In a previous article we dealt with the basics of how you create a good collaborative relationship. To summarise: When another feels themselves respected and heard, then a relationship is created in which it is possible to collaborate. For this an open, inquisitive attitude is necessary, and the three Rogerian requirements of congruence, empathy and unconditional positive regard. In this article we focus on the situation when you need to deal with a client. In other words, it’s not about a social conversation in which the balance between give and take is implicit: You are now the one who needs to do the most in terms of listening, as it is the other’s situation which is relevant, not yours.
Another field of study also looks at this collaborative relationship: In so-called common-factor research, the effects of various types of treatment are compared to see what effective ingredients they may have in common with one another. For example, Lambert (1992), in his meta-analysis, found that 40% of therapy outcomes can be explained by client variables, 15% by a placebo-effect, 30% by common factors and 15% by specific factors. The placebo-effect is due to the client’s expectation that therapy will be effective – this expectation in itself already has a positive effect, similar to that of the self-fulfilling prophecy. So, merely going to a counsellor (irrespective of what actually occurs during those conversations) already helps. ‘Specific factors’ means that which is specific for the treatment or the therapeutic school to which the counsellor subscribes (such as cognitive-behavioural therapy, etcetera). This only accounts for 15% of the outcome, while the effect of common factors is twice as large. And those common factors boil down to the therapeutic relationship. In brief, a good therapeutic relationship has twice the effect of the therapeutic school the counsellor subscribes to!
Lambert (1992) ascribes 30% of the therapeutic outcome to common factors, and Beutler et al (2004) only 22%. The latter also emphasise that it’s about how good the client thinks the relationship is, not the therapist. Until recently, only the correlation between therapeutic relationship and outcome has been demonstrated, yet Goldsmith, Lewis, Dunn and Bentall (2015) have managed to prove that the link is causal, i.e. that both a good and a bad relationship influence the outcome in a uniform way.
The tripartite model
What, then, is the collaborative relationship (often called the therapeutic relationship) exactly? Wampold and Budge (2012) propose a model depicted in the following image:
Their point of departure is that the relationship between a counsellor and a client is of a totally different nature than all other relationships. The client generally comes because he or she expects understanding and to be able to openly discuss what is bothering him or her. They expect to discuss subjects they often cannot talk about with others; that what is said remains confidential; that the counsellor will treat them in a non-judgemental manner; and that he or she possesses the necessary expertise. Wampold and Budge name this the ‘initial relationship’.
The relationship deepens as the process continues, subdivided into three areas: The real relationship; the creation of positive expectations; and the ability of the counsellor to activate his or her clients. Two of the direct results from this therapeutic relationship are a better quality of life and a reduction in the client’s complaints. As regards quality of life, this is primarily connected to one of the basic psychological needs every person has: Meaningful connections with others. Even though the connection is temporary, for the duration of the relationship it certainly supports the client’s need for meaningful connection.
The initial relationship
Clients don’t arrive on the counsellor’s doorstep by accident, they come with certain expectations. Even though they don’t know exactly what to expect, they do generally believe he or she can help them. The client certainly does form a first impression about how trustworthy the counsellor is, trust being a subject we will deal with further in a future article. As the first impression is usually made within the first half a second of their first meeting, there isn’t that much the counsellor can do to influence it other than dress appropriately, monitor his or her personal hygiene and gauge how friendly his or her welcome is perceived to be. A genuine smile (not a stewardess smile) immediately does wonders. How to smile a smile genuine? My suggestion: I consciously look forward to the privilege of getting to know someone entirely new.
The next step is to give clients a feeling of trust as soon as possible, and behave in a way that communicates that they are dealing with a professional who treats them with the necessary respect. This largely overlaps with Rogers’ ideas about congruency (see previous article). Especially in the creation of the initial relationship it’s about clients feeling they are taken seriously and that the counsellor isn’t judging them. This has a connection with Rogers’ concept of unconditional positive regard, also dealt with in the same previous article.
The real relationship
The real relationship grows out of the initial relationship as the contact between counsellor and client progresses. For example, in terms of understanding, both client and counsellor learn to understand each other better. Also here the comments in the previous article about the balance between distance and closeness are appropriate. Also as mentioned, the real relationship is therapeutic in itself, as it fulfils one of the client’s basic psychological needs: That of a meaningful connection with another person. This is as the counsellor invests a positive involvement in the client’s wellbeing.
Ability to give hope and positive expectations
Also, this aspect of collaboration is more a matter of attitude than anything else. It is connected with empowerment and your ability to communicate (verbally and via your behaviour); your confidence in clients; and their ability to successfully change. The counsellor also gives clients an increased sense of grip, partially conferred already by his or her confidence in them, partially also thanks to the dialogue, through which he or she helps them understand what makes their situation problematic and what they might do to correct that. This alone gives a heightened sense of control and supports the client’s feeling of self-efficacy.
Ability to activate due to expertise
Irrespective of the content or theoretical background of your interventions, they all have in common that they activate the client to execute healthier behaviour. And it is simply the fact that clients are tackling their issues that already has a motivating effect, both in terms of expectations and in terms of a reduction in the complaints the client experiences. In other words, it improves the quality of the therapeutic relationship when the counsellor activates his or her clients and motivates them to actually do something (different to what they used to do).
Placebo or common factor?
A number of current views question whether calling a part of the therapeutic outcome a placebo effect is justified (Weinberger, 2014). The client’s expectation is an ingredient the counsellor can influence, not merely a characteristic of the initial relationship. The second aspect of Wampold and Budge’s (2012) tripartite model – the counsellor’s ability to give clients hope, and his or her confidence in their ability to change – plays an important role in raising their expectations. When the counsellor gives clients a logical (to them) explanation as to why their situation is the way it is, and a possible route how to change that, he or she is also influencing their expectations, irrespective of which specific interventions he or she is suggesting or the theoretical background from which he or she chooses to work. This makes a large portion of the expectation a common factor. It is the fact that a solution is in sight which raises the client’s expectations.
To continue: The last category Lambert distinguishes contains the so-called ‘specific’ factors. Where Lambert (1992) estimates this at 15%, Wampold (2001) deduces 8% and Beutler et al (2004) settle for 10%. According to Weinberger (2014), some of these specific factors are also actually common factors, which may be linked to the third part of Wampold and Budge’s (2012) model. Irrespective of the theoretical school the counsellor subscribes to, many of the techniques to motivate clients into action are the same. For example, the principles of the Socratic dialogue or motivational interviewing (Miller & Rollnick, 2012) may be applied in cognitive behavioural therapy, emotion-focused therapy or client-centred therapy, etcetera. Conversational skills are far more often uniform across the various schools than not, making them common factors too.
Summing up, the tripartite model is a simple way to visualise the collaborative relationship. It shows how the three elements, the real relationship; giving hope and positive expectations; and the ability to activate clients actually build on the initial relationship. And it gives us a clear picture of the elements we can influence in order to improve the collaborative relationships, which Goldsmith, Lewis, Dunn and Bentall’s (2015) research has shown to be causal to the effectiveness of the counsellor’s interventions.
- Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., Nobel, S., & Wong, E. (2004). Therapist variables. In M. J. Lambert, Bergin and Garfield’s handbook of psychotherapy and behaviour change (5th Ed). New York: Wiley.
- Goldsmith, L. P., Lewis, S. W., Dunn, G., & Bentall, R. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. Psychological Medicine, 2015 Mar 25, 1-9.
- Lambert, M. J. (1992). Psychotherapy Outcome Research: Implications for Integrative and Eclectic Therapists. In J. C. Norcross, & M. (. Goldfried, Handbook of Psychotherapy Integration (pp. 94-129). New York: Basic Books.
- Lambert, M. J. (1992). Psychotherapy Outcome Research: Implications for Integrative and Eclectic Therapists. In J. C. Norcross, & M. Goldfried, Handbook of Psychotherapy Integration (pp. 94-129). New York: Basic Books.
- Miller, W. R., & Rollnick, S. (2012). Motivational Interviewing – helping people change (3rd Ed.). New York: Guildford Press.
- Wampold, B. E. (2001). The great psychotherapy debate. Models, methods and findings. Mahwah, NJ: Lawrence Erlbaum.
- Wampold, B. E., & Budge, S. L. (2012). The 2011 Leona Tyler Award Address: The Relationship – and Its Relationship to the Common and Specific Factors of Psychotherapy. The Counseling Psychologist, 40 (4), 601-623.
- Weinberger, J. (2014). Common factors are not so common and specific factors are not so specified: Toward an inclusive integration of psychotherapy research. Psychotherapy, 51 (4), 514-518.
Previous article mentioned:
Excerpted and edited from: Van Alphen, M.F. (2016). Observational Listening – The (Missing) Link between Emotion and Communication. Bloomington: Authorhouse UK.
Dutch book on Observational Listening: Van Alphen, M.F. (2015). Psychosociale gespreksvoering – observatief luisteren in de hulpverlening. Amsterdam: Boom.