The importance of a therapeutic relationship - in psychotherapy and beyond
The quality of a therapeutic relationship is “alpha & omega” of any form of psychotherapy. This article discusses what are the most important elements of a therapeutic relationship and suggests how this could be applied in other 'helping' professions.
The importance of a therapeutic relationship
- in psychotherapy and beyond
by Katarina Gadjanski BSc (Hons), LCCH, Dip Psych, UKCP
Prior to my psychotherapy training, I trained in both traditional and complementary medicine and was running a homeopathic and complementary therapies practice for almost ten years. My work over the years was mainly focused on treating people who suffer from psychological troubles related to their physical ‘dis-ease’. Although my professional training had made me more than competent in treating these conditions it was through my clinical experience that I’ve learnt that the ‘healing process’ of the patient is not purely dependent on the therapeutic method that I use or the correct remedy that I prescribe. Although those factors are surely very important, they are not the only prerequisites for a 'cure'. Working quite intimately with people for over a decade has taught me that the successful treatment often depends heavily on the therapeutic relationship which is formed between a therapist and a client. Thus the quality of this relationship is the crucial element in a patient's recovery. The therapeutic method that I use, or the remedy that I prescribe is often only a secondary factor.
The problem that we face within the medical profession in general is that the professional training provided to medical students (including complimentary therapies and other health professionals) is not quite sufficient in teaching inter-personal and counselling skills which are invaluable therapeutic tools, and which are especially important when we want to create a successful therapeutic relationship with our patients. However, the newly qualified medical practitioners enter the medical profession often without being sufficiently trained in such skills. It is very likely that when patients seek out help they are often not only physically ill but are also emotionally quite vulnerable. It is crucial for a patient's recovery that we are able to see the person that is “behind” the illness. Constrained by the limited time available for each patient (on NHS for example), medical practitioners often forget that there is a vulnerable person in front of them and not just a subject who has pathology.
At the time of my training 20 years ago the medical schools did not stress this enough. I became aware of this “insufficiency” in my own training quite soon after I've started my practice. Thus, I had to turn to studying counselling and psychotherapy to fill this “gap”. Within my psychotherapy training I soon learnt that in counselling and psychotherapy the therapeutic relationship is, what Jung called, “the alpha and the omega” of the treatment. One could argue that this is quite understandable because the nature of psychotherapeutic work is heavily conversational (and relational) and problems that we deal with in psychotherapy are not primarily based on physical illness but are problems within the human psyche. One could then say that it makes sense that in psychotherapy the relationship between a therapist and a client would play a crucial role in the treatment.
However, I would argue that quality of the therapeutic relationship is as an important factor in other kinds of 'helping' relationships (i.e. a doctor and a patient) and that this personal and more empathic approach could greatly influence the success of the treatment. The human mind and body are not split from each other and therefore physical pathology should not be seen and treated as something separate from the whole person. It would be of great value if the medical profession could adopt this approach from psychotherapy.
In this article I am going to highlight the elements of an empathic and more personal therapeutic relationship and am going to suggest how this approach could be applied in other 'helping' professions.
American psychologist Carl Rogers  defines a 'helping relationship' as “a relationship in which at least one of the parties has the intent of promoting the growth, development, maturity, improved functioning and improved coping with life of the other.” He explains that the term - helping relationship covers a wide range of relationships, so not only a relationship between a psychotherapist and a client but any kind or counsellor-client relationship, doctor-patient relationship and to some extent even teacher-pupil relationship.
The origin of the idea that one should see the therapeutic relationship as a working alliance (where a client and a therapist are working together and where the therapist is acting as a facilitator for change while the client has the potential and material for change) comes from psychoanalytic practice, established by Freud. The concept of truly listening to our clients, as well as our “inner” world, also originates in psychoanalysis. As opposed to many of his contemporaries Freud took seriously all the anxieties and disturbances that his clients experienced and was truly receptive to the client’s ‘narrative’. In terms of the therapeutic alliance Jung went even one step further suggesting that the therapists should see the clients equal to them and should “abandon” all preconceived opinions, methods and diagnoses. Jung  advises us to abandon any attempt to apply ready-made solutions and to approach each case as unique. Also he suggests that we should not assume that we 'know' better then the client. Jung stated that the essence of the therapeutic relationship is being fully present to another as a living being.
Although these ideas originate in psychoanalysis the concept of an equal relationship between a therapist and a patent was further developed by Rogers in the 1940s and 1950s. Rogers is the founder of Person-Centered therapy, which is one of the most widely used humanistic models in mental health and psychotherapy in the UK and USA. In this approach, therapists create a comfortable, non-judgemental environment by demonstrating congruence, empathy, and unconditional positive regard towards their patients while using a non-directive approach.
Three fundamental elements important for creating an effective therapeutic relationship
Rogers  explains that over the years of practice his original question: ‘How can I treat, cure, or change this person’ had transformed and progressed into: ‘How can I provide a relationship which this person may use for his own personal growth’. So what kind of relationship does the therapist need to provide in order for this to take place? The first element of this relationship is genuineness/ congruence of the therapist. This means that the therapist should genuinely be ‘himself’ in the relationship, without putting up a professional front or a personal façade. The therapist needs to be aware of his own feelings, what is present in his own awareness and what is expressed to the client. By being genuinely himself the therapist is providing the reality which is in him so the therapeutic relationship can have reality, and the client can then start to seek for the reality within himself.
The second element of the relationship that can provide a fertile ground for change is acceptance and unconditional positive regard. The therapist must accept the client as he is, without judging or criticism. He should have a warm regard for a client as a person of unconditional self-worth, no matter what the client’s feelings, attitudes and behavior are. The therapist must allow the client to possess and express his feelings in his own way, and must regard him positively. The client would therefore feel accepted and see the relationship as a safe and secure place where he can just be himself. Rogers  explains that this acceptance and safety of being liked as a person is a highly important element in any helping relationship.
The third aspect that is important for the therapeutic relationship is empathy and understanding. The therapist needs to understand what it feels like to be in the other person’s shoes, to see the world through the client’s eyes. He also needs to be able to communicate this understanding and empathy to the client. It is not enough to just accept the client; the therapist needs to fully understand his feelings, thoughts and personal significance. The client must feel free to explore his feelings and experiences without fear of judgement or criticism. The client should never feel that he is being pushed into the areas that he does not want to go to and the therapist needs to allow the client to take any direction he chooses.
Rogers  believes that if the therapist can provide this type of relationship then the client will discover within himself the capacity to use that relationship for his personal development, growth and change.
The client needs the therapist to believe him and to feel that he is on his side. Wilde McCormick  explains that a therapist needs to have respect for both the inner and outer life of the client and needs to have an open, non-judgemental approach. The therapist needs to develop trust and empathetic resonance, to have his heart open to another in true compassion. He should avoid labelling the client (by his pathology) and instead see him as a person that is struggling with life. Jung  suggests that we should not see problems and psychological processes as the obstacles on the way that one needs to overcome but that they should be seen and used as vehicles for change, growth and transformation of consciousness.
The therapist should also have humility, be equal in the relationship and be prepared to appear just as an human being who can also make ‘mistakes’ and get things wrong (and be able to acknowledge that). The therapeutic relationship is a working alliance where the therapist and the client join forces and work together as a team.
Through my clinical experience I've realised that when I am able to provide the supportive environment that Rogers suggests, the healing process begins and a patient uses this supportive relationship for change and growth. However, the question arises here: how could this approach be beneficial in other forms of 'helping' relationships, and specifically in a relationship between a doctor and a patient?
Therapeutic relationship in other helping professions
I think that every communication between a doctor and a patient could to some extent be therapeutic if a doctor is able to truly MEET his patient. What I mean by this is that not every communication is a true meeting between two people; a real meeting only happens when we are open and fully present to another. My homeopathy patients often say that they started to feel better after the consultation (not only emotionally but in terms of their illness as well), just as a result of being truly listened to, feeling understood and empathized with. We often tend to forget that when our patients come to see us, even if they came purely because of the physical illness, they are often also in a great emotional distress, as one cannot disconnect one's body form one's emotions.
This brings us to another question. Who are we really trying to heal – a disease or a patient? This is the question that many people in medical profession often forget, not due to recklessness or lack of knowledge but due to the pressure of the large number of patients that they are seeing daily and due to having rather limited financial resources. So under these circumstances we often concentrate on the symptoms of the illness and try to find the quickest and easiest way to remove these, namely prescribing medication. But we need to ask ourselves if this approach is really in the best interest of our patients? Firstly, is it really ethically correct to prescribe something, for example, to help with the symptoms of depression, without looking at what really CAUSED this depression or any other symptom that the patient is suffering from? We now have extensive medical research examining psychosomatic phenomena which confirms the fact that psychological factors such as trauma, grief, anger, fear, suppressed emotions, unfulfillment, etc affect not only emotional well-being but also physical state of an individual. We can even go as far as to say that there is almost no physical illness in which a psychological factor doesn't play a part and often in many cases it directly causes the illness.
To go back to Rogers and the importance of the therapeutic relationship, it is not difficult to understand why patients start to feel better if their doctors provide them with the type of relationship that Rogers suggests.
Unfortunately, across the medical field (and sometimes even in psychotherapeutic practice) we often see that the therapeutic relationship is not one of equality and that the skills of a therapist/doctor are often emphasised at the expense of a patient’s potential, resources and experiences. I am not suggesting that the knowledge and expertise of a therapist/doctor are unimportant, I am namely pointing out that in many cases doctor-patient relationships are rather impersonal, unequal and therefore limited. To their patients doctors' often do not come across as “real”, genuine people but as professionals who are too impersonal and who are “hiding” behind their expertise and their professional façade.
Personally I find this very unfortunate. I believe that even when we are under pressure because of limited resources and limited time that we have for each patient, we (therapists, doctors and medical practitioners in general) could still offer our patients the therapeutic presence that Rogers suggest. Even under these circumstances we could still try to practice genuineness, empathy, acceptance, understanding and unconditional positive regard. Through the 20 years of my clinical experience, I came to the conclusion that the quality of a therapeutic relationship is indeed “the alpha and the omega” of the treatment as it greatly improves the outcome of our patients' treatment.
 Jung. C.G. (1979) Psychological Reflections, London: Routledge & Kegan Paul
 Rogers, C. R. (1988) On Becoming a Person – A therapist’s view of psychotherapy, London: Constable
 Rogers, C. R. (1995) A Way of Being, New York: Mariner Books
 Wilde McCormick, E & Wellings, N. (2000) Transpersonal Psychotherapy – Theory and Practice, New York: Continuum
 Jung. C.G. (1990) Analytical Psychology – Its Theory and Practice, London: Ark Paperbacks