You may be a skilled therapist. But without a solid therapeutic relationship, your effectiveness is severely blunted. This article examines essential qualities for both the therapist and the therapeutic alliance.
Related article: The What and Why of the Therapeutic Alliance
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Introduction
Perhaps you are familiar with this experience that, sadly, many new clients to counselling and psychotherapy have had. The client is ushered into a comfortable therapy room with myriad framed diplomas and other recognitions of achievement on the wall, certifying that the therapist in residence is a member in good standing of that burgeoning group known as mental health professionals. The client is invited to sit down and asked how the therapist can help. The client begins to relate their tale of woe, but it all goes downhill from there. The therapist, possibly overwhelmed by the problem, generally burned out, or simply mis-attuned with fatigue, is unable to grasp the essence of the client’s angst. The client pays the fee at the end of the session, but leaves feeling unseen, unheard, and even more despairing and hopeless than before. What just happened? Or rather, what did not happen? In this article we examine the characteristics widely held to be necessary in a therapist and the qualities of a workable therapeutic alliance. First, though, we note that therapy typically has several phases.
The two phases of therapy
While we detail below the qualities generally regarded as essential for the therapist and also for the therapeutic relationship, bear in mind that different strengths of each are salient at different stages of the therapy. Ardito and Rabellino (2011) outline two clear phases in establishing a healthy therapeutic relationship.
Phase 1: The coming together
In relatively short-term therapy, the alliance becomes largely established in the first five sessions, peaking around the third. Typically, during this period, client and therapist agree on goals, begin to share a sense of collaboration and mutuality, and develop rapport (defined as having confidence in the other person to do what they have come together to do). Thus, the client develops confidence and trust in the therapist and in the therapeutic process, and the therapist comes to trust that the client really does wish to improve their life and is at least somewhat committed to the process and open to changes that may help that happen.
Phase 2: The challenges begin
As the alliance begins to feel like a more solid and genuinely supportive container, the therapist gently begins to challenge the thoughts, emotions, and behaviour patterns of the client which are maladaptive or irrational. Perceiving (perhaps unfairly) that they are being viewed as somehow “wrong” or “ineffective”, clients can doubt the empathy or support emanating from the therapist and this can temporarily weaken the relationship or cause a therapeutic rupture. A rupture can affect clients’ commitment to the therapy process leading to premature termination. If the therapist is attuned enough to notice and repair the rupture early on – skilfully – the alliance can become even stronger, with even greater prospect of successful outcomes (Ardito and Rabellino, 2011; Sutton, 2023).
Let’s look first at the qualities in the therapist which facilitate rupture repair and continued building of the relationship.
Essential therapist characteristics
The therapist-client relationship has many components, and each relationship – even within a single therapist’s practice – is unique and different from all others. Factors such as the type and severity of the problem for which the client has presented, the client’s maturity and level of self-awareness, the client’s belief that the counselling will work (expectancy), and the skill of the therapist all impact on the ultimate outcome. That said, the following characteristics are almost always found when the relationship “works” (and surprise, surprise, we channel Carl Rogers here). As you read each characteristic, pause for a moment and reflect on the question that follows it for a deeper sense of how you may be manifesting these qualities in session. Pick a particular client to focus on as you reflect, because your sense of yourself may be different with different clients.
Genuineness
The therapist needs to be a “real” human being, one who can freely be him/herself and not just “the expert” sitting in the therapist’s chair. The counsellor needs to be able to relate genuinely to others. Described by Martin Buber and others as an “I-thou” relationship, this quality speaks to the capacity of the therapist to be congruent: that is, to be able to give the client the experience of the therapist speaking truly and openly so that healing can occur (Watson and Kalogerakos in Muran and Barber, 2010)
Hmmm: Do I feel comfortable to express my true perspectives (even though I use therapist disclosure judiciously)?
Empathy
The therapist may not have experienced the precise situation which brings the client into therapy but needs to be able to recognise and understand the feelings, ideas, and motivations the client is experiencing. It is this characteristic that most greatly lays a foundation for the work because it establishes a personal connection between therapist and client, allowing the client to see that the therapist “hears” them, values them, and “gets” their needs (Sutton, 2023).
Hmmm: Do I have an accurate sense of the thing(s) causing the most angst for my client? When I reflect things back to the client using micro-skills, do they nod, add onto what I have suggested, or in some other way give me the feedback that I’m on track?
Unconditional positive regard/trust in non-judgment
For the relationship to flourish, the client needs to sense the trustworthiness of the therapist: that is, can they be confident that the therapist will not judge them? Clients who have not been privileged to experience relationships of trust without judgment may find it difficult to open up, and this characteristic is crucial in order that they do so. Being able to convey unconditional positive regard – a sense that the client is ok and welcome regardless of what is disclosed in session – is the “antidote” in terms of the therapeutic alliance to the client’s sometimes harsh judgment of self. These self-judgments are referred to by Rogers as (internalised) “conditions of worth” learned from early caregivers and others (i.e., beliefs such as that “I am only ok if I ____” (e.g., achieve certain status or goals, appease certain people) (Muran and Barber, 2010).
Hmmm: Do I see a general trend of the client increasingly opening up, allowing ever-deeper work, as the sessions progress? Does the client indicate during end-of-session feedback or at other times that they are coming to feel safe in session?
Care and warmth
Many clients feel trepidation about the idea of therapy and experience heightened anxiety at the first meeting. The more the therapist can convey an attitude of warmth and caring, the more the client can feel safe to share threatening thoughts, ideas, and feelings (Sutton, 2023).
Hmmm: Can I name anything I specifically do/say which conveys warmth and caring? Do I see/hear the client sharing thoughts or feelings which they identify as threatening?
Insight and experience
The client reveals what someone said or did – and explains it through their filters: their (probably somewhat distorted) lens for viewing self, others, and the world. The therapist’s experience and insight are invaluable in offering a different or possibly deeper perspective, in drawing attention to the language used, or in noting how the client may be presenting in session. The therapist works to create a bridge from the client’s internal frame of reference to that other (more adaptive) perspective, and to communicate the possibility of that perspective to the client while empathically reflecting back understanding of the client’s current framework. Client and therapist may hail from two very different walks of life, but in session a common knowledge can emerge, as joint learning and creative experience can make therapy rewarding and a powerful experience for both. It was Carl Jung, after all, who first said that, in the process of therapy, both the client and the therapist were transformed (Sutton, 2023; framework adapted from Miles, 2017).
Hmmm: Can I identify interventions which offered the client a different, more hopeful perspective, and which revealed insight into the client’s process (e.g., by “connecting the dots” – drawing threads of connection – for the client)?
Essential qualities in the therapeutic alliance
The therapist has a major role in creating a positive therapeutic alliance but is not the only player. The client, too, contributes to a good relationship. But in what consists a “good” relationship? Some mental health professionals observe that it is comprised of three essential qualities: an emotional bond of trust, caring, and respect; agreement on the goals and tasks of therapy; and collaboration and shared decision-making during the treatment.
Mutual trust, respect, and caring
We noted these characteristics above insofar as they pertain to the therapist. Here we emphasise how they are mutual. One definition of rapport is that two people coming together in an encounter each have the trust that the other person is able to fulfil their role in what they have come together to do. Thus, rapport in the therapy room happens when not only does the therapist convey respect for the client, but also, the client shows respect for the therapist – and that mutual trust and respect comes to reside in the relationship.
Agreement on the goals and tasks of therapy
If therapist and client have a mutual understanding of the purpose of the therapy and a shared conceptualisation of the client’s story and problems, they are able to agree on treatment goals which stem from these. This mutuality of understanding allows a shared sense of ownership for the treatment, with further agreements on what methods will be used: that is, what the tasks of therapy will be. Both parties will be engaged in “the work”, to the benefit of the alliance (Sutton, 2023).
Collaboration and shared decision-making
When there is genuine agreement on the goals and tasks, it is only a small step to real collaboration and shared decision-making which, in turn, facilitates the ability to talk about “here and now” aspects of the relationship and engenders a freedom to share any negative emotional responses with each other. Obviously, this high level of mutual trust and openness also yields the ability to correct problems or difficulties that arise from time to time in the relationship. The capacity to resolve any negative feelings, hurt, anger, or resentment is a crucial component of a successful relationship, thus avoiding damage from relational rupture, as noted above (Sutton, 2023; Kvarnstrom, 2015; Knobloch-Fedders, 2008).
The therapist qualities we’ve noted are generally “on display” for clients to perceive, and the qualities in the therapeutic relationship are likewise sensed fairly readily. No less important but out of awareness and thus more difficult to perceive are the transferential and projective processes always at work as a relationship develops. We’ll discuss those in a follow-up article.
Key takeaways
- Building a solid therapeutic relationship is important for positive outcomes in client work, but different phases of therapy typically require different therapist qualities to be foremost.
- Rogerian qualities of genuineness, empathy, and unconditional positive regard are (still!) essential for therapists.
- The qualities that are essential for the therapeutic relationship are mutual trust and respect, agreement on the goals and tasks of therapy, and collaboration and shared decision-making.
References
- Ardito, R.B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology. Retrieved on 1 March, 2021, from: https://www.frontiersin.org/articles/10.3389/fpsyg.2011.00270/full
- Knobloch-Fedders, L. (2008). The importance of the relationship with the therapist. Family Institute. Retrieved on 2 March, 2021, from: https://www.family-institute-org/behavioral-health-resources/importance-relationship-therapist
- Kvarnstrom, E. (2015). In it together: The importance of the therapeutic alliance. Bridges to Recovery. Retrieved on 2 March, 2021, from: https://www.bridgestorecovery.com/blog/in-it-together-the-importance-of-the-therapeutic-alliance/
- Miles, J. (2017). This is why the therapeutic relationship is so different. Welldoing.org. Retrieved on 1 March, 2021, from: This is Why the Therapeutic Relationship is so Different (welldoing.org)
- Muran, J.C., & Barber, J.P. (2010). The therapeutic alliance: An evidence-based guide to practice. New York City, New York: Guilford Publications.
- Sutton, J. (2023). How to build a strong therapeutic relationship with clients. Positive Psychology. Retrieved on 19 September, 2023, from: How to Build a Strong Therapeutic Relationship With Clients (positivepsychology.com)