Reflections on a Counseling Relationship

 

Considering the significance of relationships in any interpersonal interaction is not exactly blog-worthy news; the importance of the relationship between a counselor and a client is no exception. Actually, there is quite a substantial literature on the subject, with numerous references to the role that the relationship plays in what is called the "common factors" related to effective psychotherapy. Going as far back as 1936, Saul Rosenzweig posited that there are "common factors" inherent in all psychotherapies. 

 

An interesting review of the "common factors" phenomenon is included in the 1995 article by Miller, Hubble, & Duncan entitled, "No More Bells and Whistles" (Miller, S. , Hubble, M. , & Duncan, B. [1995]. The Family Therapy Networker, 19, 52-63). In this article the authors suggest that the outcome of all therapy is influenced by 4 factors common to all effective psychotherapy: 1) Therapeutic Technique, e.g., CBT, Person-centered, etc. (accounts for 15% of outcome), 2) Expectancy and Placebo, e.g., client beliefs re the effectiveness of counseling, etc. (15%), 3) Therapeutic relationship of which "bedside manner" is a euphemistic way of referring to the practitioner's influence on the relationship (30%), and 4) Client Factors, e.g., access to treatment/means to pay for treatment, supportive family, social contacts, etc. (40%).

 

Although one can argue that practitioners have control over which therapeutic technique will be

employed, clearly, he or she has no control over 55% of the factors that affect therapy outcome - according to Miller, Hibble, & Duncan, "expectations/placebo" (15%) and "client factors" (40%) - meaning that the single biggest factor that affects the outcome of counseling/therapy over which the practitioner has significant if not complete control is the therapeutic relationship (30%). Although this may seem a minor factor (30%) affecting the outcome of services, it is nonetheless almost a full third of the outcome and, when considering that the relationship is a significant part of whether a client engages in services or not, it can definitely impact client expectations about therapy not to mention "client factors" like enhancing support networks and/or client willingness to establish/utilize such.

 

An unrelated but nonetheless tangential issue to the significance of the relationship in the outcome of therapy is the fact that the health care professional--of any type--least likely type of being sued is the practitioner who clients/patients report "liking," the corollary being, the most likely to be sued is the practitioner whom the client/patient does not like or sees as condescending, arrogant, patronizing, aloof, "cold, etc. See EXAMPLE 1, EXAMPLE 2. 

 

When discussing these points with students I would point out that establishing a warm, caring and empathic relationship with a client does not preclude addressing issues a client may not want to hear. As a matter of fact, a strong, positive relationship can enable the delivery of such feedback/information more

likely to be considered. I conducted an activity with my behavioral health counseling students to demonstrate: I would ask students to think of someone they hold in high regard...someone they trusted, respected, and recognized as a "good human being" and tell them this could be anyone living or deceased provided they had had a personal relationship. I would then ask, "Did this person always tell you what you wanted to hear?" - As I paused before my next question, I would see most head gesture negatively. Then I would ask, "did this person ever say or do something that upset you or made you angry? - This time when pausing I would see most students positively nodding their heads. Then, "did this person ever upset you so much that you did not talk to him or her for an hour or a day or a week or longer? Again, positive head nods. I would then ask, "why, then, was the first person that popped into your head when I asked you to think of someone you hold in high regard, trust, respect, and recognize as a good human being someone who did not always tell you what you wanted to hear, sometimes said or did things that upset you, and perhaps even to a point where you did not speak for an hour or day or longer?" I would then answer the question for them..."because this person was always truthful, honest, and treated you with respect, always letting you know that you were important and he or she would never do anything to hurt you purposefully. 

 

As important as a positive relationship with clients may be, it is also important for students to not mistakenly think that this means they must "be friends" with clients. They need to understand that developing a positive relationship is of paramount importance but that it does not equate with only telling clients what they will appreciate hearing.

 

What do you think?

Dr. Robert

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1Thomas, M. L. (2006). The Contributing Factors of Change in a Therapeutic Process. Contemporary Family Therapy: An International Journal, 28(2), 201–210