The therapeutic relationship from an integrative perspective

by Christina Treacy

Introduction
One of the most consistent findings within the psychotherapy literature is that the therapeutic relationship is a fundamental factor that reliably predicts psychotherapy outcomes. In several meta-analyses, researchers found that approximately 38 percent of the effects of psychotherapy are associated with the therapeutic relationship (Carr, 2007). Consequently, it is an important variable in understanding the psychotherapy process (Ackerman & Hilsenroth, 2003). As such, this phenomenon has been examined extensively through the research lens (Horvath et al., 2011) and it is considered a core integrative variable. (Castonguay, Constantino & Holtforth, 2006). As a novice integrative psychotherapist, my understanding of this construct positively impacted my competence in the practice setting. Even though I may be a trainee therapist, I felt confident that I could work with clients and have successful therapy outcomes. That said, I initially found it challenging to fully comprehend the therapeutic relationship from an integrative perspective given that each school of psychotherapy views it differently.

Notably, the terms ‘therapeutic relationship’ and ‘therapeutic alliance’ are often used interchangeably within the literature, and thus reported to be the same construct under different names (Karver et al., 2006). Within cognitive behaviour therapy (CBT) literature, the relationship is referred to in terms of the working alliance and operationally defined as consisting of three essential features: the bond, the goals and the tasks of the therapy (Bordin, 1979). Accordingly, the relationship is necessary but not sufficient in terms of therapeutic change. Within the humanistic literature, it is often referred to as the real relationship (Clarkson, 1990) or the authentic humanness of the relationship (Hill & Knox, 2009) that includes empathy, positive regard and congruence (Rogers, 1957). It is deemed necessary and sufficient, and thus provides the core curative element within the therapy.

Similarly, the psychoanalytic literature refers to the relationship between client and therapist in terms of transference and counter transference, where the individual perceives the other through the lens of others who have been important to them in the past, hence the relationship is the vehicle through which therapy is conducted (Marmarosh, 2012). Moreover, from a psychodynamic and person-centred therapy perspective, the working alliance, whilst important, is viewed as only one aspect of the relationship (Baldwin, Wampold & Imel 2007).

Regardless of whether it is a curative factor in itself, or it provides the environment that supports techniques, these unitary models all emphasise the importance of the relational variable in treatment (Safran & Muran, 2006). Moreover, the therapeutic relationship involves a purposeful and conscious facet that includes caring, mutual respect and trust, as well as an inclusion of affective connectiveness between client and therapist (Horvath & Bedi, 2002). Therefore, qualitatively these approaches have different concepts but these traditionally rival approaches are not in fact as diverse as once thought; rather they have many common themes that are described differently (Grencavage & Norcross, 1990). Additionally, the famous Dodo bird verdict, often quoted in psychotherapeutic comparative studies (Luborsky, Singer & Luborsky, 1976), asserts that despite technical diversity and different theoretical backgrounds, diverse therapeutic approaches are equivalent in their effectiveness, with no single therapeutic orientation shown to be superior over the other as they all have a curative effect to their credit (Wampold, 2001). Moreover, researchers have found that no single explanation exists for successful therapeutic outcome because clients change in different ways (Cooper, 2010); hence it is important as a therapist to be open to multiple models, rather than identifying with a single theory that tries to account for it all. According to Asay and Lambert (1999), the type of therapeutic relationship that is formed determines to a large extent how the therapy proceeds. For instance, the client’s social competencies and attachment style may affect their ability to foster a strong therapeutic relationship (Mallinckrodt, 2000). However, studies found that clients with more attachment difficulties early on in life benefitted more from transference work than those who did not have attachment difficulties (Hersoug, Ulberg & Høglend, 2014). Importantly, individuals who do well in therapy would for the most part attribute their success to the relationship with their therapist (Horvath & Symonds, 1991; Martin et al., 2000).

Given that the therapeutic relationship is a unique component in most forms of psychotherapy, whilst technique and model account for only 15 percent of outcome variances (Asay & Lambert, 1999; Lambert, 1992), it is an obvious core integrative variable (Castonguay, Constantino & Holtforth, 2006). Not only do these findings support a common factor hypothesis (DeRubeis, Brotman & Gibbons, 2005; Horvath et al., 2011), but they also highlight the need for me as a therapist to consider the therapeutic relationship from many perspectives.

Therapeutic relationship influences change
Integrative psychotherapy is not a particular combination of psychotherapy theories but rather it consists of a framework for developing an integration of theories and techniques; thus, concepts and therapy interventions are combined from more than one theoretical psychotherapy approach (Cromer, 2013). This allows me as a therapist to conceptualise and respond strategically to clients’ issues, thereby providing a better fit between the individual’s particular needs and the interventions (Boswell et al., 2010). According to Norcross (2005), this approach enhances “the efficacy, efficiency, and applicability of psychotherapy” (3).

A humanistic and psychoanalytic perspective focuses on the awareness process, albeit in a somewhat different manner, so there is an emphasis on how the individual’s inner change shapes how they engage with the environment (Prochaska & Norcross, 2013). For example, if I were a psychoanalyst, I may argue that negative transference can only be accomplished when I am not very present in the relationship, as this provides a space that acts as a catalyst for the client to get in touch with unconscious feelings such as rejection and hate. This is something that they could not easily do if I was acting in a warm and loving way. Alternatively, if I was a person- centred therapist, I would propose that empathy and congruence help the person feel loved and cared about, thereby providing a corrective emotional experience that they may not have had in earlier relationships (Bohart et al., 2002). This approach therefore affords the clients feelings that they are worthy of being understood and respected, and that in turn promotes the exploration of their feelings, thus facilitating the processing of emotions. However, as a psychoanalyst I would argue that this corrective emotional experience is not part of my work, but it comes from the client through finding the resources within themselves to provoke change, whereas as a person- centred therapist I would argue that I provide a more supportive environment for this change to take place.

Conversely, if I were a behavioural therapist, I would focus on the intrapersonal or the social context, proposing that individuals’ actions in their own environments influence the change within them (Prochaska & Norcross, 2013). The collaboration aspect of the therapy gives the client a sense of autonomy and allows him or her to access inner resources for change (Ackerman & Hilsenroth, 2003). This elevates the client as it gives them a sense that they are the manager of their own destiny, which reinforces the sense of autonomy because they have some value to attribute to the work, thus acknowledging that they matter as much as the therapist (Ulvenes et al., 2012).

In comparison, as an integrative therapist, I would suggest a need for both action and awareness processes depending on the client’s requirements, as proposed by Prochaska and Norcross, (2013). For instance, unlike a purist psychodynamic therapist, as an integrative therapist I may choose to address transference using a CBT intervention in order to identify concrete examples of the issue, whilst paying attention to empathy so that I view the problem from the client’s perspective (Goldfried & Wolfe, 1998). One sets the stage for change whilst the other involves a specific process to promote change. These findings would suggest that the relationship directly affects outcome rather than solely resulting from the client having a positive opinion of the therapist and the treatment (Crits- Christoph et al., 2006). Moreover, Norcross (2002) described the relational therapeutic relationship to be “a complex, reciprocal and multidimensional entity” (8).

Intersubjectivity
Despite the important role that the client has in psychotherapy, research tends to focus mostly on the therapist (Duncan & Miller, 2000). Consequently, the client is researched as the object of the intervention and assessment rather than from the perspective of the contributions they make to the therapeutic relationship (Duncan & Miller, 2000; Orlinsky, Ronnestad & Willutzki, 2004). However, the inter-subjectivity literature argues that the boundaries around the relationship are porous, with the therapeutic relationship emerging through the therapist-client interaction (Stolorow, Brandchaft & Atwood, 1992). For example, Nolan (2014) refers to inter-subjectivity in terms of the moment-to-moment experience that creates reciprocity between both the therapist and the client. He suggests that both bring their subjective selves into the space, and consequently, they are both impacting on each other, making it very much a response between two people. He argues that it is not what one person is doing to the other or what one person is getting from the other; it is about what is happening in this space together. He describes a way of practising that in itself draws on different models. He proposes five different levels in terms of working with the relationship: sensation (i.e., sensing the other person), emotion (i.e., experience of emotions and acknowledgment of them), imagination (i.e., guided imagery), cognition (i.e., thoughts) and motor activity (i.e., different positions).

Sources of variability in outcomes
Unexpectedly, studies have shown that therapists and clients have little agreement on how they perceive the quality of the therapeutic relationship (Cooper, 2008). Nevertheless, researchers propose that the quality of the therapeutic relationship explains up to 30 percent of the variance in outcomes (Asay & Lambert, 1999; Beutler & Harwood, 2004). This suggests that it is more to do with how the therapist relates to the clients rather than the therapist themselves (Cooper, 2008). Since the therapist’s and client’s ability to form a positive relationship largely determines outcomes (Baldwin et al., 2007), practitioners tend to employ interventions that facilitate the development of such a relationship. According to Ackerman and Hilsenroth (2003), a positive relationship can be fostered if the therapist conveyed a sense of being “trustworthy, affirming, flexible, interested, alert, relaxed, confident and respectful” (20). For example, the use of exploratory techniques such as asking questions communicates curiosity and, in doing so, it shows the client that the therapist is interested, and as such promotes an emotional bond. Furthermore, Horvath et al. (2011) found that empathic, transparent, goal-oriented, cooperative therapists who provided assurances and maintained focus on the client were therapist qualities that promoted a good working alliance (Langhoff et al., 2008). Norcross (2002), investigating practitioner’s contribution to the relationship, found similarly that factors such as self-disclosure, feedback, the management of counter transference, relational interpretation and repair of therapeutic ruptures that cause reductions in the alliance over time, were important.

This suggests that the differences in effectiveness between all therapists across different orientations may be less than when comparing therapists within a single orientation, such as one psychodynamic practitioner to another. Accordingly, Mallinckrodt and Nelson (1991) found that better outcomes were associated with highly trained therapists only when goals and tasks were taken into account, which perhaps is to be expected given that these are learnt through experience. However, in relation to the emotional bond, they found therapist experience was not a determining factor, which implies that it is not enough to have experience and training. Given that some therapist qualities such as genuineness, warmth and acceptance are not abilities that can be easily taught, researchers have found that teaching empathic responding skills such as combining instruction, practice, modelling and feedback were effective in promoting the therapeutic relationship (Lambert & Simon, 2008). This finding is critical because empathy has been found to facilitate the development of the therapeutic relationship (Keijsers, Schaap & Hoogduin, 2000; Wampold, 2001).

According to Cromer (2013), clients report that certain therapist interventions enhance the therapeutic relationship. Firstly, interventions that emphasise experiencing emotions within the session were described as enhancing the relationship. Secondly, interventions that provide support for the client were important. The therapist conveyance of positive regard, empathy, understanding as well as affirming experience helps the client feel supported. Thirdly, interventions that explore the meaning of the client’s statements suggest that the therapist is interested in what the client is saying. Finally, interventions that focus on the client-therapist interactions are thought to strengthen the relationship. For example, from a transference perspective, the therapist is very interested in knowing how the client experiences them because this is how they get to the transference. Therefore, when the therapeutic relationship is viewed from several perspectives, it has both facilitative conditions and collaborative qualities (Boswell et al., 2010).

That said, some studies have shown that relational factors that are emotional- and interpersonal- based are not necessary for successful outcomes to occur, as is the case with technique-only approaches (Norcross, 2002). For example, self-help manuals and web-based therapeutic programmes are shown to be efficacious. Most notably, a recent meta-analysis of CBT studies for anxiety and depression disorders delivered via the internet found similar results to those found in face-to-face CBT interventions (Cuijpers et al., 2010). However, these researchers also found that therapist support, such as over-the-phone consultations, was shown to positively influence the effectiveness of these types of treatments (Cuijpers et al., 2010; Spek et al., 2007). Additionally, these results should be interpreted cautiously as sampling may be a confounding factor because typically these efficacy studies tend to have strict exclusion-inclusion criteria. Consequently, they can create an artificial situation and they do not generalise to real-world clinical practice (Crits-Christoph et al., 2006)

Conclusion
The demand for evidence-based practice that relies on clinical knowledge and research findings is promising as it moves the work of integrative psychotherapy toward consensus, with the therapeutic relationship viewed as a pantheorectical, curative factor (Goldfried & Wolfe, 1998). This clearly has implications for practice. However, transcending a unitary model of psychotherapy while synthesising components from a variety of sources has not generated the same level of empirical research that is associated with conventional single theory models of therapy, such as CBT, psychoanalytic or humanistic (Cooper, 2008). Nevertheless, many psychotherapists are moving toward an integrative approach to psychotherapy (Boswell et al., 2010), thus acknowledging that common factor variables such as the therapeutic relationship and its many facets are important in successful therapy outcomes. Based on these latest and converging trends, therapists working in a very pure way perhaps are neglecting concepts that work best to ameliorate client’s problems, thereby reducing opportunities for change. For instance, I have found that transference is important in terms of working in an integrative way, as it focuses on the client’s early relationships and how they get replayed into the therapeutic relationship. Alternatively, if I were to ignore the humanistic model, this means that I am missing out on the importance of qualities such as empathy, acceptance and warmth, which are necessary in establishing a good therapist-client relationship. Then again, when I work from the CBT perspective, it has a strong way of working together, such as having consensual endorsement of therapeutic procedures. Therefore, when I incorporate these concepts from different models into my way of working, it offers a more holistic approach to therapy. After all, the client lives in a social context, as do I, the therapist, and in this regard I cannot just focus on the interpersonal without also focusing on the intrapersonal. Neither can the fact be overlooked that this is a reciprocal or intersubjective engagement, and thus it needs to be viewed from both the perspective of what contributions the client, as well as I, the therapist, make to the relationship, in particular given that therapists’ therapeutic alliance ratings are less predictive of outcomes than clients’ ratings (Horvath & Bedi, 2002).

Accordingly, the therapeutic relationship is the most integrative variable that represents underlying change mechanisms that operate across different forms of psychotherapy. Therefore, I find that I must work flexibly in tailoring interventions to complement the needs of the client according to existing research relating to relational style and techniques associated with it. Moreover, understanding the therapeutic relationship from each model’s perspective provides me with knowledge about how the process of change occurs within therapy, especially with regard to the importance of the whole therapeutic encounter. Since it is not the same with each client, each time I meet a new client it will create a different dynamic. Given that a change brought about in any given facet of functioning can synergistically influence another (Goldfried, Glass & Arnkoff, 2011), perhaps therapists who tailor their relationship to individual clients could lead to an improvement of psychotherapy outcome. Nevertheless, further research needs to be performed in this domain, with particular attention given to clients and their contributions to therapy.

Christina Treacy is a 3rd year MSc in Psychotherapy student at Dublin City University.

References:
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist characteristics and techniques positively impacting the therapeutic alliance. Clinical Psychology Review, 23(1), 1-33.

Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. In M. A. Hubble, B. L. Duncan & S. C. Miller S. C. (Eds.), The heart and soul of change: What works in therapy (pp. 33–56). Washington, DC: American Psychological Association.

Baldwin, S. A., Wampold, B. E., & Imel, Z. E. (2007). Untangling the alliance-outcome correlation: Exploring the relative importance of therapist and patient variability in the alliance. Journal of Consulting and Clinical Psychology, 75(6), 842-867.

Beutler, L. E., & Harwood, T. M. (2004). Virtual reality in psychotherapy training. Journal of Clinical Psychology, 60(3), 317-330.

Bohart, A. C., Elliott, R., Greenberg, L. S., & Watson, J. C. (2002). Empathy. In J.C. Norcross, (Ed.), Psychotherapy relationships that work (pp. 89–108). New York: Oxford University Press.

Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252-260.

Boswell, J. F., Nelson, D. L., Nordberg, S. S., McAleavey, A. A., & Castonguay, L. G. (2010). Competency in integrative psychotherapy: Perspectives on training and supervision. Psychotherapy: Theory, Research, Practice, Training, 47(1), 3-11.

Carr, A. (2007). The effectiveness of psychotherapy. A review of research prepared for the
Irish Council for Psychotherapy. Dublin: ICP. Retrieved 22 November 2016 from http:// researchrepository.ucd.ie/bitstream/handle/10197/6322/EffectivenessOfPsychotherapy. pdf?sequence=1

Castonguay, L. G., Constantino, M. J., & Holtforth, M. G. (2006). The working alliance: Where are we and where should we go? Psychotherapy: Theory, Research, Practice, Training, 43(3), 271- 279

Clarkson, P. (1990). A multiplicity of psychotherapeutic relationships. British Journal of Psychotherapy, 7(2), 148-163.

Cooper, M. (2008). Essential research findings in counselling and psychotherapy: The facts are friendly. London: Sage.

Cooper, M. (2010). The challenge of counselling and psychotherapy research. Counselling and Psychotherapy Research, 10(3), 183-191.

Crits-Christoph, P., Gibbons, M. B. C., Crits-Christoph, K., Narducci, J., Schamberger, M., & Gallop, R. (2006). Can therapists be trained to improve their alliances? A preliminary study of alliance-fostering psychotherapy. Psychotherapy Research, 16(03), 268-281.

Cromer, T. D. (2013). Integrative techniques related to positive processes in psychotherapy. Psychotherapy, 50(3), 307-321.

Cuijpers, P., Donker, T., van Straten, A., Li, J., & Andersson, G. (2010). Is guided self-help as effective as face-to-face psychotherapy for depression and anxiety disorders? A systematic review and meta-analysis of comparative outcome studies. Psychological Medicine, 40(12), 1943-1957.

DeRubeis, R. J., Brotman, M. A., & Gibbons, C. J. (2005). A conceptual and methodological analysis of the nonspecifics argument. Clinical Psychology: Science and Practice, 12(2), 174- 183.

Duncan, B. L., & Miller, S. D. (2000). The client’s theory of change: Consulting the client in the integrative process. Journal of Psychotherapy Integration, 10(2), 169-187.

Goldfried, M. R., Glass, C. R., & Arnkoff, D. B. (2011). Integrative approaches to psychotherapy. In J.C. Norcross, G.R. VandenBos & D. K. Freedheim (Eds.), History of psychotherapy: Continuity and change (pp. 269-296). Washington, DC: American Psychological Association.

Goldfried, M. R., & Wolfe, B. E. (1998). Toward a more clinically valid approach to therapy research. Journal of Consulting and Clinical Psychology, 66(1), 143-158.

Grencavage, L. M., & Norcross, J. C. (1990). Where are the commonalities among the therapeutic common factors? Professional Psychology: Research and Practice, 21(5), 372-378

Hersoug, A. G., Ulberg, R., & Høglend, P. (2014). When is transference work useful in psychodynamic psychotherapy? Main results of the first experimental study of transference work (FEST). Contemporary Psychoanalysis, 50(1-2), 156-174.

Hill, C. E., & Knox, S. (2009). Processing the therapeutic relationship. Psychotherapy Research, 19(1), 13-29.

Horvath, A. O., & Bedi, R. P. (2002). The alliance. In J. C. Norcross, (Ed.), Psychotherapy relationships that work. New York: Oxford University Press.

Horvath, A. O., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). Alliance in individual psychotherapy. Psychotherapy, 48(1), 9-19.

Horvath, A. O., & Symonds, B. D. (1991). Relation between working alliance and outcome in psychotherapy: A meta-analysis. Journal of Counseling Psychology, 38(2), 139-149.

Karver, M. S., Handelsman, J. B., Fields, S., & Bickman, L. (2006). Meta-analysis of therapeutic relationship variables in youth and family therapy: The evidence for different relationship variables in the child and adolescent treatment outcome literature. Clinical Psychology Review, 26(1), 50-65.

Keijsers, G. P. J., Schaap, C. P. D. R., & Hoogduin, C. A. L. (2000). The impact of interpersonal patient and therapist behavior on outcome in cognitive-behavior therapy: A review of empirical studies. Behavior Modification, 24(2), 264-297.

Lambert, M. J. (1992). Psychotherapy outcome research: Implications for integrative and eclectic therapists. Handbook of Psychotherapy Integration, 34(1), 94-129.

Lambert, M. J., & Simon, W. (2008). The therapeutic relationship: Central and essential in psychotherapy outcome. In S. F. Hick & T. Bien, (Eds.), Mindfulness and the therapeutic relationship (pp. 19–34). New York, NY: Guilford.

Langhoff, C., Baer, T., Zubraegel, D., & Linden, M. (2008). Therapist-patient alliance, patient- therapist alliance, mutual therapeutic alliance, therapist-patient concordance, and outcome of CBT in GAD. Journal of Cognitive Psychotherapy, 22(1), 68-79.

Luborsky, L., Singer, B., & Luborsky, L. (1976). Comparative studies of psychotherapy – is it true “everybody has won and all must have prizes?” In R. Spitzer & D. Klein (Eds.). Evaluation of psychological therapies (pp. 3-22). Baltimore: Johns Hopkins University Press.

Mallinckrodt, B. (2000). Attachment, social competencies, social support, and interpersonal process in psychotherapy. Psychotherapy Research, 10(3), 239-266.

Mallinckrodt, B., & Nelson, M. L. (1991). Counselor training level and the formation of the psychotherapeutic working alliance. Journal of Counseling Psychology, 38(2), 133-145.

Marmarosh, C. L. (2012). Empirically supported perspectives on transference. Psychotherapy, 49(3), 364-369.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: A meta-analytic review. Journal of Consulting and Clinical Psychology, 68(3), 438-450

Nolan, P. (2014). The relational field of body psychotherapy. Body, Movement and Dance in Psychotherapy, 9(1), 29-40.

Norcross, J. C. (2002). Psychotherapy relationships that work: Therapist contributions and responsiveness to patients. New York, NY: Oxford University Press.

Norcross, J. C. (2005). The psychotherapist’s own psychotherapy: Educating and developing psychologists. American Psychologist, 60(8), 840-850.

Orlinsky, D. E., Ronnestad, M. H., & Willutzki, U. (2004). Fifty years of psychotherapy process outcome research: continuity and change. In M. J. Lambert, (Ed.), Bergin and Garfield’s handbook of psychotherapy and behavior change. (5th ed., pp. 307–389). New York: Wiley.

Prochaska, J. O., & Norcross, J. C. (2013). Systems of psychotherapy: A transtheoretical analysis. Toronto, Canada: Nelson Education.

Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology, 21(2), 95-103.

Safran, J. D., & Muran, J. C. (2006). Has the concept of the therapeutic alliance outlived its usefulness?. Psychotherapy: Theory, Research, Practice, Training, 43(3), 286-293.

Spek, V., Cuijpers, P. I. M., Nyklícek, I., Riper, H., Keyzer, J., & Pop, V. (2007). Internet-based cognitive behaviour therapy for symptoms of depression and anxiety: A meta-analysis. Psychological Medicine, 37(03), 319-328.

Stolorow, R., Brandchaft, B., & Atwood, G. (1992). Contexts of being: The intersubjective foundations of psychological life. Hillsdale, NJ: The Analytic Press.

Ulvenes, P. G., Berggraf, L., Hoffart, A., Stiles T. C., Svartberg, M., McCullough, L., & Wampold, B. E., (2012). Different processes for different therapies: Therapist actions, therapeutic bond, and outcome. Psychotherapy 49(3), 291-302.

Wampold, B. E. (2001). The great psychotherapy debate: models, methods, and findings. London: Routledge

IAHIP 2017 - INSIDE OUT 81 - Spring 2017