Evidence-Based Relationships

Chapter Orientation

- Virtually all clinicians and researchers agree that successful counseling and psychotherapy outcomes are more likely if clinicians establish and maintain a positive working relationship with clients right from the beginning. In this chapter, we examine many different dimensions of what has come to be known as evidence-based relationships.

The Great Psychotherapy Debate

The medical model of psychotherapy that Wampold so meticulously deconstructs in The Great Psychotherapy Debate has led us to accept a view of clients as inert and passive objects on whom we operate and whom we medicate.

—Gene V. Glass, in The Great Psychotherapy Debate, 2001, p. 9

In a 1957 publication in the Journal of Consulting Psychology, Carl Rogers boldly declared:

1. No psychotherapy techniques or methods are needed to achieve psychotherapeutic change.

2. Diagnostic knowledge is “for the most part, a colossal waste of time” (1957, p. 102).

3. All that is necessary and sufficient for change to occur in psychotherapy is a certain type of relationship between psychotherapist and client.

These revolutionary statements refocused the profession. Until Rogers, therapy was primarily about theoretically based methods, techniques, and interventions.

Learning Objectives

After reading this chapter, you will be able to:

• Describe the great psychotherapy debate as a context for the development of “evidence-based therapy relationships”

- List and apply evidence-based relationship factors based on Carl Rogers's core conditions of congruence, unconditional positive regard, and accurate empathy

- List and apply evidence-based relationship factors derived from other theoretical foundations (for example, psychoanalytic, behavioral, feminist)

• Describe how the evidence-based relationship factors apply to clients with diverse cultural orientations

Video 7.1

After Rogers, writers and practitioners began debating the possibility that it might be the relationship between client and therapist—not the methods and techniques employed—that produce positive changes.

This debate continues and has been referred to as “the great psychotherapy debate”. It can be boiled down to a dichotomy captured by the question “Do treatments cure disorders or do relationships heal people?”.

Supporters of the psychotherapy-as-relationship position have written of manualized technical procedures as the “rape” of psychotherapy, while those who believe psychotherapy should only involve empirically validated procedures lament practitioners who ignore important empirical research. The empirically oriented group promotes new terminology (that is, “psychological clinical scientists”) to distinguish clinicians who base their interventions on science from other clinicians. This heated controversy continues, in part, because we live in a world with limited health care dollars. Clearly, the fight to determine which therapies are “valid” and, therefore, reimbursable will continue.

In this chapter, we focus on an early version of the controversy that's no longer controversial. Over the past two decades, research has settled at least one dimension of the argument: Positive psychotherapy relationships contribute to positive outcomes across all therapies and settings. The question is no longer whether psychotherapy relationships matter, but how much they matter. To bring this point home, the psychotherapy-as-relationship proponents now refer to these relationship factors as “evidence-based therapy relationships” (Norcross & Lambert, 2011).

Carl Rogers's Core Conditions

Carl Rogers (1942) believed that three core conditions were necessary and sufficient to produce change in psychotherapy: (a) congruence, (b) unconditional positive regard, and (c) empathic understanding. In his words:

Thus, the relationship which I have found helpful is characterized by a sort of transparency on my part, in which my real feelings are evident; by an acceptance of this other person as a separate person with value in his own right; and by a deep empathic understanding which enables me to see his private world through his eyes. When these conditions are achieved, I become a companion to my client, accompanying him in the frightening search for himself, which he now feels free to undertake.

Congruence

Congruence means that a person's thoughts, feelings, and behaviors match. As Rogers (1957) emphasized, congruence is less a skill and more an experience.

Congruence is complex. It has been described as “abstract and elusive”. The ability to be congruent includes an internal dimension that involves clinicians being in touch with their inner feelings or real self, and an external or expressive dimension that allows them to articulate their internal experiences in ways clients can understand. Congruent therapists are authentic and comfortable with themselves. Congruence can include spontaneity and honesty; it's usually associated with the clinical skill of immediacy and involves limited self-disclosure (see Chapters 5 and 6). The following excerpt from Rogers's work illustrates these internal and external dimensions of experiencing and expressing congruence:

We tend to express the outer edges of our feelings. That leaves us protected and makes the other person unsafe. We say, “This and this (which you did) hurt me.” We do not say, “This and this weakness of mine made me be hurt when you did this and this.”

To find this inward edge of my feelings, I need only ask myself, “Why?” When I find myself bored, angry, tense, hurt, at a loss, or worried, I ask myself, “Why?” Then, instead of “You bore me,” or “this makes me mad,” I find the “why” in me which makes it so. That is always more personal and positive, and much safer to express. Instead of “You bore me,” I find, “I want to hear more personally from you,” or, “You tell me what happened, but I want to hear also what it all meant to you.” (1967, pages 390 to 391)

Rogers also emphasized that congruent expression is important even when the attitudes, thoughts, or feelings don't, on the surface, appear conducive to a good relationship. He suggested that it's acceptable—and even growth promoting—to speak about things that are difficult to talk about. However, as you can see from the preceding excerpt, Rogers expected therapists to look inward and transform their negative feelings into positive and constructive expressions of congruence.

The Evidence Base for Congruence

In a meta-analysis, Kolden and colleagues analyzed 16 research studies and 863 participants. Most of the research was conducted prior to 1990. Overall, they reported an effect size (ES) of 0.24. Using standards, 0.24 is considered a medium ES; it indicates that, for the studies reviewed, congruence accounted for about 6% of treatment variance.

Kolden et al. (2011) also included analyses based on disaggregation of the data. Studies described as client centered, interpersonal, or eclectic had significantly higher ES (r = 0.36) than studies described as psychodynamic (r = 0.04). Further, results varied as a function of therapy setting. The researchers reported the following effect sizes:

School counseling centers: ES = 0.43

Inpatient settings: ES = 0.27

• Mixed settings: ES = 0.23

• Outpatient mental health settings: ES = -0.02

In conclusion, a small but significant evidence base supports the positive influence of congruence during clinical interviews. In addition, there's robust theoretical and anecdotal support for congruence or authenticity as facilitative of helping relationships. Given the importance of congruence, we now turn to how to apply this"abstract and elusive" concept in clinical interviews.

Guidelines for Using Congruence

Students often have questions about how congruence sounds and looks in a clinical interview. Common questions (and brief answers) follow:

• Does congruence mean I say what I'm really thinking in the session?

Usually not. Your thoughts may mean something important and may warrant being shared at some point, but initial spontaneous thoughts and reactions to clients should stimulate personal reflection, not immediate disclosure.

What if I dislike something a client says or does? Am I being incongruent if I don't express my dislike?

No. If you have an aversion to something your client says or does, reflect on it, rather than reacting with judgment. As Rogers (1967) recommended, if you have a negative reaction, try to think about it as your issue, instead of blaming the client. For example, if you feel put off in response to a client's anger, you can focus on your discomfort with the anger and say something like,"When you're so angry I want to retreat, but I also realize that I want to hear more about the feelings under your anger."

• If I feel sexually attracted to a client, should I be “congruent” and share my feelings?

Absolutely not. As discussed in Chapter 2, you should never share feelings of sexual attraction with clients. Doing so is manipulative and unethical. Deal with your sexual issues and attractions in supervision and on your own time.

One general guideline for determining when and how to be transparent or congruent is to ask, Would the disclosure help facilitate my client's work? Making this decision involves relying on your clinical judgment—which is difficult for everyone, but especially for new clinicians. Too much self-disclosure—even in the service of congruence or authenticity—can muddy the assessment or therapeutic focus. The key is to maintain balance; self-disclosure in the service of congruence should be limited, purposeful, and based on solid theoretical foundations.

Rogers (1957) was wary about excessive self-disclosure:

Certainly the aim is not for the therapist to express or talk about his own feelings, but primarily that he should not be deceiving the client as to himself. At times he may need to talk about some of his own feelings (either to the client, or to a colleague or supervisor) if they are standing in the way. (p. 98)

Imagine that you're working with a client and you feel the impulse to self-disclose in the spirit of being congruent. If you're not confident that your comment will be facilitative or will keep the focus on the client, then you shouldn't disclose. Given the challenges inherent in deciding how to be congruent, you should discuss struggles with self-disclosure with peers or supervisors. This can deepen your understanding of how to be therapeutically congruent.

On the basis of recommendations from the literature and our own clinical experiences, we offer the following guidelines for self-disclosures:

- Examine your motives for the self-disclosure you have in mind. Is it more about you or more about your client?

- Ask yourself whether the disclosure is likely to be facilitative.

Ask yourself whether the comment will keep the focus on the client or will distract from the client's process and issues.

• Consider the possibility of a negative reaction. Could your client respond in a negative or unpredictable manner?

Remember, congruence doesn't mean you say whatever comes to mind; it means that when you do speak, you do so with honesty and integrity.

Case Example 7.1: Congruence Across Cultures

Cultural identity has many dimensions. In this example, during an initial clinical interview with an African American male teenager, the clinician uses congruence across several different cultural domains.

Client: This is stupid. What do you know about me and my life?

Clinician: I think you're saying that we're very different, and I totally agree. As you can probably guess, I've never been in a gang or lived in a neighborhood like yours. And you can see that I'm not a Black teenager, and so I don't know much about you and what your life is like. But I'd like to know. And I'd like to be of help to you in some way during our time together.

This clinician is being open and congruent and speaking about obvious differences that might interfere with the clinician-client relationship. It would be nice to claim that being open like this always improves clinician-client connection, but nothing always works. However, as researchers have reported, congruence tends to facilitate improved treatment process and also contributes to positive outcomes, at least in small ways.

Unconditional Positive Regard

Rogers (1961) defined unconditional positive regard as follows:

To the extent that the therapist finds himself experiencing a warm acceptance of each aspect of the client's experience ... he is experiencing unconditional positive regard ... it means there are no conditions of acceptance, no feeling of "I like you only if you are thus and so." It means a "prizing" of the person, as Dewey has used that term. .. It means a caring for the client as a separate person. (p. 98)

Unconditional positive regard implies that clients are the best authority on their own experiences. Therapist judgments are always based on inadequate information; we haven't lived with our clients, we haven't been with them long, and we can't directly know their internal motives, thoughts, or feelings.

For Rogers, unconditional positive regard was based on an underlying belief that consistent warmth, acceptance, and prizing of clients facilitated clients' growth toward their potential. He stated, "the safety of being liked and prized as a person seems a highly important element in a helping relationship" (1961, p. 34). Positive, accepting feelings toward clients allow clients to feel safe enough to explore self-doubts, insecurities, and weaknesses. That idea not only jibes with common sense but also has research support.

The Evidence Base for Unconditional Positive Regard

- conducted a meta-analysis of 18 treatment outcome studies involving 1,067 clients. These studies all included measures of unconditional positive regard. Their overall finding was an aggregate ES of 0.27 across all 18 studies. This indicates a medium positive effect, with unconditional positive regard accounting for about 7% of treatment outcomes.

The results also showed a weak, but statistically significant, tendency for studies with greater numbers of racially diverse clients to have more positive outcomes. Farber and Doolin (2011) speculated:

We tentatively hypothesize that therapists' provision of positive regard may be a salient factor in treatment outcome when non-minority therapists work with minority clients. In such cases, the possibility of mistrust and of related difficulties... may be attenuated by clear indications of the therapist's positive regard, in turn facilitating the likelihood of a positive outcome. (p. 182)

This interpretation of the findings is consistent with multicultural theory and practice. When working with minority clients, it's especially crucial to show unwavering positive regard.

How to Communicate Unconditional Positive Regard

Technically, according to Rogers (1957), unconditional positive regard is an experience and not a skill. As noted earlier, he wrote:"To the extent that the therapist finds himself or herself experiencing a warm acceptance of each aspect of the client's experience... he is experiencing unconditional positive regard" (p. 98). Nevertheless, it's useful to discuss how unconditional positive regard might look during interactions between therapist and client. A question our students frequently ask is"How can I express or demonstrate unconditional positive regard?"

It's tempting to try expressing positive feelings directly to clients through hugs or pats on the back, or with such statements as"I like or love you,""I care about you,""I will accept you unconditionally," or"I won't judge you in here." However, expressing unconditional positive regard directly to clients can backfire. Direct expressions of caring may be interpreted as phony or inappropriately intimate and may violate ethical boundaries by implying you want a friendship or loving relationship. Also, as a human being, you will sooner or later have negative feelings toward your clients; if you explicitly claim"unconditional acceptance," you're promising the impossible.

If it's not appropriate to communicate unconditional positive regard directly, then how might you express positive regard, acceptance, and respect to clients indirectly? Here are several general principles, followed by examples:

1. You arrive on time, ask your clients how they like to be addressed (and then remember to address them that way), listen sensitively, show compassion, and carefully guard the time boundaries around appointments.

How would you like me to address you? Do you prefer Mrs., Ms., or something else?

2. You allow clients freedom to talk about themselves in their natural manner.

I have information about you from your physician. She said you're experiencing anxiety, but I'd like to hear from you what that anxiety has been like.

3. By remembering your clients' stories, you communicate interest and a valuing of what they're telling you.

- Earlier today you mentioned wishing your roommate respected you. And now I hear you saying again that you find her behavior disrespectful.

4. When you respond with compassion or empathy to clients' emotional pain without judging the content of that pain, clients can feel accepted.

- The loss of your job really has you shaken up right now. You're feeling lost about what to do next.

5. Because clients are sensitive to your judgments and opinions, by simply making a sincere effort to accept and respect your clients, you're communicating a message that may be more powerful than any other therapy technique.

- I know you're saying I can't understand what you've been through, and you're right about that. But I'd like to try to understand, and hear as much about your trauma as you're willing to share.

6. Although direct expression of unconditional positive regard is ill-advised, research suggests that direct expressions of encouragement and affirmation for specific behaviors can have a positive effect.

- “I didn't see you as submissive or weak. In fact, since showing emotion is so difficult for you, I saw it as quite the opposite.” (Farber & Doolin, p. 173)

- I have confidence in your ability to do this.

• Thank you for sharing so much about yourself with me.

7. Use the concept and technique of radical acceptance from Linehan's (1993) work (see Chapter 12 for examples).

Even Rogers (1957) recognized that therapists can't constantly experience unconditional positive regard. He referred to the phrase as"an unfortunate one" (p. 98), noting that it was more accurate to say that therapists intermittently experience unconditional positive regard. He also emphasized that therapists sometimes experience conditional positive regard, or even negative regard for their clients—although when therapists feel negative regard, it's likely to be associated with ineffective therapy. Rogers's core message is that clinicians should strive toward experiencing unconditional positive regard, recognizing that it's impossible to constantly feel accepting toward your clients.

Case Example 7.2: Intermittent Unconditional Positive Regard and Parallel Process

Abby is a 26-year-old graduate student. She identifies as a White heterosexual female. After an initial clinical interview with Jorge, a 35-year-old who identifies as a male heterosexual Latino, she meets with her supervisor.

During the meeting, she expresses frustration about her judgmental feelings toward Jorge. She tells her supervisor that Jorge sees everyone as against him. He's extremely angry at his ex-wife, and he's returning to college following his divorce and believes his poor grades are due to racial discrimination. Abby tells her supervisor that she just doesn't get Jorge. She thinks she should refer him instead of having a second session.

Abby's supervisor listens empathically and is accepting of Abby's concerns and frustrations. The supervisor shares a brief story of a case where she had difficulty experiencing positive regard toward a client who had a disability. Then she asks Abby to put herself in Jorge's shoes and imagine what it would be like to return to college as a 35-year-old Latino man. She has Abby imagine what might be "under" Jorge's palpable anger toward his ex-wife. The supervisor also tells Abby, "When you have a client who views everyone as against him, it's all the more important for you to make an authentic effort to be with him."

At the end of supervision, Abby agrees to meet with Jorge for a second session and to try to explore and understand his perspectives on a deeper level. During their next supervision session, Abby reports great progress at experiencing intermittent unconditional positive regard for Jorge and is enthusiastic about working with him in the future.

One way to enhance your ability to experience unconditional positive regard is to have a supervisor who accepts your frustrations and intermittent judgmentalness. If the issues that arise in therapy are similar (or parallel) to the issues that arise in supervision, it's referred to as parallel process. This is one reason why when you get a dose of unconditional positive regard in supervision, it may help you pass it on to your client.

Empathic Understanding

Rogers (1980) defined empathy as

the therapist's sensitive ability and willingness to understand the client's thoughts, feelings, and struggles from the client's point of view. It is this ability to see completely through the client's eyes, to adopt his frame of reference [p. 85]... It means entering the private perceptual world of the other... being sensitive, moment by moment, to the changing felt meanings which flow in this other person... It means sensing meanings of which he or she is scarcely aware. (p. 142)

Rogers's definition of empathy consists of several components.

Therapist ability or skill

Therapist attitude or willingness

• A focus on the client's thoughts, feelings, and struggles

Adopting the client's frame of reference or perspective

• Entering the client's private perceptual world

Moment-to-moment sensitivity to felt meanings

• Sensing meanings of which the client is barely aware

As with congruence and unconditional positive regard, the complexity of Rogers's definition has made research on empathy challenging. Nevertheless, there's a substantial body of empirical research supporting the positive effects of empathy.

The Evidence Base for Empathy

In a meta-analysis of 47 studies including over 3,000 clients, Greenberg, Watson, Elliot, and Bohart (2001) reported a correlation of.32 between empathy and treatment outcome. Although this isn't a large correlation, they noted that “empathy... accounted for almost 10% of outcome variance,” and “Overall, empathy accounts for as much and probably more outcome variance than does specific intervention” (p. 381).

Elliot, Bohart, Watson, & Greenberg (2011) conducted a more recent meta-analysis. This sample included 57 studies with 3,599 clients and “224 separate tests of the empathy-outcome association” (p. 139). They concluded (based on a weighted r of 0.30) that empathy accounts for about 9% of outcomes variance.

- On the basis of their meta-analysis and an analysis of various theoretical propositions, Greenberg et al. (2001) identified five ways in which empathy contributes to positive treatment outcomes:

1. Empathy improves the therapeutic relationship. When clients feel understood, they're more likely to stay in therapy and be satisfied with their therapist.

2. Empathy contributes to a corrective emotional experience. When clients expect emotionally painful interactions in therapy, but instead experience acceptance and understanding, a corrective emotional experience can occur.

3. Empathy facilitates client verbal, emotional, and intellectual self-exploration and insight. Rogers (1961) articulated this:"It is only as I see them (your feelings and thoughts) as you see them, and accept them and you, that you feel really free to explore all the hidden nooks and frightening crannies of your inner and often buried experience" (p. 34).

4. Empathy moves clients in the direction of self-healing. When clients have a deeper understanding of themselves, they can take the lead in their personal change process.

5. Empathy is strongly linked to positive treatment outcomes. Some authors have suggested that empathy is the basis for all effective therapeutic interventions: “Because empathy is the basis for understanding, one can conclude that there is no effective intervention without empathy and all effective interventions have to be empathic”.

A Deeper Look at Empathy

There are many different definitions of empathy. According to Elliott et al. (2011), recent advances in neuroscience suggest that empathy consists of three core subprocesses:

1. Emotional stimulation: This happens when one person experientially mirrors another's emotions. Think of when you "tear up" in response to hearing another person in emotional pain. Emotional stimulation involves mirror neurons, structures within the limbic system, neurochemicals, and other factors (for example, bilateral dorsomedial thalamus, insula, and oxytocin).

2. Perspective taking: This happens when you try to “see” the world from another person's perspective. It requires intellectual inference. Perspective taking is considered a cognitive or intellectual foundation for empathy and appears to involve the prefrontal and temporal cortices.

3. Emotion regulation: Therapists must cope with and process their own emotions and then provide an empathic response. This process involves reappraisal and soothing of your own emotional reactions. It's a springboard for a helping response.

The most common technical responses during this process include reflection of feeling or feeling validation, but nearly every potential interviewing behavior can include verbal and non-verbal components that include empathy. Emotional regulation may involve the orbitofrontal cortex and prefrontal and right inferior parietal cortices.

Empathy is a multidimensional interpersonal process that requires experiencing, inference, and action. However, as with all neuroscience models, it's likely that any single dimension of empathic responding involves more of the whole brain than the specific regions identified. For example, if you're empathically attuned to your client and experience emotional stimulation, you might simultaneously notice multiple physical reactions (for example, your breathing slows, tears well up, your eyes shift downward).

This awareness could trigger a cognitive reflective process (for example, "What's going on with me?"), judgment ("I'm feeling too much and need to pull back emotionally"), and distress. It's also not unusual for clients' emotional state to trigger your memories. This could include hippocampal activation and associated cognitive (frontal lobe), physical (motor cortex), and visual (occipital lobe) dimensions linked to your experience.

Simple guides to experiencing and expressing empathy can strengthen empathic abilities, but there's no single strategy to help you develop the complete array of skills associated with the whole empathy package. For example, Carkhuff (1987) referred to the intellectual or perspective-taking part of empathy as"asking the empathy question" (p. 100). He wrote:

By answering the empathy question we try to understand the feelings expressed by our helpee. We summarize the clues to the helpee's feelings and then answer the question, How would I feel if I were Tom and saying these things? (p. 101)

Carkhuff's empathy question is a useful tool for tuning into client feelings, but it oversimplifies the empathic process. First, it assumes that you have a perfectly calibrated internal affective barometer. Unfortunately, this isn't the case.

Just because you would feel a particular way if you were in the client's shoes doesn't mean the client feels as you would. If you rely exclusively on Carkhuff's empathy question, you risk projecting your own feelings onto clients.

Consider what might happen if a therapist tends toward pessimism, whereas her client usually puts on a happy face. The following exchange might occur:

Client: I don't know why my dad wants us to come to therapy now and talk to each other. We've never been able to communicate. It doesn't even bother me anymore. I've accepted it. I wish he would accept it too.

Therapist: It must make you angry to have a father who can't communicate effectively with you.

Client: Not really. Like I said, it doesn't bother me. I'm letting go of my relationships with my parents.

In this case, asking the empathy question “How would I feel if I could never communicate well with my father?” may produce angry feelings in the therapist. This process consequently results in the therapist projecting angry feelings onto the client, even if the client isn't angry. Accurate empathic responding stays close to client word content and nonverbal messages.

If this client had previously expressed anger or was looking upset or angry (for example, angry facial expression, raised voice), the therapist might choose to reflect anger. Instead, the therapist's comment is inaccurate and rejected by the client. The therapist could have stayed closer to what her client expressed by focusing on key words.

Coming into therapy now doesn't make much sense to you. Maybe you used to have feelings about your lack of communication with your dad, but it sounds like at this point you feel pretty numb about the whole situation and just want to move on.

This second response is more accurate. It touches on how the client felt before, what she presently thinks, and the numbed affective response. The client may well have unresolved sadness, anger, or disappointment, but for the therapist to connect with these buried feelings involves a more interpretive intervention. Recall from Chapter 5 that interpretations and interpretive reflections of feeling require supporting evidence.

To help with the intellectual process of perspective taking, instead of focusing exclusively on what you'd feel if you were in your client's shoes, you can expand your repertoire in at least three ways:

1. Reflect on how other clients have felt or might feel.

2. Reflect on what your friends or family might feel and think in response to this particular experience.

3. Read and study about experiences similar to your clients.

Using Rogers's writings as his rationale, A. Clark (2010) referred to intellectual approaches to expanding your empathic understanding as objective empathy. Objective empathy involves using “theoretically informed observational data and reputable sources in the service of understanding a client” (p. 349). Objective empathy is based on the application of external knowledge to the empathic process—this can expand your empathic responding beyond your own personal experiences.

Rogers (1961) also emphasized that reflections of feeling should be stated tentatively so that clients can freely accept or dismiss them. Elliot et al. (2011) articulated the tentative quality of empathy: “Empathy should always be offered with humility and held lightly, ready to be corrected” (p. 147).

A second way in which empathy question is simplistic is that it treats empathy as if it had to do only with accurately reflecting client feelings. Although accurate feeling reflection is an important part of empathy, empathy also involves thinking and experiencing with clients. Rogers's use of empathy with clients frequently focused less on emotions and more on meaning. Recall that in his original definition, Rogers wrote that empathy involved"being sensitive, moment by moment, to the changing felt meanings which flow in this other person" (p. 142). Empathic understanding isn't simple: it involves feeling with the client, thinking with the client, sensing felt meanings, and reflecting all this and more back to the client with a humility that acknowledges deep respect for the validity of the client's experiences.

Misguided Empathic Attempts

Sometimes you can try too hard to express empathy, completely miss your client's emotional point, or otherwise stumble in your empathic efforts. Classic statements that beginning therapists often use, but should avoid, include the following (J. Sommers-Flanagan & Sommers-Flanagan, 1989):

1. “I know how you feel” or “I understand.”

Clients may respond with: “No. You don't understand how I feel,” and they would be absolutely correct. “I understand” is a condescending response that should be avoided. However, saying “I want to understand” or “I'm trying to understand” is acceptable.

2. “I've been through the same type of thing.”

Clients may respond with skepticism or ask you to elaborate on your experience. Suddenly the roles are reversed: The interviewer is being interviewed.

3. “Oh my God, that must have been terrible.”

Clients who have experienced trauma are sometimes uncertain about how traumatic their experiences really were. You need to monitor whether you're leading or tracking the client's emotional experience. If clients give you an indication that they feel "terrible" about their experience, reflecting that the experience "must have been terrible" is empathic. Even then, a better empathic response would remove the judgment of "must have" and get rid of the "Oh my God" and say something like, "Sounds like you feel terrible about what happened."

Case Example 7.3: What and How to Validate: Empathic Responding to Trauma and Abuse

Empathy often includes emotional validation. But sometimes clients have ambivalent feelings about their own experiences, which makes the validation process more complex. This is especially true when trauma or abuse survivors experience victim guilt—feeling as though they caused their own trauma.

Therapist: Can you think of a time when you felt unfairly treated? Perhaps punished when you didn't deserve it?

Client: No, not really. (15-second pause) Well, I guess there was one time. I was supposed to clean the house for my mother while she was gone. It wasn't done when she got back, and so she broke a broom over my back.

Therapist: She broke a broom over your back? (stated with a slight inflection, indicating possible disapproval or surprise with the mother's behavior)

Client: Yeah. I probably deserved it, though. The house wasn't cleaned like she had asked.

In this situation, the client expressed mixed feelings about her mother. Although her mother was violent, the client felt guilty for not following her mother's directions. The therapist tried a nuanced empathic response using voice tone and inflection.

This was used because focusing too strongly on the client's pain or anger might prematurely shut down exploration of her guilty feelings. Despite the minimal empathic expression, the client defended her mother's physical abuse anyway. This suggests that the client had accepted (by age 11, and still accepted at age 42) her mother's negative evaluation of her. From a person-centered or psychoanalytic perspective, a supportive statement like "That's just abuse; mothers should never break brooms over their daughters' backs" may have closed off exploration of the client's victim guilt about the incident.

(Continued)

Alternatively, this is a situation in which gentle, open, and empathic questioning might deepen the therapist's understanding of the client's unique experience and help her explore other feelings, such as anger. For example, the therapist could ask:

I hear you saying that maybe you deserved to be hit by your mother in that situation, but I also wonder what other feelings you might have?

Or the therapist might use a third-person question to help the client have empathy for herself:

What if you had a friend who experienced something like what you experienced? What would you say to your friend?

In the first version of this interaction, the therapist used a nondirective model. He didn't openly criticize the mother's violence. Do you think he might have been too nondirective? Perhaps the client might have been able to explore her anger toward her mother if the therapist had led her in that direction with an empathic self-disclosure?

When I imagine myself in your situation, I can feel the guilt, but also, a part of me feels angry that my mother would care so much about housecleaning and so little about me.

This self-disclosure is empathic and leading. Do you think it's too leading? Or do you think it's a better response than the neutrality often emphasized in psychoanalytic therapies?

Concluding Thoughts on Empathy

Empathy is a vastly important, powerful, and complex interpersonal phenomenon. People can simultaneously express conflicting meanings and emotions. Rogers believed that experiencing empathy decreased his interest in judging clients and put inhibitions around his congruence. Empathy, unconditional positive regard, and congruence are not competing individual constructs; they complement and influence one another.

Greenberg et al. (2001) discussed the challenges of being empathic:

Certain fragile clients may find expressions of empathy too intrusive, while highly resistant clients may find empathy too directive; still other clients may find an empathic focus on feelings too foreign. Therapists therefore need to know when—and when not—to respond empathetically. Therapists need to continually engage in process diagnoses to determine when and how to communicate empathic understanding and at what level to focus their empathic responses from one moment to the next. (p. 383)

The preceding description of constantly attuning your empathic responding to individual clients sounds formidable ... and it should. When we add cultural diversity to the empathic mix, the task becomes even more daunting. Nevertheless, we encourage you to embrace the challenge with hope, optimism, and patience. As discussed in Chapter 4, sitting with people as they struggle to express their emotional pain and suffering contributes to your own empathic neurological development.

Other Evidence-Based Relationship Concepts

The following theoretically and empirically supported relationship factors are derived from a variety of theoretical perspectives. We begin with relational concepts linked to psychodynamic treatment approaches.

Transference

Freud (1949) defined transference as a process that occurs when “the patient sees in his analyst the return—the reincarnation—of some important figure out of his childhood or past, and consequently transfers on to him feelings and reactions that undoubtedly applied to this model” (p. 66). Transference is especially important in psychoanalytic and interpersonal therapy because a major goal is to help clients gain awareness of repeating maladaptive relationship patterns. By gaining greater awareness or insight into repeating relationship patterns, clients can begin changing those patterns. Awareness or insight is viewed as a prerequisite to change.

Transference generally feels inappropriate, such as when a client responds to you with actions, thoughts, or feelings that are too intense, too extreme, and too capricious, and that are held on to with tenacity. Transference “exceeds anything that could be justified on sensible or rational grounds”. Sometimes, but not always, intense and obvious transference can surface early in an interview. For example, an angry young man had a negative reaction to his female counselor and became verbally aggressive during an initial screening interview. He repeatedly stated,

You f--ing women can't understand where I'm coming from. No way. Women just don't get me. You don't get me.

Because the counselor's behavior hadn't warranted a strong reaction, it's likely this client was displacing"feelings, attitudes, and behaviors" based on previous interactions he had experienced with important females in his life.

The Evidence Base for Transference

Researchers have reported that transference reactions during sessions can be reliably and validly measured. There's also evidence that measures of transference (for example, the core conflictual relationship theme, or C.C.R.T) in therapy can identify patterns that are highly similar to contemporary relationship patterns observed outside therapy. Finally, researchers have reported that working directly with transference using psychoanalytic models can produce positive treatment outcomes. For example, in a meta-analysis of 10 studies focusing on long-term psychoanalytic treatment, an ES of 0.78 was reported. As a comparator, a meta-analysis of medications for major depression produced an ES of 0.31.

These findings have implications for the beginning clinical interview. It's possible that during initial and follow-up interviews, clients will display behaviors representing transference. Although dealing with these behaviors, thearctically requires extensive training, you may want to explore with your supervisor the possibility of using trial interpretations with clients (see Chapter 5 for guidelines for trial interpretations).

Examples of Transference

Transference is often abstract, vague, and elusive. Clients may subtly react in ways that are more emotional than the situation warrants, they may make assumptions about you that have little basis in reality, or they may express unfounded and unrealistic expectations regarding you or therapy.

One common example of transference occurs when clients expect you to judge them negatively. For example, a client expressed anxiety regarding her psychological testing performance and her out-of-session homework. She stated tentatively,

Um . . . you know, I think some things that personality test says about me don't seem accurate. I must have done something wrong when I took the test.

This comment is revealing. Usually when clients get inaccurate psychological test feedback, they question the test's validity, rather than their own performance. In a similarly tentative way, she later stated, "I did the assignment, but I'm not sure I had the right idea." She made this statement despite the fact that she had done exactly as instructed. Her self-doubt was triggered because she viewed her therapist as an authority figure who might evaluate her negatively.

Her expectation of criticism suggested that she may have experienced harsh criticism in the past. In this sense, her reaction is - similar to that of a child who flinches when approached by an adult whose arm is extended. The child may flinch because of previous physical abuse; the flinch may be an automatic and unconscious response. Similarly, clients who have been exposed to excessive criticism may have automatic and unconscious tendencies to prepare themselves (or flinch) when exposed to evaluative situations. This is an example of transference.

Transference may manifest itself in positive (for example, affectionate, liking, loving) or negative (hostile, rejecting, cold) attitudes, feelings, or behaviors. Working through either form of transference as therapy progresses can be productive. However, during an initial clinical interview, the wisest course is for you to be an astute observer, noticing patterns of client responses that seem inappropriate and may stem from past relationships in the client's life. Commenting on these patterns can wait for later (see the section on interpretation in Chapter 5).

Noticing and Exploring Transference

Working with client transference requires advanced skills and firm theoretical grounding. However, the following four principles and practices can be your first steps in noticing and exploring client transference:

1. Be aware of the possibility that repeating transference reactions may occur during an interview.

2. Notice repeating patterns internally and then if a pattern becomes clear, notice it with an explicit comment that acknowledges your subjectivity and is stated tentatively:

I could be wrong, but I've noticed you seem to get angry when we talk about your father.

It's just an observation, but several times you've made some pretty negative comments about yourself.

3. Collaboratively explore repeating patterns that may be significant:

What do you make of your tendency to get angry when we talk about your father?

When have you felt similar feelings in the past?

4. Keep in mind that too much linking of your transference observations to your clients' out-of-session relationships can have negative effects. Consequently, only make those links infrequently and tentatively:

- It feels like this pattern of expecting to be punished for expressing yourself might also be happening in your relationships outside. Is that possible?

Remember, although transference gives you a special opportunity to glimpse the converging nature of your client's past, present, and in-session relationships, you don't want to focus too much on transference early in psychotherapy.

Countertransference

Freud had a negative view of countertransference (C.T). He wrote:"No psychoanalyst goes further than his own complexes and internal resistances permit". Later psychoanalytic practitioners have contributed to four different ways of thinking about C.T.

1. Classical. This is Freud's view. Client transference triggers analysts' unresolved childhood conflicts. This triggering results in analysts' acting out in ways consistent with the unresolved conflicts. This C.T is negative and should be "overcome."

2. Totalistic. This C.T refers to all reactions the therapist has toward the client. These reactions are meaningful, and should be studied, understood, and used to enhance therapy process and outcome.

3. Complementary. This C.T emanates from specific client interaction patterns that “pull” therapists to respond in ways that others (outside therapy) respond to the client. Good therapists inhibit their reactive impulses, seek to understand the nature of the transaction, and use this knowledge to frame interventions to modify the client's maladaptive relational style.

4. Relational. This C.T is constructed from the combination or integration of the unmet needs and conflicts of both client and therapist.

Most contemporary theorists and therapists have moved beyond Freud's negative view of C.T and hold one or more of the other perspectives.

The Evidence Base for Countertransference

Researchers have found that C.T reactions can teach therapists about their own important underlying conflicts as well as client interpersonal dynamics. Betan et al. conducted a survey of 181 psychiatrists and clinical psychologists, and reported:

Patients not only elicit idiosyncratic responses from particular clinicians (based on the clinician's history and the interaction of the patient's and the clinician's dynamics) but also elicit what we might call average expectable countertransference responses, which likely resemble responses by other significant people in the patient's life. (p. 895)

This conclusion is consistent with the view that C.T is a natural phenomenon and a useful source of information that can contribute to therapy process and outcome.

J. Hayes, Gelso, and Hummel (2011) conducted a meta-analysis of 10 quantitative studies that measured C.T and outcomes. They reported a small negative overall effect for C.T on outcomes (weighted r = 0.16), indicating that C.T is associated with slightly poorer treatment outcomes.

J. Hayes et al. (2011) conducted a meta-analysis focusing on whether C.T management reduced negative outcomes. Their study rationale was stated as follows: “A fundamental concept in this literature is that if C.T is to be a help rather than a hindrance, the therapist must do something to, with, or about C.T” (p. 251). They identified 11 quantitative studies where an effort was made to manage or control C.T. Overall, they reported a small effect, suggesting that efforts to manage C.T were associated with reduced manifestations of C.T (weighted r = -0.14 ).

In a third meta-analysis, J. Hayes et al. (2011) examined the relationship between C.T management and treatment outcomes. Their question was whether or not C.T management might contribute to improved outcomes. On the basis of seven quantitative studies, they reported a “significant and large” effect (weighted r = 0.56 ). It appears that when therapists actively manage their C.T reactions to clients, it can contribute to more positive treatment outcomes.

Examples of Countertransference

There are an unlimited number of potential C.T behaviors, considering that nearly any behavior or emotional response may represent C.T. For example,

- Reaching out and touching a client or drawing back from a client who wants to shake your hand or give you a hug

• Talking too much in a session; feeling inhibited and unable to speak freely in a session

- Feeling bored; feeling aroused

- Joking too much; feeling unable to shake negative and depressive thoughts and feelings

• Dreaming about your client; dreading your client's arrival

Clinicians from various theoretical orientations have acknowledged the reality of C.T. From a behavioral perspective, Goldfried and Davison (1976) advised: “The therapist should continually observe his own behavior and emotional reactions, and question what the client may have done to bring about such reactions” (p. 58). Similarly, Beitman (1983) suggested that even technique-oriented counselors may fall prey to C.T. He wrote: "Any technique may be used in the service of avoidance of C.T awareness" (p. 83). For example, clinicians may repetitively apply a particular technique to clients (for example, progressive muscle relaxation, mental imagery, or thought stopping) without realizing they're applying the techniques to address their own needs, rather than their clients' needs (see Case Example 7.4).

Countertransference Management

Using the totalistic C.T definition, C.T is defined as all therapist emotional and behavioral reactions to clients. Imagine a therapist who lost his mother to cancer as a child. His father's grief was severe. As a consequence, the father offered little emotional support when the therapist was a child. The situation eventually improved, his father recovered, and the therapist's conscious memory consists of a general sense that losing his mother was very difficult. Now, years later, he's a graduate student, conducting his first interviews.

Things are fine until a depressed middle-aged man comes in because he recently lost his wife. What reactions might you expect from the therapist? What reactions might catch him by surprise?

C.T reactions may be more or less conscious. These reactions, if unmanaged, can negatively affect therapy. The following guidelines can assist you in coping with C.T reactions:

• Recognize that C.T is normal and inevitable. If you experience strong emotional, cognitive, or behavioral reactions to a client, it doesn't mean you're a “bad” therapist.

• C.T reactions can signal the need to do personal work. This work can be self-guided and focused on awareness, especially at first.

- If you have disturbing reactions to a client, consult with a colleague or supervisor.

- Do additional C.T reading. Reading about the problems your clients are manifesting (for example, eating disorders, depression, antisocial behavior) can help you view client problems and your emotional reactions from a more intellectual perspective.

- If you establish a regular meditation practice, you may be able to lower your reactivity to clients and improve C.T management.

- If C.T persists despite your best efforts, consider referring your client and/or getting personal psychotherapy. As J. Hayes et al. (2011) noted, “Personal therapy for the therapist seems especially important when dealing with chronic C.T problems” (p. 255).

Case Example 7.4: Clinician Contributions to Countertransference

Client behavior is the trigger for C.T. Sometimes clients treat their therapists with such open hostility or admiration that therapists are quickly caught up in a transference-countertransference dance. This can cause you to behave in ways that are very unusual for you. For example, at a psychiatric hospital, a patient unleashed an unforgettable accusation against her therapist:

You are the coldest, most computer-like person I've ever met. You're a robot! I talk and you just sit there, nodding your head like a machine. I bet if I cut open your arms, I'd find wires, not veins!

On the surface, this accusation might be considered pure transference. Perhaps the client was responding to her therapist in this way because important male figures in her past were emotionally unavailable. On a deeper level, as the saying goes, it takes two to tango; the therapist also needed to examine his possible contributions to this particular interaction.

The therapist consulted with colleagues and a supervisor, engaged in self-reflection, and came to several conclusions. First, he realized that he was behaving more coolly with her than he did with other clients. Second, he became aware that he was frightened of her intense emotional intimacy demands.

He began recognizing that being more robotic was a protective response. Third, his supervisor reassured him that he wasn't the first clinician to experience C.T. Finally, he worked to respond to the client more therapeutically, rather than reacting to his own fears.

The Working Alliance (also known as the Therapeutic Relationship)

The idea that therapist and client collaborate in ways that support positive outcomes originated with Freud (1912/1958). Later, psychoanalytic theorists introduced the terms therapeutic alliance and working alliance. Greenson (1965, 1967) distinguished between the two, viewing the working alliance as the client's ability to cooperate with the analyst on psychoanalytic tasks, and the therapeutic alliance as the bond between client and analyst. Eventually, Bordin (1979, 1994) introduced a pantheoretical model that he referred to as the working alliance. Bordin's model consists of three dimensions:

1. Goal consensus or agreement

2. Collaborative engagement in mutual tasks

3. Development of a relational bond

Bordin's model is dominant today. Throughout this text, we use the terms working alliance, therapeutic alliance, and alliance interchangeably.

The working alliance has become a frequent clinical research topic. Horvath, Re, Flückiger, and Symonds (2011) noted that when searching electronic research databases for the keywords alliance, helping alliance, working alliance, and therapeutic alliance in 2010, they obtained more than 7,000 hits. This voluminous research indicates that there's strong consensus that all therapists from all theoretical orientations should intentionally and systematically make efforts to establish and maintain a working alliance. Further, emerging empirical evidence indicates that a positive working alliance is linked to more positive outcomes with minority group clients.

Several researchers have noted that clients' ability to establish an alliance is predictive of their potential to benefit from psychotherapy. If clients can't or won't engage in a working alliance, there's little hope for change, but the more completely clients enter into such a relationship, the greater their chances for positive change. Ironically, it appears that those most in need of a therapeutic relationship may be those least able to enter into one.

The Evidence Base for the Working Alliance

Therapists vary in their ability to form an alliance. In a meta-analysis, Ackerman and Hilsenroth (2003) found that clinicians who were best able to form and sustain an alliance were warm, flexible, experienced, and trustworthy. These clinicians also used reflective and affirming techniques that facilitated emotional expression and focused directly on their client's experiences.

Horvath et al. (2011) conducted a meta-analysis on the working alliance in psychotherapy. On the basis of “190 independent alliance-outcome relations representing over 14,000 treatments” (p. 47), they reported a medium ES (r = 0.275). Across many different therapies, higher alliance ratings were related to better treatment outcomes. These results are consistent with previous reviews and more recent research.

Bordin's working alliance model includes collaboration and goal consensus components. Tryon and Winograd (2011) conducted a meta-analysis on the relationship between these two alliance dimensions and treatment outcomes. They reviewed 15 studies focusing on goal consensus with an overall sample of 1,302 clients. There was a medium ES (r = 0.34) for goal consensus. They also analyzed 19 collaboration studies with 2,260 clients and reported a similar ES (r = 0.33).

When clinicians explicitly solicit feedback from clients on therapy progress (that is, progress monitoring), both the working alliance and treatment outcomes tend to improve (see Chapter 3 for more information on progress monitoring). Specifically, Lambert and Shimokawa (2011) conducted a meta-analysis on client feedback procedures and reported a variety of effect sizes, depending on the particular feedback measure employed. Overall, all measures showed a positive relationship to outcome, with effect sizes ranging from r = 0.23 to r = 0.54.

Developing a working alliance and engaging in collaboration, goal consensus, and feedback or progress monitoring are substantially associated with positive treatment outcomes. The strength of association between these variables and outcomes is greater than that of any specific therapy techniques. Horvath and colleagues wrote:"The magnitude of this correlation makes it one of the strongest and most robust predictors of treatment success that research has been able to document" (p. 56). There's little doubt that integrating this knowledge into your repertoire can improve your clinical work.

Recommendations for Developing a Positive Working Alliance

Therapists who want to develop a positive working alliance (and that should include everyone) will employ alliance-building strategies beginning with first contact. Using model, alliance-building strategies focus on (a) collaborative goal setting, (b) engaging clients in mutual therapy-related tasks, and (c) developing a positive emotional bond. Progress monitoring is also recommended. The following list includes alliance-building concepts and illustrations:

1. Initial interviews and early sessions are especially important to alliance building. Many clients will be naïve about psychotherapy. This makes role induction essential. Here's a cognitive-behavioral therapy (C.B.T) example:

For the rest of today's session, we are going to be doing a structured clinical interview. This interview assesses a range of different psychological difficulties. It is a way to make sure that we"cover all of our bases." We want to see if social anxiety is the best explanation for your problems and also whether you are having any other difficulties that we should be aware of.

2. Asking clients direct questions about what they want from counseling and then integrating that information into your treatment plan help build the alliance. In C.B.T, this includes making a problem list.

Clinician: What brings you to counseling, and how can I be of help?

Client: I've just been super down lately. You know. Tough to get up in the morning and face the world. Just feeling pretty crappy.

Clinician: Then we definitely want to put that on our list of goals. Can I write that down? (Client nods assent.) How about for now we say, “Find ways to help you start feeling more up?”

Client: Sounds good to me.

3. Engaging in collaborative goal-setting to achieve goal consensus is central to alliance building. In C.B.T, this involves transforming the problem list into a set of mutual treatment goals.

Clinician: So far I've got three goals written down: (1) Find ways to help you start feeling more up, (2) Help you deal with the stress of having your sister living with you and your family, and (3) Improving your attitude about exercising. Does that sound about right?

Client: Totally. It would be amazing to tackle those successfully.

4. Problem lists and goals are a good start, but clients engage with clinicians better when they know the treatment plan (T.P) for moving from problems to goals. The T.P includes specific tasks that will happen in therapy and may begin in the first clinical interview. Here's an example of a"devil's advocacy" technique where the clinician takes on the client's negative thoughts and then has the client respond. You'll notice that collaboratively engaging in mutual tasks offers spontaneous opportunities for deeper connection and clinician-client bonding:

Clinician: You said you want a romantic relationship, but then you start thinking it's too painful and pointless. Let's try a technique where I take on your negative thinking and you respond with a reasonable counterargument. Would you try this with me?

Client: Sure. I can try.

Clinician: Excellent. Here we go: "It's pointless to pursue a romantic relationship because they always come to a painful end."

Client: That's possible, but it's also possible to have some good times along the way toward the painful end.

Clinician: (smiles, breaks from role) That's the best comeback ever.

5. Soliciting feedback from clients from the first session onward to monitor the quality and direction of the working alliance contributes to

the alliance. Although you can use an instrument for this, you can also ask directly:

We've been talking for 20 minutes, so I want to check in with you on how you're feeling about our time together so far. How are you doing with this process?

6. Making sure you're able to respond to client anger without becoming defensive or counterattacking is essential to positive working relationships. We usually apply radical acceptance. Here's an excerpt from an initial session with an 18-year-old male in which the clinician accepted the client's aggressive message and transformed it into a relational issue:

Clinician: I want to welcome you to therapy with me, and I hope we can work together in ways you find helpful.

ient: You talk just like a shrink. I punched my last therapist in the nose. (Client glares at therapist and awaits a response.).

Clinician: Thanks for telling me that. I'd never want to have the kind of relationship with you where you felt like hitting me. And so if I ever say anything that offensive, I hope you'll just tell me, and I'll stop.

Repairing Relationship (Alliance) Ruptures

Robust scientific support for the working alliance as an important therapeutic factor has stimulated research on relationship ruptures. Relationship ruptures are defined as tensions or breakdowns in the clinician-client collaborative relationship. Concepts similar to relationship rupture include empathic failures and therapeutic impasse. The idea is that if clinicians can weather relationship storms, it may strengthen the working alliance and improve outcomes.

Like the working alliance, the concept of relationship rupture and repair has roots in the psychoanalytic tradition. However, similar to the working alliance, rupture and repair in psychotherapy are now considered pantheoretical concepts. From a C.B.T perspective, Newman (2013) wrote: “The importance of the therapist's competency in managing strains or ruptures in the therapeutic relationship cannot be overstated” (p. 57).

The reality is that all clinicians, regardless of theoretical orientation, will experience relationship strains and ruptures. Sometimes these ruptures will be hardly noticeable; other times they'll be large and obvious.

Whether small or large, ruptures can disrupt therapy process, lead to negative outcomes, and cause clients to drop out of treatment. Having rupture resolution skills is essential. There is little doubt that ruptures will occur, and repairing them can improve treatment outcomes.

The Evidence Base for Rupture Repair

Safran and colleagues conducted a meta-analysis on the relationship between rupture repair episodes and treatment outcomes. They comprised three studies with 148 total clients and reported an “aggregated correlation” of r = 0.24, indicating that rupture repair episodes were significantly associated with positive outcomes (p = 0.002).

Safran et al. also conducted a meta-analysis on the effects of rupture resolution training or supervision on treatment outcomes. Again, they reported positive results. According to the results of seven studies with control group comparisons, therapists with rupture resolution training obtained slightly more positive outcomes (r = 0.15, p = 0.01). The researchers concluded that “rupture resolution training/supervision leads to small but statistically significant patient improvements relative to treatment by therapists who did not receive such training”.

Examples of Relationship Ruptures

Relationship ruptures have been organized into two types: withdrawal ruptures and confrontation ruptures. Withdrawal ruptures involve client silence, topic shifts, and explicit overcompliance. A palpable sense of disengagement may signal a withdrawal rupture:

Inician: You've been talking about wanting to focus on career goals. That's a good idea. But based on our time together today, it seems like your anxiety is what's stopping you from moving forward with your career. And so my recommendation is that we start with anxiety reduction and then move on to focusing on your career later.

Client: (10 seconds of silence) ... Okay.

Clinician: You don't seem very enthused with that plan.

Client: Oh, no, that's okay.

Clinician: Do you have any thoughts or reactions to the plan?

Client: No.

In contrast to withdrawal ruptures, confrontation ruptures usually include aggressive statements. Clients may express discontent or resentment. Clients also commonly accuse their therapists of incompetence or make disparaging comments (for example, “The whole idea of therapy working for me is ridiculous”). For example:

Client: I've read half a dozen books on anxiety reduction and came to the conclusion months ago that those psychobable techniques aren't worth my time and effort.

In most cases, withdrawal and confrontation rupture behaviors have different underlying dynamics. Withdrawal is often a product of anxiety or fear and linked to expectations that the therapist will reject what the client is feeling and thinking. This leads to conscious or unconscious vulnerability and withdrawal or avoidance. For many clients, it's safer to avoid expressing disappointment than to risk rejection and/or a punitive therapist response.

Confrontation ruptures are often surface anger expressions that cover deeper disappointment and hurt. They can be seen as an aggressive form of the message, “You don't get me.” When clinicians manage client anger and engage in deeper exploration with clients, it's not unusual to uncover disappointment and a wish for nurturance.

Rupture Repair: General Guidelines and Specific Strategies

Rupture repair can be direct or indirect. Directly addressing ruptures may involve various interviewing techniques including self-disclosure/immediacy, gentle questioning, acknowledgment of an empathic failure, and concession to the client's perspective. The following are some examples of clinician statements:

• Self-disclosure/immediacy: I recall one time when I was in therapy and my therapist started going in a direction I didn't care for. I remember feeling I should just keep my mouth shut and not say what I really thought. I'm worried that's happening with us. And so if you're feeling even the least bit of doubt about focusing on anxiety in our counseling, I hope you'll tell me.

Gentle questioning: You seem more quiet than usual. I'm wondering what you really think about focusing on anxiety before moving on to career goals. I would love to hear your genuine perspective—even if you're disappointed or angry—and I'm open to changing directions based on what you want.

• Acknowledgment of an empathic failure: You know what … I think I missed the significance of what you were saying earlier about your anxiety. I'd like to revisit that and try listening better to your thoughts and feelings this time around.

• Conceding to the client's perspective: My sense is that you're more enthused about working on your career goals. If it's okay with you, how about we reverse the order? Let's work on career goals first and then if it seems necessary, we can shift to anxiety later.

Indirect rupture repair occurs when you don't comment on the rupture, but instead shift your focus to what you missed or where you think the client would rather go. In the case involving anxiety reduction versus career goals, the therapist could simply switch direction. ("I'm sorry. I've rethought your situation, and now I think we should go with your career goals. Is that okay?") Similarly, as a clinician, you may decide to change your therapeutic task (for example, "Today let's try visual imagery instead of progressive muscle relaxation") or unilaterally accept responsibility for an empathic failure ("I'm sorry. I think you were saying you feel numb and not so much anxious.").

Although steps toward rupture resolution can vary depending on theoretical orientation and clinician style, Safran et al. (2011) identified six generic steps.

1. Repeating the therapeutic rationale

One way to think of this is as providing a role re-induction. This involves restating the reasons why it makes sense to proceed in a particular manner.

Even though it's terribly difficult to face anxiety directly, one thing we know for sure from research and clinical practice is that avoiding anxiety will only give anxiety more control over you.

2. Changing tasks or goals

“Let's cross that off our goal list” or “Let's put that into a new list of what we might talk about in the future if we decide to.”

It seems like when I just ask you to talk openly about whatever you like, that doesn't work very well for you. How about if I ask you a few more questions to help us both focus, and we'll see if that seems better?

3. Clarifying misunderstandings at a surface level

When I said I think we should put anxiety first, I wasn't meaning that we have to put it first on our list. I'm open to working on the career goals first ... or simultaneously.

4. Exploring relational themes associated with the rupture

This is just a hunch on my part, but my feeling is that part of the reason you stay quiet and don't share your thoughts openly with me is because you anticipate that I'll judge you in some negative way. Does that seem true to you?

5. Linking the alliance rupture to common patterns in a patient's life

Are there any times in your daily life when you're hesitant and don't share openly even with people who would be likely to accept and try to understand your feelings/perspective?

How about if we look at situations and people in your life and make some first guesses about who you can trust to listen to you if you want to talk and who you should continue to hesitate with?

6. New relational experience

Inside therapy:

I noticed you spoke your feelings directly to me just now. How did that feel?

Outside therapy:

You just told me a story about being assertive and speaking up for yourself, and it sounds like the outcome was pretty darn good. What are your thoughts on being able to do that and have a good outcome?

Rupture repair occurs on multiple levels. Often, clients aren't completely aware of the reasons underlying their rupture-related withdrawal or aggression. From the psychoanalytic perspective, therapist efforts to repair ruptures are soothing unconscious communications that say, "It's okay. We can talk about this, and we can work through painful emotions together." From the behavioral perspective, it's also possible to view rupture repair as the therapist's modeling effective, open communication as a means of facing uncomfortable feelings.

Therapist Modeling

Modeling is a powerfully ubiquitous force in contemporary psychology. The fact that humans learn through modeling was articulated in Mary Cover Jones's early work with phobic children and later became a cornerstone of Bandura's social learning theory. Modeling is considered a form of treatment in its own right; it's an empirically supported approach used extensively in treating anxiety disorders and skill deficits. However, for the purposes of this chapter, modeling is viewed as a phenomenon that occurs within the therapist-client relationship.

Psychoanalytic and object relations theorists use the terms identification and internalization to describe what behaviorists consider modeling. Individuals identify with others whom they love, respect, or view as similar. Through this identification process, individuals begin to incorporate or internalize unique and specific ways in which that loved or respected person thinks, acts, and feels.

No one knows the precise psychological dynamics that cause people to imitate or model their behavior after someone else. It could involve the identification-internalization process. Or it could be caused by other factors (see Case Example 7.5).

Case Example 7.5: Modeling or Internalization?

Imagine the following scenario: A young adult's probation officer refers her to a mental health professional after several minor criminal convictions. The client arrives for the initial clinical interview, but is reluctant to talk openly. Eventually the client begins to like the therapist and enjoys spending time with him.

They talk about specific triggers that have gotten the client in trouble in the past as well as how to stop and reflect before acting impulsively. Therapy is successful, and in the final session the therapist asks the client what she found most helpful. Although they've worked together on cognitive-behavioral strategies such as problem solving and consequential thinking, the client describes her success as based on something else.

I guess I think it was two things, Doc. You're a good guy, and at some point in my time with you I started thinking I wouldn't mind being more like you. And then, when I faced situations where I would usually make a bad decision, it was like your voice popped into my head and then I thought, hmm, I wonder what the doc would do? And then I did what I thought you would do instead of what I would usually do.

According to psychoanalytic theory, identification is the precursor to internalization. Decades ago, object relations theorists hypothesized that as we develop, we internalize components of various caretakers and others in our early environment. These internalizations serve as the basis for how we feel about ourselves and how we interact with others. If we internalize “bad objects” (that is, abusive parents, neglectful caretakers, vengeful siblings), we may experience disturbing self-perceptions and interpersonal relationships. Psychotherapy involves a relationship that can replace maladaptive internalizations with adaptive or positive internalizations. Strupp (1983) summarized this: “Since the internalization of 'bad objects' has made the patient 'ill,' therapy succeeds to the extent that the therapist becomes internalized as a 'good object'” (p. 481).

Clients may improve because of identification and internalization, or they may improve because of observational learning. Either way, when therapists are positive, respectful, and reflective people whom clients can identify with and/or imitate, it contributes to positive outcomes.

Mutuality and Mutual Empathy

Feminist approaches emphasize egalitarian relationships between clients and therapists. These relationships involve mutuality and empowerment. Although feminists endorse and embrace the person-centered core conditions, feminists also focus on social and cultural factors, gender dynamics, and power differentials that impact how clients experience themselves and their worlds.

Mutuality refers to a sharing process; it means that power, decision making, goal selection, and learning are shared. Although other psychotherapies consider treatment a mutual process wherein clients and therapists are open and human with one another, nowhere are egalitarian values and the concept of mutuality emphasized more than in feminist therapy. In addition, mutual empathy has been identified as a therapeutic factor in relational cultural therapy. Mutual empathy is defined as clients seeing-experiencing-knowing their emotional effect on their therapists within a safe environment.

When achieved, it allows clients to see their therapists experiencing empathic resonance. This connection—as opposed to the withdrawing-isolation-punishment that caregivers often have in response to their children's deep emotions—is viewed as healing in and of itself and as promoting self-acceptance of painful emotions (see Case Example 7.6).

Case Example 7.6: Mutual Empathy—A Feminist Relationship Factor

Chantelle, a 25-year-old woman attending community college, came to the student health service for counseling. She was intermittently tearful as she described her abusive childhood. Her counselor, a 25-year-old female counseling intern, listened, paraphrased, offered reflections of feeling, and stayed connected with Chantelle through the stories and tears. At one point, the client expressed hate for herself and then described repeated scenarios where she felt coerced. into providing sexual favors for males in her household in order to have access to transportation and food. With tears of empathic resonance in her eyes, the therapist said, “I have this image of you in prison and the men who are in control only hand you the keys to go on leave if they shame you into giving them sexual gratification.”

The client noticed her counselor's emotion. In response she had a powerful emotional outpouring. Later, when asked about what was helpful in her work with the counseling intern, the client identified her counselor's tears.

She said that her mother and sisters always minimized and humiliated her for "complaining" about living in a home where she had food and shelter. For the client, the whole idea and experience of someone else having an empathic emotional response to her shame and self-revulsion played a big role in her healing.

When therapists encourage mutuality, they do so to empathically resonate with and empower clients. Although mutuality doesn't alter the fact that authority rests with the counselor, feminist therapists place the power for change in their clients' hands. They respect the client's authority, and actively work to help clients respond to the dominant social discourse with the authority of their own voices. This includes a focus on client assertiveness and a deep valuing of self. Feminist therapists believe respectful, reciprocal interactions—including mutual empathy—can develop personal power in clients; empirical data support this claim.

Evidence-Based Multicultural Relationships

In 2001, the Institute of Medicine (I.O.M) defined evidence-based medicine as “the integration of the best research evidence with clinical expertise and patient values” (p. 147). Somewhat later, the American Psychological Association's Task Force on Evidence-Based Practice (2006) extended the I.O.M's statement to evidence-based practice (E.B.P) in mental health treatment. The task force wrote: “ E.B.P is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences (p. 273).”

These definitions acknowledge the essential relevance of addressing client or patient culture within all evidence-based approaches. Morales and Norcross (2010) wrote: “Clinical practice without attending to culture cannot be characterized as E.B.P” (p. 824). However, the sad truth is that despite the fact that all therapists should attend to client culture as a part of practicing E.B.P, there's very little quantitative research evidence specifically focusing on E.B.P with minority cultures.

This leaves us with a conundrum. How do we follow the I.O.M and A.P.A guidelines when we have minimal research on which to base clinical decision making? The answer: Without more nuanced data to depend on, the best clinical approaches for using evidence-based relationships when working across culture is to focus on the relationship variables discussed in this chapter. The caveat: You should do so in a manner consistent with (a) the multicultural competencies (Chapter 1), (b) available qualitative and anecdotal information, and (c) existing quantitative research.

Clinical researchers have used several approaches to adapt evidence-based techniques for working with diverse clients. These approaches all tend to emphasize intercultural relationships and the multicultural competencies. For example, researchers have solicited culturally valuable information from focus groups, tribal leaders, and cultural consultants. The following paragraphs represent an integration of ideas for connecting with cultures along with evidence-based relationship factors.

Congruence. Clinical practitioners, multicultural experts, and qualitative data all indicate that when clinicians are open and genuine with clients from minority cultures, rapport is enhanced and outcomes are likely to be better. In a qualitative study, Gallardo (2013) reported that Latina (o) clients viewed charlar (small talk) as a positive therapy factor.

Unconditional positive regard (U.P.R). Another word that can be used instead of U.P.R is respect. Of all relationship variables, respect has possibly the most universal utility. According to quantitative and qualitative research and clinical anecdotes, it appears safe to say that clients from all minority groups respond better when they have unequivocal respect from members of the dominant culture. The tricky part is how to express respect to individual clients with diverse cultural, sexual, and ability status. The solution probably involves following the multicultural competency guidelines: Develop your multicultural awareness, knowledge, and skills (see Chapter 1).

Empathic understanding. Empathy across cultural divides should never be presumptive; it should be expressed with maximum tentativeness and humility. Rogers (1957, 1961) should be your guide, and he would have you tread gently in the emotional world of others. Tentative phrases like the following are recommended: “If I'm getting this right...” or “Tell me if I'm wrong about this, but it seems like...” or “Could it be that you're feeling...”

Transference. Regardless of your racial or cultural identity, your clients may have an immediate transference reaction to you. If you're an Asian therapist and you're meeting with a Vietnam-era veteran, the client's reaction to you may have nothing to do with you as a person and everything to do with your appearance and the client's history. Techniques such as charlar, self-disclosure, and making a statement about your purpose, combined with professionalism, are all recommended.

Countertransference. Countertransference triggers related to race and culture abound. If you're an Iraq War veteran and your client is a bearded man named Abdul from Iraq, you may need to steady your emotional self. Working with your supervisor to openly reflect on and cope with your reactions to clients from minority cultures is strongly recommended (Ponton & Sauerheber, 2014).

Working alliance. There is quantitative evidence that the working alliance is modestly associated with positive outcomes in psychotherapy with Canadian Aboriginal clients (Shaw, Lombardero, Babins-Wagner, & Sommers-Flanagan, in press). This outcome is consistent with expectations based on clinical practice. What remains in question is how clinicians can best foster a working alliance with culturally diverse clients. A good beginning is to provide clients with a clear statement of purpose individualized to specific cultural orientations. For example, with a client who has a collectivist orientation: "My goal is to provide the best help I can to you and your family."

Rupture repair. It should be assumed that when therapy relationships extend across cultures, they may be more fragile and ruptures may be more frequent. This implies that culturally effective clinicians attend to potential relationship ruptures and provide reparative statements as needed. At minimum, repair statements should include a clear apology along with a commitment to not make the same mistake again.

Modeling. To assume that clients from minority cultural groups should automatically view clinicians from the dominant culture as positive role models is presumptuous and unacceptable. Minority clients need their own role models. That said, it's still acceptable to join with minority clients and have similar thoughts and feelings in response to specific issues. For example, even if clients don't acknowledge an emotional reaction to discrimination, you might use modeling to imply that emotional expression with you is acceptable:"I don't know if this is how it affects you, but when I hear about the racial insults you've experienced, I feel angry and sad."

Mutual empathy. Although there's no empirical research on how mutual empathy operates when counseling across cultures, it makes logical and intuitive sense that showing minority clients your genuine and empathic emotional responses to their experiences might facilitate the development of positive relationship bonds. It's recommended that you use genuine expressions of empathic compassion to allow opportunities for mutual empathy to develop.

Summary

Carl Rogers (1942, 1957) initially articulated the importance of relationship variables in psychotherapy. He claimed that therapy techniques were irrelevant and that change occurred as a function of a special type of relationship between therapist and client. Contemporary researchers and practitioners still debate whether relationships or techniques are more important to therapy. Therapeutic relationship factors are now referred to as “evidence-based relationships”.

Rogers identified three core conditions that he believed were necessary and sufficient for effective therapy: (a) congruence, (b) unconditional positive regard, and (c) accurate empathy. Congruence is synonymous with genuineness or authenticity and generally means that the therapist is open and real with clients. Unconditional positive regard involves accepting and respecting clients.

Accurate empathy is a complex and multidimensional concept that involves feeling feelings right along with clients. Empirical research indicates that Rogers's original core conditions contribute to positive therapy outcomes.

Several relationship factors derived from other theoretical perspectives also have been linked to positive therapy outcomes. These comprise transference, countertransference, the working alliance, repairing relationship ruptures, therapist modeling, mutuality, and mutual empathy. Relationship factors, such as building the therapy alliance, are important from the initial clinical interview onward.

Evidence-based practice in counseling and psychotherapy includes sensitivity to and consideration of cultural factors. This is somewhat problematic in that there's only minimal empirical research available that focuses on how evidence-based relationship factors work with specific cultural minority groups. At this point, the best guide for practice is to use the evidence-based relationship factors described in this chapter along with the multicultural competencies.

Suggested Readings and Resources

The following readings offer additional information on relationship factors that have scientific support and theoretical roots.

Evans, K., Kincade, E. A., & Seem, S. R.. Introduction to feminist therapy: Strategies for social and individual change. Thousand Oaks, C.A: Sage. This is a well-organized and well-written introduction to feminist theory and therapy.

Freud, S.. An outline of psychoanalysis (J. Strachey, Trans.). New York, N.Y: Norton. This quick read provides a succinct description of psychoanalytic principles in Freud's own words.

Jordan, J.. Relational-cultural therapy. Washington, DC: American Psychological Association. Jordan is a prominent feminist therapist and author. In this book, she articulates a feminist approach to therapy that emphasizes relational mutuality as a healing force.

Miller, S. D., Duncan, B., Wampold, B. E., & Hubble, D. (Eds.).. The heart and soul of change: Delivering what works in therapy (2nd ed.). Washington, DC: American Psychological Association. This book focuses on common factors associated with positive change in counseling and psychotherapy. It provides practical suggestions for integrating common factors into your interviewing practice.

Newman, C. F.. Core competencies in cognitive-behavioral therapy: Becoming a highly effective and competent cognitive-behavioral therapist. New York, N.Y: Routledge. There are many C.B.T books available. This one is relationally sophisticated and includes two whole chapters on the therapeutic alliance.

Norcross, J. C. (Ed.).. Psychotherapy relationships that work: Evidence-based responsiveness. New York, N.Y: Oxford University Press. This book is the compilation of the findings of the task forces from Divisions 12 (Clinical Psychology) and 29 (Psychotherapy) of the American Psychological Association. It includes 21 chapters that report data on the contribution of relationship factors to psychotherapy outcomes.

Rogers, C. R.. On becoming a person. Boston, M.A: Houghton-Mifflin. This text contains much of Rogers's thinking regarding congruence, unconditional positive regard, and empathy.