The Therapeutic Relationship Essay
In the assigned chapter, Bohart and Tallman (2010) discussed clients and their effect on therapy. They argued that client and extratherapeutic influences are the single most important factor in determining therapy outcome. In fact, up to 87% of the variance in therapeutic outcome is attributable to the client, factors that occur outside therapy, and unexplained variance (Bohart & Tallman, 2010, p. 84). Bohart and Tallman further argued that approximately 40% of variance can be ascribed to client factors while only 13% can be accounted for by treatment (e.g., the therapeutic relationship, interventions, therapist, model of therapy). Unfortunately, traditional conceptualizations of psychotherapy have largely ignored these client factors (Bohart & Tallman, 2010, pp. 92-84). Instead, the focus has been on the therapeutic process, the therapist, and his or her interventions, which do not contribute as much to therapeutic outcome as client factors. According to Bohart and Tallman, it is clear that more attention must be given to the critical effect clients have on the outcome of therapy (pp. 94-95).
First, Bohart and Tallman (2010) discussed the role of the medical model in psychotherapy (pp. 92-94). The medical model focuses on diagnosis and specific treatment based on that diagnosis. Bohart and Tallman said that the medical model of psychotherapy is not supported by research. They said that research shows that “all bona fide therapeutic approaches work about equally well, regardless of diagnosis… Research also challenges the importance of technique” (Bohart & Tallman, 2010, p. 92). They also discussed the inconsistent findings regarding professional training and therapeutic outcome. Last, they pointed out that, although both the person of the therapist and the therapeutic alliance have been shown to contribute to positive therapeutic outcome, positive change can occur without a therapist. Bohart and Tallman even cited research showing that therapy and self-help were about equally effective.
While I agree that more traditional conceptualizations of psychotherapy are not always beneficial to clients, I believe the authors over-simplified this discussion. For example, EMDR and CBT have been proven effective in treating Post-Traumatic Stress Disorder, significantly more so than other types of therapy. In other words, while Bohart and Tallman (2010) made a valid point, they overlooked other valid research that contradicts their position. Even their brief discussion about the “exceptions” to their argument served to support their conclusions about people’s capacity for change.
A second key point that Bohart and Tallman (2010) made pertained to listening (pp. 98-99). “You are not listening until the client says you are” (Bohart and Tallman, 2010, p. 99). That quote made me think about how important it is to make sure the client feels understood. The focus should not be on my understanding of the client, but rather on if...
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Modern counseling models and techniques are as varied and diverse as the counselors and clients who use them. Most counselors have a particular theory, method or school of thought that they embrace, whether it is cognitive behavior therapy, solution-focused therapy, strength-based, holistic health, person-centered, Adlerian or other. Yet all of these approaches and techniques have at least one thing in common — their potential effectiveness is likely to be squelched unless the counselor is successful in building a strong therapeutic alliance with the client.
The crucial nature of the therapeutic alliance is not a new idea. In 1957, Carl Rogers wrote an article in the Journal of Consulting Psychology outlining the factors he considered necessary for achieving constructive personality change through therapy. Four of the six items directly addressed the client-therapist relationship. Rogers asserted that the therapist must:
- Be genuinely engaged in the therapeutic relationship
- Have unconditional positive regard for the client
- Feel empathy for the client
- Clearly communicate these attitudes
In the decades since Rogers’ article was published, many other studies have explored the therapeutic alliance. In 2001, a comprehensive research summary published in the journal Psychotherapy found that a strong therapeutic alliance was more closely correlated with positive client outcomes than any specific treatment interventions.
So, what constitutes a therapeutic alliance?
“Most scholars who write about the therapeutic alliance describe it as a relational factor in counseling that includes three dimensions: goal consensus between counselor and client, collaboration on counseling-related tasks and emotional bonding,” explains American Counseling Association member John Sommers-Flanagan. “The best ways to form and strengthen the alliance are specific counselor behaviors that contribute to those three ‘alliance’ dimensions. Focusing on these dimensions helps grow the therapeutic relationship.”
“For example, goal consensus or agreement involves listening closely to the client’s distress and hopes and then being able to articulate that distress and hope back to your client,” says Sommers-Flanagan, an author and associate professor in the Department of Counselor Education at the University of Montana. “This can happen from any theoretical orientation. For a cognitive behavioral therapist, it could include collaboratively generating a problem list. For a more existentially oriented counselor, it could involve asking the client ‘What do you want?’ and then gently exploring the many nuanced dimensions of how your client answers that question.”
“Collaboration on counseling-related tasks can involve nearly any task that is clearly described and that clients understand as related to their problems or goals,” he continues. “This could involve everything from taking a social history to implementing a progressive muscle relaxation procedure.”
“Emotional bonding between counselor and client is different for every unique counselor and client,” Sommers-Flanagan says. “It might involve compassionate or empathic listening or humor, or just sitting together while the client experiences strong emotions, or giving positive and supportive feedback to clients.”
The power of relationship
Although it may be next to impossible to find a counselor who doesn’t agree that bonding with clients is important, becoming overly reliant on technique and method still poses a common temptation for many professionals.
“Counselors are in love with their techniques and interventions,” ACA member Jeffrey Kottler says ruefully. “We hungrily buy books and attend workshops hoping for the next latest and greatest breakthrough.”
Kottler appreciates what research into evidence-based practices and promising theories can contribute to the counseling profession’s body of knowledge. At the same time, he contends that specific techniques aren’t nearly as important to the therapeutic process as some practitioners might think.
“I can recall few instances, either from research studies or my own practice, in which clients reported that it was some singular technique or intervention that was most helpful to them,” says Kottler, a prolific author, researcher and professor of counseling at California State University, Fullerton. “Instead, they so often say that they felt heard and understood and valued by their counselor. They talk a lot about the power of the relationship.”
“[Obviously] in many cases, clients need a lot more than feeling understood or enjoying the benefits of being in a respectful, facilitative alliance,” he adds. “Yet without the foundation of a constructive relationship, anything else that we do isn’t going to work very well or last very long.”
After all, one key to effectively addressing a client’s issues is to first understand those issues within the context of the client.
“It’s critical for the counselor to learn the client’s worldview in order to enhance cooperation in the counseling process,” says ACA member Jeffrey Guterman. When counselors diagnose the problem and launch into a prescribed method of treatment without first discussing the client’s concerns and goals, they are likely to be met with resistance, explains Guterman, a licensed mental health counselor (LMHC) in Fort Lauderdale, Florida, and the author of Mastering the Art of Solution-Focused Counseling, published by ACA.
It is also difficult to accomplish true change unless the counselor is listening to what the client wants, not what other people think the client needs, says Guterman.
He recalls one client in particular. “I had a case of a 71-year-old man with alcohol abuse who was persistently resisting efforts by several mental health professionals, relatives and friends to get him to go to Alcoholics Anonymous (AA). He had a long history of alcoholism, but all along he insisted he didn’t believe in a higher power. Other professionals said to him, ‘It doesn’t have to be religious; it could be spiritual.’”
Rather than dismissing the man’s objections to AA, Guterman took the time to listen and attempt to understand where he was coming from. The client had previously tried treatment programs that followed the AA model, Guterman says, but he always ended up drinking again. “When he was referred to me, I assessed that he was an atheist and that this was the defining worldview in his life,” Guterman notes. “That was the main barrier to his entering into treatment.”
Guterman referred the client to a program that took a secular approach to treatment rather than asking those in recovery to focus on a higher power. The man felt validated and listened to by Guterman and willingly accepted the referral into treatment.
Guterman says it is not uncommon for people wrestling with alcohol or drug abuse to reject the idea of addiction and thus be unwilling to consider abstinence. Some clients come to treatment seeking only to control their drinking, he says, and under the AA model, these individuals would be considered in denial. Although it might be best for people who struggle with alcohol abuse not to drink at all, Guterman says, if a client isn’t ready to consider that option, he believes it is better for a counselor to address what goal the client is ready to work on, such as controlling alcohol intake. Otherwise, the client may drop out of treatment altogether, which means he or she isn’t getting any help at all. But if a counselor meets the client where he or she is, there is always the possibility of change, Guterman says.
Giving clients room
“It’s a difficult lesson to learn — to allow space for the client to take the session where he or she wants it to go and at the pace he or she feels comfortable with,” says ACA member Olga Gonithellis, an LMHC in New York City. “This requires therapists to challenge their automatic tendency to want to direct the session and [instead] approach certain topics only when the client has opened the door.”
Allowing the client space while simultaneously trying to establish communication, and ultimately an alliance, sometimes requires a bit of creativity and a lot of patience on the part of the counselor, Gonithellis notes.
“An adolescent girl came to see me after her psychiatric hospitalization for suicidal ideation,” she recalls. “For the first three to four sessions, she refused to talk about the incident, made minimal eye contact and played with her cell phone during the session while repeatedly stating that she didn’t need therapy.”
Initially, Gonithellis alternated between giving the girl space to be silent and validating her emotions, but the client remained distant.
“The next time she came in, I had brought some magazines, glue and scissors,” Gonithellis says. “I told her, ‘I know you don’t want to talk, and I’m OK with that. But instead of just sitting here in silence for the next 45 minutes, maybe we can go through these magazines together and cut out pictures that we like and create a collage. Is this OK with you?’ and she nodded yes. Her affect and energy level changed drastically as she became more present and animated. We spent the session being verbally silent, yet speaking through our selection of images.”
In the next session, the girl made more eye contact and seemed more comfortable. In subsequent sessions, she continued to grow more relaxed and less guarded. “It seems like presenting her with another way of connecting was meaningful and symbolic of being willing to meet her halfway,” Gonithellis says.
For Clayton Martin, meeting clients halfway was a little more complicated, requiring him to stare down hostility and, in some cases, even household implements. Martin, an ACA member, started his career by providing in-home counseling as part of a Medicaid-funded community health program in Fort Lauderdale. His clients were troubled youths who were in counseling only at the insistence of a parent or other authority figure. And these adolescents definitely did not want Martin in their homes.
“I’ve had young people come at me with a fireplace poker the minute I set foot in the house,” he recounts. “I’ve had children display extreme resistance. I’ve been the eighth counselor to come into the home … where the seven counselors that preceded me just wagged a finger at this kid or were completely out of touch with [the client’s] worldview and just tried to enforce discipline.”
Rather than being intimidated, Martin sought to understand what was behind each client’s bravado and anger. “The first step when you walk into the home and this kid is demonstrating extreme resistance, cussing you out, coming after you or just ignoring you is to just roll with it,” he says. “Accept it, don’t show any fear and don’t show any anger.”
Martin tried to look at the situation from the adolescents’ point of view. “They may have been set up to distrust authority figures or helpers. Instead of letting myself get thrown off by a violent reaction, [I would] accept what they were doing as a natural and understandable personal safeguard,” he says.
When it comes to adolescents, Martin says, counselors cannot fake a sense of acceptance or a willingness to understand their stories. Adolescents know when they are being lied to, he says. “Insincerity is blood in the water to the youth client. They know when someone is being genuine, and they know when someone is not being genuine,” Martin notes.
Retreating into the role of the authority figure or trotting out scripted “advice” is a sure way to lose (or never gain) the trust of these clients, Martin says. “But if you can just stand there and let them blow themselves out like a hurricane, showing no fear, showing acceptance of how they feel, eventually [most of them] will come around,” he says. “They’ll see that you’re not there to wag a finger at them, that you are not going to treat them with kid gloves or from a certain distance because you are frightened of them, and they’ll open up.”
Validation, acceptance and empowerment
Another critical part of getting young clients to open up is making them feel heard and understood, Martin says. “The next part of this process for me is to validate their story. [I’ll say something] like, ‘Hey, it’s obvious that you don’t like me being here. I can’t say I blame you. If some strange guy were to walk into my house who my mom had made show up because I’m not acting right, I wouldn’t want him there either. I’m just wondering whether you can tell me a little bit about some of the counselors you might have seen in the past or the things that led up to your mom thinking I needed to be here.’”
Validation and acceptance are necessary parts of any therapeutic intervention, regardless of the client population, notes Gonithellis. “Allow room for feedback [and] keep checking in every so often,” she urges. “By making space for clients to give feedback about the counseling process, the therapist shows acceptance of the client’s sincere feelings, good or bad. Simply asking a question such as ‘How are we doing?’ or ‘Are these sessions helpful?’ gives clients the chance to express themselves, while conveying the message that their reactions, positive or negative, will be heard and respected.”
Lauren Ostrowski, a licensed professional counselor and ACA member in Pottstown, Pennsylvania, concurs. “Meet the client where they are,” she says. “This is true even if this means spending five minutes on topics that are important to the client that may not be directly related to the reasons they are coming into counseling.”
Allowing clients to stray from an ordained course to touch on these tangential — yet personally important — matters can help clients feel that the counselor sees them as more than just a set of symptoms or a diagnosis, Ostrowski says. In addition, these tangents often reveal important information about the client and empower them in session, which can further cement the therapeutic alliance, she says.
Enthusiasm for the work can be a boon to the counselor-client relationship as well. “I love working with the troubled youth clientele,” Martin says. “I love working with the kids who are going to come at you with a fireplace poker and cuss you out magnificently on the first session because … if you have good chemistry with these guys and the appropriate background and a fire for working with that clientele, you can do some amazing things with them.”
But sometimes, despite attempts to offer respect, validation and space, client and counselor still don’t click. Is it time to throw in the towel when both the client and counselor are frustrated?
Not necessarily, says Guterman, who reiterates the importance of first learning the client’s point of view. In such situations, he recommends that counselors again ask themselves if they have made their best effort at thoroughly understanding the client’s worldview.
If that’s not the problem, Guterman suggests evaluating the pace of the counseling sessions’ progress. “Are you pacing with the client? All clients are different, and some clients prefer to go slow,” he says. “You [the counselor] may be solution focused, but if you go too fast, the client who is very problem focused may think that the problem is being stolen away from them.”
Even counselors who have absorbed a client’s worldview may forget that it is the client who ultimately is in charge. The client will define the goals that he or she would like to achieve.
“Let the client determine what is most important,” Ostrowski advises. “Sometimes what seems small to a counselor may be the most crucial element of what is happening in a client’s life right now.”
It may also be helpful, both for strengthening the therapeutic alliance and for therapeutic progress, to shift the perspective periodically, Ostrowski says. Although the client is most likely coming in for counseling because he or she is unhappy or wants to change something, most clients can think of something in their lives that is going well, she says. “Allow for some positive discussion,” Ostrowski suggests. “Thinking of something that is going well … can provide a springboard for discussing strengths that can help with parts of their life that they would like to change.”
Another approach that can benefit the therapeutic alliance is subtly reminding clients that counselors are human too, with lives and interests that extend outside the office, Ostrowski says. For example, briefly talking about a movie that a client has seen recently can be a nonthreatening way to build or strengthen rapport, she notes. Some counselors might balk at engaging in these brief personal interludes, but Ostrowski believes they are helpful in connecting with clients. “Is there really any harm in spending less than a minute to discuss how loud the Fourth of July fireworks were this year?” she asks.
In cases in which a lack of therapeutic alliance exists, it is always tempting to look at the client as the source of the problem, but counselors should also look in the mirror, Guterman says. “We always tell our clients the only one you can change is yourself. This applies to us counselors too,” he asserts. “If we’re not connecting with our clients, what can we do differently?”
Guterman acknowledges, however, that it is particularly difficult to connect with clients who have been mandated to counseling. These clients, typically ordered into therapy by the courts because they have a history of being abusive parents or spouses, or because they have problems with anger or substance abuse, simply do not want to be there.
Similar to the approach Martin took with his angry adolescent clients, Guterman finds it best in such cases to get straight to the point. “Usually, the best thing is to join with the client and say, ‘Yeah, I can understand that you don’t want to be here. I wouldn’t either. But since you are here, what do you want to work on?’ … Enhancing cooperation rather than creating resistance is important,” Guterman emphasizes.
Another part of enhancing client cooperation, and thus strengthening the therapeutic alliance, is for counselors to demonstrate knowledge of and respect for diversity and multiculturalism. Possessing an understanding and appreciation of the client’s culture can play an important role in the approach a counselor takes.
For instance, abusive parents who get sent to court-mandated counseling might think there is nothing wrong with hitting their children. This could be because the parents come from a background or culture in which hitting is an acceptable form of punishment or discipline. Regardless of the parents’ reasoning, a counselor is not likely to be able to change that mindset.
“If you say hitting is never necessary, you’re going to get shut down,” Guterman says. “So you ask, ‘What is your goal?’ And often they will say, ‘To get these people off my back.’’
Guterman then summarizes the reality of the situation: If they hit their children again, their children will be taken away from them. This creates an impetus for the parents to let Guterman teach them other ways of disciplining their children.
In certain cases, however, counselors might find that they cannot make the unwilling client willing, despite applying all their skills.
“I’ve been in situations where I’ve exhausted my tool kit,” Martin acknowledges. “The next thing I will do is go to the parent and say, ‘They’re [the child is] not ready for counseling. Maybe they’re ready for a different sort of intervention — a wilderness program or something like that — but they’re not ready for counseling now.’”
Martin then would give the parents his card and invite them to call him if the situation changed. “I make sure that the client is there when I say to them directly, ‘If you change your mind and get to a place where you feel like we can do some work together, please give me a call,’” Martin says.
On occasion, the parents still didn’t want Martin to stop the counseling sessions with their child, so Martin kept going back and doing whatever he could.
“I had a kid who fought with me and ignored me for a year,” he recounts. “We had two conversations that led to some sort of therapeutic benefit, and at a point when he was really acting up and fighting a lot in school, I took this kid on a tour of an alternative school [for troubled children], and that turned out to be therapeutic. He decided he did not want to stay on track to go to the alternative school and made some adjustments to his behavior. Ultimately, that’s what got him out of therapy, because that’s what got him to stop getting into trouble.”
“So,” Martin says, “even if what we would consider counseling wasn’t effective, I was able to do something that produced a positive result for the guy.”
Constantly hitting walls while trying to connect with clients was tough, admits Martin, who eventually left his position as an in-home counselor and is now working with youth at a substance abuse center. But he doesn’t think his efforts were in vain.
“In some way, shape or form, I feel like I’ve connected with everybody, even the folks who have terminated on me or have found therapy to be unsuccessful on the whole,” he says.
Martin credits one of his first mentors with helping him understand that. “I came to her with a difficult case and asked, ‘What do you do with the person who won’t work, with the person who resists everything?’” Martin remembers. “And she said, ‘You accept what they’re doing and accept where they are on their personal journey, and you plant a seed and hope that it opens up later.’”
A spirit of excitement
Martin believes there is something — however small — that he can connect to on some level with every client, and that’s what motivates him to keep coming back.
“With everyone I counsel, no matter how much they despise me or how much they resist, I try to bring a spirit of excitement to the relationship,” he says. “[A spirit] that I can’t wait to come and have another session with them because there’s something about them that I find intriguing, something I want to learn and there’s something that I’m really excited to continue discussing with them.”
“I just try to convey that element of acceptance, of excitement,” Martin says. “So no matter what behavior they are manifesting, there is something really worthwhile [about them]. … Like that kid I fought with for a year. He was strong. That kid held on to a poker face for a year and didn’t flinch. And that made him interesting to me. I wanted to know how else that toughness manifested itself.
“And sometimes we’d have conversations about it [the client’s toughness] that would put half a smile on his face. I’d like to think that he looked back on those conversations later and thought, ‘Hey, maybe that guy was on to something and I can use this thing that I’ve got for a different purpose.’”
At the same time, Martin cautions that a counselor’s interest in and excitement about clients has to be sincere, particularly with those who don’t want to be in counseling in the first place. “If you fake it, they will smell it, and they will hate you more than ever,” Martin says.
At the end of the day, a counselor’s authentic desire and determination to connect may be at the heart of the therapeutic alliance.
“Maybe I am young and naïve, but I think that you can really find something intriguing, redeemable or enjoyable about any client,” Martin asserts. “If you dig hard enough, you’re going to find something about the kid that’s going to make you want to come back the next week. And once they sense that about you, it’s a game changer like no other.”
Jeffrey Kottler and Richard Balkin will be giving a keynote on “The Power of Relationships in Counseling — and the Counselor’s Life” at the ACA Conference & Expo in Orlando, Florida, in March.
To contact the individuals interviewed for this article, email:
Laurie Meyers is the senior writer for Counseling Today. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org
Professional Issues, resistant clients, therapeutic alliance, therapy