More Than a Method: Why the Therapeutic Relationship Matters

Therapy is about more than techniques and interventions. While different approaches offer different tools, the relationship within which those tools are used often plays a significant role in creating meaningful change.  As I continue to reflect on the evidence that informs my own practice, I am reminded that how therapy is provided, and the relationship within which it takes place, also matters. The therapeutic relationship is not simply the friendly or supportive part of therapy that sits alongside the “real” intervention.  The relationship itself has an evidence base. 

What does the research tell us?

One of the largest studies in this area was a meta-analysis by Flückiger, Del Re, Wampold and Horvath (2018). The researchers brought together 295 independent studies involving more than 30,000 people receiving psychotherapy and examined the relationship between therapeutic alliance and treatment outcomes.  They found a consistent positive association between the quality of the therapeutic alliance and psychotherapy outcomes across different therapeutic approaches. But therapeutic alliance means considerably more than simply liking your therapist.  A therapeutic alliance includes the relational bond between therapist and client, agreement about the goals of therapy, and agreement about the tasks or work that therapist and client will undertake together.

Norcross and Lambert (2018) examined the wider research concerning psychotherapy relationships.  Their work highlights relational elements including empathy, collaboration, responsiveness to the individual, positive regard, goal agreement and the therapist's capacity to recognise and repair difficulties or ruptures within the therapeutic relationship.

That last point particularly interests me.

A strong therapeutic relationship does not mean therapist and client will always agree or that the therapist will always get things right. Misunderstandings can happen.  What matters is whether those moments can be noticed, talked about and repaired.  That moves us away from an idea of the therapist as the expert who simply does therapy to someone and towards therapy as a collaborative process involving two people.

What about the therapeutic modality?

Bruce Wampold's work on the common factors in psychotherapy adds another important dimension.  His research does not suggest that therapeutic methods or interventions are irrelevant. Rather, it challenges the assumption that the particular technique or modality alone explains why psychotherapy works.  Factors shared across different therapies, including therapeutic alliance, empathy, expectations, therapist effects and having a credible explanation and pathway for change also contribute meaningfully to outcomes.

There is an important distinction here. This is not relationship instead of evidence-based intervention.  It is relationship and evidence-informed intervention.

Why does this matter in trauma-informed care?

For me, this research becomes particularly meaningful when considered through a trauma-informed lens. People who have experienced traumatic events or interpersonal harm may have had experiences in which safety, trust, choice, boundaries or relationships have been disrupted. We therefore need to think carefully about the environment in which therapeutic work occurs. A trauma-informed therapeutic relationship should not remove choice from the person in the name of treatment. It should seek to create safety, collaboration and transparency while respecting the person's pace, boundaries and autonomy.

Psychoeducation can also play an important role. Understanding emotions, behavioural responses, relationships, the brain and nervous system can help make experiences that once seemed confusing begin to make sense.

How this influences my practice

I describe my therapeutic work as trauma-informed and integrative. Rather than being committed to one therapeutic modality for every person, I draw on different theoretical perspectives and evidence-informed approaches according to the needs of the individual.   But underneath those approaches sits something fundamental:

The Relationship.

Can this person feel heard?

Can we talk openly about what they need from therapy?

Do they understand why we are doing what we are doing?

Can they tell me when something isn't working for them?

Can we change direction together?

And can therapy provide a space in which thoughts, feelings and experiences that may be difficult to explore elsewhere can be explored and acknowledged?

The psychotherapy research gives considerable weight to these questions.

It reminds me that evidence-informed practice is not simply about knowing which intervention to use.   It is also about understanding how we meet the person in front of us, how we build a collaborative relationship, and how we use our knowledge and interventions within that relationship.

For trauma-informed practice, I believe that distinction matters.

References

Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172

Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303–315. https://doi.org/10.1037/pst0000193

Wampold, B. E. (2015). How important are the common factors in psychotherapy? An update. World Psychiatry, 14(3), 270–277. https://doi.org/10.1002/wps.20238

This blog forms part of my ongoing commitment to continuing professional development, reflective practice and evidence-informed care. It is not a substitute for therapy. If anything discussed here raises something you would like to talk about, you are welcome to contact me.