Therapist–Patient Relationship Research Paper

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The therapist–patient relationship is accepted widely as a central aspect of psychotherapy, although there is less agreement on how this relationship plays a role in treatment. This research paper will examine the varying perspectives on the therapist–patient relationship in both historical writings on psychotherapy and in current research and theory. Methodological issues in attempting to study empirically the therapist–patient relationship will also be delineated, and speculations on future directions for research and theory will be offered. But first, the next section will attempt to define the therapist–patient relationship.

1. Definition Of The Therapist–Patient Relationship

A ‘relationship’ is something that emerges when two or more people interact. However, with the therapeutic relationship, and perhaps any human relationship, it becomes difficult to think about or observe this ‘emergent’ property of the interaction independent of the contributions of each of the participants. Thus, the thoughts, feelings, attitudes, and behaviors of the participants, as well as the technical interventions of the therapist, all potentially play a role in the formation and maintenance of the therapist–patient relationship and need to be considered in any conceptualization of this facet of psychotherapy. In the broadest sense, then, the therapist–patient relationship is the emergent entity that is produced by the expectations, attitudes, thoughts, feelings of the participants about each other, as well as their behaviors towards each other.

Despite this broad and elusive definition of the construct, we know a good therapist–patient relation-ship, and a bad one, when we see it. A good therapist–patient relationship is usually evident when patient and therapist are acting in a warm, caring, empathic, and productive way towards each other. A bad therapist–patient relationship is characterized by distance, hostility, lack of respect, manipulation, or poor capacity to work effectively together.

The positive, ‘reality’ based aspects of the therapist–patient relationship are subsumed under the concept of the ‘therapeutic alliance.’ Bordin’s (1979) definition of the therapeutic alliance in particular has had considerable influence in theoretical and research writings. The therapeutic alliance, according to Bordin (1979), consists of three elements: (a) agreement between patient and therapist on the goals of therapy, (b) agreement on the tasks of therapy, and (c) the affective bond between patient and therapist. While the bond incorporates the emotional aspects of the patient–therapist attachment, agreement on goals and tasks refers to expectations or cognitive elements of the relationship. To understand how these aspects of the therapist–patient relationship have come to be accepted widely and how they apply to the full range of different psychotherapies requires a historical perspective, given in the next section.

2. History Of Concepts Of The Therapist–Patient Relationship

Modern views of the therapist–patient relationship can be traced directly to Freud’s writings. Freud considered the therapist–patient relationship to be a unique laboratory for observing aspects of patient’s personalities that may have relevance to the patient’s symptoms or psychopathology. Moreover, he utilized the relationship to effect change in the patient.

Freud described several components of the therapist–patient relationship. In terms of the patient’s contributions to the relationship, Freud (1958) described both positive and negative transference reactions. Transference refers to the expectations, desires, thoughts, and feelings that are ‘transferred’ from a previous relationship on to a new relationship (e.g., the therapist). Positive transference was further divided into the reality-based ‘friendly and affectionate aspects of the transference which are admissible to consciousness and which are the vehicle of success’ (Freud 1958) vs. other positive feelings and perceptions (e.g., sexual feelings, strong dependency) that were not reality-based, originating instead from the patient’s unconscious linking of the therapist with significant past relationships. Similarly, negative transference included negative feelings and perceptions that originated from past relationships and were not evident in the therapist–patient relationship. Finally, Freud acknowledged that distortions in the therapist– patient relationship might result from the therapist unconsciously linking the patient to significant people in the therapist’s past (‘countertransference’).

While the reality-based friendly feelings motivated a patient to stay in treatment and engage in therapeutic work, distorted positive and negative transference reactions served as the basis for the therapist’s technical interventions. By illustrating these distortions to the patient, previously unconscious conflicts became conscious and such insight lead to patient improvements.

A number of subsequent psychodynamic theorists expanded upon Freud’s discussion of the therapeutic relationship. The term ‘ego alliance was used by Sterba (1934) to refer to the patient’s capacity to work with the therapist in treatment, alternating between experiencing and observing. Subsequently, Greenson (1965) described this capacity as the ‘working alliance,’ and theorized that it stemmed from the patient’s mature ego functioning in conjunction with an identification with the work orientation of the therapist. Zetzel (1956) discussed the patient’s attachment to the therapist (labeling it the ‘therapeutic alliance’), and postulated that it originated from positive aspects of the mother–child relationship.

Because the analysis of transference became the defining feature of many approaches to psychodynamically-oriented psychotherapy, a relatively large literature has developed on this aspect of the therapist–patient relationship. Esman (1990) has collected a sample of influential papers on transference that illustrate the perspectives of a range of psychoanalytic writers including Freud, Klein, Winnicott, Gill, Kohut, Kernberg, Lacan, and others.

Although there are historical disagreements about whether the positive aspects of the therapist–patient relationship represent patient distortions or realistic appraisals of the treatment situation, the writings of Bordin (1979) served to mark the beginning of consensus on the importance of the realitybased, collaborative therapist–patient relationship (the ‘alliance’). This is not to say that other schools of psychotherapy had been silent on the importance of the therapist–patient relationship. In many ways, client-centered psychotherapy, developed by Rogers, can be seen as an approach that relied exclusively on a positive therapist–patient relationship for inducing change. Unlike the psychodynamic emphasis on reactions of the patient to the therapist, Rogers’ (1951) focus was on the therapist’s contribution to the relationship. Rogers claimed that if certain ‘facilitative conditions’ (therapist empathy, genuineness, and unconditional positive regard) were provided to a patient, the patient’s natural tendencies for growth and healing would be activated.

The behavioral school of psychotherapy, however, has often been characterized as minimizing the role of the therapist–patient relationship. This school of therapy describes behavior change in terms of principles of learning (i.e., classical or operant conditioning; social learning theory), with no focus on the context in which therapy takes place—i.e., the therapist–patient relationship. Practicing behavior therapists came to realize that this was an oversimplification. Goldfried and Davison (1976), for example, devoted an entire chapter of their book on clinical behavior therapy to the therapist–patient relationship, describing how behavior therapists can use the therapeutic relationship to directly sample aspects of the patient’s problematic behavior. Moreover, a positive relationship was seen as crucial to facilitating favorable patient expectations for change and receptiveness to the behavioral approach, enlisting patient’s active cooperation in treatment, and motivating the patient to attempt new behaviors outside of therapy.

Beck’s cognitive therapy approach has long acknowledged that the therapist–patient relationship was important to successful outcome, but it was largely considered a ‘given,’ with only brief explicit attention to the relationship in the original writings on cognitive therapy as a treatment for depression (Beck et al. 1979). However, as cognitive therapy expanded its scope to the treatment of other disorders, especially personality disorders, the therapist–patient relationship has come into focus increasingly as a key element of the process of treatment (Newman 1998).

3. Emphases In Current Theory

As mentioned, different schools of psychotherapy have largely converged in their agreement that the therapist–patient relationship is of central importance to successful psychotherapy. Even pychodynamic approaches to treatment, which historically have focused attention on patient distortions about the therapist, now highlight the role of the reality-based aspects of the therapist–patient relationship. The consensus about the importance of the therapeutic alliance is evident in a recent edited volume by Safran and Muran (1998) presenting chapters examining the alliance in psychodynamic, cognitive, experiential, strategic, family, and group psychotherapies.

While each approach to psychotherapy tends to stress somewhat different aspects of the therapeutic alliance, Safran and Muran (1998) have identified a number of principles on which there is basic agreement across therapeutic schools regarding what the therapist can do to facilitate a positive alliance. Among others, these include establishing a bond with the patient by conveying warmth, respect, and interest, outlining the tasks and goals of treatment at the beginning of therapy, focusing on realistic goals, maintaining a clear therapeutic focus, keeping a balance between being active (which helps maintain the treatment focus and the patient’s involvement) vs. receptive to patient needs and experiences, and addressing ruptures in the alliances when they occur.

Despite the agreement that has emerged regarding the importance of the alliance, there remains considerable disagreement about how a positive alliance results in more favorable treatment outcome. One view is that the alliance in itself is curative. This perspective proposes that a positive relationship between therapist and patient provides a corrective emotional experience for the patient. Through their relationship with the therapist, the patient emotionally learns over time that other people are not abusive, controlling, manipulative, or otherwise destructive in relationships, as the patient has experienced others to be in the past. Thus, the patient’s core expectations or beliefs about people change, and this improves relationships outside of therapy.

The second view on the role of the therapist–patient relationship posits that a good alliance sets the stage for psychotherapy techniques to have their impact. Whether the techniques are cognitive–behavioral, such as homework assignments, or psychodynamic, such as interpretations of interpersonal patterns, the patient’s receptivity to such therapist techniques will depend upon the extent to which the patient has a good bond with the therapist and basically agrees with the therapist on the goals and tasks of therapy. In this model, it is neither a good relationship nor good techniques that lead to better outcome, but rather the interaction of the two—a combination of good techniques in the context of a good relationship.

Both of the above models assume that the alliance is a relatively stable aspect of the therapist–patient relationship. A contrasting perspective has been offered that views the alliance as a relatively fluid process with ongoing ruptures occurring frequently during treatment sessions (Safran et al. 1990). It is unclear at this point whether such moment-to-moment fluctuations in the alliance are the norm or whether they occur primarily in the treatments of certain types of patients (e.g., those with severe problems in interpersonal relationships).

4. Research On The Therapist–Patient Relationship

Beginning in the 1970’s, a variety of studies reported on the development of scales for assessing the alliance and examined its relation to psychotherapy outcome. Several reliable self-report measures and observer ratings scales (applied to tapes of psychotherapy sessions) were constructed. Many of the scales are linked to the theoretical model described by Bordin (1979).

Horvath and Symonds (1991) summarized the emerging literature on the relation of the alliance to psychotherapy outcome. In a meta-analysis of 24 studies, these authors reported that, on average, there was a small to moderate relationship between the quality of the alliance during treatment and eventual treatment outcome. Moreover, the alliance was found to be related to treatment outcome across diverse psychotherapies. The size of the statistical relationship, however, suggests that the alliance is not the only factor, or even a particularly strong factor, in determining psychotherapy outcome. In brief, while the therapist–patient relationship appears critical, there is no reason to suggest that a good therapist–patient relationship is the only curative factor in psychotherapy.

Several studies have examined the common clinical hypotheses that good psychotherapeutic technique has its greatest impact in the context of a positive alliance, i.e., the alliance and technique interact to produce better outcomes. No definitive results, however, have been reported to date, with some studies reporting evidence for an interaction (Gaston et al. 1994), and other studies yielding inconclusive but suggestive findings with small samples (Gaston et al. 1998).

5. Methodological Issues In Research

A host of methodological issues need to be considering when conducting research on the relation of the alliance to treatment outcome. Perhaps the most crucial issue relates to whether a positive alliance is actually a causal factor in producing better treatment outcomes. The reverse causal direction needs to be entertained as well: as symptoms improve, patients are more likely to report a positive attitude about the therapist and treatment. Thus, significant correlations between the alliance (measured during treatment) and outcome may be spurious—early improvement in symptom lead to both a positive alliance and good eventual treatment outcome. This potential confound between the alliance and prior improvement was addressed by Gaston et al. (1991), who found large correlations between the alliance and outcome even when prior improvement was controlled; however, because of small sample sizes the findings were not statistically significant. Thus, this important issue of the direction of causality remains to be addressed in future research.

A methodological issue that might limit findings on the relation of the alliance to outcome is the possibility that the alliance may interact with patient dispositional variables in predicting outcome. For example, Horowitz et al. (1984) found that two of four alliance measures interacted significantly with patient pretreatment motivation for psychotherapy in predicting outcome—a good alliance only matters if the patient is also motivated for treatment.

A further consideration is that while most research has examined average levels of alliance over the course of psychotherapy or sampled alliance at a single session, the patterns in change in the alliance over treatment might be more related to outcome than average levels. This hypothesis was examined by Patton et al. (1997) who speculated that alliance scores would be initially positive, decline somewhat during the difficult working through middle phase of therapy, and then increase again during the termination phase. The results of the study were consistent with the authors hypothesis.

6. Future Directions

The almost universal acceptance of the therapeutic alliance as an essential part of psychotherapy points the way to some obvious future directions for scientific study. If a positive therapist–patient relationship is key to successful outcome, can therapists be trained to maximize the quality of the alliance? If not, is this because good therapists are ‘born’ not ‘made’? Resolution of this issue could have profound implications for the training of psychotherapists. If therapists cannot be taught how to establish and maintain a good alliance, perhaps greater effort should be placed on the selection process for training programs in the disciplines (psychology, psychiatry, social work) which conduct psychotherapy. Priority would be given to applicants who have innate interpersonal skills (e.g., empathy) that are associated with positive therapist–patient relationships. If, however, therapists can be trained to maximize the quality of the alliance, such training should become a core element of all training programs, regardless of which treatment modalities are emphasized.

Rather than focusing on the broad question of whether the alliance predicts treatment outcome, future research is likely to continue to explore more refined and specific questions that attempt to unravel the contexts under which a positive alliance is especially important. Larger and more definitive studies, following up on intriguing preliminary findings with smaller samples, can identify the treatment variables and patient dispositional variables that interact with the therapeutic alliance to produce optimal outcome. Research on human relationships, emerging from basic studies in social cognition and interpersonal processes, is likely to provide direction for understanding the nuances of the therapist–patient relationship. Similarly, as intensive empirical examination of the therapist–patient relationship increases our knowledge about the influence of this relationship, we may find applications of these findings to other helping relationships in medicine and elsewhere in society.

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