Therapeutic Relationship vs. Treatment Model

When I call therapists in other locations to check them out for a referral, I briefly describe the case and ask what their approach would be. Quite a number of these therapists have said something like, “I mainly focus on the relationship, since that’s where the healing comes from.” In a recent survey I saw a number of similar comments. One question focused on choice of technique in a particular context, and a number of respondents wrote some version of, “The technique is irrelevant – it’s the relationship that heals.” Based on my nonscientific sample, I suspect that this position is not uncommon among therapists.

The way it is expressed indicates that this view of the relationship’s primacy is not about psychodynamic theory – in which the therapy relationship is systematically utilized for healing. Psychodynamic people tell you that they’re psychodynamic; they’re clear about what they’re doing, and about the role of technique. No, these therapists are saying that they’ve extracted the essence of the so-called “common factors” research, and concluded that as long as they develop a good relationship with their client, everything else falls into place.

The common factors research – focusing on factors such as empathy, warmth, and positive regard, that may be common across treatment approaches – is quite important, and the centrality of common factors to therapy’s effectiveness has become ever more widely recognized and embraced (e.g., Duncan, Miller, Wampold, & Hubble, 2010). However, this valuing of the relationship over treatment approach reflects a profound misunderstanding of the common factors research.

Duncan & colleagues’ (2010) recent synthesis of the common factors research emphasized the integration and inextricability of the various factors. That is, you can’t just add more empathy or therapeutic alliance to an otherwise non-viable treatment approach and suddenly have a viable treatment. Rather, the common factors are necessarily grounded in a coherent and credible treatment model – itself a common factor – that is embraced by therapist and client. Such a treatment model serves as the foundation for the explanation of the problem, the plans for rectifying the problem, and the hope for successful change. These constitute much of the basis for the therapeutic alliance, the most important predictor of treatment success (Norcross, 2010).

Although it is heartening to see that the common factors literature has reached the practice community, it is concerning to see that it has been commonly misinterpreted in such a way that many therapists may be disregarding the importance of using a coherent treatment approach. It is also worth mentioning that not all coherent treatment approaches are equal; for example, our own trauma-informed phase model of treatment is particularly facilitative of the common factors. Other approaches may be more or less so.

I have often advised friends looking for love not to try to find it via dating. It’s difficult to develop a strong relationship merely by wishing to do so, even if over dinner. Rather, I have advised these friends to do what they care about – in the company of others – because relationships are best built from shared experiences. In therapy, similarly, you can focus on “building a relationship” but then what do you have? Probably a client who feels good while with you, but doesn’t make much progress in therapy. It’s better to build the relationship by going through the essential activities of therapy, one step at a time. As the client identifies and invests in his/her goals, develops a good understanding of what’s in his/her way and what to do about it, and starts to do those things, making real steps towards success… Well, when the therapist is helping the client to make progress in therapy, the relationship tends to do pretty well too.

References

Duncan, B. L., Miller, S. D., Wampold, B. E., & Hubble, M. A. (2010). The heart and soul of change: Delivering what works in therapy (2nd Edition). Washington, DC: APA.

Norcross, J. C. (2010). The therapeutic relationship. In B. L. Duncan, S. D. Miller, B. E. Wampold, & M. A. Hubble (Eds.), The heart and soul of change: Delivering what works in therapy, 2nd edition, pp. 113-141.