Development of the Therapeutic Relationship

Introduction
 The inner philosopher might say that it is not the pursuit of knowledge itself, but how we can use said knowledge to advance humanity that is most important in the search to understand our existence. Psychology is still a very young science, but in its infancy the potential to use it to help heal the mind speaks to a truly noble goal. Most generally applying psychology to heal the mind takes the form of Psychotherapy. One could argue that the most important aspect of psychology is its potential healing properties, and therefore it is Psychotherapy and the importance of the therapeutic alliance in the healing process of all forms of Psychotherapy that is the most important.

What is Psychotherapy?
 In order to understand the importance of the therapist role and therapeutic relationship, we first need to understand exactly what psychotherapy and it’s goals are. When one enters psychotherapy, it is normally with the goal of eliminating some kind of psychological pain in order to achieve goals which in their current state they are being held back from achieving (Lebow, 2012). Once established, the therapy proceeds with the understanding that it is the “patient’s belief system that is the primary source of difficulty and that the ultimate goal of therapy is to uncover and change it” (Lebow, 2012, p.50).

 The role of the therapist in this healing process is achieved through the possession of certain qualities such as “warmth, genuineness, sincerity, and openness” (Lebow, 2012, p.50). In addition, the therapist helps structure the therapy with the patient through a correct understanding of how patients view their world which is achieved through empathic listening (Lebow, 2012).

What is the Therapeutic Alliance?

Similar to the ideas proposed by one of the fathers of humanistic psychology Carl Rogers in terms of the role of the therapist (Lebow, 2012, p.50), the therapeutic alliance refers to “the personal qualities of the patient, personal qualities of the therapist, and the interactions between them’’ (Wright & Davies, 1994, p. 27). Although the therapeutic alliance in and of itself is not sufficient for a fully healing process, it is nonetheless a mandatory component of all successful psychotherapies (Lebow, 2012).

Historical Evolution of Psychotherapy

 It has been proven over the course of history that having a form of therapy that emphasizes the relationship between a therapist and the patient is far more beneficial to the healing process, than one that discourages it, such as Freud’s psychoanalysis in its original incarnation (Wampold, 2012). Freud believed that although the best way to achieve a healing process was through the confrontation of a patient’s views and beliefs, he made the mistake of believing that the development of a therapeutic relationship was merely a pathological expression of transference from the patient to the therapist (Andersen & Miranda, 2000). This was reflected in his views that although a therapist should listen to and try and understand where a patient is coming from, it should be done so from a professional distance with the end goal of getting the patient to recognize that the emotions they experience with their therapist are actually an expression of repressed trauma (Andersen & Miranda, 2000).

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 One of Freud’s main critiques at the time, Carl Jung, practiced psychotherapy from his own perspective; analytical psychology (Landis, 1940). Analytical psychotherapy was better than psychoanalysis in that it allowed for and encouraged complete open communication between patient and therapist (Landis 1940). However, it wouldn’t be until Carl Rogers’ discovery of the importance of the therapeutic relationship that the direction of using psychology for healing the mind would be forever changed.

Carl Rogers and the Therapeutic Alliance
 As stated earlier, there are several aspects that are vital to successful psychotherapy, and these in many ways parallel the work of Rogers (1986). Rogers (1986) spoke of the qualities of unconditional positive regard, genuineness, trust, and empathetic understanding. These mirror the modernized qualities of warmth, genuineness, sincerity, and openness, respectively. Unconditional positive regard is when the therapist experiences “a positive, nonjudgmental, accepting attitude toward whatever the client is at that moment” (Rogers 1986, p. 135). Genuineness is the degree to which the therapist is their true self when working with the patient (Rogers, 1986). Trust is the basic element of allowing a patient to develop and grow in their own way without having a bias that the patient is incapable of doing so (Rogers, 1986). Finally, empathetic understanding is the ability of the therapist to accurately sense, understand, and communicate the feelings and meaning of what the patient says (Rogers, 1986).

  These qualities allow the patient to open up more easily to the therapist because they are allowed to express themselves freely as they truly are (Ardito & Rabellino, 2011). By being free of judgement, a safe environment is created in which one is able to truly come to terms with their experiences and work with the therapist to overcome them to achieve functional skills and growth (Ardito & Rabellino, 2011).

What Makes the Therapeutic Relationship Special?

The therapeutic alliance changes over time from the initial stage in which the relationship is primarily based on how supportive the patient views the therapist as being early in the therapy (Ardito & Rabellino, 2011). Later, this transforms into a collaborative relationship defined by the therapist and the patient working together to achieve their established goals and overcome problems (Ardito & Rabellino, 2011). Within the later part of the dynamic relationship, there exists certain pathways based on the contextual model of psychotherapy that make it a unique social relationship prone to healing (Wampold, 2015). These pathways consist of “a) the real relationship, b) the creation of expectations through explanation of disorder and the treatment involved, and c) the enactment of health promoting actions” (Wampold, 2015, p. 270).

The real relationship taps into the trait of genuineness described earlier. In essence, by being completely open with each other, a strong social bond is established. However, unlike any other social bond, there is a guarantee of confidentiality, and that no matter what manner of disturbing information a patient reveals, the bond will be unaffected (Wampold, 2015). This provides a guaranteed empathetic relationship for the patient.

Expectations from the patient in how therapy will help them go beyond a placebo effect in which by merely thinking the treatment will help them, the effects of treatment are improved (Wampold, 2015). What this means is that most patients enter into therapy with a preconceived notion of how their condition affects them, usually in a non-constructive way that don’t allow for adaptations in daily life (Wampold, 2015). The therapeutic alliance is unique in terms of expectations in that they not only help the patient come up with strategies for the specific difficulties they came in for, but also develop coping strategies they can apply elsewhere in daily life (Wampold, 2015).

Finally, the health promoting actions of the therapeutic relationship are the suggestions made by the therapist to ideally help treat the unique problems the patient experiences (Wampold, 2015). As long as the patient feels that these suggestions would help them, then these suggestions for healthy action can directly benefit the patient in daily life such as “relying less on dysfunctional schemas […], improving interpersonal relationships […], being more accepting of one’s self […], expressing difficult emotions […], taking the perspective of others […], and so on” (Wampold, 2015, p. 272)

Empirical Evidence of Importance

 A large amount of research has been done on quantifying and proving the impact that the therapeutic alliance has on patient outcomes. When a meta analysis on common factors such as “alliance, empathy, expectations, cultural adaptation, and therapist differences” (Wampold, 2015, p. 270) were compared to specific factors such as “treatment differences, specific ingredients, adherence, and competence” (Wampold, 2015, p. 270), it was found that the common factors are a vital mechanism of change in the therapeutic process.

Influence on the Direction of Psychology: Modern Psychotherapy

The first wave of psychotherapy was inspired by Freud’s less than effective psychoanalysis (Ferguson & O’Donohue, 2015). Frustration with Freud’s methods gave birth to second wave of psychotherapy which consisted primarily of behavioural and cognitive therapies which emphasized the role of cognitive processes in psychological disorders (Ferguson & O’Donohue, 2015). Although the second wave methods were for the most part successful, there were still several problems with them, and aspects of the treatments that could not be explained. It was Carl Rogers’ work that directly inspired and started the third wave of psychotherapies, which recognized the importance of understanding and empathizing with the patient. These include therapies such as “acceptance and commitment therapy (ACT), dialectical behavior therapy (DBT), functional analytic psychotherapy (FAP)” (Ferguson & O’Donohue, 2015, p. 431). ACT incorporates humanistic aspects by focusing on the use of language in defining, and by extension, solving one’s problems (Ferguson & O’Donohue, 2015).  DBT seeks to establish a patient’s level of reactivity in an environment, and then develop strategies to cope with that stress. FAP arguably had the largest influence from Roger’s (1986) work, in that it places special emphasis on the therapeutic relationship in order to identify the function of a behaviour, and then use that unique repertoire to establish treatment guidelines. This means that treatment is unique to each patient (Ferguson & O’Donohue, 2015).

Conclusion

By identifying the factors most responsible for the healing process in psychology, Carl Rogers and other psychologists were and are better able to improve and expand upon psycho-therapeutic techniques, which makes improvements to the healing capabilities of psychology even further. By improving psychotherapy through exploitation of the therapeutic alliance in psychotherapy, the most important aspect of psychology was discovered and advanced the field greatly. This is demonstrated in Carl Rogers’ work and the influence it had on all future therapies, and the differences his work made on all psychotherapies when comparing those that came before his work versus after.

References

• Andersen, S. M., & Miranda, R. (2000). Transference: How past relationships emerge in the present. The Psychologist, 13(12), 608-609. Retrieved from http://myaccess.library.utoronto.ca/login?url=https://search.proquest.com/docview/619509325?accountid=14771
• Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2, 11. doi:http://dx.doi.org/10.3389/fpsyg.2011.00270
• Wright, J & Davis, D (1994). The therapeutic relationship in cognitive-behavioral therapy: Patient perceptions and therapist responses, Cognitive and Behavioral Practice, Volume 1, Issue 1, 1994, Pages 25-45, ISSN 1077-7229, https://doi.org/10.1016/S1077-7229(05)80085-9.
• Ferguson, K &  O’Donohue, W. (2015). Behavior Therapy: The Second and Third Waves. International Encyclopedia of the Social & Behavioral Sciences (Second Edition), 431-436, https://doi.org/10.1016/B978-0-08-097086-8.21090-8.
• Landis, C. (1940). Review of Technique of analytical psychotherapy. The Journal of Abnormal and Social Psychology, 35(4), 590. doi:http://dx.doi.org/10.1037/h0052851
• Lebow, J. L. (2012). Twenty-first century psychotherapies: Contemporary approaches to theory and practice. John Wiley & Sons.
• Rogers, C. (1986). Client-centered therapy . In I. L. Kutash & A. Wolf (Eds.), Psychotherapist’s casebook (pp. 197 – 208 ). San Francisco : Jossey-Bass.
• Wampold, B. E. (2012). Humanism as a common factor in psychotherapy. Psychotherapy, 49(4), 445-449. doi:http://dx.doi.org/10.1037/a0027113
• Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270-277.