Both therapist and client have valuable contributions to bring to therapy, and the the value of the therapeutic relationship between therapist and client was not .. Strunk and DeRubeis () describe how the techniques of CBT may be. Meeting with a therapist who is licensed further ensures the client . Clients benefit from having a good therapeutic relationship with their therapists. be characterized by curiosity, openness, and respect as the therapist. In brief, your role as the therapist [or any helping professional] is to create a safe space, empower your client, protect your client's spirit, and to see a it is necessary to clearly describe and distinguish between two kinds of power. Until they understood this dynamic, their marital relationship was quite.
I felt that I had to be good for example. Like I had to prove to my therapist that I am good. He was like my daddy, who gave me his wisdom and I had to support that and to receive his approval. After some time this began to change and the projections stopped. Stavroula experienced her relationship with her counsellor as a type of parental relationship but she also explained that this was a projection on her behalf.
However, although she made a comparison, it was through a certain viewpoint and eventually she did not provide a description. When observing the experiences that were shared between the present and the previous subtheme, one could distinguish a gendered dimension of the way that the different experiences are being described. More specifically, most of the participants who talked about the therapeutic relationship in terms of friendship worked with a female counsellor and all of the participants who likened the counselling relationship to a family relationship worked with a male counsellor or an older female counsellor.
Taking in mind that friendship, as described by the participants, held the meaning of reciprocity and comfort, whereas, parental relationships held the meaning of support and acceptance, there emerge certain patterns concerning the role of gender in the description of the therapeutic relationship.
Therefore, the pattern of friendship may manifest a more equal relationship of the female counsellor-female client dyad, whereas, the parental pattern could be shaped around a difference of power between the client and the counsellor. Comparing the Therapeutic Relationship to Professional Relationships [ TOP ] Other interpersonal relationships that were used in order to describe the therapeutic relationship were those of the gynecologist-patient relationship or of a non-specific professional relationship.
All these comparisons seemed to be made in order for the participants to determine the closeness or the distance that they felt towards their therapists. An example of a participant who likened her counselling relationship to one with a gynecologist is Kaiti, who stated that: The psychotherapist is the same as the gynecologist, she comes very close, she gets into you [laughs]. She gets into your core and learns everything about you.
Kaiti, in her account, tried to describe an intimate relationship and a very personal one. She expressed that opening up to a stranger was very difficult and she used the comparison with the gynecologist because of its uniqueness and its intimate nature. The same example, but from a different viewpoint, was used by Danai, who experienced feelings of intimacy but considered them to be a reason that kept her away from a possible erotic relationship with her counsellor.
But I think that the relationship with the therapist resembles the relationship with the gynecologist. I could maybe see my gynecologist erotically at some point, but when he has seen me giving birth the chances are decreased.
In a previous subtheme, Danai compared her therapeutic relationship to friendship, expressing feelings of closeness. Here, she talked about how this closeness could also be the reason for setting internal boundaries.
Thus, the way she experienced her counsellor made her feel less concerned about seeing him erotically. Setting boundaries was the main pattern that six participants used in order to liken their therapeutic relationship to a strict professional one.
The participants here seemed to emphasize the distance between a counsellor and a client. For example, Foteini stated: First of all let me tell you that I am a person who has dependency issues, with people. So I knew from the beginning… I had said to myself that I would have with my therapist a strictly professional relationship.
The past experiences of Foteini may have shaped her need to keep a protective distance from her therapist, in order for her to feel safe. In a way, the description of her relationship as strictly professional underlined an ethical dimension of the therapy process.
On the other hand, Eirini talked about her need to experience distance throughout the development of her relationship with her counsellor: I told her that I wanted to talk with her using our last names. I am not interested in some other kind or relationship, for example friendship… at all…just the professional type. I wanted for her to be distant, although I wanted a sweet and relatively communicative person, which she is, but apart from that my relationship with her is exactly as it was from the start.
Eirini appeared to be using the comparison of a professional relationship in the context of boundaries, although, she did not explain why she needed her distance. Her focus point was that this was something she needed in order for her relationship to be functional for her, albeit this counselling relationship lasted for almost two years.
The pattern, though, remained the same; even though the counselling relationship is a professional relationship, when the participants described only that element of it, they made it in order to talk about boundaries.
Experiencing the Therapeutic Relationship [ TOP ] As long as the counselling experience was concerned, the majority of the participants stated that they were satisfied with their counsellor and shared mostly positive experiences and feelings about their counselling relationship.
In the present super-ordinate theme, the experiences, the feelings and the dynamics of the therapeutic relationship are explained. The two sub-themes that were produced concerned a the feelings of trust and safety and b the experiences of the closeness - distance spectrum. Trust [ TOP ] The feeling of trust was discussed by 11 participants and was focused both on the comfort, that the participants felt with their counsellor, and on the belief that their counsellor would help them with their issues.
As Kleio stated in the following extract: The strange thing is that I truly trusted him from the beginning. If he said that something would be good for me I trusted him Kleio. For Kleio, this feeling emerged from the beginning of the counselling process. On the other hand, for most participants, it was a feeling that unfolded with the progression of the therapeutic relationship.
Thus, for eight participants, trust developed gradually. An example was that of Kaiti, who explained how her relationship with her counsellor helped her to overcome her initial reservations about therapy and to allow herself to be affected by it: In the beginning I was hesitant, but I am very lucky because the person that I chose helped me a lot.
This connection… Truly I was very cautious during the first days, but after that I was not shy anymore.
Therapeutic relationship - Wikipedia
Therefore the relationship plays a crucial role; you know the relationship between the psychotherapist and the patient. Kaiti talked about trust as a gradual process, which was developed through a connection with her therapist. Kaiti also experienced a transition in her attitude from hesitant to trustful, which was imperative for the counselling outcome.
It is as though she felt relieved that she was able to develop these feelings of trust. In a similar vein, Antonia discussed her feelings of hesitance, which in her case lasted for the first year of counselling.
Look, in the beginning I was hesitant, he was a stranger, I saw him for the first time. I can tell you that I was like this for the first year. As a result, from feeling trustful towards their counsellor, 13 participants discussed the issue of self-disclosure in the therapeutic relationship.
The level, that is, they felt comfortable in sharing their feelings and revealing parts of themselves to their counsellors. Indeed, the participants that talked about self-disclosure highlighted the capability of the counselling relationship to serve as a unique context where they could share sensitive information and experiences, in contrast to other interpersonal relationships.
For example, Christina stated: In the above extract, Christina appeared to be talking about a very unique relationship with her counsellor and self-disclosure played a primary role in that.
How to Build a Trusting Counselor Patient Relationship
These feelings were unlike the feelings that she had about self-disclosing to her husband, for the verb that she chose to use perhaps manifested the lack of security to reveal experiences or thoughts that she considered to be sensitive.
Another participant who talked about self-disclosure was Lena. More specifically, Lena discussed the depths of self-disclosure. Her account, as quoted below, appeared to illustrate, in a somehow poetic manner, the level of trust that she experienced in her counselling relationship: But I talked to him very openly. I talked about my parents, their relationship to one another, how they influence me, how foolish I am, how incompetent, how smart, how competent.
All the pieces of my self-awareness, I testified all to him. Thus, for most participants the formation of a trusting relationship with their counsellor seemed to be important for the counselling process and also something that they enjoyed in their therapeutic relationships.
There was, however, an experience where the difficulty of self-disclosure was prominent. As Chara stated in the following extract: Exposed in the way that… if you want to get help; you would have to disclose a lot of stuff, which you would not discuss in different circumstances.
Undressing in that way upsets me; I feel tension [cries]. Yes, this wears me down [cries]. For Chara, the safety to self-disclose was a quality that did not exist in her relationship with her therapist, although she visited the same therapist for almost a year. She expressed feeling uneasy and upset when discussing how difficult it was for her to talk freely during her sessions.
Not only did she not self-disclose freely, but she reported feeling exposed and worn down during that process. Her experience, although hurtful, highlighted the central role of trust in building a strong therapeutic relationship and the consequences of its absence.
Closeness — Distance [ TOP ] Apart from feelings of trust and safety, a number of participants discussed issues linked with closeness and boundaries in the counselling relationship. On the one hand of this spectrum, five participants talked solely about how close they felt to their counsellor and about how helpful they found this closeness. Closeness, here, was not being discussed as an abuse of boundaries, but rather as a sense of an intimate therapeutic relationship.
Christina, who was one of them, stated in the following extract: I feel very close to her. She is a really nice person. I am very pleased with that and I wait impatiently for our next appointment. A lot of things in my life have been upset and I believe that I have a person to support me. For Christina, closeness seemed to be perceived almost as a need. Bearing in mind that in the previous subtheme she stated that she did not dare to disclose even to her husband some of the issues that concerned her, the relationship with her counsellor appeared to be one that she cherished and needed.
Therefore, she expressed feeling pleased because she had developed a therapeutic relationship based on trust and closeness. On the other hand, six participants talked about both the closeness they felt towards their therapist, but also about the boundaries and the distance inherent in their experience of the therapeutic relationship.
Iro, for example, described a distanced interpersonal relationship while also expressing feelings of closeness: I like this distanced relationship.
No I like this distance. On the other hand, I can phone her at any time … you know in moments of crisis [laughs]… it helps me. I feel close to her. For Iro, this distanced relationship appeared to have positive connotations. She explained that, although the distance was necessary to her, she felt close to her therapist because she could call her at any time. This therapeutic relationship, which, at the same time, was experienced as distant and close, highlighted the unique character of the therapeutic dyad, where boundaries do not necessarily prevent feelings of closeness.
As she stated in the following extract, outside of the therapeutic context she felt a stranger towards her therapist, even though she enjoyed feeling close to her during the sessions: The minutes that we are in the room together she is very friendly, she is close to me… I feel that…But when she receives me for our session or when the session is finished she is distant… Especially when she has other people waiting for their sessions… But they are clear [the boundaries]; from the moment you leave her door you are a stranger.
Properties of defences are unconscious, managing affect, being discrete from one another, are reversible, and may be adaptive or pathological. The DSM IV-TR places defences in different levels, and suppression is placed under level seven, which is a high adaptive level and allows for optimal adaptation and handling of difficulties. Noluthando had disengaged herself from activities that she used to enjoy, i.
The lack of activity provides her with more time to think about the negative aspects of her life and maintains her ruminating state.
This also isolates her further from the emotional support of her friends and peers, confirming her belief that she is alone and cannot share her difficulties with others. Protective Factors [ TOP ] Noluthando reported being passionate about drama and although she had lost interest in much of her activities, drama is still something she enjoys.
Her involvement in drama may give her a sense of belonging, a feeling of being pro-social with her peer group, forming part of a community group, and may provide an opportunity for feelings of responsibility and success, which are protective factors against depression, as described by Barrett and Turner Noluthando has a close relationship with two adults, namely her cousin, and, after the suicide attempt, she developed a deeper relationship with one of her older sisters.
These relationships are social protective factors, according to Barrett and Turner Noluthando immediately set goals in the initial stages of therapy to open up more with othersmaking known her motivation to feeling better and improving her level of functioning. The model was adapted from a Cognitive Behavioural Therapy model of anxiety disorders. According to Mooreythe model for depression was developed based on a CBT understanding of maintenance factors in depression.
The model is considered useful in conceptualising cases and when used in treatment planning, when working with depression. Automatic negative thinking is the negative thoughts one experiences in any given event or situation that are biased from a negative perspective. Cognitive distortions and their misinterpretations also fall within this cycle.
The cycle of rumination involves thinking about a negative event, in which thoughts are about what one could have done differently, how it happened and what went wrong. Ruminations may form part of the past or present, as part of this cycle. Self-attacking describes how one persistently attacks and provides criticism to the self. Mood and emotion as a cycle involves feeling in a low mood, feelings of sadness and emptiness, anxiety and irritability. This leads to further self-attacking.
The withdrawal and avoidance cycle is a significant maintenance factor in depression. When a person is in a depressed mode, they may feel worthless and may have thoughts of failure, which results in less engagement in activities than what they used to take part in and enjoy. The disengagement of activities prevents the negative thoughts from being tested and reduces the possibility of finding pleasure in activities that one enjoys.
The unhelpful behaviour cycle describes behaviours that try to compensate for unpleasant feelings and negative beliefs. The cycle of motivation and physical symptoms describes the biological symptoms of depression and may lock the person into the depressive mode. Feelings of inadequacy may result in the person with depression, leaving them with feeling worthless and with nothing to offer. The environment also forms part of the six cycles and may trigger and maintain depression.
The six cycles do not naturally occur in a step-by-step fashion and clients will not necessarily fall into all six cycles Moorey, Her ruminations include thoughts of feeling as though she is to blame and feelings of guilt, as she feels that perhaps she could do something different to change the circumstances within her family. She then places much pressure and responsibility on herself for aspects of her life that are beyond her control. Her mood and emotions include feelings of being depressed, guilt, irritability, inadequacy, and suppression from having any feeling.
The unhelpful behaviours that she engages in are her inactivity, the suicide attempt she made earlier in the year, not eating, and avoiding her feelings. The Treatment Plan [ TOP ] In working with Noluthando, I experienced difficulty in following a treatment model strictly, and this will further be elaborated on through the discussion on what happened in therapy, below.
The reasons that I found implementing the therapy model difficult at times, was that often Noluthando was in an uncommunicative state and I feared developing a further barrier between us, and at times, it felt inappropriate and damaging to the relationship. However, the treatment plan was followed and was often naturally integrated into therapy.
I battled at times this was part of my process of integration of using CBT and focusing on the therapeutic relationship, and seeing them as separate constructs to find the balance of the implementation of the therapeutic relationship and using technique. When applying this treatment model to Noluthando, I tried to work with the automatic negative thinking cycle, by testing negative thoughts and beliefs. This involved confronting her negative beliefs, the way she thinks about things, and testing them against reality and other viewpoints.
When working with her ruminations and the self-attacking cycle, I used problem-solving and the development of compassion. Developing compassion would be important for Noluthando, as she frequently believed that she was a failure and needed to learn to be gentler with herself. In approaching the withdrawal and avoidance cycle, I suggested that Noluthando start to slowly engage herself in activities again and to start opening up, rather than isolating herself.
Noluthando could deal with her unhelpful behaviour cycle by not avoiding her feelings, eating when it is difficult, and to rather engage in problem-solving and reaching out to someone for help when things do become too difficult.
Psycho-education aided in this. In terms of the motivation and the physical symptoms cycle, it benefited her to become aware of her symptoms, to keep healthy through exercise, and sleeping and eating in a healthier way. It is of value to create awareness of this for Noluthando and for her to come to an understanding of how to live in her environment and possible alternatives to this.
Therapy Narratives [ TOP ] The description of the sessions below provides the details and reflections of 11 therapy sessions, to outline what happened in therapy and to provide a narrative of the therapeutic relationship that developed between Noluthando and myself. The sessions are divided into four themes regarding the development and changes in therapy and the therapeutic relationship.
After a description of what happened in therapy sessions, under each theme, the therapeutic relationship, its value in therapy, and my experience of the therapeutic relationship are discussed. In the first session, Noluthando was extremely quiet, her voice was strained and she spoke very little, and she seemed to find the experience difficult.
She had a depressed mood and displayed low energy throughout the session. She spoke of the problems that she experiences when she lives at home with her family and how she has been experiencing this for a number of years.
I spoke about the suicide attempt with her and she provided little detail other than the method that she used drinking a poisonous substanceand that she left no suicide note. I asked Noluthando to make a commitment to therapy and we signed a contract that detailed our working together in therapy.
Both Noluthando and I kept a copy of this contract. During the session, I asked her about what she would like to gain from therapy and what her goals were. Noluthando reported having difficulty trusting people as they have broken her trust in the past.
We worked through the questions together, which aided me in understanding some of her symptoms. She obtained a score of 16 points. This score is indicative that the client is on the borderline between a mild mood disturbance to clinical depression.
Therefore, I made plans to be more practical in Session 2 and introduced the idea of a timeline. Noluthando seemed willing to give the exercise a try, which involved placing a horizontal line across a page and placing dates as we worked collaboratively in collecting her history. She wanted me to write, and looked at the page whilst dates and events were added. When she spoke of her mother and father, she recalled how she has never experienced her mother not drinking alcohol.
However, through the timeline, she was able to speak about hopes for her future and a possible career in drama. I noted how her posture and voice changed to being upright and more assertive, revealing an uplifted mood when speaking about drama.
In fact, I felt that I did most of the talking in the session, as Noluthando would not answer questions in more than a few words. How would you describe yourself? Is there anyone that you like to talk to? It may be quite difficult for you to be here, because in therapy you will do a lot of the talking.
This is the reason I want to come here. I want to overcome that. Maybe that can be a goal in therapy, something we can work and challenge together?
Yes quiet short laugh. I felt that it would possibly take time for her to develop trust with me as she has difficulty with trust in her other relationships. In the second session, I noted that by me being more practical in the session by working on a timeline together, allowed more information to be shared between Noluthando and myself. This could be because the focus appeared to not be on her but rather on the task.
I reflected on how difficult it was for Noluthando to openly communicate and how I could try to create a space in therapy where she could begin to open up more. This would entail moving at a pace, which would be comfortable for her. I felt that she might have difficulty speaking in the session because of the emotional content, as shown in the transcript below.
It sounds like quite a few people in your family do not get along. What is that like for you? It is hard, silence because now you have to choose between family members. What do you think of your family not getting along? He is not open to talking about it. How often is your mother drunk? I felt that the collaborative relationship in CBT may help her to feel responsible for therapy and may assist in her working together with me.
Belsher and Wilkes believe collaboration in CBT to be one of the key therapeutic principles when working with adolescents.
- Therapeutic relationship
- There was a problem providing the content you requested
- Women as Counselling and Psychotherapy Clients: Researching the Therapeutic Relationship
I was concerned that the techniques of CBT may break down communication in therapy and that the therapeutic relationship may not develop. Strunk and DeRubeis describe how the techniques of CBT may be experienced as boring and not age appropriate, by younger people, and I did not want her to have this experience. The Development of the Therapeutic Relationship: It was hoped that by doing this it may relieve some of the anxiety she may have been experiencing in sessions so that she may open up similar to the previous session with the timeline.
Whilst drawing, she spoke about her father and how she learnt of his HIV positive status by reading about it in some notes he had made, which she had come across by accident. She related how difficult it was for her as she did not know who to speak to about the information that she had learnt about her father. She described her father as not wanting to talk about his feelings.
She described a family that does not communicate with one another. Although I experienced Noluthando finding the session difficult, I found her to open up more than the initial two sessions.
Noluthando completed the BDI in this session and her score increased from 16 points to 19 points. I was concerned about this and reflected about it after the session and discussed it with my supervisor. I thought that perhaps she under reports her experiences and feelings as, in this particular session, she shared how she often smiles even though she is not okay on the inside. Before the session ended, I provided her with an automatic thought record to start recording her thoughts.
Thought records provide the client with the task of responding and challenging negative automatic thoughts in writing and the therapist can then help the client to find a more balanced or alternative thought.
I felt that perhaps she would not be accepting of completing the thought record on her own, and was interested to see if she would bring it with her to the following session. This accounts for the difficulties associated with the concept of alliance, which is built interactively, and so any assessment must also consider the mutual influence of the participants.
In a helpful contribution, Hentschel points out that the problematic aspect of empirical studies investigating the alliance is their tendency to view the alliance construct as a treatment strategy and a predictor of therapeutic outcome: The use of neutral observers or the creation of counterintuitive studies is therefore recommended.
From this historical excursus, it is clear that research into the assessment of the psychotherapeutic process is alive and well. The development of a dynamic vision of the concept of therapeutic alliance is also apparent. The work of theorists and researchers has contributed toward enriching the definition of therapeutic alliance, first formulated in Research aimed at analyzing the components that make up the alliance continues to flourish and develop. Numerous rating scales have been designed to analyses and measure the therapeutic alliance, scales that have enabled us to gain a better understanding of the various aspects of the alliance and observe it from different perspectives: Attention has recently turned toward the role of the therapeutic alliance in the various phases of therapy and the relationship between alliance and outcome.
So far, few studies have regarded long-term psychotherapy involving many counseling sessions. This topic, along with a more detailed examination of the relationship between the psychological disorder being treated and the therapeutic alliance, will be the subject of future research projects. Equally important, in our opinion, will be the findings of studies regarding drop-out and therapeutic alliance ruptures, which must necessarily consider the differences between that perceived by the patient and that perceived by the therapist.
Conflict of Interest Statement The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Acknowledgments The authors thank Mauro Adenzato for his valuable comments and suggestions to an earlier version of this article. A Research Handbook, eds Greenberg L.
Guilford Press;— Bibring E. On the theory of the results of psychoanalysis. The generalizability of the psychoanalytic concept of the working alliance. Clinical Applications of Attachment Theory. Routledge and Kegan Paul Budman S. Cohesion, alliance and outcome in group psychotherapy.
Psychiatry 52, — [ PubMed ] Burlingame G. Cohesion in group therapy. Is therapist alliance or whole group cohesion more influential in group psychotherapy outcomes?
How to Build a Trusting Counselor Patient Relationship
Is one assessment enough? Patterns of helping alliance development and outcome. Franco Angeli Elvins R. The conceptualization and measurement of therapeutic alliance: The effects of psychotherapy: The predictive validity of six working alliance instruments. The role of the therapeutic alliance in the treatment of schizophrenia. Relationship to course and outcome. Psychiatry 47, — [ PubMed ] Freud S. Hogarth Press;— Gaston L. The concept of the alliance and its role in psychotherapy: Theory, Research and Practice, eds Horvath A.
John Wiley and Sons;85— Gelso C. Components of the psychotherapy relationship: Group alliance and cohesion as predictors of drug and alcohol abuse treatment outcomes. Short psychotherapy interventions four sessions.
The working alliance and the transference neurosis. Erlbaum;1—38 Hentschel U. On links to other constructs, determinants of its effectiveness, and its role for research in psychotherapy in general. Comparison of therapeutic factors in group and individual treatment processes.
Theory, Research, and Practice, eds Horvath A. Wiley;— Horvath A. Therapist Contributions and Responsiveness to Patients, ed. Oxford University Press;37—69 Horvath A. Guilford Press;— Horvath A. Development and validation of the working alliance inventory. The role of the therapeutic alliance in psychotherapy. The development and decay of the working alliance during time-limited counseling.
Thinking about thinking in therapy: Relation between working alliance and outcome in psychotherapy: Clinical Prediction in Psychotherapy. Jason Aronson Howard I. Therapeutic alliance mediates the relationship between interpersonal problems and depression outcome in a cohort of multiple sclerosis patients.