I believe that the single most effective element of the therapeutic relationship, that is curative on its own, is the fact that it is really happening on a moment to moment basis. This is an unbeatable argument for the patient that s/he is worthy of relating to and that relationships (at least some) can work, despite occasional conflicts or disturbances. At the end of therapy patients often tell me, that although we worked on their relationships with significant others and this was helpful, the decisive turn around was the relationship we shared. I am a Dance Therapist, so actual physical interaction may be part of the process and enhance its effects. But I have patients who mostly just talk, and the effect is the same.

I think, mirrow neurons play an important, but unconscious role - not only in gestures etc. but also in mind (behavior in conflict, self confidence). But I dont know any studies about this. As psycho analysts still waive this possibly helpful way of interaction, few research is done...

For me, it is about 'being' with the client as well as 'being with' the client. My understanding and experience from a Rogerian (predominantly person centered)perspective is that the relationship is curative in that it occurs in the here and now with both parties being psychologically available and willing to stay with the process. Building and maintaining trust within the relationship is also a key factor and can facilitate going to places with the client which may hold fear or fear of the unknown.

I work both f2f and synchronously online (IRC) where despite the lack of physical proximity or visual/audio clues, the online relationship can be equally powerful in facilitating the client to moving closer to their authentic self.

I am interested to note Marianne's thoughts that maybe physical interaction may enhance the process, and it sounds as if while this may be true, that we both experience the therapeutic relationship as being 'enough' to help the client hear themselves and move in the direction they feel is right for them.

Perhaps reading Carl R Rogers (especially regarding the 6 Core conditions), John McLeod, Mick Cooper or Roger Casemore, may add to your knowledge base of Person Centered counselling (which is theory based on 'the relationship') in researching this question.

Best wishes

My immediate thought is that whether and how therapeutic alliance may be curative on its own possibly depends on the nature of client's problems and what she/he was looking therapy/support for. I would suppose that if a difficulty with forming and/or sustaining satisfying relationships is the core underlying issue for this person, then positive therapeutic alliance itself might restore confidence and hope for future meaningful relationships. Whether it is as curative when other issues seem the main reason for therapy, I don't think I can say. I would be curious to find out what others think. Many thanks for an interesting question!

Hope not be giving you a common sense clue.

Asap a human relationship is established , and I mean all kinds possible, language and dialogue remain the main media , what is called empathy- syn pathos is a consequence viable or not. So, give what a person pretends need to hear may establish a therapeutic alliance and personal good relationship, but it does not mean that a cure is being established. I always doubt empathy as tool, once the demands of the client may not the best for his own " cure ". As they say, if you give too much attention to to hammer, you may hurt a finger.IMHO

Both as a clinician, once a patient, and a researcher interested in the very same question, I believe that what is curative about the therapeutic relationship has to do with the possibility of displaying, both therapist and client, their selves, -evidently more the client than the therapist- and trying out new ways of being with the other, negotiating one's own needs with those of the other, being open to be influenced by the other, both in a symbolic and sub-symbolic or implicit level. But this is only possible through a process with bumps and difficulties, miscoordinations and repairs (what others would call enactments). In other words, it seems there could be a sort of corrective experience, but I´d rather call it "transformative" experience, since more that "rectifying" something, this curative relationship seems to promote an expansion of experiential repertoires in the client, and to some degree also in the therapist . Perhaps what is most difficult to apprehend is the question of how it works. Through research we have had the possibility to identify important and useful elements of the therapeutic relationship that are associated to change, but we still have a pretty long way ahead of us in the process of elucidating, empirically, the "mechanisms" responsible for this change.

There is a very interesting psychoanalytic article by Daniel Stern et al,(1998). Non-Interpretive Mechanisms in Psychoanalytic Therapy: The ‘Something More’ Than Interpretation. Int. J. Psycho-Anal., 79:903-921., that answers this question via attachment research and the growing evidence for an aspect of the procedural unconscious involved with "implicit relational knowing." When a therapist and patient have a moment of "authentic" connection (hate that word, but it works here) in which an insight or understanding develops in the context of a "real" , shared experience, there seems to be an extra power to the experience, something like the experienced "marking" of an attuned parent (see Target, Gergely, Fonagy et al about affect regulation).

This seems to make whatever has been learned or understood be something more than an academic or cerebral learning experience.

Marie Rudden

I think that the therapy relationship is curative on its own mostly when it's a challenge to build therapeutic alliance, such as with patients with personality disorders or attachment difficulties. If and when the patient, after a struggle, can build an emotional bond with the therapist, a corrective emotional experience has taken place and that's when the therapeutic alliance has been curative. For example, a patient with rigid, obsessive-compulsive personality was having significant stress at the beginning of our work due to the unstructured nature of our therapy sessions. He kept asking me every session how this works, am I ever going to tell him what to do, and was complaining that it feels awkward that he has to talk rather than a question and answer format. I was having difficulty building alliance with this patient and was worried he might drop-out. About a year later, he said that it was very difficult for him at the beginning as our sessions were making him uncomfortable, but because he got a sense that he trusted me and that I seemed to be genuinely trying to help him, he forced himself to go out of his comfort zone. He said: "I had to be comfortable with unstructured interaction to be able to continue". His being able to connect with me in a relaxed and unstructured manner seemed to bring a curative experience. I think therapy relationship itself can be curative with patients who have some barrier to building a working alliance. I can imagine this would be more challenging and more curative if successful with an avoidant patient or patients who have trust issues, etc.

Thanks, I appreciate all your responses, but I am really trying to understand how the relationship itself heals. I understand that it enables us to explore issues like Jo Ames point out or that it involves a sharing experience as Marianne pointed out. But how is that transformative on its own. That's my question

Thanks for bearing with me

Interesting question, I think the key is the role of the oxytocin system promoting calm and connection when the relationship triggers trust signs. In all kinds of therapy this mechanism may underlie curative effects of a good therapeutic alliance

The Rogerian principles apply in establishing the context for developing the therapeutic relationship. Most measures of the TA tap an affectional bond or attachment plus a willingness to engage in the therapeutic process. The TA is a significant quintessential variable across all modes of therapy ....i see it as a combination of clinical expertise and therapist attractiveness (in its broadest sense) as well as patients' mental representations of historical relationships that may or may not facilitate a positive alliance. I think the question is whether it is actually transformative on its own.. Beyond establsihing trust and attachment...there are other variables at play.

Orlinsky studied the role of the therapist in the process of change and he found an answer in the therapist representation. According to his studies, clients or consultants internalize the therapist and as therapy progresses therapists are incorporated and they become part of the self. So, therapists' support and understanding becomes part of the clients' self. In the same line, Kohut also proposed something like new learnings. Through the therapeutic relationship the client redefines himself or heself. My question in this respect is How much time of therapy is necessary for this ti happen? The studies have been done in long term therapy, but how about short term therapy?

What does therapeutic mean?

I will only share some wild thoughts.

The relationship promotes a new experience of empathic connection with another human being and the feeling of being understood and having the patient emotions mirrored by the therapist. This is in some way a new experience to those who search for help and this will allow another processes to unfold - those are then different according to the different therapeutic modalities.

Give some more ideas Jacques: what kind of answers are you looking for? On what level? ou got some pretty good answers there....

Some really good answers here Jacques... but yes, perhaps more ideas as Katri has indicated. It may be possible to answer this differently across different specific working populations? I am investigating suicide risk assessment and response within the context of the therapeutic alliance, and apart for the tremendously scant literature on the same (and I'm referring to the integration of these two domains - a total of 8 articles within my inclusion/exclusion criteria which are pretty simple), the sense of needing to deeply understand (but not collude) with the patient's suicidal wish has a major part to play in the 'working' alliance. Of course, this is way simplified in a hugely complex domain, but all the same.....(geees not sure what happened here; just deleted a couple lines accidently while trying to add something sorry now I've lost it:()!

The therapist-client relationship is a test of cooperation and an opportunity to improve it. A common denominator in many psychological disorders is the client's limited degree of cooperation. If that level of cooperation can be increased within the therapeutic relationship, and then transferred to other people, significant therapeutic progress has been achieved (regardless of the theoretical orientation).

Thanks to all for addressing my question and for providing smart and thoughtful answers. I will try to refine my question further to comply with Jacinta and Katri comments. If i understand correctly the answers, they have the following structure, the therapeutic relationship is helpful because it leads to corrective experience (Sumru's thoughtful answer), or because it increases cooperation (Henry), or because it allows the patient to internalize the patient (Carmen's nice quote of David Orlinsky research on internalization). Carmen also adds that therapy helps patients redefine themselves (an interesting idea).

Those kinds of responses, in my humble opinion, tell me that the therapeutic relationship is important and even necessary, but what's really important are the corrective emotional experience, the intenalization, the increased cooperation, the redefinition of one self. It tells me that those are "transformative" and not the therapeutic relationships.

So I hope I am clearer, and that you now understand more what I am trying to understand, which is how the Relationship Itself is TRANSFORMATIVE and not the vehicle for something else.

It could be that I am just stuck on something here. In any case have a great day and thanks for bearing with me.

Dear Jacques:

I have been very curious trying to understand exactly how the quality of the relationship between a baby and his mother contribute to shape brain architecture.

There must be a parallel process with the therapeutic relationship.

I understood how processes like intersubjectivity and attunement could explain the importance of the relationship for a healthy emotional development, but I wanted to understand exactly how.

This is completely speculative, but I think Neuroscience will be able to explain exactly how, the therapeutic relationship is transformative if we are able to extrapolate the knowledge about mother-infant relationship to therapist-patient relationship.

I can recommend you to read about:

• Mirror neurons, right brain to right brain communication.

• Epigenetic influences of social experiences across the lifespan

(The research of Frances A. Champagne can freeze the blood in my veins as there is an explanation how the quality of maternal care can affect the expression of the genes in a molecular level…Maybe…the future will show how having a very meaningful relationship with a significant other who is attuned to the patient can lead to intersubjective realms and deep interactions that alter the epigenome).

Jacques: if you find some information related to this speculative thought, please contact me as I am very curious as you are. When I am with my patients, I can distinguish moments of special attunement. Feeling understood is a great thing….and NeuroScience can contribute in the future explaining the molecular mechanisms that explain the therapeutic effect.

[email protected]

I also just got the Stern's paper suggested by Marie Rudden, and will let you know if it helps me!

Hey Jacques,

As you’re well aware, you certainly tend to hear CBT-oriented folks emphasize the “necessary but not sufficient cause” of symptom change side of the alliance. When I read papers arguing that the alliance itself causes symptom change the authors seem to be saying that the alliance can be used as a kind of tool in the hands of a skilled therapist to promote corrective emotional or need-satisfying experiences, or maybe as a tool for the therapist, in session, to observe and ultimately change maladaptive interpersonal behaviors or distorted cognitions (it also seems common to talk about the alliance in general rather than referring to components of the alliance or possible differential effects across disorders/problems). Conceptualizing the alliance as a vehicle or tool that can be used to achieve therapeutic goals by a skilled therapist seems very different than claiming that a strong alliance in and of itself directly causes symptom change. So I'm often not quite sure what authors mean when they state that the alliance causes symptom change. As you know very well, this gets into a range of other issues (e.g., are we talking about Bordin’s conceptualization of the alliance as bond/goals/tasks [I found in one CBT study that the goal and tasks subscales may be strongly associated with depressive sx change than the bond), differences across treatment modalities/disorders, pervasive temporal and third variable confounds in observational, non-experimental research). In any case, that’s my general impression of the papers I read. Much of what I said may be repeating what was already stated above.

Dear Jacques,

As I see it Corina aproached quite near the core of the answer to your question. It is all about vinculation. Some call it placebo effect. Others psychotherapeutic non-specific effect. Etc, etc. As long as a relationship evolves and a bonding develops, vinculation establishes. In psychotherapy, it is like a re-enactment of a learned model or a learned desired model.

Dear Jackques (and others),

I will take a different approach here. Like Goldstein who claimed one could not study the reflex arc outside the brain in which it was taking place, and one could not study the brain outside the whole person in which it functioned, and one could not study the whole person outside his or her biopsychosocial context, I don't believe we can isolate the relationship and study it AS IF there were not simultaneously other factors also in play.

Having said that, though, the relationship (to me and my gestalt colleagues) is not a static noun but a dynamic verb (relating) and it is a contacting, or meeting of one with another over time. There is an aesthetic process to it (an embodied and sensory process that provides the "channels" through which this meeting occurs). I say this, which might seem pedantic, because "the relationship" in real life is not an abstraction, but a process that happens between whole persons, and in that mix between whole persons is where the "magic" takes place. I think that when people see and are seen, when they feel met and understood, and when there is a genuine, authentic person (i.e. the therapist) instead of a professional role attending to its professional obligations and evidence-based interventions (as important as research is; don't shoot me), then the client is not alone. The therapist is a "safe" person with whom to experience this as well; the client does not have to step on broken familial glass to get done what needs to be accomplished.

How do you factor human contacting without sounding, well, HUMANISTIC!?

I wonder if to some degree we are all describing the same phenomena, using the language of our different modalities - that our difficulties arise within relationships and that it is within relationships that curative transformation can take place.

My training is in psychoanalysis and so my model would speak in terms of early experiences leading to maladaptive expectations of the world. The model conceptualises these expectations as unconscious structures or objects, the dynamic between which tend to be based upon the relationships, real or fantasised, between significant early entities.

As we go through life, these expectations may be reinforced or modified by experience – although it is often the case that we seek out experiences that reinforce these expectations, rather than change them. However, in psychoanalytic terms there is the possibility of introjecting more benign objects, and the relationships between them, perhaps through the process of identification. Within these later experiences, the relationship with a therapist offers a particularly potent example of a present day relationship that can lead to change. The abstinence of the therapist in not bringing too much of their everyday self to the relationship – at least in the more classical forms of the therapy – allows the patient to more clearly project onto the therapist these internalised expectations and for them to be identified and cognitively challenged. Hopefully, too, the therapist having had their own analysis, is less liable to confuse the process with their own unrecognised expectations about the world. In fact, a key tool of the psychoanalytic therapist is their own introspection, observing their thoughts and feelings that arise in response to their patient and using these observations to gain a better understanding of the way that the patient interacts with the world.

Some of the changes within therapy can more obviously be described as cognitive and about which we are conscious – a long-held belief about the world is found to be dissonant with experience and becomes modified. For me, some of the more important changes in therapy are less tangible, less conscious and are more about adjustments to that internal world of internalised objects. For that reason I'd say that the therapeutic relationship is the primary vehicle of change. That relationship, its vicissitudes and modifications, becomes internalised, much the same way as the individual's early relationships did, and can lead to less maladaptive expectations of our adult world. I assume that the quality of the therapeutic relationship is an important factor in even the most purely cognitive CBT treatment.

As I said at the start, this is one way to tell the story – not necessarily the only way or even the best for everyone. And all of the above is one way to describe what is actually happening within neurons and synapses.

Following this interesting discussion over some days, I have the impression that many points are concerned with the problem to find the “true” reduction. However, the world is the world. Period. Every different description (which we, of course, need necessarily!) is an ANSWER to a particular QUESTION – which has more to do with being more or less adequate than true.

To start with the last contribution (Geoff Ferguson): Without being a psychoanalyst, the psychoanalytic answer (perspective) in the first part seems to me much more adequate to the question than talking about neurons and synapses at the end. “pressure”, “volume” and “temperature” is NOT one way to describe what is ACTUALLY happening as movements of molecules (which is NOT one way to describe what is ACTUALLY happening within the multitude of elementary particles). Particularly, “what is actually happening within neurons and synapses” is ONLY happening under particular conditions (!). To these conditions belong – as Gestalt psychologist Philip Brownell pointed out (above in this discussion) – that these neurons and synapses are part of the dynamic development of a brain which is part of the dynamic development of a human organism which is part of dynamic interactions within a social group. For example, the “same” neurons and synapses within the same brain within the same human organisms without any social relationship would function totally differently (however: even that is an artificial perspective, because the human organism wouldn´t have survived by it´s own, and – getting the (social founded) ressources to survive biologically, the brain wouldn´t have developed this way, and therefore some neurons would even not exist neither some/most of these synapses – particularly those which have to do with the psychoanalytic story of relationship).

Going with that perspective of an “adequate” answer, I think that you, Jacques, kicked an interesting discussion, however, I have to confess that I more and more lost the idea what you are really looking for, when you are talking of “how the relationship ITSELF is transformative”. I totally agree that there is a difference between (for example) CBT or (part of) psychodynamic therapy, which see and use the “therapeutic relationship” as a working alliance from the perspective of creating a good BASIS in order to do something specific (techniques in the sense of “specific therapeutic factors “). Here the relationship is indeed a vehicle for something else. While, in contrast, (part of) Humanistic Therapy uses the therapeutic relationship not as a basis for a therapeutic technique but the (special!) therapeutic relationship IS the essentially healing condition. Similarly, there are tools etc. to help an adult to learn a foreign language, but the social relationship in early childhood and the stream of sounds from which every (healthy) baby learns every real language spoken on earth and its grammar, is not a “tool” in that sense, but something diffenrently.

BUT, for me in many contributions I found more or less ways to describe aspects of this/these condition(s), and you still insisted that you want to know about the healing/transformative power of the relationship ITSELF.

For me, it reminds me to the Zen-koan of describing the sound of the clapping of just one hand (or, adopted to your question: describing this clapping-sound ITSELF without talking of hands, acoustic, hearing, etc. etc.).

“on its own” is nothing curative, if you mean “on its own” without referring to social processes, developmental dynamics, transformative processes (like assimilation and accommodation) in everyday life, meaning making etc. etc. Healthy breathing “by its own” - without air - is not possible.

In order to try to give a more adequate answer (than that what you found already in the many contributions - which I liked mostly!) I (we?) need to know more, what your question really is/means.

Gary Yontef, a gestalt therapist, said that relationship is contacting over time. Yet, we can only do it one current moment at a time. A person can stay with what emerges from the meeting in the current moment, to remain experience near and available with spontaneity to the other, or one can filter all that through the gauze of one's theory about past episodes of contacting. I believe the more vibrant influence is the current contacting, what emerges as experience of self THROUGH that meeting. Just as the mind emerges through the lower functioning of the brain as the whole person engages in the environment, the self emerges as the person meets the other. Not all such self experience is therapeutic (whether it happens in therapy or outside of it); some emergent experience is debilitating. I think what makes a relationship transformative (for better or worse) is the emergence of self through contacting.

Thank you, Geoff, for reminding us of the important contributions of Winnicott to this discourse. (similarly did Moreno (Psychodrama), the Berlin Gestaltists (f.e. Kurt Goldstein) or Carl Rogers (person-centered) stress the relationship as a non-tool in psychotherapy).

Meanwhile, these early contributions converge with more recent findings of evolutionary psychology, neuro-science, attachment-theory, and systemic approaches (interdisciplinary and in psychotherapy) to understand our brain as a “social organ”. So called cognitive processes are not processes that can be understood and described by just looking at one single isolated brain (or even parts). In contrast, even on the physiological/histologic level the factual structure of the synaptic network depends essentially on the social experiences (prae – and postnatal), particularly in the first years but with a still high plasticity in later years. The development of the new-born organism (with already a lot of abilities but even more potentials) to a human being with can self-reflective take part in our social life depends on the unfolding of the ability to refer to, understand and communicate inner experiences. And the tools to do this stem from interpersonal language, terms, pp pp - in short from the social + cultural processes around the biological boundaries of the infant/human being. These tools to combine 1st-person-processes with the 3rd-person-pespective and create understanding, meaning, narratives etc. are not inborn but need a 2nd-person-raltionship who empathically give words/terms/stories to inner processes. Those aspects which have never been empathically understood and named by a significant other will stay as experiences “without wording and (Heidegger) worlding” – therefore is un-understandable, un-communicatable, etc. And the person feels, experiences, perceives and/or act partly in ways which are not understandable by himself.

(of course, this is only ONE aspect. The 3rd person perspective (=selfreflexive understanding) to 1st-person experience can also be erroneous – due to biography the feeling of loneliness can be interpreted as being hungry, or it can be much more important for the organism to listen to the needs of other person + to try to fulfill their expectations, than the own inner needs and boundaries (which again can lead to chronic strain - one structural aspect of the dynamics of depression).

From this perspective, an empathic, congruent and regarding relationship, where inner processes are “symbolized” (as Carl Rogers called it) can overcome the incongruence of (pre-mentalized) inner processes and a self-understanding – which includes mentalization and using social tools (language pp). Such a relationship is similar of a mother-child relationship (which is also NOT a “tool of socialization”!) - a 2nd person helping to develop the bridging (evolutionary) potentials of 1st person experience and 3rd person perspective by co-creating meaning.

That would be – in very short and rough words MY answer to the question in our discourse (started by Jacques). However: “MY” means, due to my “social brain” I can only think while standing on the shoulders of really great others – and Winnicott is one of them (although I don´t know so much particularly of his approach in detail as I should …).

Kind regards,

Jürgen

What is, that you are doing now, in this discussion? This is "psychotherapy". Many personality, real or virtual, many words, none decision, less words, some changement, but why? Because someone request it. Yes, what I say, is "meta-communication", excuse me. I said nothing.

Read Ferenczi Sándor, maybe he may shows better his understanding of the clues to better understanding of what a relationship may means.

I think that the alliance has both direct and indirect (it catalyzes other therapeutic processes)effects. As I understand your question Jacques, your are asking about the direct effects of the alliance on treatment outcome. Using Bordin's conceptualization of the alliance (bond and agreement on goals and tasks) I believe that the alliance is curative because the ability to be bonded and agree on tasks and goals is important in all relationships not just therapeutic relationships. Therefore, becoming bonded to the therapists and agreeing on tasks and goals with the therapist is practice for doing these things in extra-therapy relationships. By observing and commenting on the process of alliance formation in the therapy relationship the therapists can focus and accelerate the client's practice on alliance formation.

On a side note, I believe we have spent far too much time examining the direct effects of the alliance and not enough time examining the indirect effects.

I think the contribution of Dennis Kivlighan showed very clearly the difference between “therapeutic ALLIANCE” (used, for example, in CBT) and “therapeutic RELATIONSHIP” (a core concept in, for example, Humanistic Psychotherapy): The former (alliance) means to create a basis for working with specific techniques and to make the cooperation for goals and tasks easier. The latter (relationship, as conceptualized, for example, by Carl Rogers) means to create situations (space of experience) which is similarly to the situations in (more or less) healthy infant´s development: where the “social brain” patterns (and re-patterns) the neuronal network due to the processes. And in the multitude of processes are social processes which connects inner experiences of the organism (1st-person-experinece) with the tools (f.e. language, terms, explanations, narratives, pp) of the social group(culture). In this (healthy) development the infant create an understanding of his inner feelings and outer behavior – which is lacking (partly) for a neurotic person – and therefore can established in a therapeutic relationship which fulfills these conditions.

As a consequence, the difference between thp. “alliance” and “relationship” is a difference that makes a difference (as Gregory Bateson put it)

Hi Juergen, Thanks for your useful clarifications. I agree, I think that the distinction that Jacques is posing is between the quality of the therapeutic relationship as important in promoting a process of change or the relationship itself as integral to that change. So one might think that a good alliance between therapist and patient/client would encourage trust, understanding and identification. These qualities might lead the patient to be more open to accept suggestions by the therapist or to be motivated to undertake exercises or study. However, in my work I'm more interested in the way that entering into the relationship itself becomes part of the mechanism of change.

Winnicott has written usefully about this. In 'Fear of breakdown' he describes how the patient's difficulties arise from a fear that something will happen that will destrroy his or her sense of self. In order to prevent this catastrophe, the patient will adopt various defensive strategies to isolate and repudiate the feared thoughts. Winnicott's insight is that this breakdown has in fact already occured. The individual as an infant experienced that catastrophe in the form of a failure of his or her environment to respond in sufficient time to their need. At that time the infant lacked the ability to deal with the failure. A defensive structure was then established, what WInnicott calls a False Self, which lays a pattern for future living and relating.

Winnicott suggests that optimally the patient will experience a similar and inevitable failure in the therapeutic relationship. (As no relationship can be perfect.) However, this time the patient as an adult, and with a facilitative therapist, can re-experience that earlier trauma and grow beyond the earlier defensive structures. An earlier relationship contained a trauma that could not be experienced, was frozen or sealed off and because it was thus timeless, continued to have a limiting effect upon the individual's capacity to relate and to fully live. Re-experiencing, even mildly, in the safer setting of the therapeutic relationship enables that experience to enter into time and then to become past.

So the relationship with the therapist itself is a vehicle for change, not a useful attribute to increase the effectiveness of other tools.

And I totally agree with you, Juergan, that we exist within a social nexus. It is not useful to think of ourselves as existing outside of relationships. Within psychoanalysis there are useful models to describes these processes, projective identification being a major insight into the way inwhich we shape eachother and are shaped by others. Winnicott, again, has useful things to say about this - for example, his statement that there is no such thing as an infant, rather there is always an infant/mother, from which the infant emerges. More recently Christopher Bollas has described the ways in which we use our environment of people, physical objects, ideas to construct our 'character', in the sense of a character in our personal story.

Regards

Geoff

The question is difficult to answer just because there is still no agreement on how to assess the quality of the therapeutic relationship (TR): albeit some questionnaires have been developed, none of these is based on a universally shared definition of TR, not to mention a good/bad TR. Different instruments bring to different assessments of the TR. The study itself of the TR (and the therapy skills needed to foster it, as compared to the technical skills) is affected by this problem. If you wish to better go into the subject, you can find more in the volume:

Borgo S. & Sibilia L. (Eds.) The Patient-Therapist Relationship: its Many Dimensions. Roma: CNR,1994.

For the above reason and other reasons as well (here too long to explain) the claim the the TR can be curative in itself cannot be considered as empirically established.

That said, it is a common clinical experience that many patients get better much before the therapist has implemented any of those he/she considers a theraputic procedure. This simple observation rises but not answers too many questions.

Lo deseable y contrastado es la combinación de psicoterapia y tratamiento psicofarmacológico

I'm not sure if I'm understanding Jacques' question. Any explanation (unless it is a tautology or "analytic") invokes something else (x produces y because of z). But is it, Jacques, that you want no "z" in the equation? The problem I see in that is that even if someone invokes "internalization" as curative/transformative, can always further ask: so what is it about internalization (x) that cures (y)? you'll have to invoke a new "z" to give an account, isn't it? Or even if you invoke a zone in the brain, you can ask: so what is it about that zone in the brain that cures/transforms...

Maybe that's why it feels one gets stuck with this.

I think you migth have an interest in a possible brain model based answer. The article is now posted on RG as of today.

Moss, R. A. (2013). Psychotherapy and the brain: The dimensional systems model and clinical biopsychology. Journal of Mind and Behavior, 34, 63-89.

I discuss Roger's (1957) variables of warmth, genusineness and empathy as these realte to right and left cortical processing, in addition to proposed effects of other therapeutic procedures. I hope you may find this of interest.

Sorry everyone, I was away. Thanks for all the interesting responses. I am curious about Juergen's distinction between therapeutic relationship and therapeutic alliance. I will think more about it.

Dennis, please say more about what you mean by indirect effect of alliance.

Thanks for all your respones

Much of the earlier writings on the alliance described it as a catalyst, enabling other process to operate more effectively. In statistical terms I think ythat this mens that the alliance would serve as a moderator. This is what I mean by indirect effects of the alliance.

Most of the alliance research has not viewed the alliance as a potential moderator. In one of my favor non-published studies we found that that the alliance moderated the effects of TLDP Specific Strategies in predicting change in interpersonal problems. Specifically, when there was a strong alliance greater use of TLDP Specific Strategies was significantly related to decreases in interpersonal problems. When the alliance was weak, however, greater use of these strategies was related to increases in interpersonal problems.

I have always thought that there should be more studies examining possible moderating effects of the alliance

Yes, I think this is an interesting way to study those questions. I have a question though as moderators are often measured at pre-treatment and if they are measured later in treatment as I believe you are suggesting, then it's a bit complicated to measure change in outcome, isn't it?

I believe we discussed some of those issues in this relatively recent chapter

Barber, J. P., Khalsa, S-R., & Sharpless, B. A. (2010). The validity of the alliance as a predictor of psychotherapy outcome. In J. C. Muran & J. P Barber (Eds.), The Therapeutic Alliance: An Evidence-Based Approach to Practice (pp. 29-43). New York: Guilford Press.

Thanks

Thanks for the reference, I look forward to reading it.

Traditionally moderators were seen as a priori variables, often person characteristics, measured prior to treatment. With some of the newer time-series modeling, I believe that it is possible to model an interaction between two time-covaring variables (e.g. Alliance and technique) and then relate this interaction term to changes in outcome.

Speaking as a counsellor and retired prof of statistics, I find a lot depends on the counselling method used as to its curative effect. Some clients have said that I will never know how much I have helped them, which has surprised and humbled me. It indicates that we often don't know what is going on so how do we measure the effect? Comparing methods is notoriously difficult both operationally and statistically. Questionnaires are also very unreliable as clients may not be totally honest as I have found in self-esteem questiionnaires. Also separating the counsellor-client effect and the value of the counsellor's knowledge is tricky.

According to my studies, I feel enough confident to state that any human relationship can be studied under different perspectives, and that the patient-therapist relationship,or the patient-doctor etc. are no exceptions. So, the first question could be: which is the perspective you wish to choose?

The theoretical supermarket is even too large! Had I to organise the supermarket, I would say: the different perspectives can be grouped according to the main psychological research areas which they are focused upon (note that I am a researcher, not by chance!). So, I would identify i.e. a behavioral perspective, but also a cognitive one and an emotional one. It seems to me that any other perspective (ethological, anthropological, economic, cultural, etc.) could be subsumed by the former three I mentioned: behavioral, cognitive, and emotional.

But, assumed that this choice has been done, we still have to define the therapeutic relationship (or TR) as such: can it be called "therapeutic" just because it happens in a therapeutic setting and one of the participants is a socially defined "expert", or because it favors the therapy goals? Perhaps the second option more closely resembles the definition of "therapeutic alliance" (TA), already mentioned.

To better clarify, here are my own choices: the TA is a kind of relationship which specifically fosters the goals of psychotherapy for a specific dyad therapist-patient. So, TA is a "good" or "positive" TR: a relationship which allows to implement effective psychotherapy procedures (never forget that we can also have different kinds or "bad" TR!). Of course, this requires that goals of treatments can be specified and that effective procedures exist (this is not true for all psychotherapy approaches).

My definition of relationship - anyway - is in the "behavioural" section, as it is the same given, for example, as in human ethology: a set of habitual dyadic interactions (see R. Hinde for this) between two organisms (who know each other, I add). It is to remind that "therapist" and "patient" are social roles, where the relationship develops between persons playing those roles. So, if the TR is defined as above (any interaction between two people in different social roles in a social setting), it is not a "relationship" in my definition. It can be observed to start since the beginning, when therapist and patient contact each other. The TA, instead, is a relationship, and therefore it can only develop in time, to allow to develop "habitual interactions".

Some generic social skills are of course required, in the same way as some basic conditions are needed for a surgeon to apply any surgical procedure, such as a good eyesight (with or without glasses), and hand without tremors! Books are full of definitions of such social skills for psychotherapists and I will not repeat it here. But are these social skills really "therapeutic"? In my opinion, if they are, they are therapeutic in the same way as the placebo response.

This is a very complex area made more so because the term curative has multiple meanings depending on the context. The curative experience of therapy may assist someone who is dying of cancer to deal with the anger and anxiety associated with impending death – a form of adjustment. It may be curative, when the client no longer washes their hands every fifteen minutes. It may also be very gentle such that weeks into therapy the client can no longer remember the reason for beginning therapy. To borrow for John Hattie and his reflections on school interventions in relation to the multiple therapeutic orientations…. they all work but some work better than others, probably within specific contexts.

Geoff’s reference to change is interesting and many clients change in therapy. Many change despite therapy and some in anticipation of therapy. My own research shows, however that few people who experience non-directive and non-educative therapy, gain insight into the process that prompted the change in therapy. They may experience change through therapy but given the same problem after finishing therapy they typically do not have any processes to deal better with the recurrence other than returning to therapy. Client-centred therapy certainly can change the client but it does not scaffold learning about the process of change – which is a lost opportunity for the client. That was a finding from a paper I recently wrote:

Bowles, T. (2012). Developing adaptive change capabilities through client-centred therapy. Behaviour Change 29(4), 258-271.

Physiologica/neural concordance between therapist and patient during their interaction could be an intriguing topic related to your question. I suggest you my paper : "Somatic underpinnings of perceived empathy: The

importance of psychotherapy training"

Thanks all for your comments

Jacques, I know I am late in replying, but the corrective emotional experience is thought by some to be the curative factor of which you speak: Alexander and French (1946) described the idea of the corrective emotional experience (CEE) as the key therapeutic factor in psychotherapy. According to the authors, the CEE "reexpose[s] the patient, under more favorable circumstances, to emotional situations which he could not handle in the past. The patient, in order to be helped, must undergo a corrective emotional experience suitable to repair the traumatic influence of previous experiences." (Alexander & French, 1946, p.66). You may also wish to look at Teyber (2005), who states in his book 'Interpersonal Process in Therapy: An Integrative Model:' “Following Strupp (1980), clients change when they live through emotionally painful and long-ingrained relational experiences with the therapist, and the therapeutic relationship gives rise to new and better outcomes that are different from those anticipated and feared. That is, when the client re-experiences important aspects of her primary problem with the therapist, and the therapist’s response does not fit the old schemas or expectations, the client has the real-life experience that relationships can be another way. When clients experience this new or reparative response, a response that differs from previous relationships and that does not fit the client’s negative expectations or cognitive schemas, it is a powerful type of experiential re-learning that readily can be generalized to other relationships (Bandura, 1997).”

References

Alexander, F., French, T., et al. (1946). Psychoanalytic therapy: Principles and application. New York, NY: Ronald Press.

Bandura, A. (1997). Self-efficacy: The exercise of control. New York, NY: WH Freeman Publishers.

Teyber, E., & McClure, F. (2011). Interpersonal process in therapy: An integrative model. Belmont, CA: Brooks/Cole, Cengage Learning.

Also, the following articles have numerous references:

Bernier, A., & Dozier, M. (2002). The client-counselor match and the corrective emotional experience: Evidence from interpersonal and attachment research. Psychotherapy: Theory/Research/Practice/Training, 39(1), 32-43.

Hartman, D., & Zimberoff, D. (2004). Corrective emotional experience in the therapeutic process. Journal of Heart-Centered Therapies, 7(2), 3-84.

Hope that answers your question. :)

You might also want to have a look at what Robert Moss PhD (on RG) has to say about "emotional restructuring" in his theory of "clinical biopsychology.

Irvin Yalom states provocatively that it is the relationship between client and therapist that is the real agent of change and cure (independent of the school or method of therapy). He is explaining is view on the backdrop of an what he calls "authentic relationship". I found his reading very worthy to think about it (c.f. his book Existential Psychotherapy, the chapter on Isolation).

The therapeutic relationship is different from any other relationship. While working though issues of concern, the alliance, I believe is curative because the person moves from neediness to self efficacy. This is based on the theory of "Power as 'knowing participation in change.'

There are many power theories. Here is the citation for the Power Theory to which I referred.

http://drelizabethbarrett.com/background/power-knowing-participation-change-theory

Dr. Elizabeth Manhart Barrett. this researcher is well known for her theory and for creating a power measurement tool.

DEFINITION: Power is the capacity to participate knowingly in change as manifest by awareness, choices, freedom to act intentionally, and involvement in creating change.

The (therapeutic) relationship is the base of the working alliance. A developed relationship is therefore fostering the therapeutic bond (it includes self opening, trust, treatment expectancy, allegiance, self-efficacy...) (Bordin 1984) and mediates goaldirected collaboration etc.

The therapeutic relationship as a meeting space for a person who needs help and another person who is prepared to help has the potential to promote self-knowledge, understanding of themselves and their emotions.

This process of trust and closeness leads to the construction or management of internal resources in the patient to cope with the problems.

The procedure is constructive and transformative of the subjects involved, promoting the development of strategies, resources ... is a discovery! It is a process of clarifying and mitigating problems, and this is organizing to help the patient deal with their internal emotional conflicts.

So ... relationship is curative or better is caring.

Dear Everybody and Paula

thanks for you thoughts

Re. your answer Paula, my question is how trust and closeness lead to the construction of better internal resources

Everybody have a great week end

Jacques

Sorry but IMHO expressions such as "meeting space", "construction", "discovery", all metaphors, I suspect do not really help to identify or understand the therapeutic alliance, neither to teach how to obtain it. Unless they are operationalized in some way, useful to observe, study, correct and therefore teach it.

Moreover, I do not agree that the goals of the therapeutic alliance (and of psychotherapy at large, of course) should be defined as internal to the patient (why souldn't they be also contextual or behavioural?), and expressed in terms of internal conflict.

All this reminds me of a lexicon very resembling that of the pre-scientific era of psychotherapy.

And I would like to ask: What else should we expect from the "therapeutic alliance" (I put in brackets as "alliance" is also a metaphor) if not to foster the psychotherapy goals?

I hope everybody is fine.

BTW. some of you may find a recent paper published in JCCP by Sigal Zilcha-Mano who did a post doc with me that address the issue of causality of the alliance.

DOI:10.1037/a0035141 (it's on research gate

https://www.researchgate.net/publication/258921180_Does_Alliance_Predict_Symptoms_Throughout_Treatment_or_Is_It_the_Other_Way_Around?ev=prf_pub

That is, Sigal showed that alliance preceded change in symptoms during the entire treatment. This is not the first finding from our group showing that.

Our prior finding was also published in JCCP 14 years ago

https://www.researchgate.net/publication/12185799_Alliance_predicts_patients'_outcome_beyond_in-treatment_change_in_symptoms

Now having shown this, I am again asking how is this happening :)

Have a good week

Article Does Alliance Predict Symptoms Throughout Treatment, or Is I...

Article Alliance Predicts Patients' Outcome Beyond In-Treatment Chan...

Great questions about implementation...

We have a wealth of knowledge on therapeutic alliance - these concerns of applicaiton and implementation are another matter.

The discipline and practice of nursing has also been raising these concerns about training and practice realities that support and create barriers to therapeutic relationships (including time for self reflection; cultural safety/competency support, and so on). The Registered Nurses Association of Ontario (RNAO) have a 2006 Best Practice Guideline that addresses some of the implementation issues...but also raises this as a topic of future research:

http://rnao.ca/sites/rnao-ca/files/storage/related/943_BPG_TR_Supplement.pdf

I look forward to hearing about more implementation/application approaches from this community.

I completely agree with Geoff Ferguson and other contributors who say that "trust, understanding, and identification" are vitally important to the process of effective psychotherapy. If the therapist expresses sincere warmhearted caring, empathic understanding, and nonjudgmental unconditional acceptance of the client's authentic communications and experiential states, that helps the client to develop trust, emotional security, and insightful self-understanding, which contributes to the healing of emotional pain and inner conflict, as well as enhancing psychological well-being and constructive functioning. Therapists must be willing and able to at least temporarily suspend egocentric or narcissistic self-awareness, self-concern, and preconceived interpretations of the client (such as predetermined theoretical interpretive models and harsh or blaming value judgments of the client) because only when self-forgetful of egoistic mind chatter can the therapist be deeply invested to empathically contact and deeply commune with the client's communications and experiential dynamics. That empathic communion and warmhearted caring produces deeply penetrating (incisive) experiential insight into the client's current psychological dynamics, along with insights about how best to help clients achieve liberation from psychological pain and related psychological growth. This process of caring empathic communion is basically the same as Martin Buber's description of the I-Thou relationship. This process of warmhearted caring empathic communion of the therapist with the client in psychotherapy is discussed in a book that I have recently published on behalf of my late father, Dr. Max Hammer, who was a highly respected psychotherapist, Professor of Clinical Psychology, and supervisor of Clinical Psychotherapy Intern training. The title of this book is, “PSYCHOLOGICAL HEALING THROUGH CREATIVE SELF-UNDERSTANDING AND SELF-TRANSFORMATION.” (ISBN: 978-1-62857-075-5) (see especially Section B of Chapter 3, pages 205-215).

The therapeutic alliance is not the same as the therapist client relationship. The alliance refers to the separate and joint reponsibilities of patient and therapist to one another within the therapeutic process. The therapist client relationship refers to how the P/T interaction is seen within the therapist's modality In fact the therapeutic alliance is essentially the same across all modalities.

One answer to this question may be in attachment theory. This theory proposes that individuals have an attachment style that affects interpersonal relationships. Four styles have been identified: secure, avoidant, anxious and disorganized. The latter three are insecure. The clinician must have a secure style for this to work. The client reacts to the clinician with a secure style and learns from the clinician how whichever style the client has how to review the reasons for the development of this style and change feeling and thinking to a secure style, partly using the clinician as a model. This change occurs within the relationship and thus is "curative." Another less complex answer is within the positive transference nature of the relationship the client internalizes positive messages from the clinician and this experience creates new neural pathways that are positive that replace the negative pathways learned from previous negative experience.

I agree Larry. I think much of good therapy is so subtle it is almost an art form.

I agree with some of the recent posts that effective psychotherapy involves helping the client develop trust and emotional security, which is much more likely to occur if the client directly experiences the therapist as being sincere, warmhearted/deeply caring, empathically understanding (fully present and tuned into the client at an experiential and energetic level), nonjudgmental/accepting, and emotionally secure (non-defensive). The development of these kinds of qualities that contribute to the development of trust, good communication, liberating insight, empathic experiential closeness, and genuine caring, true love, or genuine friendship, in psychotherapy and various kinds of personal relationships are discussed in two books that I have recently published (For more information about the books, please see the attachments, my ResearchGate profile, and/or my author/publisher website, http://sbprabooks.com/MaxHammer)

http://sbprabooks.com/MaxHammer

This attachment provides more information about two books that I have recently published, where I address the process of effective psychotherapy, the development of psychologically healthy, satisfying, successful, personal relationships, and related issues.

My research into the therapeutic alliance in prison-based drug treatment has highlighted that in certain client groups (such as prisoners), negotation of the alliance and the the wider relationship may model a style of (collaborative) relationship that clients may never have experienced before. In doing so it can help them to improve their own support networks. However, my personal conclusion tend to lean towards the alliance being a necessary contributor to positive ouitcomes more often than being curative in and of itself.

It makes sense to many of us that "damage" occurred within early relationships would be best "repaired" within a relationship. There is evidence that insecurely attached individuals who are in a primary relationship with a secure person will likely convert to secure attachment after about 5 years with them. As psychotherapists, our goal is to speed up that process, as well as lower the experience of interpersonal threat so that the client/patient can experiment with non-defensive interactions with others. That requires us to be self-aware, self-reflective and secure so that we do not reinforce anxiety and defensive/strategic interactions.

Dear Lee. You mention "evidence that isecurely attached individuals...". Can you mention a text about this?

Thank you

Honestly, allowing a clincian to be apart of a personal part of your world is healing within itself. People are lonely and therapy nobody how dogmatic or fundmental . It gives people a sense of pride or esteem. By proxy people are healed because "of alliance"

Heather Graduate Student

At Capella University

The effects of the P-T relationship should and can be separated from those of the specific procedures implemented by the therapist. Only then the question of  what about the relationship is curative can be addressed. 

Attachment theory originated by Bowlby is one way to find an answer to the question of the curative potential of the client-clinician relationship. Many clients present with psychosocial problems for which the basis is a negative self-concept. This negative self derives from self blame over not having a sufficiently satisfactory attachment to their primary attachment figure, usually the mother. Albert Ellis advises that children often make an erroneous assumption about this lack of attachment resulting from a defect in them. This assumption generates both anxiety and depression and interferes with social functioning. As the relationship between the client and the clinician develops and deepens the clinician becomes the attachment figure for the client. The client internalizes the positive accepting feeling of the clinician. This restores self-esteem and is curative in terms of improved social functioning that results from diminished anxiety or depression. The ability of the clinician to help the client understand this process also is a factor.

Attachment theory originated by Bowlby is one way to find an answer to the question of the curative potential of the client-clinician relationship. Many clients present with psychosocial problems for which the basis is a negative self-concept. This negative self derives from self blame over not having a sufficiently satisfactory attachment to their primary attachment figure, usually the mother. Albert Ellis advises that children often make an erroneous assumption about this lack of attachment resulting from a defect in them. This assumption generates both anxiety and depression and interferes with social functioning. As the relationship between the client and the clinician develops and deepens the clinician becomes the attachment figure for the client. The client internalizes the positive accepting feeling of the clinician. This restores self-esteem and is curative in terms of improved social functioning that results from diminished anxiety or depression. The ability of the clinician to help the client understand this process also is a factor.

Attachment theory originated by Bowlby is one way to find an answer to the question of the curative potential of the client-clinician relationship. Many clients present with psychosocial problems for which the basis is a negative self-concept. This negative self derives from self blame over not having a sufficiently satisfactory attachment to their primary attachment figure, usually the mother. Albert Ellis advises that children often make an erroneous assumption about this lack of attachment resulting from a defect in them. This assumption generates both anxiety and depression and interferes with social functioning. As the relationship between the client and the clinician develops and deepens the clinician becomes the attachment figure for the client. The client internalizes the positive accepting feeling of the clinician. This restores self-esteem and is curative in terms of improved social functioning that results from diminished anxiety or depression. The ability of the clinician to help the client understand this process also is a factor.

The attachment of the client to the clinician as an attachment figure that occurs as the client-clinician relationship develops is a basis for its curative power.

The attachment of the client to the clinician as an attachment figure that occurs as the client-clinician relationship develops is a basis for its curative power.

Maybe have a look at Jerome Frank‘s “Persuasion and Healing“

It maybe worth checking the polyvagal theory anti its applications. The regulation of Autonomous Nervous System is more than just interesting. It shows, how regulation of psychological defense result in adaptation of dysregulated affects which trigger maladaptive behaviors. I would recommend: Dana, D. (2018). The Polyvagal theory in therapy: engaging the rhythm of regulation (Norton series on interpersonal neurobiology). WW Norton & Company.