Communication techniques and therapeutic relationships in

psychiatry

VERBAL COMMUNICATION
Verbal communication occurs when we engage in speaking with others. It can be
face-to-face, over the telephone, via Skype or Zoom, etc. Some verbal
engagements are informal, such as chatting with a friend over coffee or in the
office kitchen, while others are more formal, such as a scheduled meeting.
Regardless of the type, it is not just about the words, it is also about the caliber
and complexity of those words, how we string those words together to create an
overarching message, as well as the intonation (pitch, tone, cadence, etc.) used
while speaking. And when occurring face-to-face, while the words are important,
they cannot be separated from non-verbal communication.

NON-VERBAL COMMUNICATION
What we do while we speak often says more than the actual words. Non-verbal
communication includes facial expressions, posture, eye contact, hand
movements, and touch. For example, if you’re engaged in a conversation with
your boss about your cost-saving idea, it is important to pay attention to both the
their words and their non-verbal communication. Your boss might be in
agreement with your idea verbally, but their nonverbal cues: avoiding eye
contact, sighing, scrunched up face, etc. indicate something different.

WRITTEN COMMUNICATION
Whether it is an email, a memo, a report, a Facebook post, a Tweet, a contract,
etc. all forms of written communication have the same goal to disseminate
information in a clear and concise manner – though that objective is often not
achieved. In fact, poor writing skills often lead to confusion and embarrassment,
and even potential legal jeopardy. One important thing to remember about written
communication, especially in the digital age, is the message lives on, perhaps in
perpetuity. Thus, there are two things to remember: first, write well – poorly
constructed sentences and careless errors make you look bad; and second,
ensure the content of the message is something you want to promote or be
associated with for the long haul.
LISTENING
The act of listening does not often make its way onto the list of types of
communication. Active listening, however, is perhaps one of the most important
types of communication because if we cannot listen to the person sitting across
from us, we cannot effectively engage with them. Think about a negotiation – part
of the process is to assess what the opposition wants and needs. Without
listening, it is impossible to assess that, which makes it difficult to achieve a
win/win outcome.

VISUAL COMMUNICATION
We are a visual society. Think about it, televisions are running 24/7, Facebook is
visual with memes, videos, images, etc., Instagram is an image-only platform,
and advertisers use imagery to sell products and ideas. Think about from a
personal perspective – the images we post on social media are meant to convey
meaning – to communicate a message. In some cases that message might be,
look at me, I’m in Italy or I just won an award. Others are carefully curated to tug
on our heartstrings – injured animals, crying children, etc.

We communicate continually throughout each and every day. We do it without

thinking – we operate on communication autopilot. However, I encourage you to
think about how you communicate. How do you communicate verbally? What
nonverbal cues do you use when you are disinterested? Excited? Nervous? Are
you a good listener? Can you write a concise, clearly articulated message? Are
there barriers to how you communicate effectively?

Understanding how you communicate is the first step to communicating more

effectively. You can easily look online for communication courses. There are a
variety of credit and non-credit course available to help you improve your
communication skills, including our non-credit series.

Therapeutic relationship
The therapeutic relationship refers to the relationship between a healthcare
professional and a client or patient. It is the means by which a therapist and a client
hope to engage with each other and effect beneficial change in the client.
In psychoanalysis the therapeutic relationship has been theorized to consist of three
parts: the working alliance, transference/countertransference, and the real
relationship. Evidence on each component's unique contribution to the outcome has
been gathered, as well as evidence on the interaction between components. In contrast
to a social relationship, the focus of the therapeutic relationship is on the client's needs
and goals
Therapeutic Alliance / Working Alliance
The therapeutic alliance, or the working alliance may be defined as the joining of a
client's reasonable side with a therapist's working or analyzing
side. Bordin conceptualized the working alliance as consisting of three parts: tasks,
goals and bond. Tasks are what the therapist and client agree need to be done to reach
the client's goals. Goals are what the client hopes to gain from therapy, based on their
presenting concerns. The bond forms from trust and confidence that the tasks will bring
the client closer to their goals.
Research on the working alliance suggests that it is a strong predictor of psychotherapy
or counseling client outcome. Also, the way in which the working alliance unfolds has
been found to be related to client outcomes. Generally, an alliance that experiences a
rupture that is repaired is related to better outcomes than an alliance with no ruptures,
or an alliance with a rupture that is not repaired. Also, in successful cases of brief
therapy, the working alliance has been found to follow a high-low-high pattern over the
course of the therapy. Therapeutic alliance has been found to be effective in treating
adolescents with PTSD, with the strongest alliances were associated with the greatest
improvement in PTSD symptoms. Regardless of other treatment procedures, studies
have shown that the degree to which traumatized adolescents feel a connection with
their therapist greatly affects how well they do during treatment
Necessary and sufficient conditions
In the Humanistic approach, Carl Rogers identified a number of necessary and sufficient
conditions that are required for therapeutic change to take place. Rogers stated that
there are six necessary and sufficient conditions required for therapeutic change

1. Therapist–client psychological contact: A relationship between client and

therapist must exist, and it must be a relationship in which each person's
perception of the other is important.
2. Client incongruence: That incongruence exists between the client's experience
and awareness.
3. Therapist congruence, or genuineness: The therapist is congruent within the
therapeutic relationship. The therapist is deeply involved, they are not 'acting'
and they can draw on their own experiences (self-disclosure) to facilitate the
relationship.
4. Therapist unconditional positive regard: The therapist accepts the client
unconditionally, without judgment, disapproval or approval. This facilitates
increased self-regard in the client, as they can begin to become aware of
experiences in which their view of self-worth was distorted or denied.
5. Therapist empathic understanding: The therapist experiences an empathic
understanding of the client's internal frame of reference. Accurate empathy on
the part of the therapist helps the client believe the therapist's unconditional
regard for them.
 6. Client perception: That the client perceives, to at least a minimal degree, the
therapist's unconditional positive regard and empathic understanding.
Transference and Counter-Transference
The concept of therapeutic relationship was described by Freud (1912) as "friendly
affectionate feeling" in the form of a positive transference. However, transferences, or
more correctly here, the therapist's 'counter-transferences' can also be negative. Today
transference (from the client) and counter-transference (from the therapist), is
understood as subconsciously associating a person in the present, with a person from a
past relationship. For example, you meet a new client who reminds you of a former
lover. This would be a counter-transference, in that the therapist is responding to the
client with thoughts and feelings attached to a person in a past relationship. Ideally, the
therapeutic relationship will start with a positive transference for the therapy to have a
good chance of effecting positive therapeutic change.
Operationalization and Measurement
Several scales have been developed to assess the patient-professional relationship
in therapy, including the Working Alliance Inventory (WAI) the Barrett-Lennard
Relationship Inventory and the California Psychotherapy Alliance Scales (CALPAS) The
Scale To Assess Relationships (STAR) was specifically developed to measure the
therapeutic relationship in community psychiatry, or within care in the
community settings.

References
1. ^ Greenson, R.R. (1967) The technique and practice of psychoanalysis. (Vol.1). New York:
International Universities Press.
2. ^ Gelso, C.J. & Carter, J. (1985). The relationship in counseling and psychotherapy: Components,
consequences, and theoretical antecedents. Counseling Psychologist, 13, 155-243.
3. ^ Gelso, C.J. & Carter, J. (1994). Components of the psychotherapy relationship: Their interaction and
unfolding during treatment. Journal of Counseling Psychology, 41, 296-306.
4. ^ Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook
of Counseling Psychology (4th ed.). (pp. 267-280).
5. ^ http://www.ohsu.edu/xd/outreach/occyshn/training-education/upload/
DevelopingTheraputicRelationships_Ch10.pdf[dead link]
6. ^ Gelso, C.J. and Hayes, J.A. (1998). The Psychotherapy Relationship: Theory, Research, and
Practice. (p. 22-46): John Wiley & Sons: New York.
7. ^ Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance.
Psychotherapy: Theory, Research & Practice, 16(3), 252-260.
8. ^ Ardito, R. B., & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy: Historical
Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2.
DOI:10.3389/fpsyg.2011.00270.
9. ^ Stiles, W.B., Glick, M. J., Osatuke, K., Hardy, G. E., Shapiro, D. A., Agnew-Davies, R., Rees, A. &
Barkham, M. (2004). Patterns of alliance development and the rupture-repair hypothesis: Are
productive relationships U-shaped or V-shaped). Journal of Counseling Psychology, 51, 81-92.
10. ^ Capaldi S, Asnaani A, Zandberg LJ, Carpenter JK, Foa EB. Therapeutic alliance during prolonged
exposure versus client-centered therapy for adolescent Posttraumatic Stress Disorder. Journal of
Clinical Psychology. 2016 Oct;72(10):1026-36
11. ^ Horvath, A. O., Greenberg, L. (1986). The development of the Working Alliance Inventory: A
research handbook. In L. Greenberg and W. Pinsoff (Eds.) Psychotherapeutic Processes: A Research
Handbook, New York: Guilford Press.
12. ^ Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in therapeutic
change. Psychological Monographs: General and Applied, 76, 1-33.
13. ^ Gaston L., Marmar, C. R. (1991). Manual for the California Psychotherapy Alliance Scales -
CALPAS Unpublished manuscript. Department of Psychiatry McGill University, Montreal, Canada.
14. ^ *McGuire-Snieckus, R., McCabe, R, Catty, J., Hansson, L., and Priebe, S. (2007). A new scale to
assess the therapeutic relationship in community mental health care: STAR. Psychological Medicine,
37, 85-95.