[archipelago]

People here often talk about their therapists and issues. Sometimes those issues seem separate from the relationship, sometimes not. Sometimes people wonder if they should approach certain topics with their therapists for either personal reasons or because the approach doesn't really "allow" for that type of discussion.

I do relational psychoanalysis. The relationship itself is one of the main focuses. It is a rather new, but powerful approach, very unlike traditional models. There is a focus on the here and now, the ongoings in the therapy context, the interactions that go on, as well as explorations both of past and future. A few here might be familiar with it, but for most it is not all that common.

Anyway I was reading about therapeutic outcomes, and found a meta-analysis that covers a broad range of different approaches and comes with the emphasis on the therapeutic relationship as a huge factor in the outcome of therapy.

The basics are that client factors make up 40% of the outcome, so that includes things like motivation, personality, etc. The placebo effect takes up about 15% of the outcome and this can mean just about anything. The technique or approach also takes up about 15%, which is pretty small actually considering how attached people are to the theoretical orientation. But the news is that the therapeutic relationship takes up about 30% of the outcome regardless of approach. That is twice the technique.

Just to point out to those who don't feel that they can use time to talk about the relationship itself. It is much much more important than the actual technique.

[FeelingOpaque]

That's very interesting, do you have any material that explores it further?

[Nerak67]

It depends what you are in therapy for. For example, I do cbt for social anxiety. I do not believe that discussing my relationship with my therapist is going to stop me from having panic attacks when I have to go on a job interview.

On the other hand if you are dealing with relationship issues I can see it.

[archipelago]

The reading I did was for a paper and was online in the library. There is not an online link to it unfortunately but the stats I quote are from it. It's by Lambert and Barley called "Research summary on the therapeutic relationship and psychotherapy outcome" (2001). There's lots of material out there on the importance of the therapeutic relationship and also on the kind I do, relational psychoanalysis. Just thought it might be interesting to people who wonder about their therapy, how much is approach related, how much is the actual connection, and if they have curiosities about whether or not to bring up issues when the approach doesn't seem to let it come up, this is evidence that is pretty clear that the relationship has a big effect so is worth considering.

[tealBumblebee]

I agree with you.

When I was first understanding how relationships worked, I was misguided (not intentionally) by a crisis counselor person who said my T was using "x" approach and then, after research, found out how "x" approach doesn't value the therapeutic relationship.

So of course I spazzed out on T, who told me that she wasn't a proponent of "x" approach and she went on to tell me that her approach (which I asked her not to tell me specifically what it is, so maybe its the same as yours) is heavily relationship based and that studies show that approaches that focus on the therapeutic relationship have greater success rates long term than those who don't.

Heck, she could even be basing it on the same study *shrug*

[FeelingOpaque]

It makes sense to me. I suppose a T's relationship for most is the first time they have a relationship where they can be vulnerable and safe, and hopefully won't be the only one.

[archipelago]

Even "techniques" that have not previously paid much attention to the therapeutic relationship but more on skills and such are starting to do research that shows that before any of that skills stuff can happen there has to be time for the the relationship.

I just feel lucky that I stumbled onto an approach that takes up the relationship and uses it sort of as a "technique." I find it really does work and I've heard others say the same.

[FeelingOpaque]

So what's it like being in that sort of relationship? How does it help you?

[sweepy62]

I believe that the therapeutic relationship to me is of upmost importance of course imo depending on your issues, and what your working on. Clients working on for example, csa, a strong relationship is required. My t uses different therapeutic models.

Originally Posted by Nerak67

It depends what you are in therapy for. For example, I do cbt for social anxiety. I do not believe that discussing my relationship with my therapist is going to stop me from having panic attacks when I have to go on a job interview.

On the other hand if you are dealing with relationship issues I can see it.

I agree with this. If relational and attachment issues are your need, this approach sounds great. I don't have those kinds of issues though (plenty of other issues), and the relationship with my T is never a topic of discussion. Not because we don't have a strong relationship, but it is just not an issue we need to discuss.

It's nice that there are so many types of therapy available to meet peoples' varied needs.

[Bentay]

I think the therapeutic relationship is very important but my T hasn't discussed this. I'm not too sure why, perhaps this is because I am receiving CBT for SA. Although having said that, I do believe some time should be given to discussing the relationship itself.

[archipelago]

While it does depend on what you are going in for and also who you are and what you want, I just wanted to show that there is evidence that supports the importance of the relationship regardless of approach, in case that was helpful.

[Lauliza]

Originally Posted by archipelago

While it does depend on what you are going in for and also who you are and what you want, I just wanted to show that there is evidence that supports the importance of the relationship regardless of approach, in case that was helpful.

For any type of T to be successful the client has to feel some connection with the therapist. So i think the relationship is crucial. That might mean something different to every person, but if there's no rapport, I don't see how it could be helpful at all. I've been to a few of ts in the past where I went for one session and never returned. I also saw one for a year or so and stopped going after it just seemed like a burden to me. I thought she was nice but that was it. No major connection so I didn't miss her at all. Given that, I still think the theoretical approach is important so in some (not all) cases the relationship shouldn't outweigh it.

[scorpiosis37]

Originally Posted by archipelago

The basics are that client factors make up 40% of the outcome, so that includes things like motivation, personality, etc. The placebo effect takes up about 15% of the outcome and this can mean just about anything. The technique or approach also takes up about 15%, which is pretty small actually considering how attached people are to the theoretical orientation. But the news is that the therapeutic relationship takes up about 30% of the outcome regardless of approach. That is twice the technique.

Just to point out to those who don't feel that they can use time to talk about the relationship itself. It is much much more important than the actual technique.

I just read the article and it seems that the authors are not singling out the therapeutic relationship itself but, rather, talking about the "facilitative conditions" of therapy which certainly include the therapeutic alliance, but also extend to the therapist's empathy, attunement to the client, and the congruence or fit between therapist and client. Even in therapies like CBT and DBT which do not focus on the therapeutic relationship, it's important for the T to be in tune with the client in order to understand what the client's issues are, where the client is at, what self-care strategies the client does and does not possess, when to push the client and when to give the client more assistance and so forth. In those instances, the client may have no need to discuss "the relationship," but the client will certainly make more progress if the T is attuned to the client, the T is addressing the correct issues with helpful strategies, and the T and the client are a good fit.

That seems different to me than therapy necessarily focusing on "the relationship." I'm certainly someone who needs that relationship in my own therapy. Like the OP, I'm in a type of therapy that focuses on that relationship. In fact, I'm in therapy because I grew up with neglect/abuse and never had a secure attachment. In order to heal from that, I need to go through the process of having a secure attachment with my T. I need that instead of things that others might need, like behavioral modification, mindfulness, self-coping skills, etc. I do fine with those things, but I need to learn how to heal, trust, and develop secure attachments in my relationships. On the other hand, I have friends who are in therapy and don't need the kind of T relationship that I do. They need an attuned and empathetic T, but what they struggle with are self-coping skills, destructive behaviors, bipolar episodes, etc. It's unnecessary for them to put time into contemplating or discussing the therapeutic relationship. The "fit" between client and T matters (they need a T with the right skill set), but "the relationship" is not a topic that needs to be analyzed. I tend to agree with Chris when she says that everyone who is in therapy needs something a little different, and it's great that there are so many different styles of therapy to accommodate those different needs. Sometimes, it also takes clients a few tries before they figure out which type of therapy works for them.

I also do not think that the percentage thing can be applied beyond the very specific examples and studies conducted in the article. It would be silly to say that, for any client in therapy, X percent of the outcome can be attributed to this factor, and X percent of the outcome to that factor. That's way too simplistic. In actual practice, those percentages would be different for each client. For me, the therapeutic relationship probably accounts for something like 80% of my progress (if I had to do something as arbitrary as attach a number to it). For my friend who also sees my T, the relationship probably accounts for somewhere around 10% of her progress. It's just not that important to her, or her mental health concerns. She's bipolar and in a volatile relationship, and she needs a T to help her learn how to calm herself down and not act-out or become destructive when she gets upset. Her therapy is focused on that. She does not feel any particular attachment to T; T is simply a tool to learn how to regulate her emotions and behaviors.

[stopdog]

There is also negative attachment.

[Bill3]

I agree with Sierra and Scorpiosis. Having a strong therapeutic alliance is quite different from making discussion of the therapeutic relationship a central part of therapy.

[Lauliza]

Originally Posted by Bill3

I agree with Sierra and Scorpiosis. Having a strong therapeutic alliance is quite different from making discussion of the therapeutic relationship a central part of therapy.

This is what I think I've been trying to say but couldn't articulate as well as you all. The relationship with my pdoc is part of our work together because I don't easily relate to men. With my female T our work centered around DBT & skill building. The two therapeutic experiences can't really be compared.

The relationship I had with my last T meant the world to me. I felt cared for and loved by him. It truly was a corrective emotional experience.

But as far as the research goes, I don't have much faith in psychotherapy research since it does not follow the "gold standard" of scientific research protocol-double-blind, controlled studies. It's also not uncommon to limit the study participants to those with one thing wrong with them (i.e., moderate depression) which is a sample that is certainly not representative of the population, who often show up in psychiatrists' offices with more than one disorder. Many participants are college students, who might be away from home for the first time. Students with an initial onset of depression might not have the same treatment needs as, for example, pre-menopausal women whose children recently left for college.

But don't you know it's really CBT that can cure everything now (modality; irrespective of relationship)? I know there are research limitations with every field, some more than others, but seriously, there is a newer trend to prescribe CBT to patients for pain in lieu of pharmaceutical pain relief. Insomnia. Fibromyalgia. Injuries. Chronic disease. Because of 'evidence' found through research, many (if not most) patients in the UK have no other option than CBT.

I'm in relational psychotherapy myself but many people have been harmed by relational therapy. I think the side effects of this type of therapy have been ignored or minimized. I'm not anti-CBT either but just want to express caution when interpreting evidence that research informs.

People with good relational skills are more likely to exceed in work, school, family...and yes, psychotherapy.

And what stopdog said.

Afterthought: I think modality does matter in many cases.