Therapeutic relationship

A therapeutic relationship involves a therapist and a client. The client provides information while the therapist listens, facilitates, and interprets the client's perceptions and feelings. The relationship is based on trust and confidentiality, so the therapist must maintain professional boundaries, including physical distance and limits on self-disclosure. The relationship is meant to be temporary, sometimes for only a few sessions, although in psychotherapy many clients remain with the same therapist for years.

Overview

Establishing a therapeutic relationship between a client and a provider can involve a delicate balance. The client must develop trust and the therapist must provide an open, safe place for the client even as they encourage frank communication. When individuals have experienced psychological trauma, such as post-traumatic stress disorder (PTSD), establishing safety and trust may be difficult. At the same time, therapists must maintain emotional distance to process the sometimes extensive issues of clients.

Therapists also must establish appropriate boundaries should clients wish to move outside of the professional relationship and into a friendship or romance. To maintain boundaries, they must be careful to avoid too much self-disclosure, especially regarding personal experiences, lest clients develop sympathetic feelings that might interfere with their therapeutic goals.

Working with a therapist, a client develops one or more goals to be met through treatment. Over the course of therapy, the professional gains perspective on the client's experiences, emotions, and circumstances not only through input from the client, but also by developing an understanding of their emotions and needs. Although it may be difficult, therapists must remain objective and refrain from solving problems for clients. It remains the responsibility of the client to make decisions and generate outcomes.

History

In the early days of psychotherapy, the professional was a physician who was called in to cure hysteria, the general term used for emotional disorders. Doctors such as Sigmund Freud were actively involved with the patient, asking questions and discussing symptoms as necessary. At the same time, they tried to remain neutral to allow patients to make their own discoveries. In time, Freud believed, the identity of the doctor meshed with those of important people in the patient's life—especially parents—through a process called transference. They believed continued therapy uncovered deep wounds and destructive emotions, leading to resolution of the client's problems.

The next important stage in therapy came with the humanistic approach of Carl Rogers in the 1940s. Rogers's idea was to give the client unconditional positive regard, which means viewing the client without judgment or criticism. He believed that acceptance would help clients develop higher self-esteem and self-respect while the therapeutic relationship remained the same. Rogers felt it was up to the client to reveal deep feelings and problems while the therapist listened and remained objective.

By the 1990s, therapy was influenced by feminist theory, which holds that the relationship between the client and therapist is the essence of treatment. Called relational therapy, the approach requires more empathy, personal involvement, and disclosure by the therapist. It also acknowledges that both parties can be affected by the therapeutic relationship. The method soon gained respect as an effective approach in treating PTSD. Researchers have found that symptoms of emotional detachment and helplessness improve when PTSD clients bond with therapists early in treatment.

Transference and Countertransference

Freud developed the concepts of transference and countertransference, theorizing that a person may transfer childhood urges, memories, or fantasies to their therapist or another person significant in the client's life. At one point, they connected transference with repressed desires during early sexual development in children. For example, if the therapist wore a bowtie, it might awaken the client's fantasies regarding a relative who wore such a tie. While Freud focused on the client's role, relational theorists believed that the therapist played an equal part in generating transference, which resulted in countertransference.

In countertransference, the therapist's own complexes, experiences, and emotions could potentially surface in the process of treating a client. If the client was experiencing a loss or personal struggle similar to one the therapist has recently experienced, the therapist needed to be mindful of their own emotions while treating the client. However, the ideas were never defined in a consistent way by later psychoanalysts. Subsequent scholars simplified the concepts to transference of unresolved emotions or attitudes from the past to present situations.

Ethics

Ethical treatment of clients is one of the biggest responsibilities of the client-therapist relationship, and all professional organizations for therapists establish standards of ethical behavior. For example, the ideals of the American Psychological Association include protecting clients' rights, upholding professional responsibilities, and maintaining honesty and integrity. The therapist's first rule is to do no harm.

Maintaining confidentiality is a staple of the therapeutic relationship and the ethical standards of the profession. Without the assurance of privacy, clients could not freely discuss their deepest fears and traumatic experiences. Any limits on confidentiality or potential gaps in security must be disclosed before the client gives informed consent. In general, a requirement that therapists break confidentiality typically stipulates that it must be done to protect others from harm (and in some cases to protect the clients themselves), particularly the more vulnerable members of society; in many cases, these exceptions fall under what is known as the therapist's "duty to warn."

Ethical therapists also avoid overlapping services, unless it is in the best interest of the client. More is not always better if the result is confusion on the part of the client, especially if the therapist's goal is financial gain. Additionally, close client-therapist relationships, especially those of a sexual nature, are always unethical. Ethics also preclude intimacy with close friends or relatives of the client and with former clients.

Bibliography

"Confidentiality and Its Exceptions." Society for the Advancement of Psychotherapy, 10 May 2015, societyforpsychotherapy.org/confidentiality-and-its-exceptions-the-case-of-duty-to-warn/. Accessed 6 Sept. 2024.

"Ethics." Fully Human Psychotherapy, www.fullyhuman.co.uk/ethics/. Accessed 6 Sept. 2024.

Joyce, Anthony S. "Transference." The Corsini Encyclopedia of Psychology. 4th ed., vol. 4, Wiley, 2010, pp. 1797–1800.

Kahn, Michael. "Why Study the Relationship?" Between Therapist and Client: The New Relationship. Holt, 1997.

Knapp, Herschel E. "Defining the Therapeutic Relationship." Therapeutic Communication: Developing Professional Skills. SAGE, 2015.

Macmillan, Malcolm. "Transference and Countertransference." Encyclopedia of Counseling, Vol. 2: Personal and Emotional Counseling. SAGE Publications, 2008, pp. 928–31.

Sullivan, Larry E. Ed. "Positive Regard." The SAGE Glossary of the Social and Behavioral Sciences. SAGE Reference, 2009, p. 394.