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What sets apart an exceptional therapeutic relationship from an average one?


Today, one out of three Americans receive psychotherapy treatment. Given that nearly 50% of Americans surveyed in 2021 reported recent symptoms of an anxiety or depressive disorder, according to the National Institutes of Health (NIH), this number is not surprising. But if collectively we are investing more of our time and resources in therapy, it behooves us to try to better understand what sets apart an exceptional therapeutic relationship from an average one. And the answer may or may not surprise you in its intuitive nature. That is, more than the specific modality of therapy used, or technical interventions employed, or even the years of experience the therapist has, research shows that the key to success lies in the quality of the client-therapist relationship, as well as the hope and expectancy created as a result. A conclusion of the Third Interdivisional American Psychological Association Task Force on Evidence-Based Relationships and Responsiveness makes this clear: “The therapy relationship accounts for client improvement (or lack of improvement) as much as, and probably more than, the particular treatment method.


So what exactly makes for a quality client-therapist relationship? In a context as particular as that of psychotherapy, where essentially two strangers come together and share intensely intimate information on the premise of complete confidentiality, exactly what factors make one relationship more effective than the next one?



The importance of the first encounter


First, the therapist must be mindful of the critical importance of the first meeting with the client, because the premature drop-out rate is highest after the first session than at any other point. In the initial meeting, the therapist must understand that the client is very quickly trying to ascertain whether the therapist is worthy of their trust, possesses the necessary expertise to help them, and whether the therapist will take the time and effort to understand not only the problem they are coming in with but the context in which the problem is presenting. An interesting piece of trivia is that humans apparently make very rapid determination, within 100 milliseconds, based on viewing someone’s face, of whether that person is trustworthy. What that means is that likely the client is making very rapid judgments based on details like how the therapist is dressed, the decor of the room, and other features of the therapeutic setting. This, combined with a client’s preconceived notions about the nature of psychotherapy, culminates in the overall impression that a client walks away with from the first session - and determines whether a therapeutic relationship can ensue from this first meeting.



Perception of genuineness and trust in the therapy process are key


Once the initial therapeutic relationship is established, a factor that sets apart an exceptional therapy process is how much the client and therapist perceive one another to be genuine. The importance of genuine human connection is widely recognized, and when done right, psychotherapy provides the client a human connection with a caring and empathetic individual, which is in and of itself health-promoting, especially for a client who otherwise would not have such a connection. Secondly, it is critical that a client feels that they have an explanation for their difficulties that are then in their power to overcome or cope with. If they are presented with an explanation but are made to feel they are powerless in the face of it, there is no therapeutic work to be done. This also means that the client and therapist must be in agreement about the goals of therapy as well as the necessary therapeutic tasks, so that there is a sense that they are both engaged in “collaborative, purposive work.” This then has the effect of increasing the client’s confidence and expectations that the treatment will be effective. Then, once there is trust in the therapy process and in the therapist, the specific health-promoting tasks of the therapy can finally be induced, whether that is modifying maladaptive ways of viewing the world, understanding dysfunctional patterns so they can be approached differently, gaining self-insight, or learning to accept oneself, to name a few.



The “person of the therapist” also makes a difference


Furthermore - and not surprisingly from everything examined just now - it has been observed that the person of the therapist makes a difference, too. Research indicates that things like the therapist’s interpersonal skills, persuasion, warmth, and sometimes even charisma matter. We’ve all probably experienced that good bedside manners in a physician can make an important impact on our overall experience when receiving treatment in a medical setting. Still, a course of antibiotics prescribed by a cold physician ultimately does not differ too much from the same course of antibiotics prescribed by a warm and compassionate physician. But in the psychotherapeutic context, it makes a tangible difference in the treatment outcome. Think about it: if a therapist barely took the time to listen to you and lacked empathy, even if this therapist had the same treatment plan as that of another therapist, who carefully listened to you and took the time to cultivate trust with you, would you feel inclined to do the therapeutic work to follow it? Simply put, in the psychotherapy context, delivery matters. Moreover - and this is encouraging in the era of teletherapy - data shows that the important impact that a strong client-therapist relationship has on treatment outcome is observed whether the therapy is conducted virtually or face-to-face.



Client-therapist fit is critical - so don’t compromise on that


So what does this all mean for you if you are searching for a therapist? Don’t compromise when it comes to a good fit with your therapist, because everything else follows from this client-therapist relationship. Assess how you feel in your initial interactions with a prospective therapist, whether that’s during an initial consultation or even in email exchanges. It doesn’t mean you need to nitpick, but it’s important that you ask yourself: do I feel comfortable? Hopeful about the prospect of working together with this therapist? If you don’t feel comfortable when talking to your therapist or you don’t feel heard or seen, there is no shame in seeking out someone else who feels like a better fit. In my private practice, I make it a point to offer a free initial consultation for this very purpose. Working with a client in one of their most private and vulnerable moments is a privilege that must be earned - so I don’t assume that I will necessarily be a fit for everyone. So be a discerning consumer - your mental health is certainly worth it.




References


Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult

psychotherapy: A meta-analytic synthesis. Psychotherapy (Chicago, Ill.), 55(4), 316–340.


Geslo, Charles. (2014) A tripartite model of the therapeutic relationship: Theory, research, and

practice, Psychotherapy Research, 24:2, 117-131, doi: 10.1080/10503307.2013.845920


Hatcher, R. L., & Barends, A. W. (2006). How a return to theory could help alliance research.

Psychotherapy: Theory, Research, Practice, Training, 43(3), 292–299. https://doi.org/10.1037/0033-3204.43.3.292


King, R. J., Orr, J. A., Poulsen, B., Giacomantonio, S. G., & Haden, C. (2017). Understanding

the therapist contribution to psychotherapy outcome: A meta-analytic approach.

Administration and Policy in Mental Health and Mental Health Services Research, 44(5), 664–680. https://doi.org/10.1007/s10488-016-0783-9


Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III.

Psychotherapy, 55(4), 303–315. https://doi.org/10.1037/pst0000193


Rosenzweig, S. (1936). Some implicit common factors in diverse methods of psychotherapy.

American Journal of Orthopsychiatry, 6(3), 412–415. https://doi.org/10.1111/j.1939-0025.1936.tb05248.x


Wampold B. E. (2015). How important are the common factors in psychotherapy? An update.

World psychiatry : official journal of the World Psychiatric Association (WPA), 14(3),

270–277. https://doi.org/10.1002/wps.20238


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