The Significance of the Clinical Relationship in Client Growth:
Which Came First, the Chicken or the Egg?
© Chapman 2003
We all know what we have learned and learned what we were taught – client and practitioner alike. Regardless of the issue/problem/pathology that brings the client to treatment, change for the client will not occur until and unless the client can first see that change is appropriate and second, believe that the treatment prescribed by the practitioner is an appropriate way to pursue that change. But practitioners have debated the most direct path to client change for decades—is it the relationship between the client and counselor or the prescribed treatment that results in personal growth for the client?
It goes without saying that a concrete course of treatment, grounded in empirically based research, is a necessary component of effective therapy. BUT the prescribed treatment/skill development/"whatever" will only work if the client is motivated to practice/engage in the treatment and the impetus for this engagement is more the result of an affective experience the client has in therapy than the logic of the prescribed course of treatment. By this I mean that the client will experience something of an awakening in therapy that translates into awareness that change is appropriate but also that a plan is required, namely the prescribed treatment.
As a visual person, allow me to proffer an example: My client is scared to death to ride a bicycle. She is 45 years old and never ridden a bike...scared to death, no way is she going to ride, end of story! However, she has just learned that her 6-year-old granddaughter's favorite pastime is riding a bike and the granddaughter is coming to spend a week with grandma while her parents go on a cruise. Grandma, my client, is really upset because she knows that bike riding will be a big part of the child's visit and my client is now in a quandary - I want to be with my granddaughter but I am scared to death of bicycles. We could start therapy to explore all the myriad reasons why my client is scared to death to ride the bike, but we both know that if grandma is going to resolve this dilemma and ride with her granddaughter, she is going to have to "get on a bike and learn how to ride."
If "learning to ride a bike" is the metaphorical evidenced based treatment for my client, I can present all the evidence in the world for this—and my client will likely agree intellectually because she is smart and knows I am an informed practitioner—but she is still not going to learn to ride the bike unless she gets on a bike. What will get her to engage in the prescribed treatment? I submit, her faith in me as a practitioner, yes, but more importantly her faith in me as a person. When the person-therapist "arcs" with the person-client, it is that person to person relationship that permits the "magic" of therapy to happen.
Again, I agree that just because I am "a great guy" and my client is comfortable seeing me in therapy and might even be willing to spend thousands of dollars to see me "for years" in analysis, the fact remains that she is not going to change until she "does something" to accomplish that change and that "something" needs to be grounded in research. BUT, I believe, as a Counselor Educator, that there is a greater chance that my client will ride the bike with her granddaughter if she trusts me and believes in me and, as a result comes to believe in herself and her ability to learn how to ride, even if I teach her nothing about bike riding, i.e., she teaches herself or asks her husband to teach her, than there is that she will ride if she is not comfortable with me as a person, but nonetheless exposed to the "premier" evidenced based therapy available today.
In short, therapy is more than "chatting" and it had better provide clients with a tangible result. But change is an inside job and the practitioner’s relationship with the client is arguably more important in facilitating that change than is the prescribed treatment. Stop and ask yourself from which of your professors have you learned the most...the ones who were the "smartest" or the ones who motivated you to learn? If the latter, this is what I mean by the primacy of relationship in therapy.
It would seem that if there is no major disagreement about the importance of delivering the twin objectives of therapy, namely evidence based treatment by a practitioner cognizant of the importance of the clinical relationship. If this is so, then arguing the primacy of the counseling relationship in effective counseling might be nothing more than ideological posturing. There is, however, another issue in the delivery of effective counseling that may be appropriate for consideration. Presbury, Echterling & McKee (2002) argue in Ideas and Tools for Brief Counseling that the seat of expertise on the self is the client and not the practitioner, "No matter how well informed you become about people and counseling in general, the individual client always remains the expert on his or her own experience" (p48). Consequently, "the most important aspect of successful counseling is the relationship" (p.49) if the counselor is going to engage the client in a course of treatment that results in change. O'Hanlon & Beadle (1994) suggest an approach to counseling respectful of this fact that they call, "Carl Rogers with a twist." This approach to delivering therapy does not discount the use of empirically based strategies but recognizes the implications of Roger's admonishment to acknowledge the importance of validating, listening, and understanding the client.
I realize that no one reading this will argue the importance of these practitioner attributes, but what is important is the question, "who is the expert" on the client's experience? Too often I sense that the practitioner is trained to view the client as somehow defective, not as a person, but as a psychological entity. It is as if we have trained counselors and therapists to view the client as a "good person" whose "psychic gyroscope" has malfunctioned and it is the practitioner's job to perform the necessary re-calibrations to set the client on the correct course. I am not sure that is how I want to be viewed by my client when I deliver counseling services.
"Roger's with a twist" is an approach to therapy that builds on the all but universally accepted micro-counseling skills of empathy, genuineness, congruence, etc. but adding three rather assertive if not directive practitioner tasks: "1) provide specific feedback on the client's complaint, 2) clearly ground the client’s complaint in the "past tense," and 3) replace the client's language of "stuckness" or despair with a language of possibility" (Presbury et al, 2002; p 51). All of this is "before" any empirically based approach to therapy has been suggested let alone implemented. Again, as I suggest above, this is not to suggest that the relationship in and of itself is the solution to the client's presenting problem, but to underscore its primacy as the vehicle of change.
There are many—perhaps most—clients for whom the path to therapy has been carved through the deepest, darkest forest of dysfunctional relationships and for these clients, improvement is not so much the result of what the empirically based therapist does "to" the client, but rather what is accomplished "with" the client. In other words it is not the assertiveness training or the REBT or the "whatever" treatment that results in improvement, but the client becoming "unstuck" and able to see the proverbial forest for the trees and recognize the way out that change presents. It is the relationship with the client that presents the practitioner with the opportunity to invite the client to consider the possibilities.
Yes, some will suggest that I am simply restating the argument for CBT and putting my own spin on it. As Beck argues, and I paraphrase, "all therapy is cognitive therapy because no one changes their behavior until they change their thinking." What I argue here, that is somewhat different than what many conventional psychologists might argue, is that the clinical relationship affords clients the opportunity to re-calibrate their own psychic gyroscopes. What if change in the present is more the result of client expectations of the future than determined by the perceived realities of the past? What if client improvement is not so much the result of new skills taught in therapy as the result of recognized possibilities in the future?
I believe that clients ARE the experts on their own experience and the clinical relationship permits them to discover that fact. Like the observant naturalist that sees the camouflaged creature by the woodland path, clients can be taught to recognize their own potential. I teach my students that they know they have arrived as an effective therapist when a client proceeds to outline a personal epiphany that is, in essence, a synopsis of the last several sessions AND the counselor agrees, feigning complete surprise and awe, and resists the temptation to say, "DUH, that's only what we have been discussing for the last several sessions! J
Counseling as a Continuum
As with most things in life, rare is the occasion when we encounter a construct that is truly "black or white." As Billy Joel opines in a cut from "River of Dreams," it's all "shades of gray." I like to look at this variance as representative of a continuum, the practice of counseling and therapy being no exception as we practitioners all exist on the continuum between the “art” and “science” of counseling and therapy.
Although I can probably argue that several continua exist in counseling and therapy with little objection from my readers, e.g., a "here-and-now” - “there-and-then" orientation, "directive - non-directive" approaches, etc., I wish to expand this essay on the primacy of the relationship in counseling as an explanation of the success—or lack there of—or clients engaged in treatment.
We all reside on this “art and science” continuum, to the practitioner, yet some of us gravitate more towards the "art" of delivering counseling & therapy, such as myself, while others, incline towards the "science." It is a mistake, however, to believe that anyone exists outside this continuum, although we can point to some of the more famous psychologists and argue that they have likely pitched their psychological tent pretty darned close to one pole or the other, Skinner being a particularly interesting case in point.
Many believe that Skinner was the consummate scientist regarding psychology. Some of these admirers go so far as to suggest that he eschewed the more phenomenological or metaphysical end of the continuum of psychology or as some might opine, towards the “philosophical." Skinner, however, never lost sight of the fact that psychology evolved out of philosophy and he never "eschewed" the more affective aspects of therapy. Rather he argued—effectively I might add—that the affective aspects of therapy are no less real or important than the more tangible, just impossible to measure and therefore operationally define. He therefore dedicated himself to the "science" of psychology and has become one of its more influential theoreticians, birthing both a theory of personality as well as a widely used approach to counseling.
It is this dedication to the science of “measuring the measurable” that is the genius of Skinner, but his use of the scientific method neither severs psychology's link with philosophy nor negates the importance of addressing the affective side of the human psyche as Bandura demonstrated in his theory of social learning.
Where am I going with this...because we can employ the scientific method to ascertain the effectiveness of a particular technique does not mean that a technique is ineffective until and unless it has been shown to be effective. Just as humans walked securely on the Earth before Newton postulated and then proved the existence of gravity, so do practitioners deliver effective therapy, perhaps not even realizing what it is they are doing that makes the difference. I will go out on a limb, albeit a limb on the “arts” end of the continuum, and suggest that one does not need to exclusively employ evidence based techniques in order to deliver effective treatment. With only about 20% of the world’s population employing the help of Western psychology, psychiatry, and professional counseling, 80% of the world seek out healers, shamans, elders, and other such “helpers” and improve as the result of their efforts. Although we are only now revisiting these alternative methods of healing in order to explore their utility according to Western science, the point remains that those who have sought the help of such practitioners have benefited from their actions. Yes, I recall the research that points out that approximately a third of subjects receiving a placebo treatment benefited from the experience, probably because they expected to be helped and were treated in such a way as to reinforce that expectation, but the point remains: A practitioner's affect may well spell the difference between the client that improves when exposed to “evidence based” treatment "X" when delivered by "practitioner A" while other clients, also exposed to the same treatment "X" delivered by someone else, do not fair as well.
Please do not misunderstand me. I am not suggesting that any charismatic practitioner can disregard the science and "just do what feels good" and expect to help a client. But science should be the servant of humanity not the other way round.
There is a wonderful quote by Paulo Friere: "If education is to be truly liberating, it must focus upon the existing situation of people, allowing them to reflect upon their condition and empowering them to change it" (http://www.isarastrology.com/schermer.html; 1994) I believe this can be said of counseling and therapy as well. The psychological scientist that worships at the alter of rational empiricism is likely to win the battle of delivering sound, evidence-based treatment, but lose the war raging inside the individual client that presents for treatment.
To illustrate my point, I would like to suggest something of an "informal experiment" that will at the least be “fun” and may be of some practical use. This is a classroom exercise developed by John Suler, a clinical psychologist and professor at Ryder University in NJ. This exercise is designed to demonstrate the power of the relationship and to document its ability to impact the affect on oneself and others. True, changing one's behavior in the moment is not the same as teaching the skills that result in the "quantum Change" William Miller speaks of, but there is a saying in AA that I have come to embrace having seen it work for 30 years, "fake it ‘till you make it."
To review Professor Suler's exercise, visit its outline on his web page: http://www.rider.edu/users/suler/happiness.html
After you review the experiment and perhaps conduct it yourself, revisit the point I make in this missive: Is it the treatment or the “treater” that motivates the change? But then again, like all things in life, this too is likely a continuum J
What do you think?
Presbury, Echterling & McKee (2002). "Ideas and tools for brief
counseling." Upper Saddle River, NJ:Merrill Prentice-Hall
O'Hanlon & Beadle (1994). "A field guide to possibility land: Possibility
therapy methods. Omaha, NE:Possibility Press.