The Most Important Part of Therapy Is Often Misunderstood
This article was originally published on Psychology Today
“Why can’t you just tell me what you think? It's like you don’t care!” Jamie said, visibly angry, when talking about a personal decision she was struggling with. I had been her therapist for over a year and it wasn’t the first time she expressed a similar frustration. It was an emotionally charged moment and I was actually feeling a bit angry, unsure of what to say, and cornered into an impossible situation.
After a moment of silence, she asked “Are you mad at me?” I replied, “I am glad you’re allowing yourself to be angry with me...and yes, I am feeling a bit angry, helpless, and stuck. I wonder if you’re helping me understand how stuck and helpless you feel inside when I don’t tell you what you should do.”
In our next session, Jamie (not her real name) told me: “I already knew that I appreciated how I can feel angry with you and you will listen to me. But I didn’t realize until last week how important it is to know that you can get angry too, and that you will let me know and we can talk about it.”
I start with this vignette from my practice because it illustrates some important aspects of the relationship between therapist and client. Why does this relationship matter? For decades, research has consistently shown that the therapeutic relationship plays the most important role in whether and how therapy works. Its impact is only second to extra-therapeutic client’s characteristics (e.g., resilience, social support) and greater than the specific “techniques” that are used by the therapist. This is not to say that different therapy approaches make no difference. However, whatever happens in therapy—the use of any theory, intervention, or technique—happens in a relational context, the relationship between therapist and client, and it is that context what makes the most difference.
Despite its importance, I believe the therapeutic relationship is often understood in a limited way. Therapists tend to focus on attributes such as empathy, acceptance, compassion, and collaboration—and for good reason. These are essential to building trust and safety between therapist and client, and research shows they are effective. At the same time, some therapists might struggle to hold space for other feelings and parts of themselves that may not fit their “therapist persona,” such as ambivalence, disappointment, competition, or disconnection towards their clients.
What is the therapeutic relationship?
The therapeutic relationship includes, “all the feelings and attitudes that the therapist and the client have toward one another, and the manner in which these are expressed.”. This definition is theoretically neutral, although therapists from different orientations may interpret it differently. As a psychodynamic therapist doing long-term work with my clients, I believe this definition is very helpful because it highlights three key aspects:
“All the feelings and attitudes”: Therapy is usually associated with feelings of support, warmth, safety, and positive regard between both people. As mentioned before, this is essential to build rapport and trust. But what about more difficult feelings, such as anxiety, anger, envy, boredom, or shame? These are natural human experiences and, at its core, therapy is an encounter between two human beings. So it is unavoidable, if we pay close attention, that feelings like these will enter the therapeutic relationship, whether consciously or not. The source of these "feelings and attitudes" is two-fold: the experience therapist and client have of each other, and their own histories and personalities. Part of the work of therapy consists of creating a space where these feelings can be acknowledged, understood, and utilized in the service of our clients’ needs and goals.
“Toward one another”: The therapeutic relationship, and therapy itself, is a bidirectional process, in which both people have feelings, thoughts, and reactions toward the other. This means that client and therapist may emotionally impact and change each other, sometimes in deep ways, if they’re open to it. Recognizing this mutuality can be unsettling, especially when we consider that some of those feelings might be difficult, but acknowledging it is essential to tell the full story. What happens in therapy is created jointly (co-created) by both parties. That said, the therapeutic relationship is mutual but not symmetrical. It is up to the therapist, not the client, to navigate and manage their own reactions and experiences, to make sense of them, understand what they’re about, and decide—after careful consideration—how they could benefit the work.
“The manner in which they are expressed”: The definition of therapeutic relationship includes not only what’s experienced inside each person, but also how those experiences find their way into the actual interactions. While the feelings between therapist and client can sometimes be verbalized, they’re often expressed in action or through what's left unsaid. This is particularly true when the feelings are uncomfortable and, by definition, when they are unconscious. For example, what is a client who is chronically late trying to express? What about the therapist who never confronts them? Or the client who seems to be helplessly compliant and always agreeable with the therapist? Or the therapist who feels unusually distracted, interested, or bored with a particular person? All these situations might be conveying something meaningful about the therapeutic relationship. It behooves the therapist to “listen” to them, consider their meaning in the context of the relationship, and work with the client to make sense of what might be going on.
The therapeutic relationship, especially as the work deepens, is complex and evolving. It should include things like collaboration, empathy, and positive regard. This will help create a space where clients can feel safe sharing their stories and experiences from "outside" of therapy. But hopefully, clients will also feel free to talk about their experiences, thoughts, and feelings towards the therapist and their relationship. Feelings are not “wrong” or inappropriate by themselves, and, in fact, can be very helpful. Oftentimes, client and therapist will discover that whatever is unfolding between them resembles the client's relational history and experiences in the “outside” world. The therapist, on the other hand, must recognize, accept, and understand their own experience, and be very judicious about how, when, or with whom to use it. The choice to share my experience with Jamie was based on the nature of our relationship, one in which we were able to feel connected and trusted each other, and on my hopes that it would be helpful to her.
“I leave my own feelings at the door,” I heard a colleague say a while ago. I felt very confused. How could I leave the main tool in my toolbox outside the shop? In my experience, our ability to connect emotionally with our clients, to get to know them from within, to struggle together in the difficult moments, is a big part of what makes therapy work. Your therapist will hopefully be welcoming, warm, affirming, responsive, insightful, and empathic, but it is important that they are also trying to be open to the full range of their emotional experience. Otherwise, they would be bringing only parts of themselves to a work that demands our entire humanity.
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Photo credit: Giulia May