Gelso C.J., Kivlighan D.M., Markin R.D.
Psychotherapy: 2018, 55(4), p. 434–444.
Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Gelso at email@example.com.
Findings amalgamated for the American Psychological Association indicate that patient progress and treatment quality are strongly related to the strength of the personal (‘real’) relationship between client and therapist – more strongly than the working relationship focused on the therapy. Showing that you like, value and care for someone may be therapeutic in itself.
Summary [Though not specific to clients with drug and alcohol problems, the principles derived from this review of psychotherapy studies are likely to be applicable, partly because severe substance use problems generally form part of a complex of broader psychosocial problems. Addictions work may not necessarily best be conceptualised as psychotherapy, but there is a therapeutic element to it which makes these findings relevant to keyworkers and counsellors.]
The featured review is one of several in a special issue of the journal Psychotherapy devoted to features of the therapist-client relationship related to effectiveness, based on the work of a task force established by the American Psychological Association. This particular review examined the links between outcomes of individual psychotherapy and the personal or ‘real relationship’ between therapist and client.
Commissioned by a task force of the American Psychological Association, this review amalgamated findings relating patient progress and ratings of treatment quality to the strength of the personal (‘real’) as opposed to working relationships between clients and psychosocial therapists.
Across all relevant studies the link between the ‘real relationship’ and outcomes was large and statistically significant. Assuming a causal connection, it would be a more important determinant of patient progress than working alliance or the type of therapy.
Though causality cannot be established by the types of studies included in the analysis, the safest stance is to presume that how the therapist is and behaves affects how well their patients do, and does so partly via the personal relationship they help forge with the client.
‘Real relationship’ refers to the non-work, person-to-person rather than therapist-to-client connection between therapist and client. In contrast, the working or therapeutic alliance is the work relationship, typically seen as the extent of agreement on the goals and tasks of therapy and the strength of the emotional bond between patient and the therapist. The ‘bond’ dimension particularly overlaps with the real relationship, but remains distinct because it is a working bond. For example, expressing confidence in the therapist as a therapist or a connection with them as an effective professional, or the therapist expressing appreciation for the patient as a patient, are indicative of the working alliance bond. When either feels a connection to the other as a person, and feels liking or caring for the person of the other, the bond is more in the realm of the real relationship. Studies have found that working alliance and the real relationship substantially co-vary, but are separable and independently associated with outcomes. Therapist and patient self-disclosure are also related to the real relationship, as is the concept of therapist congruence, one close to the genuineness dimension (see below) of the real relationship.
The “real” in “real relationship” reflects its psychoanalytic origins. Psychoanalysts contrasted the realistic, person-to-person relationship between analyst and client when they perceive and experience each other as they are, with the distorted relationship generated by the displacement of past unresolved conflicts onto the present therapeutic relationship, a phenomenon known as ‘transference’. To this was added a second ingredient to the real relationship – that the participants in the analytic dyad are genuine with each other, are being themselves rather than artificial or holding back.
Modern definitions of the real relationship retain these elements: it is the personal relationship between therapist and patient marked by the extent to which each is genuine with the other and perceives/experiences the other in ways that ‘befit’ (are suitable for or appropriate to) the other. These two elements, genuineness and realism, each vary on two dimensions: magnitude and valence. ‘Magnitude’ refers to the degree of realism and genuineness in the therapeutic relationship. ‘Valence’ refers to the degree to which these feelings are positive versus negative; you may perceive someone realistically and feel they are genuinely themselves, but either like or dislike what you see. A strong real relationship would consist of largely positive feelings based on realism and genuineness. For more on the nature of the real relationship unfold the supplementary text.
Virtually all modern quantitative research on the real relationship has assessed it using the Real Relationship Inventory, which has client versus therapist and longer versus shorter versions. These questionnaires generate a total score and subscale scores for realism and genuineness by asking respondents to rate statements (samples below) from strongly disagree to strongly agree.
• “I had a realistic understanding of my therapist as a person.”
• “My therapist did not see me as I really am.” (reverse scored)
• “My client’s feelings toward me seem to fit who I am as a person.”
• “There is no genuinely positive connection between us.” (reverse scored)
• “My client has little caring for who I truly am.” (reverse scored)
• “I am able to be myself with my therapist.”
To assess the possible effect of this relationship on outcomes, the review incorporated the first meta-analysis amalgamating results from relevant studies to estimate the overall strength of the link between the real relationship and patient progress or ratings of treatment quality, and to probe for influences on the strength of the link. Link strength was calculated as a correlation coefficient, an expression of the degree to which outcomes co-varied with the strength of the real relationship. The chosen metric ranges from -1 (perfect negative co-variation, meaning that as one side of the link gets larger the other diminishes) to +1 (perfect positive co-variation, meaning that as one side of the link gets larger so does the other). Correlation coefficients were also converted to effect sizes. Effectively these metrics indicate how influential the real relationship had been if causally linked to patient progress or their ratings of treatment quality.
The analyses included any study, reports from which enabled calculation of the correlation between the strength of the real relationship and either: improvements in the patients from before to after treatment; patients’ and/or therapists’ assessments of progress to date, most often completed at the end of treatment; or patients’ reports on the quality or outcome of the session in which the real relationship was assessed. After eliminating studies reporting overlapping data, the resulting 16 studies included five each linking real relationship to before-versus-after treatment progress and therapists’ assessments of progress, and six linking it to session quality.
Confidence in the findings reported below is weakened by the paucity of studies, and the fact that that nearly all were conducted by a few committed researchers. Research on the real relationship is in its early stages.
Overall the strength of the link between the real relationship and patient progress or treatment quality equated to a statistically significant correlation of 0.38 and a large effect size of 0.80. In other words, the more solid the person-to-person relationship between therapist and client, the better outcomes and quality assessments tended to be. There was little indication that the analysis had missed studies which would have substantially altered this finding.
Though universally positive, the strength of the link varied between studies more than expected by chance. Perhaps because there were so few studies, none of the possible influences assessed by the review significantly accounted for this variation. The influences tested were the type of outcome or assessment being linked to the real relationship, and whether client or therapist assessed the real relationship and/or outcomes.
Three studies investigated how the link between real relationship and patient progress or session quality ratings came about. They indicated that differences between therapists in how well they generate early real relationships, or strengthen these relationships during therapy, are more influential than differences between clients in how well they generate the relationship. Therapists who foster the real relationship have patients who on average do better in therapy.
However, the patient also contributes. There is evidence that real relationships are forged more strongly by patients who can stand back and accurately observe themselves, who attend to their inner feelings, tend to form secure attachments in general, and gain insight during treatment. On the other hand, a tendency to hide from one’s inner feelings is associated with weaker real relationships.
Therapists should pay close attention to the strength of their real relationships with patients and seek to cultivate and strengthen them during treatment. Certain therapist actions seem to facilitate strong real relationships. These include:
• Seeking to grasp empathically the patient and his or her inner experience. Therapist empathy is significantly related to the strength of the real relationship. Successful understanding of the patient facilitates the realism element on the therapist’s side, and because feeling seen and understood accurately can be so intimate, it fosters the patient’s personal connection to the therapist. In addition, it is likely that therapist empathy begets empathy in the patient, and patient empathy fosters seeing the therapist as they truly are, deepening the realism aspect of the real relationship on the patient’s side.
• Managing countertransference. Self-understanding, managing one’s own anxiety, and grasping the boundaries between oneself and the patient, enable therapists to be genuine with patients and to see patients as they are rather than as projections of the therapist’s conflicts. In turn, this fosters the same real relationship qualities in the patient.
• Sharing reactions with the patient. Although therapist self-disclosure is an imperfect indication of genuineness, it is modestly associated with the strength of the real relationship. Well-timed disclosures (including disclosures of feelings within the therapeutic relationship and about the patient) highly relevant to the patient’s needs (rather than those of the therapist) strengthen the patient’s perceptions of the therapist as genuine.
• Explaining when not sharing. Despite the above, therapists can appear genuine to the patient even while being relatively non-disclosing; it helps if the therapist explains why they are holding back. When the therapist clarifies why they are not disclosing, they are actually disclosing, but at a different level.
• Being consistent and constant. At the most fundamental level, the patient’s sense that they can count on the clinician to be there, and be there on time, fosters a sense that the therapist can be personally trusted and is interested in the patient as a person. This seems particularly important for highly vulnerable patients. In addition, consistency is a key factor in helping the patient trust the therapist as a person, and this includes consistency between the therapist’s verbal and non-verbal behaviour. Consistency also lends credibility to the real relationship the therapist is offering the patient.
commentary Across the 16 studies the link between real relationships and outcomes or ratings of treatment was relatively substantial – stronger than between outcomes and many other variables, including the type of therapy and the working alliance between therapy and patient. However, the warning that this research is largely the work of “proponents” of the real relationship must be taken seriously, and these researchers include the authors of the featured review. It makes the findings vulnerable to the so-called ‘researcher allegiance’ effect – a concern in several social research areas (1 2 3 4 5), where programme developers and other researchers with an interest in a programme’s success have been found to record more positive findings than fully independent researchers. However, that concern seems less salient in this case, because no ‘brand name’ therapy associated with an individual or research team is at stake, and it is just as likely that researchers have become proponents because the real relationship truly is highly important, yet has been neglected.
The reviewers’ practice recommendations presume a causal link between alliance and patients’ progress, which can be leveraged by the therapist to augment that progress. In other words, that how the therapist is and behaves affects how well their patients do, and does so partly via the bond they help form between themselves and the client. Though causality has not been established ( discussion below), the safest stance for trainers, supervisors, therapists, counsellors, patients and clients, is to presume causality, that a good relationship is an important determinant of treatment success, and that nurturing and maintaining such a relationship are core tasks. The findings must also have important implications for the recruitment of therapists and the selection or self-selection of their patients, which presumably should be based partly on an attempt to find pairings who ‘click’.
Given the nature of the studies which supported the review’s practice recommendations, causality cannot be considered proven, but for at least two reasons it seems likely. First is the consistency of the association between the strength of the real relationship and outcomes. Second is the plausibility of the proposition that establishing a good relationship will help keep patients in therapy and actively working with the therapist, and that this greater opportunity for therapy to work will often translate into it actually working better. Additionally, there seems little or nothing to lose and possibly much to gain from establishing a good relationship with clients, nothing to gain and possibly much to lose from failing to do so, and ethical considerations demand a positive attitude to troubled individuals who have come to you for help.
Confirmation of a causal link would require studies which randomly allocated patients to therapeutic programmes that deliberately generated strong versus weak relationships. On ethical grounds, such studies are not possible, meaning evidence for causality primarily relies on the accumulation of indirect evidence. Studies which provide this evidence are typically unable to eliminate the possibility that (for example) patients who were going to do well in any event were more likely to feel close to their therapists, and/or that such feelings were partly due to the fact that patients were already doing well and therefore felt appreciative of their therapists, or that therapists more capable of generating these feelings were also more competent in other ways. In these scenarios, the real relationship would remain associated with better outcomes, but not because it helped cause them. As causality theorists have explained, “Thunder correlates with power outages, but thunder does not cause power outages. To distinguish causal from noncausal correlations, it is important to control for alternative causes.” Without effectively random allocation of patients to therapies/therapists characterised by poor versus good personal relationships, these “alternative causes” cannot completely be eliminated.
Among relevant studies in the substance use sector is a study of the training of addiction counsellors, the findings of which highlighted the possibility that following the principles of motivational interviewing (which, for example, advise against direct warnings or uncalled for advice) could weaken the genuineness element of the real relationship. The implications of this study are most easily absorbed from a brief, informal account by Drug and Alcohol Findings.
The study found clients’ engagement in treatment was unrelated to the frequency with which the therapist made statements compatible with motivational interviewing’s ethos such as asking open questions, but was strongly related to embodying its overall spirit and to more general social skills including empathy, warmth, supporting the client’s autonomy, and coming across as ‘genuine’, an amalgam of seeming open, honest and trustworthy. Genuineness was difficult for raters to agree on, but still it was about as strongly related to engagement as the other qualities.
Another surprise was that when the counsellor’s general social skills were taken into account, the frequency with which the therapist contravened motivational interviewing’s mandates significantly and quite strongly related to client engagement, but in the opposite direction to that expected: the more the counsellors ‘broke the rules’, the better their clients engaged. Moreover, when socially skilled counsellors acted in these ways, they actually enhanced the effect their skills had on client engagement. For the researchers, genuineness seemed the explanation. Therapists who honestly and openly expressed the concerns they were feeling and gave advice they felt the client needed without holding their tongues, or trying to manipulate the client into doing the expressing for them, would have rated higher on being genuine, and perhaps also come across this way to the clients.
Listed below are analyses of the other reviews commissioned by the American Psychological Association task force.
Overall conclusions based on the other 16 reviews
Alliance in couple and family therapy
Alliance in child and adolescent therapy
Cohesion in group therapy
Goal consensus and collaboration
Therapist self-disclosure and ‘immediacy’
Therapist and client emotional expression
Repairing ruptured alliances between therapists and clients
Treatment outcome expectations
Feeding back client progress data therapists
Last revised 28 March 2019. First uploaded 16 December 2018
REVIEW 2018 Congruence/genuineness: a meta-analysis
REVIEW 2018 Psychotherapy relationships that work III