This essay will define an effective therapeutic relationship and discuss its role in producing positive therapeutic outcomes. For this purpose the fundamental core qualities as conceptualized by Rogers and Bordin needed to form a therapeutic alliance will be identified and discussed and linked to positive therapeutic outcomes. Drawing together these discussions and other identified fundamental qualities leads me to the hypothesis that therapeutic outcomes rely heavily on the therapist’s commitment to their own internal work and subsequently their ability to integrate this depth of awareness into real contact with clients in order to facilitate change.
What is an effective therapeutic relationship?
The therapeutic relationship is fundamentally the relationship between the therapist and client specifically defined by the purpose of supporting the client to find a more satisfying way of living (McLeaod & McLeaod, 2011). Contained within the relationship is the internal view of both the therapist and client regarding their connection, its effectiveness therefore relies on the nature of these views and their ability to support positive outcomes (Priebe and McCabe, 2008; and Norcoss & Wampold, 2011). The importance of the therapeutic relationship is shown in Lamberts (1992) four factor model of change which identifies the therapeutic relationship as being the largest therapist associated component affecting therapeutic outcomes (Sprenkle & Blow, 2001).
Bordin (1979) first conceptualized the therapeutic alliance as containing three factors; the emotional bond between the therapist and client, the agreement of treatment goals and understanding of tasks needed to accomplish those goals. Bordin further hypothesized that the strength of the relationship is the greatest prediction of therapeutic outcomes rather than the type of relationship (ibid).
How does a counsellor develop an effective therapeutic relationship that facilitates the change process?
Extensive research highlights the therapist’s ability to embody fundamental qualities as crucial in developing a facilitative environment that allows for deep contact with the client and therapeutic change (Corey, 2009; Sprenkle & Blow, 2001; and Norcross & Wampold, 2011). Rogers first conceptualized these qualities as congruence, unconditional positive regard and empathic understanding and linked there efficacy in facilitating positive therapeutic outcomes (Corey, 2009; and Rogers, 1957).
Congruence as an interpersonal skill implies authenticity on the therapist’s behalf, the action of attending to the therapy process with an intention to be present and genuine in the interests of building a trusting connection and environment for change (Greenberg & Geller, 2001). When applied to Hills (2004) three step model of change, congruence in the exploration stage of the therapeutic process does not stand alone but rather influences the nature of the therapist’s interaction (McLeod & McLeod, 2011). For example Hill identifies the following skills needed to establish rapport; questioning, attending, listening, silence and reflection, congruence in this example is the shell that contains these skills and influences their ability to yield therapeutic outcomes (ibid). With the therapist’s congruence, also referred to as a grounded presence, the client learns to trust in the relationship, is modelled healthy relational dynamics, which in turn supports their internal understanding, acceptance and healthy expression of their own values, attitudes and beliefs (Mann, 2001; and Greenberg & Geller, 2001).
Unconditional positive regard is the ability of the therapist to accept the client in their totality in a positive light without any need to change their experiences and feelings or identify them as wrong (Rogers, 1957; and Mann, 2011). This has particular validity in the cultural context, if the therapist holds the clients cultural values and sensitivities with respect and positive regard the therapist can integrate culturally appropriate techniques that are individually successful, further supporting a strong therapeutic connection (Corey, 2009, p.45). Iberg (2001) points to the positive outcomes from attending to the client with unconditional positive regard as a decrease in defensiveness and a greater sense of self worth. This is shown to have huge impacts on the experiences of the client within their environment by influencing new ways of behaving and being in the world that stems from a new level of self worth (ibid).
As defined by Rogers (1957, p.98) empathy is: “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view”. Importantly empathy is more than just an understanding of the clients experience; it contains the therapist’s capacity to see beyond the feelings of the client and offer an understanding that will help foster a level of awareness that lies beyond the client’s current capacity (Corey, 2009). Watson (2002, as cited in Corey, 2009) draws attention to the cognitive and emotional transformations that occur within the client as a by product of empathic understanding.
Literature suggests that across all theoretical positions, though more pronounced in the humanistic therapies, empathy is an essential and indispensable component of the therapeutic alliance and is inseparable from other relational components (Feller & Cottone, 2003; and Norcross, 2002). Clark (2010) posits that this level of understanding and feeling as described by Rogers is the cornerstone by which the client’s perception of psychological threat is lessened, therefore allowing the sharing of vulnerabilities and confidences that deepen the emotional bond between the client and therapist. An emotionally supportive backdrop brought about through empathic understanding increase the client’s level of therapeutic satisfaction and safety which is suggested to enhance the likelihood of adhering to and actively participating in the treatment process (Bohart, Elliot, Greenberg, & Watson, 2002)
Stemming from humanistic theories Ivey, Ivey & Zalaquet (2010) proposed the integration of micro skills which rest on the foundations of ethics, multicultural awareness and wellness as pivotal in creating the right type of therapeutic relationship that will enable clients to grow. The microskills hierarchy indentifies the importance of key attending behaviours such as “eye contact, body language, vocal qualities and verbal tracking” and their role in supporting other microskills such as listening skills, interviewing, confrontation and personal integration and style. (Ivey et al, 2010, p.14).
Microskills theory focuses heavily on the therapists need to recognize cultural and individual differences within each therapeutic relationship and act according to those differences, rather than being fixed on a particular approach (Corey, 2010). Ivey et al (2010, p.16) posit that “microskills are meaningless” if they are not built on the grounds of respect and cultural sensitivity. Much similar to Rogers core concepts it could be surmised that the hierarchy of microskills as suggested by Ivey are not the core determinant of an effective therapeutic relationship but rather its the foundations on which they are built; cultural awareness, respect for the individual and the therapists ability to modify treatment to suit these differences.
Ottens and Klein (2005) highlight the potential for differing perceptions of the therapist and client regarding the quality of their connection which draws attention to the need for the therapists skilful monitoring of the therapeutic relationship. This fundamental skill supports the relationship by identifying and repairing alliance ruptures that could have possibly resulted in early treatment termination (Safron, Muran, & Carter, 2011). Literature further indicates that negotiating alliance rupture supports the client in identifying their needs as important without the fear of damaging the relationship, further providing them with corrective emotional and relational experiences whilst also strengthening the alliance (Safran & Muran, 2000).
The agreement between the therapist and client of goals and tasks as suggested by Bordin, is imperative to the development of a collaborative and purposeful therapeutic relationship. Literature suggests this component considerably effects treatment adherence and success through developing clear expectations of treatment outcomes (Bordin, 1979; and Corey, 2009). Goals aim to set the framework of therapy through identifying the client’s dissatisfaction and frustrations, which allow the therapist to engage in and manage a therapeutic journey that matches the client’s expectations, goals and needs (Banerjee et al, 2009; McLeaod & McLeaod, 2011).
The ability for the therapist to tune into the client’s limits whilst also providing an environment that challenges the client is imperative in building a facilitative environment for change (Mann, 2010). Therapeutic experiments such as gentle confrontation, voice dialogue or empty chair work are set within the individuals limits and shaped by existing field conditions including moral and ethical boundaries. Therefore it is the therapist’s skill of presence, mindfulness and empathic understanding that will reveal the moments in which experimentation will be an effective tool.
This essay has shown that within a therapeutic environment that is sufficiently holding the therapist can effectively support the client in exploring uncomfortable territory they have otherwise avoided. Through the exploration of this territory the client is supported to become aware of their current experiences in relation to their past experiences, bringing with it a gift of transformational, experiential learning.
It has been shown that the form of theoretical engagement is a key element in the therapeutic process but at the core is the therapist’s ability to be mindful and present to what is required at any given time regardless of the theory associated with it. Through the exploration of the fundamental qualities of effective therapy it is suggested that a movement is needed away from the techniques and methods applied to the client and more towards the therapists need for self exploration and personal therapeutic work for the effective embodiment of the core qualities supportive of change. Furthermore it is unreasonable of the therapist to expect the client to venture to areas they themselves have not explored.
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