants. This follows Greenson’s (1967) suggestion that there
is a real relationship aspect in all communications, regardless of
how fantastical they may seem.
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The psychotherapist can foster the real relationship by sharing
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aspects of him- or herself and his or her feelings toward the patient.
Examples of sharing (Kasper, Hill, & Kivlighan, 2008) occurred
between a 51-year-old, White male therapist and a 24-year-old,
White female patient involved in therapy with a 12-session limit.
(Patient identifying information such as name, age, and parental
status have been masked in this case, as well as the following
case.) Throughout treatment, the therapist expressed a range of
feelings in the moment, for example, caring, sadness, disappoint-
ment, and connection. One example that highlights the real rela-
tionship concerned the therapist’s feelings about the patient’s
reactions to the forthcoming termination:
Therapist (T): Last week when we were talking about when
we’re gonna end and how long we’re gonna
go . . . I was sort of wondering what’s going
in that it doesn’t seem like it matters to you
one way or the other how long we meet.
Patient (P): No; actually, the truth of the matter is, like I
mean I think I mentioned to you that I would
like to go on more than 12.
The patient then goes on to say that she thinks that it would be
selfish to ask for more sessions. The therapist follows with the
following:
T: So you didn’t in some ways wanna hurt me or upset me.
For me it hurt, that it felt like it didn’t matter [to you] how
long [we met].
In subsequent research interviews, the patient expressed to the
researchers that because of the therapist’s self-disclosure, she felt
that this was a powerful session, resulting in greater closeness and
an understanding of the impact she has on others.
Another example of deep sharing that is reflective of the real
relationship is taken from the 17th and terminating session (Hill et
al., 2008). The therapist is a 55-year-old, White heterosexual man,
and the patient is a 29-year-old, African American lesbian with
long-standing anxiety and depression. This vignette demonstrates
how the therapist’s genuine sharing facilitates the patient’s genu-
ineness:
T: Jo, I respect you so much.
P: Do you?
T: I respect you so much. The way you go at these huge
issues and face them with such courage . . . the work
437
you’ve done with me since November has been so hard
and so challenging, and you have been so strong and
capable and successful. I respect your integrity, I respect
your courage.
P: Thank you, but I’m glad I met you because there’s no
telling if I met with someone else. Not to say that it would
have been . . . it’s probably more of a feeling you know,
with you than let’s say somebody else who is just kind of
like “so how do you feel about that?” . . . you really talk
about issues and . . . It matters what we talk about in
here. I always reflect back and say “Oh that makes
sense” or then I’ll jot it down . . .;
T: You surprised me right from the get-go, Jo, you just got
in the driver’s seat and you put your foot on the gas pedal
and you went to work. You initiated and you led me and
us to such profound conversations at times. It’s been a
deep sharing.
P: Oh, yeah, it really has.
These two case examples clearly highlight the real or person-
to-person element of the therapeutic relationship, even though
there certainly is reference to the work of treatment, and the
working alliance is also a part of the interactions. The real rela-
tionship, in other words, is center stage in the interactions, whereas
the working alliance is secondary.
The real relationship may also be fostered by the therapist
working with the patient to see the therapist as s/he is. Yalom
(2002), for example, described a case in which he and his patient
shared impressionistic notes of each session. The patient idealized
Yalom, and Yalom wanted to diminish this idealization so that the
patient could see him realistically. Thus, in Yalom’s notes of the
sessions that he shared with the patient, he deliberately tried to
reveal his most human feelings, including his frustrations, irrita-
tions, insomnia, and vanity.
In a more moderate manner, Dr Patrice Duquette (personal
communication, May, 2009; published in Gelso, 2011) provided an
example of using the real relationship to help her patient who was
suffering from intense anxiety and withdrawal. Duquette is a
highly experienced, White, and psychodynamically oriented psy-
chiatrist, and the patient is a 36-year-old, White heterosexual
female, who is married and has one child. In the following vi-
gnette, Duquette’s observations are in parentheses following the
patient’s verbalizations:
P: I can hear myself being tight. I do not want to really feel,
do not want to have those feelings. But I do not want to
be like this either. (Her mouth is set tight, her forehead is
raised and eyes tightened; her voice is very tight and has
a cry it in.)
T: Can you feel your throat at all?
P: Not really. Cannot feel it separate from all the other
tightness. Not quite. Do not want to almost. Feels like I
cannot feel or think, like my brain has just stopped.
T: Try a bit. Can you feel anything? Can you direct your
energy to feel where you are? Can you look at me?
 438 GELSO, KIVLIGHAN, AND MARKIN
P: A little bit. (Tears well up obviously in her eyes, her
mouth twists more, her eyes go to an almost vacant look,
with her eye contact less intensely focused.) Now I just. . .
just . . . it just feels like there is a big gaping hole.
(Silence, and she continues looking, but is appearing
more frightened by the second.)
T: Stay here. Can you look at me? At me . . . here?
P: A little . . . (More tears, eyes are still looking vague and
fading.)
T: What do you see? Here? Are you along?
P: I see you.
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T: (Nods and gestures, as if to say, “More.”)
P: I can see you (mouth still twisting, patient is limiting her
verbal output.)
T: What do you see in me? Can you see my eyes? What do
you see?
P: That you are present.
T: Who is? Who am I?
P: Double D. (Patient chuckles, as if it were a private joke.
Therapist recalls that this is how the patient writes her
name in her appointment book and smiles slightly in
recognition.) Dr Duquette, that’s who you are. (She says
this in a firmer voice, with a moment of eye contact. Such
moments had come up before in group situations, when I
had directed her and others to use my full name by way
of fuller recognition of me and our relationships in a
given moment.)
T: And so?
P: That you see me, care about me, are listening. And that as
you see me, you are like 99.9% accurate about what you
see. (Her voice is settling, she speaks more spontane-
ously, her eye contact is more directed.)
Meta-Analytic Review
Method
Because this was the first meta-analysis of the real relation-
ship literature, we included all studies (published and unpub-
lished), regardless of the publication date, that reported data
allowing the calculation of the correlation between the strength
of the real relationship and (a) treatment outcome, in the form
of pretest⫺posttest change, (b) treatment progress, and/or (c)
session quality or session outcome. Pretest⫺posttest change
was defined as studies that used a psychometric instrument
(e.g., Outcome Questionnaire– 45) that patients completed prior
to commencing treatment and at the completion of treatment.
For treatment progress, patients and/or therapists assessed the
progress to date, in their treatment. These progress reports were
often, but not always, completed at the conclusion of the patient’s
treatment. For session quality or outcome, patients reported on the
quality or outcome of the session in which the real relationship was
assessed. Studies were excluded if they did not have the informa-
tion necessary to calculate a correlation between the real relation-
ship and any of the criterion variables or if the data set was not
independent of other studies included in the meta-analysis.
We searched the PsycINFO database for published studies on
the real relationship and the preidentified outcome variables. We
also contacted researchers known to conduct research on the real
relationship for unpublished studies and student theses or disser-
tations. All except one study were published in English. The
exception was a South Korean dissertation in which the key
information was translated by a doctoral student.
We used the search term “real relationship” paired with the
terms, “therapy/counseling outcome,” “session quality/outcome,”
and/or “treatment progress.” Titles and/or abstracts of potential
studies were independently coded by the third author and two
advanced graduate students in counseling psychology. Disagree-
ments were discussed among the coders until a consensus was
reached.
Several studies examining the real relationship were not in-
cluded in the meta-analysis because their data sets partially over-
lapped with studies that were included in the meta-analysis. The
Kivlighan, Baumann, Gelso, And Hill (2014); Kivlighan et al.
(2017); and Li, Kivlighan, Gelso, and Hill (2016) studies were not
included in the meta-analysis because their data sets partially
overlapped with those of Kivlighan, Hill, Gelso, and Baumann
(2016), which contained the most inclusive data set. The Kiv-
lighan, Gelso, Ain, Hummel, and Markin (2015) and Markin,
Kivlighan, Gelso, Hummel, and Spiegel (2014) studies were not
included in the meta-analysis because their data sets partially
overlapped with those of Gelso et al. (2012), which contained the
most inclusive data set.
We developed spreadsheets for coding both study-level and
effect size-level data. The second author and an advanced graduate
student in counseling psychology independently extracted the tar-
geted data. Disagreements were again discussed and resolved by
the two judges. When sufficient data for computing standardized
effect sizes were unavailable, study authors were contacted. Along
with data necessary for computing standardized effect sizes (Pear-
son’s r), the following data were extracted: (a) type of outcome
assessed (see earlier text), (b) sample size, and (c) who (client or
therapist) made the ratings.
Pearson’s correlation coefficient (r) was the effect size measure
used in this research. In addition, we report the equivalent d for each
relation examined. Methods described by Cooper, Hedges, and Val-
entine (2009) were used to compute this effect size and its variance.
The Comprehensive Meta-Analysis V3 (www.meta-analysis.com)
statistical software was used to conduct the analyses.
When studies contained multiple effect sizes, we aggregated
data within studies and then between studies, based on the specific
comparisons from our different analyses. We computed Pearson’s
r and 95% confidence intervals (CIs) as summary statistics. The
heterogeneity among effect sizes in an analysis was assessed using
the Q-statistic (assessing whether between-study heterogeneity
exceeds that expected by chance alone). All analyses used random
effects models.
For the correlation between the real relationship and outcome,
the type of outcome (pretest⫺posttest change, treatment progress,
or session quality) was assessed as a between-study moderator of
the correlation between the real relationship and outcome. Within-
 REAL RELATIONSHIP AND OUTCOME 439

study moderators included as follows: (a) source of the real rela-
tionship rating (client or therapist), (b) source of the outcome
rating (client or therapist), and (c) rater match (the same rater for
both the real relationship and outcome). For each of the analyses
that we conducted, we assessed publication bias by visually in-
specting funnel plots for asymmetry.
Results
Five studies reported the correlation between the real relation-
ship and psychotherapy progress, five studies reported the corre-
lation between the real relationship and pretest⫺posttest outcome,
and six studies reported the correlation between the real relation-
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Moderators and Mediators
Moderators
A moderator test was conducted to determine whether the
type of outcome assessed was related to the magnitude of the
correlation between the real relationship and psychotherapy
outcome. For this analysis, we created two dummy variables:
(a) whether or not the outcome assessed represented progress
and (b) whether or not the outcome assessed represented session
quality. Therefore, outcome assessed as pretest to posttest
change was the reference group. Neither the progress dummy
variable (coefficient ⫽ 11.69, z ⫽ 0.90, p ⫽ .371) nor the
session quality dummy variable (coefficient ⫽ 0.08, z ⫽ 0.62,

ship and session quality. The omnibus effect size was significant
(r ⫽ .38, 95% CI [.30, .44], p ⬍ .001, d ⫽ 0.80, N ⫽ 1,502 p ⫽ .538) was significant. Therefore, the type of outcome
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participants). A forest plot for this analysis is displayed in Figure
1. This result shows a moderate-sized association between the real
relationship and outcome.
There was significant heterogeneity across the studies (Q[15] ⫽
30.74, p ⫽ .01), and the extent of heterogeneity was moderate
(I2 ⫽ 51%). The fail-safe N was 866. Visual inspection of a funnel
plot (see Figure 2) revealed some asymmetry. In the figure, the
open circles represent the data from the studies in the meta-
analysis and filled circles represent imputed studies. The Egger test
showed no evidence of publication bias, t ⫽ 1.21, p ⫽ .247. A
sensitivity analysis using the trim-and-fill method was performed,
with two imputed studies, producing a symmetrical funnel plot.
The point estimate incorporating these two imputed studies was
only slightly smaller than the original results (r ⫽ .35, 95% CI
[.27, .42]).
assessed was not related to the strength of the real relation-
ship⫺outcome correlation.
Within-study moderator tests revealed that (a) who assessed
the real relationship (client or therapist) was unrelated to the
strength of the real relationship⫺outcome correlation (coeffi-
cient ⫽ ⫺0.09, z ⫽ ⫺0.51, p ⫽ .614), (b) who assessed the
outcome (client or therapist) was unrelated to the strength of the
real relationship⫺outcome correlation (coefficient ⫽ 0.20,
z-value ⫽ 1.33, p ⫽ .183), and (c) whether the assessor of the
real relationship and outcome was the same (e.g., client as-
sessed both the real relationship and outcome) or different (e.g.,
therapist assessed the real relationship and client assessed out-
come) was unrelated to the strength of the real relation-
ship⫺outcome correlation (coefficient ⫽ ⫺0.18, z- ⫽ ⫺1.19,
p ⫽ .235). Therefore, the rater source did not appear to affect

Study name Statistics for each study Correlation and 95% CI

Lower Upper
Correlation limit limit Z-Value p-Value
Ain, 2011 0.420 0.188 0.608 3.410 0.001
Bhatia & Gelso, 2017 0.290 0.177 0.395 4.897 0.000
Bhatia & Gelso, in press 0.420 0.312 0.517 7.022 0.000
Eugster & Wampold, 1996 0.310 0.134 0.467 3.377 0.001
Fuertes et al., 2007 0.360 0.114 0.564 2.820 0.005
Fuertes Moore & Ganley, in press 0.530 0.303 0.700 4.173 0.000
Gelso et al., 2005 0.360 0.165 0.528 3.515 0.000
Gelso et al,. 2012 0.730 0.548 0.846 5.800 0.000
Gullo et al., 2012 0.560 0.263 0.760 3.408 0.001
Kivlighan et al., 2016 0.230 0.069 0.379 2.781 0.005
Lee, 2017 0.440 0.230 0.611 3.894 0.000
Lo Coco et al., 2011 0.230 -0.052 0.478 1.606 0.108
Markin et al., 2014 0.180 -0.032 0.376 1.668 0.095
Marmarosh et al., 2009 0.280 -0.004 0.523 1.930 0.054
Owen et al., 2011 0.300 0.007 0.545 2.006 0.045
Perez-Rojas, 2015 0.490 0.343 0.614 5.872 0.000
0.378 0.309 0.442 10.048 0.000
-1.00 -0.50 0.00 0.50 1.00

Favors A Favors B

Meta Analysis

Figure 1. Forest plot of effect sizes and confidence intervals for the meta-analysis of real relationship and
treatment outcome. “Box” size is relative to sample size, with sarger boxes indicating a larger sample. “Favors
A” indicates a negative correlation, whereas “Favors B” indicates a positive correlation. The last line of the table
is the estimated results (random effects) for the meta-analysis.
 440 GELSO, KIVLIGHAN, AND MARKIN

Funnel Plot of Standard Error by Fisher's Z

0.00

0.05
Standard Error

0.10

0.15
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This document is copyrighted by the American Psychological Association or one of its allied publishers.

0.20

-2.0 -1.5 -1.0 -0.5 0.0 0.5 1.0 1.5 2.0

Fisher's Z

Figure 2. Funnel plot of real relationship and outcome after using the trim-and-fill method. Open circles
represent studies used in the meta-analysis and filled circles represent imputed studies. The open diamond is the
r and confidence interval from the original analysis, and the filled diamond is the r and confidence interval from
the trim-and-fill analysis.

the size of the real relationship⫺outcome correlation, at least in
this small number of studies.
Mediators
The number of studies was too small to conduct formal medi-
ation analyses for therapist effects. However, three studies (Kiv-
lighan et al. (2014); Kivlighan, Gelso, Ain, Hummel, and Markin
(2015); and Li et al. (2016)) have examined whether differences
between therapists or differences between clients in forming and
growing a real relationship best predict treatment success?
The first study (2014) found that therapists who, on the whole,
were rated as having stronger third-session real relationships had
clients who reported more treatment progress. However, for clients
within any single therapist’s caseload, there was no association
between the client’s real relationship with their therapist and
treatment progress. Although complicated, this difference between
therapists as a whole and individual therapists as rated by clients
on their caseloads implies that the therapist’s contribution to the
real relationship and its connection to session progress is stronger
than the patient’s contribution.
Kivlighan, Bauman, et al. (2014) reported a similar finding.
They also found that therapists who, across all of their clients,
were rated as having increasing real relationship strength as treat-
ment progressed had clients who reported a greater decrease in
symptoms. Within any given therapist’s caseload, however,
changes (increases or decreases) in the client-rated real relation-
ship with their therapist were unrelated to change in client symp-
toms across treatment. Again, this difference between therapists as
a whole and any given therapist’s caseload suggests that therapists
are more significant contributors than are patients to the role of the
real relationship in symptom improvement as treatment progresses.
Another study extended these two investigations by examining
between-therapist differences (Li et al., 2016). Researchers used
the common fate model (Ledermann & Kenny, 2012) to model the
dyadic real relationship and to examine how this dyadic real
relationship was related to session evaluation. Psychotherapists
who, across all of their clients and sessions, had stronger dyadic
real relationships had clients who reported better session evalua-
tions, whereas therapists who, across all of their clients and ses-
sions, had weaker dyadic real relationships had clients who re-
ported worse session evaluations. When clients within a therapist’s
caseload reported a stronger dyadic real relationship with their
therapist, there was no statistical association with session evalua-
tion.
Taken together, the three statistically sophisticated studies show
that between-therapist differences in early real relationship, between-
therapist differences in the growth of the real relationship, and
between-therapist differences in the dyadic real relationship are better
predictors of treatment outcome than between-client differences in the
real relationship. That is, in plain English, the individual therapist
makes more difference than the individual client when it comes to the
real relationship.
Patient Contributions
The real relationship is a bipersonal concept, consisting of both
the patient’s and the therapist’s contributions. From the patient’s
side, the real relationship is strengthened by the patient’s efforts to
share and understand what he or she feels and thinks, to be genuine
in the relationship. The real relationship is also enhanced by the
patient’s realistic experience and perception of the therapist. That
is, the patient’s ability and willingness to see the therapist as he or
she is, rather than in a distorted way tied to transference and other
processes, fosters a strong real relationship. Perhaps as an over-
riding concept, the patient’s ability and willingness to form a
healthy attachment to his or her therapist may be a fundamental
part of doing so. It should be added that a strong real relationship
 REAL RELATIONSHIP AND OUTCOME
on the part of the patient does not preclude transference but instead
may coexist with it, as noted by the moderate correlation between
transference and the strength of the real relationship (see review by
Gelso, 2014).
These assertions about the patient’s contributions have been
empirically supported by the few studies that have been conducted
on the topic. For example, it appears that a cluster of patient
qualities is associated with the strength of the real relationship
(Kelley et al., 2010). This cluster includes that patients’ capacity to
stand back and accurately observe themselves (often referred to as
observing ego), to attend to their inner feelings, and to gain an
insight during treatment seem to be part of a strong real relation-
ship. Similarly, the tendency to hide from their inner feelings is
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associated with weaker real relationships. Finally, the strength of
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the real relationship has been found to relate both the patients’
tendency to form secure attachments, in general, and sound attach-
ments to their therapists, in particular (Moore & Gelso, 2011).
Limitations of the Research
The main limitations of the research conducted to date on the
real relationship pertain directly to the few studies that have been
conducted. Thus, although the findings of this meta-analysis are
highly promising regarding the relation of the real relationship to
psychotherapy outcomes (session outcome, treatment progress,
and treatment outcome), the number of studies is small, especially
for the three outcome types taken separately. Several nonsignifi-
cant moderator analyses may be due to low power. More studies
are needed that associate the real relationship with the treatment
outcome, both immediately following termination and at follow-
up. No studies of which we are aware have been done on the latter.
Similarly, no studies have examined the real relationship in
psychotherapies of varying theoretical orientations. Is the real
relationship different with therapists who practice psychodynamic,
cognitive-behavioral therapy, experiential, integrative, and other
treatments? What is the relation of the real relationship and out-
come for brief versus longer term therapies? Nearly all of what we
now know is based on brief treatments, and work on longer
treatments is sorely needed.
Another limitation of the research is that nearly all of the studies
on real relationship have been conducted by a few invested re-
searchers. It is well documented throughout the history of psycho-
therapy research that findings emerging from laboratories that
espouse the theoretical construct being studied have somewhat
different, and usually more favorable, findings than those in which
the investigators are not proponents (researcher allegiance effect;
Luborsky et al., 1999). Findings will probably be modified as a
larger number of investigators, including those who are not pro-
ponents, study this construct and its impact.
It would be helpful to study from a qualitative perspective what
patients and therapists believe make for a strong real relationship
and what they believe weakens it in particular treatments. It would
be especially useful to ground these opinions in specific experi-
ences, for example, of patients commenting on their own therapy
experiences or of therapists commenting on specific cases. Such
work could lead to further refinements in practice, training, and
theory.
Because research on the real relationship is still in its early
stages, there are many questions that await empirical scrutiny.
441
Among the major ones are as follows: (a) What therapist⫺patient
interactions occur in sessions in which there are stronger or more
salient real relationships? (b) Which therapist and patient factors
facilitate stronger real relationships? (c) How do cultural factors
such as race, ethnicity, and sexual orientation relate to the strength
of the real relationship? (d) Which factors, for example, multicul-
tural competence and theoretical orientation, may moderate or
mediate the relation of such cultural factors and the real relation-
ship? (e) How does the real relationship manifest itself in treatment
in other countries? To date, the only other countries in which the
real relationship has been studied are Italy (Coco, Gullo, Prestano,
& Gelso, 2011) and South Korea (Eun Ju, 2015), and the findings
have been consistent with research in the United States. (f) How
does the real relationship vary in strength and impact for patients
with differing personalities and disorders? (g) How does the real
relationship differ from the working alliance, particularly the bond
aspect of the alliance? Although we have discussed the differences
theoretically and clinically, it would be useful to empirically pin
down the similarities and differences, including at the level of
measurement instruments. For example, there is no doubt that the
bond subscale of the Working Alliance Inventory (Horvath &
Greenberg, 1989) contains some items that tap real relationship.
Separating these out from those items that assess the working bond
would be helpful. These are but a few of the many questions that
may be fruitfully examined in future studies.
Diversity Considerations
At this point, little is known about how diversity, such as race,
ethnicity, and sexual orientation, influences the real relationship.
To date, three studies have examined such factors, and these
present intriguing findings.
One such study examined how therapists’ multicultural orien-
tation (MCO) was associated with the strength of the real relation-
ship, working alliance, and treatment outcome (Owen, Tao, Leach,
& Rodolfa, 2011). A total of 176clients rated the MCO of their 33
psychotherapists, and also rated their working alliances, real rela-
tionships, and treatment outcomes. Clients’ ratings of the real
relationships with their therapists were positively correlated with
treatment outcomes for both White (n ⫽ 95) and racial-ethnic
minority (n ⫽ 81) clients. Also, client ratings of their therapists’
MCO indicated that MCOs of therapists were positively associated
with ratings of the strength of the real relationship. The greater
therapists’ MCO in the eyes of their clients, the stronger the real
relationship between therapists and clients.
In another such study involving 144 clients and their 19 thera-
pists, clients rated some therapists as having stronger real relation-
ships and working alliances with their racial-ethnic minority cli-
ents, whereas other therapists were seen to have stronger working
alliances and real relationships with their White clients (Morales et
al., 2018). These differences were independent of the race of the
therapists. Nuanced findings such as these may prove valuable, as
they take us closer to understanding which therapists work best
with which clients regarding race and ethnicity.
A third diversity-related study focused on the real relationship
with lesbian (n ⫽ 76) and gay (n ⫽ 40) clients (Kelley, 2015). The
real relationship accounted for a significant variance in clients’
positive feelings about their therapists above and beyond months
in therapy, therapists’ helpful and unhelpful therapy practices, and
 442 GELSO, KIVLIGHAN, AND MARKIN
the working alliance. This study offers evidence of the importance
of the real relationship in the eyes of lesbian and gay clients.
No studies to date have examined how therapist and/or patient
gender bear upon the role of the real relationship. Although vir-
tually all studies on the real relationship break down samples by
gender, none of these investigations has actually studied gender
and the real relationship. This absence is especially striking in light
of the long-standing, replicated findings about differences in men
and women in various relational characteristics.
Therapeutic Practices
How can practitioners foster and develop a strong real relation-
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
ship? Empirical evidence suggests that the real relationship
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changes across sessions, usually strengthening (Gelso et al., 2012;
Kivlighan et al., 2016). This change may represent a natural
evolution that comes about through the participants getting to
know each other more deeply, and/or this change may result from
similarities between therapist and patient in terms of human qual-
ities, for example, sense of humor, basic interests, and attunement
to others. When therapists and patients are “part of the same tribe”
(Gelso & Silberberg, 2016) in these ways, they more likely take to
each other as persons, thus paving the way for a strong real
relationship. Certain therapist actions also facilitate a strong real
relationship. These include the following:
• Seek to grasp empathically the patient and his or her
inner experience. Evidence indicates that therapist empa-
thy is significantly related to the strength of the real rela-
tionship (Fuertes et al., 2007). The therapist’s successful
understanding of the patient facilitates the realism element
on the therapist’s side, and because feeling seen and un-
derstood accurately can be so intimate, it fosters the pa-
tient’s personal connection to his or her therapist. In addi-
tion, it is likely that therapist empathy begets empathy in
the patient, and patient empathy fosters seeing the therapist
as s/he truly is, thus deepening the realism aspect of the real
relationship on the patient’s side.
• Manage countertransference. Self-understanding, manag-
ing one’s own anxiety, and grasping the boundaries be-
tween oneself and the patient (Hayes et al., this issue) all
deepen seeing the patient as s/he is (rather than as projec-
tions of the therapist’s conflicts) and being genuine with the
patient. They also, in turn, foster the patient seeing the
therapist as s/he is and being genuine with the therapist.
• Share reactions with the patient. Although therapist self-
disclosure is certainly an imperfect indication of genuine-
ness, it does relate modestly to the strength of the real
relationship (Ain, 2008, 2011). Well-timed disclosures (in-
cluding disclosures of feelings within the therapeutic rela-
tionship and about the patient) highly relevant to the pa-
tient’s needs (rather than the therapist’s needs) foster
therapist genuineness in the patient’s eyes.
• Explain when not sharing. Despite the connection of ther-
apist self-disclosure to the real relationship and genuine-
ness, we know from clinical experience and research evi-
dence that therapists can be genuine while being relatively
nondisclosing. One of the factors that fosters the patient’s
perceptions of therapist genuineness when not disclosing
involves telling the patient why the therapist is not disclos-
ing. When the therapist clarifies why s/he is not disclosing,
the therapist is, in fact, disclosing at a different level, what
might be seen as a metalevel.
• Be consistent and constant. At the most fundamental level,
the patient’s sense that s/he could count on his or her
clinician to be there, and be there on time, fosters a sense
that the therapist can be personally trusted and that the
therapist is interested in the patient as a person as well as a
patient. This seems particularly crucial for patients who are
highly vulnerable. In addition, consistency is a key factor in
helping the patient trust the therapist as a person, and this
includes consistency between the therapist’s verbal and
nonverbal behavior. This consistency also provides credi-
bility to the real relationship that the therapist is offering to
the patient.
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http://dx.doi.org/10.1037/h0045357 Accepted May 11, 2018 䡲
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