THE THERAPEUTIC RELATIONSHIP: BUZZ PHRASE OR ESSENCE OF SUCCESS?
What is the effect of the relationship between client and therapist on changing outcomes now measured by most services? Divine Charura and Paul Nicholson explore what a therapeutic relationship is – and why it is a vital element in effective interventions in addiction settings.
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Often, staff who work in addiction settings appear to measure the success of their work through the number of cases resulting in reduced substance misuse or in detox, rehabilitation and maintenance of sobriety/abstinence. We have noted that what is often not looked at is the impact of the therapeutic relationship on the outcomes measured by most services that provide support for individuals whose lives are affected by addiction.
This article discusses the relevance of the therapeutic relationship when working with clients in such settings or in the community and explores the impact of the therapeutic relationship on the likelihood of successful therapeutic outcomes.
WHAT IS THE THERAPEUTIC RELATIONSHIP?
One of the key debates we are aware of from the helping professions’ literature and from our psychological therapies work is the disparity in views over the nature of the therapeutic relationship and its relevance to the therapeutic encounter. This debate is intertwined in key questions found in general psychology and counselling history, and it is easy to get lost in the myriad of diverging opinions when construing a satisfactory definition.
Establishing unanimity on this issue is dominated by debates surrounding the nature of the self, and how we try to conceptualise it with all its complexities when working with individuals or groups. This has, over the years, led to a competitive tribalism between theoretical models, provoked studies advocating a ‘which model is best’ approach surrounding best practice, and kept a consensus at bay about where the therapeutic relationship fits into the holy grail of therapeutic efficacy.
But recent studies into common factors constituting this type of professional helping relationship help to clarify the picture and show the importance of relationship to therapeutic outcomes (Stiles et al 2006, Haugh and Paul 2008).
Schools have endeavoured to prove one particular school’s efficacy over another. But recent findings showed that there is little to separate the model of therapy practiced – with some researchers even arguing that there is no difference in measure of outcome between different therapeutic approaches (Beutler et al 2004; Wampold, 2001; Stiles et al 2006).
The therapeutic relationship – sometimes termed as the therapeutic alliance, the global alliance, the therapeutic bond or the working alliance among others – refers to the relationship between a healthcare professional and a client/patient (Haugh and Paul 2008). It is the means by which a helping professional and a client hope to engage with each other and, between them, engender beneficial change in the client.
In addiction work, the beneficial change is a goal set at the onset of the individual contacting the service;. It can vary according to the service. This variance might be on harm reduction or be about total abstinence, relapse prevention and maintaining sobriety.
In our experience, people who access addiction support services can present with attitudes that could translate as ranging from lack of motivation to total commitment to change. Sometimes this can be elicited through motivational dialogue with clients in which their behaviour, attitudes and goals for the future can be identified and explored. It is from this contact that we postulate that staff working in such settings should explore how they can be engaged in a supportive, ethical and change-facilitating therapeutic relationship.
Addiction impacts on the concept of self in many complex ways and often leads to behaviours that can be challenging and frustrating for some. We thus highlight the need for patients to engage in a therapeutic relationship which enables them to start an exploratory, and goal-oriented journey in relation to change.
It is also important for staff to access supervision for their work to be supported with any challenges they may be facing.
WHAT IS A GOOD RELATIONSHIP?
Technically, the varied qualities of a good therapeutic relationship have distinctive emphasis and are interpreted differently according to profession or practice philosophy. But most definitions of the therapeutic relationship share three common factors (Bordin 1979; Gaston 1990, cited in Haugh and Paul 2008) as below:
>> the collaborative nature of the relationship – this could present challenges for staff especially when clients present to services/appointments intoxicated, under the influence of substances or seem unwilling to engage in the proposed interventions
>> the affective bond between client and therapist/staff – we postulate that this develops over time and is highly dependent on how the therapist offers facilitative conditions for change and how the client perceives these; ethics and professional boundaries are central to this
>> the clients’ and therapists’ ability to agree on treatment goals [This is dependent on the therapists ability to explore what the individual brings and clients ability to illicit and articulate the motivation to change and the goals to work towards] (Bordin 1979; Gaston 1990, cited in Haugh and Paul 2008).
We also highlight the need for continual evaluation of progress and opportunities to explore challenges to relapse prevention strategies.
It is important to affirm and explore client progress, however small. This can include the positive impact of behaviour change such as reducing drinking/substance use or applying for voluntary/paid job after rehabilitation or the positive impact of abstinence on the wider family, societal network system. An example is re-engaging with friends, family or services which offer support.
In literature, it is clear that the debate has shifted so that the role of the therapeutic relationship has become more of the area of focus rather than whether the therapeutic relationship itself is considered necessary.
Some studies now outline that not only is the therapeutic relationship an essential factor in the prediction of successful therapeutic outcomes but also that it is the biggest in-therapy determinant of all factors, outscoring even the choice of practice model (Stiles et al 2006, Haugh and Paul 2008).
We also note that research on the statistical power of the therapeutic relationship reflects over 1,000 findings and facilitative determinants which include the quality of the clients engagement and participation in therapeutic interventions (most important), the therapeutic bond, skillful application of interventions, the therapist’s contribution especially through “empathic, affirmative, collaborative and self-congruent engagement”.
After more than 40 years of research, these are considered essential ingredients in the therapeutic relationship (Orlinsky, Grawe and Parks 1994:361-2, Haugh and Paul 2008).
WHAT MAKES THE THERAPEUTIC RELATIONSHIP AND THE ROLE OF THE THERAPIST IN IT SO SIGNIFICANT?
First, contact is healthily established, providing safety necessary for exploration, self-acknowledgement and growth beyond previous perceived patterns of relating. These can include coping patterns to which which clients might default of drinking or using substances to cope with life’s experiences.
Recent research suggests that the therapeutic relationship contains features of an attachment relationship and that the therapist serves as a safe attachment figure for clients.
Here we use the word attachment in the sense of describing a relationship in which the client perceives that s/he can put trust to be supported and helped. So therapists can be seen by clients as a secure basis for exploration and help. Skourteli & Lennie (2011) cut to the heart of the matter by stating that the therapeutic relationship contributes to the re-evaluation and revision of internal working models of self.
This message has been echoed in the work of Johnson and Cladwell (2011), who postulated that positive
outcomes in therapeutic work were contingent on the perceived confidence of the therapist. So all who work with clients should identify and invest in support to offer their best interpersonal and therapeutic skills in their work. In addiction settings, this could be evident through service provisions which show a progressive support of clients from contact (when clients present with dependency) to discharge (when clients progress with their lives, having gained skills to minimise their use/ being totally abstinent).
In a good therapeutic relationship, subjectivity of both parties is exchanged promoting a sense of shared perception of how life is, how we fit in it and establishing clarity on the benefits of changing substance use behaviour. This can be facilitated by the therapist’s empathic responses in ways that the client can perceive that s/he is being understood, validated as a human being, not judged as an ‘addict’ ‘victim’, label, or set of symptoms.
The curative factor of the therapeutic relationship is ultimately found in its humanising, relational quality. Where people feel judged, unaccepted and perceive that the care and support they are receiving is ‘tokenistic’, they are likely to resist engagement and ultimately will drop out of the service, leading to high possibilities of relapse.
So the therapeutic relationship is one of the most basic cornerstones in supporting people to maintain abstinence, autonomy, and regain their ability to be successful in drawing on their internal and systemic resources such as family, friends and support workers.
The therapeutic relationship might be a buzz phrase representing another miracle component in effective treatment in addiction work. But it is borne from a long history of involved debate, research and practice across many other
therapeutic professions. It has
emerged not only as an agreed requirement for successful therapeutic interventions, but also as a common factor found among all forms of effective helping.
DIVINE CHARURA is a senior lecturer in counselling and psychotherapy at Leeds Met University. He also works as a UKCP registered psychotherapist (NHS) and has work experience in diverse therapeutic settings including working in addiction settings for the last seven years.
PAUL NICHOLSON is a BACP accredited counsellor and senior lecturer in psychological therapies at Leeds Met University. He has worked in NHS forensic psychiatry for 15 years. He has an enduring interest in relational perspectives in therapy and developing a cohesive language which accurately reflects the processes involved.
* Beutler LE, Malik M, Alimohamed S, Harwood TM, Talebi H, Noble S & Wong E (2004). Therapist variables. In MJ Lambert (2004) (ed) Bergin and garfield’s Handbook of Psychotherapy and behaviour change (5th edn, pp227-306) by John Wiley and sons.
* Johnson LA, Cladwell BE (2011). Race, Gender and Therapist Confidence: Effects on Satisfaction With the Therapeutic Relationship in MFT. American Journal of Family Therapy Jul/Aug 2011 vol 39 issue 4, p307-324.
* Haugh S, Paul S (eds) (2008). The therapeutic relationship: themes and perspectives by PCCS.
Orlinsky, Grawe, Parks (1994); Stiles et al (2006); Bordin 1979; Gaston 1990, cited in Haugh and Paul (2008) The therapeutic relationship: perspectives and themes by PCCS.
* Skourteli MC, Lennie C (2011). Counselling Psychology Review vol 26 issue 1, p20-33.
* Stiles WB, Barkham M, Twigg E, Mellor-Clark J, Cooper M (2006). Effectiveness of cognitive-behavioural, person-centred and psychodynamic therapies as practised in UK National Health Service settings. In Psychological Medicine, 36, pp555–566.
* Wampold BE (2001). The great psychotherapy debate. Mahwah NJ: Lawrence Erlbaum.