The Therapeutic Relationship

Dr Maria Livanou
Aims

 Explore definitions of the therapeutic relationship (TR)

 Develop and understanding of ‘non-specific factors’ in therapy
 Consider the TR in PCT, psychodynamic and cognitive-behavioural
therapy
 The relationship between TR and the outcome of therapy
 The assessment of the TR
Definitions / conceptualisation
 in the literature, referred to as: therapeutic relationship,
helping relationship, working alliance, helping alliance or
therapeutic alliance (for a review see McCabe and Priebe,
2004)
 “an agreement of goals and sharing of thoughts and
emotions” (Okamoto et al., 2019)
 the therapist described as a companion in a clients’ unique
journey towards core of self (Joseph, 2008)
Bordin’s (1979) tripartite conceptualisation of the therapeutic alliance

Strong bond
between client
and therapist
(attachment)

Agreement
about therapy
processes and
tasks
Agreement
about therapy
goals and
objectives
The importance of the TR within different schools of psychotherapy (a)

 most schools of thought are in accordance - the quality of the TR

contributes to positive outcomes indirectly
 it can influence whether the client will come back after the first assessment,
whether they will feel free to disclose information which is necessary for a
comprehensive formulation, whether they will give therapy a try, whether they
will comply with the processes of therapy, etc.

 some however claim that the TR influences directly the outcome of

treatment
The importance of the TR within different schools of psychotherapy (b)

 Is the TR a ‘common factor’ (or non-specific factor)?

 Some consider it a necessary but not sufficient condition in

psychotherapy.
Those who value empirically supported approaches (i.e., evidence-based
approaches, such as CBT, Schema therapy, Dialectical Behaviour Therapy,
etc.).

 Others consider it the main therapeutic medium – i.e., necessary and

sufficient (→ Client-Centred Approach)
Person-Centred Therapy (PCT) - a

The TR is the backbone of the approach

 encourages self-disclosure (Joseph, 2004), activates the clients

self-actualizing tendency and promotes the healing process
(Rogers, 1959; Edwards and Lambie, 2009).

 Role of the therapist is central (the therapists’ behaviour is clearly

described)
Person-Centred Therapy (PCT) -b

Empathic therapist

 UNDERSTANDING: how the client feels and thinks and what are the problems
and conflicts that s/he is facing
 REFLECTION OF FEELING: mirroring the client’s feelings
 THE CLIENT’S FRAME OF REFERENCE: looking at things through the
perspective of the client – adopting the client’s ‘frame of reference’
 SENSITIVITY: being sensitive to meanings
Person-Centred Therapy (PCT) - c

The TR is characterised by

 Unconditional positive regard - acceptance

 Congruence - authenticity - sincerity

Cognitive-Behavioural Treatment (CBT) - a

TR sometimes necessary but not sufficient for therapeutic change

(Beck et al., 1979, cited in Wills & Sanders, 2020; p.3)
 in the treatment of panic and agoraphobia or compulsive rituals, Exposure Therapy is
often considered to be the main therapeutic element, but without a good TR the person
may not be able to engage with the treatment

…and other times it is crucial to therapy

 e.g. in the treatment of clients who have interpersonal conflicts; the way in which they
relate to the therapist can provide information for a better conceptualisation of their
abilities, experiences and difficulties (Beitman, 2003)
Cognitive-Behavioural Treatment (CBT) - b
 Easterbrook & Meehan (2017) – case study; the TR played an important role in
helping a client overcome depression
 Weck et al. (2015) - the therapeutic alliance scores were significantly lower for
those whose CBT was considered ‘a failure’ when compared to those whose CBT
was considered ‘a success’.
 Zilcha-Mano et al (2016) – study based on 241 client-therapist pairings; the
therapeutic relationship predicted better outcome of treatment
 Still, study had limitations, e.g., 30 sessions, not 5-20 which is the usual in many settings (e.g., NHS)
 Cameron et al. (2018) - meta-analysis of 14 studies of CBT for depression →
treatment outcomes were positively correlated with strength of TR
 Is the TR associated with positive therapeutic outcomes? (i)

 TR has been linked to therapeutic outcome by a significant body of

research
(Horvath, 2001; Arnow et al., 2013; Falkenstrom et al., 2013)

 Meta-analysis, based on hundreds of studies, reported a strong

positive correlation between the TR and outcome
(Horvath et al, 2011)
Confounds, chickens and eggs

Argument 1: It is not the TR that is associated with

outcome, but the treatment-seekers ability to engage
with treatment (→confound)

Argument 2: The TR is not a cause of improvement; it is

a result (a product) of improvement. (→chicken and egg
situation)
When treatment is going well, the therapist tends to be described as…

 Warm
 Attentive
 Interested
 Respectful
 Credible
 Skilful
 Affirming / supportive
 Empathic understanding

(see Lambert & Barley, 2001)

Assessment of the TR

Examples:
 The California Psychotherapy Alliance Scale (CALPAS; Marmar et al, 1989)
 Patient working capacity, patient commitment, goal disagreement, therapist negative
contribution, and therapist understanding and involvement
 The Working Alliance Inventory (WAI; Horvath & Greenberg, 1989) self-rated
with 36 items. Measures the strength of the therapeutic alliance.
 three forms: one for the therapist, one for the client and one for the independent judge.
 Client Attachment to Therapist Scale (CATS; Mallinckrodt et al, 1991): 36-items,
self-report measure; assesses clients’ perceptions of the client-therapist
relationship from the perspective of attachment theory
 Secure
 Avoidant-fearful
 Preoccupied-merger
Summary

 Overview of the role and importance of the therapeutic relationship

 Consideration of its role in PCT and CBT

 Critical approach about its significance

 Assessment

Continue with independent study

 Recommended area to consider: Diversity and difference in the therapeutic
relationship
 Diversity and challenges to the therapeutic relationship / barriers to relating.
References (1)
Arnow, B. A., Steidtmann, D., Blasey, C., Manber, R., Constantino, M. J., Klein, D. N., Markowitz, J. C., Rothbaum, B. O., Thase, M. E.,
Fisher, A. J., & Kocsis, J. H. (2013). The relationship between the therapeutic alliance and treatment outcome in two distinct
psychotherapies for chronic depression. Journal of consulting and clinical psychology, 81(4), 627–638. https://
doi.org/10.1037/a0031530
Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research &
Practice, 16(3), 252–260.
Cameron, S., Rodgers, J. and Dagnan, D. (2018) 'The Relationship Between the Therapeutic Alliance and Clinical Outcomes in Cognitive
Behaviour Therapy for Adults with Depression: A Meta-Analytic Review.' Clinical Psychology and Psychotherapy, 25(3) pp. 446-456.
Edwards, N. and Lambie, G. (2009) 'A person-centered counseling approach as a primary therapeutic support for women with a history
of childhood sexual abuse'. The Journal of Humanistic Counseling, Education and Development, 48(1) pp. 23-35.
Falkenström F, Granstrom F and Holmqvist R (2013) Therapeutic Alliance Predicts Symptomatic Improvement Session by Session.
Journal of Counseling Psychology, (60), 3, 317-328. http://dx.doi.org/10.1037/a0032258
Horvath, A. O. (2001). The alliance. Psychotherapy: Theory, Research, Practice, Training, 38(4), 365–372. https://
doi.org/10.1037/0033-3204.38.4.365
Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48, 9 –16.
Horvath, A.O. and Greenberg, L.S. (1989) Development and Validation of the Working Alliance Inventory. Journal of Counseling
Psychology, 36, 223-233. https://doi.org/10.1037/0022-0167.36.2.223
References (2)
Joseph, S. (2004) 'Client-centred therapy, post-traumatic stress disorder and post-traumatic growth: Theoretical
perspectives and practical implications'. Psychology and Psychotherapy: Theory, Research and Practice, 77(1) pp. 101-119.
Joseph, S. (2008) ‘Humanistic and integrative therapies: the state of the art.’ Psychiatry, 7(5), pp.221-224.
Okamoto, A., Dattilio, F., Dobson, K. and Kazantzis, N. (2019) 'The Therapeutic Relationship in Cognitive-Behavioural
Therapy: Essential Features and Common Challenges.' Practice Innovations, 4(2) pp. 112-123.
Mallinckrodt, B., Gantt, D.L. and Coble, H.M. (1995) Attachment Patterns in the Psychotherapy Relationship: Development
of the Client Attachment to Therapist Scale. Journal of Counseling Psychology, 42, 307-317. https://doi.org/10.1037/0022-
0167.42.3.307
Marmar, C. R., Gaston, L, Gallagher, D, & Thomson, L. W (1989). Alliance and outcome in late life depression. The Journal
of Nervous and Mental Disease, 177, 464-472.
Rogers, C. (1959) 'A theory of therapy, personality, and interpersonal relationships'. In Koch, S. (ed.) Psychology: A Study
of a Science. New York: McGraw-Hill, pp. 184-256.
Weck, F., Grikscheit, F., Jakob, M., Hofling, V. and Stangier, U. (2015) 'Treatment Failure in Cognitive-Behavioural Therapy:
Therapeutic Alliance as a Precondition for an Adherent and Competent Implementation of Techniques.' British Journal of
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