The Relationship between Client and Therapist

The term “therapeutic alliance” has a long tradition in the field of clinical psychotherapy and, in recent decades, has been elaborated on and expanded by the relational school in the modern psychoanalytic community.  Most often linked to the pioneering work of Carl Rogers, the term alliance was first used to describe the quality of the relationship between client and therapist and how specific factors within the relationship (e.g., empathy, congruence, and unconditional positive regard) may support long-term treatment success.

Rogers’ understanding of the importance of the alliance is viewed by some experts to be based on Freud’s original formulation of the analytic process in which he recognized the importance of closely listening to the client’s expressed sentiments and associations, as well as the need not only to tolerate, but even encourage, the client’s unconscious projections and transferences onto the therapist.

A body of scientific research has supported the role of the therapeutic alliance as a reliable predictor of positive clinical outcomes, a trend that has been demonstrated across a range of therapeutic orientations and modalities and evidenced among diverse client populations with a wide range of presenting conditions.  Various psychological measures, including the Working Alliance Inventory (WAI), have been used to assess the quality of the alliance from the client’s perspective.  Overall, research demonstrates that a strong working alliance between the client and therapist is associated with treatment success.  Most assessment tools including the WAI conceptualize alliance as consisting of numerous components of the therapeutic relationship such as the presence of collaborative goal setting, shared decision-making on interventions, and the development of an emotional bond between client and therapist.

Despite this evidence, when a client enters a therapist’s office, seldom is the notion of “therapeutic alliance” on his or her mind.  Generally, the client has a problem, one that he or she has struggled with, and the immediate need is to get the help necessary to solve it.  If the therapist is respectful and professional, for most clients that supports, at least initially, belief in the therapist’s capacity to be of help.

I would suggest, however, that people who have been in therapy for some time and/or have worked with different therapists would agree that the quality of the relationship with their therapist (what is often referred to as the “real relationship” in the psychoanalytic literature) is foundational to supporting the client’s capacity to optimize treatment.  Therapy is no easy task, and the emotional risks clients need to take (often involving vulnerability, embarrassment, shame, guilt, fear of being judged, etc.) to progress can only be managed and navigated by a therapist whom they deeply trust, respect, and value.

In this article, I will highlight how I aim to support the therapeutic alliance with clients in my own clinical practice.  It is my hope that understanding one clinician’s perspective on supporting the therapeutic relationship will be helpful for clients and therapists alike.  Clients may utilize this information to inform them on how best to select a therapist with whom to work and/or to enter domains of contact with their current therapist that they may not have recognized as possible or meaningful.  Therapists need to continue to reflect upon their relationships with their clients and utilize the ideas and observations raised in this article to promote opportunities to strengthen the alliance in sessions and safeguard/troubleshoot issues or events which may negatively impact it.

The Demand Factor 

Psychotherapy is unlike any other interpersonal situation, especially in terms what I like to call “the demand factor.”  What I mean is that in any other social context, a person is faced with certain expectable demands by the other: children are confronted with the expectations of their parents; schools and academic settings are oriented around learning and mastering subject matter; and the workplace domain is predicated upon the employee acting in accordance with managerial directives, the corporate culture, and the company’s goals. In each of these domains, there is considerable pressure to conform.

In contrast, the psychotherapy office should be a space where the client is not expected to be or act in any particular way to appease the therapist.  Even the client’s improving on the psychiatric symptoms or problems that led to the pursuit of treatment in the first place or the client’s agreeing with/abiding by the statements, beliefs, or recommendations explicitly stated or indirectly communicated by the therapist may be suggestive of compliance tactics used by the client (often unconsciously and unintentionally) based on previous conditioning in other social settings; this compliance may also be encouraged by the therapist.  Whatever the cause, the client may end up trying to be the “good patient” at the expense of real growth.

A significant foundation of building a solid therapeutic alliance is the client’s gradual recognition that he or she does not have to act in accordance with the therapist’s preferences, opinions, or desires.

In many psychotherapies, a portion of the treatment often revolves around the therapist trying to avail the client of the ways in which he or she is not only unaware of, but often reliant upon, adhering to the demand factor in his or her relationships despite significant negative consequences.

The Dialogue

At the crux of the therapeutic relationship is the dialogue between the client and therapist and how it evolves and changes.  A good therapist must be a gifted conversationalist, able to create the conditions necessary for an ongoing and exploratory discussion that the client enjoys and is intrigued by, does not feel threatened by, and finds within it the unveiling of new pathways for self-reflection and discovery.

In my work with clients, I often find that I am most helpful when I stay quite close and connected to exactly what the client is telling me, despite the many thoughts, ideas, and notions I might have about what is being said.  I guard against jumping the gun or attempting to make some profound statement or interpretation, mainly because the client has either already thought about what I am about to say or is not really prepared to consider my ideas for any number of reasons.

There is an old distinction discussed in the psychoanalytic literature between “experience-near” and “experience-distant” phenomena that emerge in the therapeutic dialogue.  The latter refers to the therapist’s taking what the client is saying and meeting it with an idea or observation that is far from the patient’s awareness or rational/emotive ability to use effectively.  Conversely, staying “near” to what the client is saying involves close listening, empathic resonance, and remaining aligned with, and reflective of, the emotional position of the client; this close contact with the client’s current stance ensures that the therapist’s offerings are easily digestible.  For example, if the client is describing how critically her mother treated her at a school event during childhood, it would not be effective for the therapist to suddenly suggest reasons as to why the client’s mother may have acted in such a manner.

The therapist’s capacity to linger with the client’s sentiments helps the client feel that his or her experience is legitimized by a therapist who is primarily focused on recognizing and attempting to understand the client’s unique subjectivity.

Additional and opposing perspectives on the client’s life narratives, as well as suggestions regarding other ways of seeing things and perhaps feeling about them, usually occurs much later in the treatment process after the client feels known by the therapist.  Intimacy, in my perspective, is the amalgamation of deeply shared emotional experience that fosters a transition into the unknown.  When you feel profoundly acknowledged for your own personhood, you paradoxically gain a new freedom to explore your unknown self.  In this way, psychotherapy should be aligned with intimacy: the client and therapist should each feel progressively known, and then unknown, and then known again, to the other as treatment evolves.

Close Listening 

It is obvious that the psychotherapy client must feel that the therapist is listening to what he or she is saying.  Yet “close” listening attempts to achieve another level of engagement.

In close listening, the therapist undergoes a process of itemizing and formulating all of the complex and interconnected components of the client’s narrative, including memories, ways of interpreting meaning, personal values, emotional experiences, ideas, wishes, hopes, etc.  The “close” quality involves the therapists’ capacity to examine and reflect upon this narrative to identify gaps, disconnections, and/or contradictions, as these are likely the places that represent some cognitive or emotional distortion, defense, or adaptation of which the client is unaware.

For example, if the client is describing how extroverted he was in high school and college yet alludes to a persistent discomfort with dating, there is an emerging mismatch between the client’s general social tendencies and his feelings about romantic situations.  Drawing the client’s attention to these gaps/mismatches advances the therapeutic alliance by progressing the client’s awareness of his or her own mental life and by ensuring the client that his or her own filters and blind spots will be caught by a therapist who does not merely accept things at face value.

The Studio and the Canvas  

The client comes to therapy to solve a problem, whether it may be a marital issue, chronic anxiety, or difficulty navigating a life transition.  The therapist must help the patient define the problem and present an approach to solving it. As therapy progresses, it is generally the case that what is discussed in sessions veers from the presenting concern.  But it is imperative that the therapist continuously identify how what is being discussed or worked on is tied, directly or indirectly, to the reason why the client sought therapy in the first place.

As in any relationship, the therapist should introduce the client to the roles that will be played in therapy.  For example, in my practice I advise the client to discuss whatever he or she chooses and to attempt to verbalize whatever comes to mind as we are talking.  This is aligned with the psychoanalytic tradition that values the client’s free associations and spontaneous productions of memories, thoughts, feelings, and even dreams as a pathway to discovering deeper unconscious meanings. As for my role, I tell my clients that I will listen closely, ask questions, request elaboration, and remain attentive not only to what the client is saying but also to the client’s nonverbal communications and emotional displays.

I clarify that I do not see my role as an advisor, mentor, or advice-giver.  Rather, often in my practice I use the analogy of the therapeutic space being a kind of art studio in which I am the owner of the studio, and the client is the visiting artist.  For the client, I provide a safe, comfortable, and private setting, along with the necessary tools (paint, paintbrushes, and a large canvas).  The client as artist is encouraged to use the space and the tools provided to mark the canvas in whatever way he or she chooses.  The ensuing dialogue concerning what the client/artist has placed on the canvas and what it may mean constitutes psychotherapy.

Zones of Engagement: Empathy vs. Confrontation

The quality of the therapeutic relationship, in my view, involves the therapist’s finding the right balance of engagement with the client that broadly involves two primary zones and their corresponding modes of relating: (1) the client needs to feel the therapist’s empathic support while, at other times, (2) the client needs to be confronted.  Each client is unique, however, and a delicate balance between these two modes must be carefully customized so that the therapy does not orient toward one at the expense of the other.

To elaborate, many theoretical approaches to psychotherapy including the psychoanalytic self-psychology school emphasize the therapist’s need to resonate with the client’s subjectivity, i.e., the client’s unique perceptions of personal experience and the affective/mood states associated with them.  The therapist’s reflective mirroring presence substantiates and scaffolds the client’s sense of self (or self-esteem), affirming and validating the client and advancing the client’s cohesion of identify.  This perspective argues that many life problems are due to a fragmented sense of self in which disjointed aspects of the personality correspond to psychic conflict.  Guilt, for example, is theoretically attributable to a divided sense of self (who you are vs. who you should be).  The therapist’s empathic mirroring of the client gradually expands and endorses the who you are component while simultaneously diluting and diminishing the who you should be component.

The confrontation mode, on the other hand, involves the therapist’s ability to shift out of the empathic zone and into a stance which challenges the patient on any number of levels including possible false beliefs and assumptions, cognitive distortions, defensive maneuverings, and motivations driven by unconscious processes. In this mode, the therapist tries to find ways to help the client assimilate new acknowledgements and recognitions that heretofore have been blocked, suppressed, or defended against.  For example, a client may blame herself for repetitive professional difficulties not of her own doing.  Through therapy, she may realize that the types of workplace cultures and managerial styles she gravitated towards were an unconscious repetition of her authoritative family-of-origin system.  However, it may have taken some time, and repeated attempts by the therapist, for her to accept that her tendency to seek out the familiar was responsible for her career challenges rather than some personality flaw or limitation in her abilities.

The advancement of the therapeutic alliance is often prompted by the client’s implicit signaling to the therapist as to what zone he or she would like to venture.  That is, the client signals when he or she needs empathy or confrontation, and, if the therapist is listening, he can respond accordingly.

Sabotage

As children we are introduced to an external moral perspective, i.e., our parents, teachers, and other authority figures, religious doctrine, and even neighborhood- and community-based value systems that instruct us as to what is “right” and what is “wrong.” This external moral perspective often persists into adulthood, leaving a person largely concerned with acting in accordance with the views of others and the cultural mores of the social institutions in which he or she is embedded.  With this trajectory, self-reflections are often limited to what I should or should not be doing.

Psychotherapy does not necessarily seek to detach the client from these external moral perspectives. However, therapy ideally should introduce another lens through which the client can evaluate his or her thoughts and behaviors.  This new lens centers on enhancing the client’s awareness of and sensitivity to ways in which he or she may assume liability or risk, i.e., may be inadvertently or directly doing things that are not self-protective or that are inherently devaluing.  Acts of self-sabotage are surprisingly common and arguably a characteristic of the human condition, perhaps because childhood experience is so heavily focused on external moral precepts rather than on supporting an internal capacity to recognize and avoid actual or potential self-damaging acts, situations, and relationships.

It is not unusual for psychotherapy clients to struggle with this because the external moral ethos they carry represents a psychological attachment to figures from their past who were responsible for instilling it.  Consequently, the transition to an awareness and prioritizing of self-affirmation and self-protection is complicated and often resisted.  The client’s default position, something that is not easily supplanted, is the habitual tendency for self-sabotage in any number of areas (e.g., physical/self-care; relationships; financial health; work/life balance; parenting; professional/career); the continuation of self-sabotage maintains the status quo and avoids any disruption in these domains.

An important component of the therapeutic alliance, I believe, involves the therapist’s persistent attempts to invoke in clients a sense of self that is worthy of protection and to inspire a more careful discernment as to when, and to what degree, they choose to be vulnerable and with whom.

Alignment and Misalignment: The Client’s Truth

One perspective on successful living and fulfillment suggests that alignment between one’s personal beliefs/values and his or her actions/behaviors creates an emotional equilibrium (or sense of peace).

This alignment is not easily achieved, unfortunately, as there are many competing forces in the mind and conflicting priorities in life.  Misalignments (or “incongruences”) in any number of important domains of life are characterized by breakdowns between one’s purported belief and the actual things he or she does. To address the pains and tensions resulting from these misalignments, many people live in a state of adaptation; they have chosen a course of accommodation in which energy is directed toward compensatory dynamics that assuage the misalignment.  For example, a man who is discontented in his marriage may get involved in an affair, seek to over-achieve at work, or “overparent” his children.  The wish to leave his wife may correspond to beliefs about divorce that are deeply embedded and reprehensible. Thus, the only way out of the bind (“psychic conflict”) is to find some way to deflect or diffuse the disconnect between what he wants and what he cannot do.

Psychotherapy is many things, but at its core is the client’s reckoning with his or her own truth, i.e., what is truly desired despite what it may suggest or how it may be judged by others.  A positive therapeutic alliance features progressive efforts to identify how the client may be misaligned and what strategies of accommodation may have been selected.

Trust

Essential for creating a safe emotional space where clients feel comfortable being open and emotionally vulnerable, trust is a major component of a strong therapeutic alliance.

In my practice, I approach trust from the vantage point of “establishing the frame.” The frame is a concept that refers to the structure and mechanisms of the therapeutic encounter; if it is introduced to the client at the outset of treatment, and maintained consistently across time, the client comes to have a sense of safety in the experience, trust in the therapist, and faith in the therapeutic process. The frame consists of the following components:

• Informed consent: the therapist clarifies the nuts and bolts of the therapeutic relationship and actively presents and endorses all aspects of privacy and confidentiality, scheduling, payment, role expectations (what the therapist and client mutually agree to do in collaboration to support the success of treatment), and a commitment to legal and ethical mandates of professional practice.
• Clear boundaries: the therapist maintains an authentic yet professional relationship with the client that imbues the working atmosphere with warmth, concern, and the persistent diligent effort by the therapist to understand the client’s perspective. Additional boundary considerations that involve the therapist’s acting in a singular professional role with the client are also described.
• The therapist’s emotional strength and stability: the client has often struggled with, and been traumatized by, unstable caregivers or partners who disappointed the client, could not tolerate the client, or thought the client was “too much to handle.” A trusting therapeutic relationship can only be cultivated when the client feels, over time and with experiential proof, that the therapist is sturdy, clear-headed, rational, and capable, and can “handle” whatever the client may bring.
• The therapist’s honesty: simply put, clients inevitably trust therapists who are honest with them; as consumers of psychological services, clients tend to be most positively impacted by a down-to-earth, humble therapist who can lay out the client’s situation, challenges, and psychological dynamics clearly and without jargon. Overly intellectualized or textbook-sounding interventions made to clients fail to strike a chord and are typically viewed as esoteric and superficial.  Most clients want the therapist to spell things out as he or she sees them.

Finally, I have found that trust in the therapeutic relationship is also supported by introducing the client to previously unrecognized yet legitimate areas of hope.  Often the client has lost sight of new avenues of potential and domains about which he or she may feel encouraged or even emboldened; relatedly, it is also helpful when the therapist can help the client see his or her life challenges more realistically.

The “Corrective Emotional Experience”

In the early 20^th century, the psychoanalyst Sandor Ferenczi argued that change in psychotherapy was not prompted by intellectual insights (offered by the therapist to the client), but, rather, by new relational experience exemplified in the bond between the client and therapist.  One of Ferneczi’s students, Franz Alexander, ultimately identified this sentiment as the “corrective emotional experience,” i.e., the client finds in the therapist a refuge from, and an alternative to, previously wounding and traumatic relationships.  Consequently, the benign and non-traumatizing therapeutic relationship provides the client with a template for future relationships and reference points as to the process and dynamics of intimacy.

Paradoxically, the potential for a corrective emotional experience in therapy may not be so easily accepted by the client.  Clinical theorists have boiled down the project of psychotherapy to an analogy of the client’s unconsciously offering the therapist a “test” to determine if the therapist can pass.  The test involves the therapist’s indoctrination into the many negative components of the client’s personality and character, including weaknesses, limitations, and projections onto the therapist (“transference”).  What is familiar to the client is the anticipation that the therapist, in the face of exposure to the client’s “badness” or “toxic unhealthy parts,” will respond negatively or even abusively, thus re-traumatizing the client yet again.

So, in a way, the test is sort of rigged.  Part of the client would like the therapist to pass it and provide a corrective emotional experience.  But another part of the client may expect (and may even be more comfortable with) the therapist’s failing the test, resulting in a re-enactment of the client’s traumatic past.

In my practice, I have often found that I must persist even despite the client’s unconscious desire for me to fail.  I have learned to respect and empathize with the client’s tenacious maneuverings which are ultimately designed to resist new experience and avoid the need to refine antiquated appraisals of themselves and others.

Conclusion

Throughout this article, we have explored the significant role of the therapeutic alliance in individual psychotherapy.  A positive client-therapist relationship that is characterized by trust, clear roles and expectations, and the therapist’s consistent demonstration of strength, stability, and expertise is a predictor of treatment success and provides the necessary conditions for psychological change.

I have attempted to describe various ways in which I approach the underlying components of the therapeutic relationship and the process of therapy itself.  It is humbling indeed to realize that underlying the therapeutic situation is a host of complex dynamics mutually influencing the client and therapist that the therapist must be skilled at identifying, managing, and navigating the client through.

For psychotherapists, strengthening the alliance not only demands a dedication to professional development and self-reflection but also an ongoing commitment to the nuanced needs of their clients. For potential clients or those currently engaged in psychotherapy, it is my hope that this article sheds light on additional opportunities you may pursue with your therapist to explore and expand the many facets of your bond.