The Therapeutic Relationship: Explained
What is a “therapeutic relationship?”
In the field of psychology, particularly in the application of clinical services, the relationship between a therapist and a client is often called a “therapeutic relationship.” The assumed function of the therapeutic relationships varies slightly from clinician to clinician, it is most often understood as the foundation upon which therapeutic change occurs. When understood in this way, the therapeutic relationship therefore not just to the existence of a relationship in a therapy context, but it also implies a type or quality of the relationship as well. Just like in other relationships, the quality of a friendship is not based on the concept of friendship itself, but rather it is dependent upon the individuals in the relationship, how they communicate, how they relate, how they take accountability, how they envision the future of the relationship, etc.
It should be no surprise then, that the therapeutic relationship depends on the qualities that both the client and the therapist bring to the therapy context. If one person is committed to therapy and the other is indifferent or opposed to therapy, the quality of the relationship would suffer (and likely cease to exist). Can you imagine any benefit to therapy if you showed up to a session and your therapist didn’t seem interested in what was going on for you as they scrolled on their phone? Or worse, if they didn’t choose to show up to the session at all? This would be a poor therapeutic relationship. Other factors that impact the quality of the therapeutic relationship would be responsiveness, mutual trust, and personality features that are viewed positively by both parties. But hold on, why does any of this matter?
Underlying Philosophy: For therapy to be effective, i.e., for symptoms to decrease and for new adaptive skills to develop, I believe that the therapeutic relationship is the most significant contributing factor. Research supports the significance of the therapeutic relationship, though the conclusions of various studies differ on the percentage of change that can be causally attributed to this relationship. On the low end, the therapeutic relationship could account for around 12% of observed improvement, on the high end (reflecting an ideal client-therapist match) this percentage could be as high as 80%. If we want to be more reserved in our interpretation of this data, perhaps something like 40-50% can plausibly be attributed to the therapeutic relationship.
When I say that I believe that the therapeutic relationship is the most significant factor, this is due to research implicating the role of “extra-therapeutic” change, which is to say change that occurs outside of therapy, which is better described as the time-effect. This is something outside of the therapist and client’s ability to directly cause and therefore it is unhelpful in understanding what makes therapy work.
By contrast, some therapists tout particular techniques as responsible for the majority of change which is accomplished in therapy, the research indicates that this factor tends to be far less impactful, at around 15%, which has a similar impact as the client’s expectations about the benefits and assumed outcomes of therapy.
I believe that technique matters, but on the basis of this research and my own clinical experience, the most important factor contributing to change is the therapeutic relationship. Let’s explore what is required for a quality therapeutic relationship as we discuss how this relationship changes over the course of therapy.
The Start of Therapy: Defining and Developing the Therapeutic Relationship
The start of therapy often begins with initial assessment and diagnosis of a client by a therapist. During this initial interaction, both the therapist and client ought to be feeling out the connection to determine if there is sufficient evidence of a quality therapeutic relationship. When I conduct an intake, I view it as my responsibility to call attention to this relationship as early as is feasible to help create a permission structure where the client is directly tasked with evaluating the fit and while doing my best to correct for some of the power-imbalance that is typical in a therapeutic relationship. I do this in part by explaining that my role as a therapist is to help the client reach their desired therapy goals, I may be an expert with respect to my training and experience, but the client is the expert in their lived experience and has ample information about what has and hasn’t worked in the past, which is fundamental to planning an effective treatment plan. The therapist also has an observational role due these sessions to help weigh in on whether they feel like there is a possibility of a quality therapeutic relationship. If a therapist sees red flags, I believe it is their responsibility to inform the client of their observations and discuss what next steps can look like. This can include making a referral to another clinician, but it also offers a unique opportunity to speak to an observed challenge and see if both parties are interested in finding a way to move forward. This sort of communication and collaboration is indicative of a quality therapeutic relationship. If both the client and therapist feel like there is enough evidence for therapeutic change (which is dependent upon the therapeutic relationship), a follow up session is scheduled and the therapeutic relationship has officially began. Without this sort of commitment to the therapeutic relationship, it is unlikely that change will occur. This is why I believe cultivating buy-in and drawing attention to the therapeutic relationship is essential. Commitment is a foundational element of the therapeutic relationship.
Client-Therapist Match
As described above, one element of the therapeutic relationship is feeling like there is a good match. This belief is separately determined by both the client and the therapist, and ideally should be discussed before moving forward in therapy. What is included in this category? A few things come to mind; trust (do you believe that your potential therapist has your best interest in mind AND is committed to helping you achieve your goals for therapy?), personality match (do you believe that your therapist has enough overlap with your personality to make for effective therapy? Think about the ways you determine if someone can be considered a friend, they might not need to be a direct copy of you, but it’s unlikely that you want a friend who appears to be your direct opposite. This is an opportunity to ask your potential therapist some questions about themselves and about the way they approach therapy to see if there is evidence for personality overlap/similarity); and pacing/communication styles/neurotype overlap (this final category can be described a number of different ways, to me this category includes features of communication during the therapy session which may be reflective of neurotype overlap.)
By “neurotype” overlap, I am speaking as a “neurodivergent” therapist who tends to work with other neurodivergent clients. To be “neurodivergent” is to have a nervous system which operates differently than the majority of the population, who are referred to as “neurotypical.” Many different types of brains can fall into the category of neurodivergent, but in my work I most often am referring to clients with ADHD and/or ASD/Autism along with various other co-occurring conditions. Used more broadly, neurodivergence can be used to described people with OCD, Depression, PTSD, and a whole host of other conditions. When used this way, the term is creating a contrast between particular ways of thinking and being compared to what is statistically typical for the majority of the population.
It follows that the majority of my clients would also be neurodivergent, as neurodivergence reflects a neurotype overlap between myself and my clients. This means that there are more similarities between us in how we think, feel, and act compared to someone with a neurotypical brain. The key here is that the similarity between your brain and your therapist’s brain can make a meaningful impact in therapy. I have heard from numerous clients how much of a difference working with a neurodivergent therapist makes. I also believe some of that can be attributed to other personality factors that I embody, but the principle of neurotype overlap seems to be significant on its own.
To determine if there is a neurotype overlap or if there is a desired context for communication, you might ask yourself: Do I think this person allows enough time for me to share during session? Do I feel like they spoke too little, allowing me to fill the majority of the session when I wanted more insight/reflection from them? Do I feel like there was enough give and take in the conversation, even if the breakdown of who was speaking was unequal?
Effective Collaboration
Similarly, throughout this process of observation and evaluation, you may have noticed that therapy depends on effective collaboration between you and your therapist. Many of the questions posed above can be recalled to help determine if it feels like you are being valued for your contributions and if you feel as if your potential therapist is also participating sufficiently in their contributions. Potential red flags here would include if your therapist seems to be controlling/directing the conversation without sufficient input from you or if they seem to be planning the direction of therapy broadly (or the session in particular) without incorporating your goals and preferences. If it feels like their is insufficient collaboration, please speak up at this point to see if your potential therapist is willing to change on the basis of your request. If they do, this is another indication of a quality therapeutic relationship. Responsiveness and willingness to change is another hallmark of a high quality therapeutic relationship being formed.
Agreeing on Treatment Goals & Tasks
Another related element of the therapeutic relationship is mutual agreement about the direction of therapy, which is often called the “treatment plan” and can also be implied when agreeing on goals or specific tasks for therapy. If you ask your therapist if they offer DBT (Dialectical Behavioral Therapy) and they say no, at this point you may conclude that this is not the therapist for you. However, if you feel like there has been an indication of a quality therapeutic relationship, you may ask (or your therapist may share responsively) how they plan to treat symptoms which you hoped DBT would help with. If you feel like they have a plan to address your concerns, even if they use a different modality or set of therapy tools, you may choose to proceed and see how these are applied down the line. This is therefore a type of collaboration, but one where you have a lot of say if it seems like your potential therapist is unwilling or unable to provide what you are interested in. Likewise, your therapist may determine that your therapy goals or timeline are unrealistic given their own experience, and ideally that will be communicated with you to help you both determine if a follow-up session should be scheduled.
Those are the basic elements of the therapeutic relationship which develop during your first interaction and last until the intake is complete (this can occasionally take more than a single session), next we will explore the therapeutic relationship as it develops between the start and end of therapy, which I am calling the “meat of therapy.”
The Meat of Therapy: Disruption and Repair
Kintsugi: the act of repairing something broken (often pottery) with material such as gold or other precious metals
From the client’s perspective, there is not often a significant difference observed during this period compared to the beginning of the therapy relationship. This indicates that the first impression makes a huge impact for the remainder of therapy, on one hand. On the other hand, there is a lot going on under the hood that your therapist is often more aware of. Over the course of any relationship, there are changes which can disrupt and end the relationship and there are changes which can be incorporated into the relationship with minimal harm and even potential benefit. Likewise, in the therapeutic relationship there are going to be moments where the relationship is tested. It might be that your therapist responded to you in an unexpected way, perhaps triggering a memory or even a trauma response of a previous relationship (therapeutic or otherwise), or it could be that you become more comfortable communicating your needs as you learn to create more space for yourself in various aspects of your life, which could result in pushing back against your therapist.
Because therapists are also human, there is the potential that this sort of push-back is received more negatively than intended, which could result in some form of conflict. What matters most in this period of therapy is how that rupture/harm is acknowledged and addressed. Is there sufficient trust and accountability-taking in the therapeutic relationship that the rupture can be repaired? If so, this is another indication of a high quality therapeutic relationship. However, sometimes the rupture feels like it cannot be repaired and the therapeutic relationship ends. While this tends to be uncommon, it does happen. Even in circumstances like this, there can still be improvement gained from a decision to separate from your therapist. As I see it, I would describe an action to move on from a therapist as autonomy-preserving, which is to say that you are valuing your individual decision above what your therapist might want for you.
Now as a disclaimer, there are certainly reasons that a client would decide to end therapy which doesn’t highlight their autonomy, such as being forced to end therapy due to a change in economic circumstances, or in circumstances where there is a desire to return to maladaptive thinking or behaviors. Likewise, a therapist can decide to end therapist with a client due to other factors going on in their personal or professional life. While it might seem like a negative, I like to imagine that there are often positive and neutral ways to frame the end of therapeutic relationships. Like all other relationships throughout the course of one’s life, a therapeutic relationship can end unexpectedly or on bad terms. In an ideal world, the therapy that preceded the rupture can help set you up to respond adaptively.
Termination of Therapy: Disconnecting and re-Framing
Whether therapy ends prematurely or it ends after all therapy goals have been accomplished, the termination of the therapeutic relationship is a necessary and beneficial part of the therapy process. From my perspective, it is the therapist’s job to equip you and support you to be able to handle all that life throws at you on your own. When you reach that point of self-confidence and subsequent stability, to me there is no better indicator that therapy has reached its natural conclusion. You’ve graduated from what originally brought you to therapy. There is much to celebrate! However, this portion of therapy can also be difficult for a multitude of reasons. Closure is hard. Endings can be uncomfortable and can dredge up all sorts of emotions. But you’ve got this! All the work you have been doing has led you to this moment. I want you to know that your therapist likely feels similarly about the end of therapy.
For me, termination is one of the harder aspects of the job. I get to help and watch as you develop as a person, as you learn new skills, as you become more confident and vibrant. And they when therapy ends, I am left to hope that you continue to grow and succeed as life progresses. It is for this reason that I do my best to remained focused in the present, to celebrate the wins with my clients as they come and to process the difficult pieces in their own time as well. The end of the therapeutic relationship doesn’t discount the work that has been done, nor does it devalue the therapeutic relationship that helped bring this change about. Rather, the termination step is evidence that relational aspects of therapy made a profound difference in your life and here’s the best part, your participation in the therapeutic relationship can be carried with you. You can use the same sort of skills throughout the rest of your life. Is a friend (or potential friend) or relationship reflective of the qualities that we described above? Are they interested in sharing power with you, do they have a similar brain to yours, are they good at communicating with you, are they responsive to your critiques and requests for change? If not, are they worth keeping around? This is the beauty of the therapeutic relationship: it’s not just something that happened when you were in therapy, it changed you. As Gandalf told Bilbo near the start of the Hobbit, “[if you come back] you will not be the same.” You are not the same after your therapy adventure, and I hope that you will have a tale or two to share with folks about the work that you did here, about how you grew and changed and why any of it mattered.
If you’ve been a client of mine, I hope that you know that I truly enjoyed our adventure. I wish nothing but the best for you.
And lastly, if life gets chaotic and you feel like there is more work to be done, you know where to find me!
