Therapeutic Relationship

Six blind men were asked to determine what an elephant looked like by feeling different parts of the elephant's body.
The blind man who feels a leg says the elephant is like a pillar; the one who feels the tail says the elephant is like a rope; the one who feels the trunk says the elephant is like a tree branch; the one who feels the ear says the elephant is like a hand fan; the one who feels the belly says the elephant is like a wall; and the one who feels the tusk says the elephant is like a solid pipe.
A wise man explains to them
All of you are right. The reason every one of you is telling it differently is because each one of you touched the different part of the elephant. So, actually the elephant has all the features you mentioned [1]

Introduction The Therapeutic Relationship.

During the last two decades a substantial body of literature concluded that the therapeutic alliance makes important and consistent contributions to therapeutic outcomes (Horvath & Symonds, 1991). Empirical research on the therapeutic relationship in general and the therapeutic alliance has been growing (Horvath, 2001). The results of these investigations have been summarized and synthesized in a number of significant studies (Horvath & Bedi, 2002; Martin, Gaske & Davis, 2000). Freud (1940) coined the notion of therapeutic alliance by emphasizing the importance of the “pact” between the analyst and the patient who “band” themselves together with a common goal based on the demands of external reality.

More and more research studies have identified the relationship between the client and the therapist as the major influence on the effectiveness and outcomes of therapy (Cooper 2004; Norcross, 2002; Ackerman & Hilsenroth, 2003; Burns & Nolen-Hoeksema, 1992; Cooley & Lajoy, 1980; Luborsky, McLellan, Woody, O'Brien, & Auerbach, 1985). Greenberg and Safran (1989) noted that the positive working alliance between therapist and client foster the necessary conditions for a client to express and explore any inner feelings and simultaneously facilitates a safe space to experiment with new behaviours and the completion of therapeutic task. Evidence also suggests that the alliance is particularly predictive of outcome when measured early in treatment. Furthermore, poor early alliance predicts client dropout (see Constantino et al., 2002).

This early psychodynamic perspective was further advanced by Zetzel, (1956), who introduced the term therapeutic alliance as a conscious, collaborative, rational agreement between therapist and client. These authors perceived the alliance as helping rather than directly effecting any change. They also emphasized the unconscious (positive) transference conceptualization (Zetzel, 1956).

A transtheoretical explication of the therapeutic relationship is provided by Clarkson (1990), who posited five forms of relationships. These are the working alliance, the transferential/countertransferential relationship, the developmentally needed/reparative relationship, the person to person/real relationship and the transpersonal relationship. In a similar vein, Karasu (1994) describes three modes of relating which pertain to the experiential, behavioural, and psychodynamic schools of psychotherapy. These are the human alliance, the teacher-pupil and the parent-child relationship, respectively.

Clarkson (1995) advocates that the most important factor in effective psychotherapy work lies in the creative space between and in the relationship. Clarkson also coined the notion that the relationship is not another meta-narrative and argued for an integrative framework with five kinds of relationships as part of a conceptual matrix, and that all five of these relationships overlap and interlink with each other. Clarkson (1995) describes the multiplicity of relationships in psychotherapy and provides a new framework to understand and guide practitioners in the journey of the therapeutic relationship. Clarkson identified an integrative psychotherapeutic framework with five different relationships occurring at the same time as part of a complex matrix system. These are the working alliance, the transference-countertransference relationship, the developmentally needed or reparative relationship, the person to person or real relationship and the transpersonal relationship. Clarkson suggests a five relationship framework, and that these relationships should not be considered as different stages but rather as different states in psychotherapy that co-exist within a client’s unique experience in therapy.

Particularly interesting is the management of the transpersonal relationship and the way Clarkson advocated a new grid to differentiate seven types of universes of discourse, and to encompass the transpersonal experiences in the therapeutic relationship within a seven-level model (i.e, physiological, emotional, nominative, normative, rational, theoretical, transpersonal).

Another perspective on the therapeutic relationship emerged in the 1950s. This school of thought considers the therapeutic relationship as real and based primarily on the here and now of the therapist-client encounter (Rogers, 1957; Yalom, 2002; Cooper, 2004; 2005; Spinelli, 1997; Strassser, 1999). A substantial body of evidence suggests that the quality of the therapeutic relationship is one of the key factors in determining outcomes (Cooper, 2004; Norcoss, 2002). The consistent failure to find differences in the efficacy of different forms of psychotherapy, and the therapy nonspecific factors, with a significant unexplained proportion of the variance fosters the attention of research on the therapeutic relationship (Lambert 1983).

Luborsky et al., (1986) cited findings from the data of four major outcome studies, showing how the personal competencies of the therapist contribute more significantly to the outcome of the therapy than the treatment modality effects. From his findings, Strupp (1980) argued that a major factor distinguishing poor outcome cases was the therapist’s difficulty in establishing a good therapeutic relationship with the client. Strupp (1980) inferred that such difficulties for the therapist might emanate from a negative interaction cycle, in which the therapist responds to the client’s hostility with counterhostility. In this context the therapeutic alliance has emerged as a concept of great importance. The idea that the relationship plays an important role across different helping contexts is central to the understanding of the alliance. Tacit assumptions about the nature of the alliance in therapy have not yet been fully examined. Nevertheless a number of important studies have shown that the alliance is significant in just about any form of therapy, regardless of the particular approach employed (Hovath & Bedi, 2002; Martin et al., 2000; Luborsky, Singer, & Luborsky, 1975; Shapiro, 1985; Smith & Glass, 1983).

The growing volume of research on the alliance focuses on exploring the relation between the alliance and therapy outcomes across various helping contexts such as different types of treatments, diverse populations, gender effects, therapist training and experience (Horvath 2005). The question is whether the alliance is in itself a curative component of therapy or whether the quality and process of the relationship creates the interpersonal context for other therapeutic elements. Perhaps one route to better understanding alliance development, maintenance, and negotiation is to study the views of experienced therapists to determine, for example, how they first establish a good alliance, the flow that the alliance tends to take during the process of therapy with both engaging and less responsive clients, and how they manage or fail to manage the alliance and to balance these complex issues with different types of clients. The question whether the alliance is essentially an intrapersonal process or an interpersonal phenomenon also needs to be considered. It is interesting to note that the evidence appears to support both perspectives (Horvath, 2005). The consistent superiority of the client’s self-reported perspective as opposed to any observational measures in predicting outcome suggests the intrapersonal position (Horvath & Bedi, 2002).

At the same time large-scale studies across a wide range of populations and types of assessment methods reported “enthusiastic collaboration’’ as the single most consistent indicator of a positive alliance

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