The Importance of the Relationship With the Therapist:

by Lynne Knobloch-Fedders, PhD

The Importance of

the Relationship

With the Therapist:

Research shows that the therapeutic

relationship is one of the strongest

predictors of successful treatment

Before beginning psychotherapy, most patients

wonder, “Will this counseling really help me with

my problems?” Research shows that many factors

affect whether treatment is successful, including

the severity of the problem(s) being treated, the

patient’s belief that the counseling will work and

the skill level of the therapist.

However, research over the past ﬁfty years has

demonstrated that one factor – more than any

other – is associated with successful treatment:

the quality of the relationship between the therapist

and the patient.

In 1913, Sigmund Freud hypothesized that the

relationship between the therapist and patient was

a key component of successful treatment. Since

that time, research has shown that the quality of

this relationship (the “therapeutic alliance,” as it is

called) is the strongest predictor of whether or not

therapy is successful.

Strikingly, the quality of the therapeutic

relationship appears critical to treatment success

no matter what type of treatment is studied. Large

studies have been conducted of individual, couple

and family therapy, using a variety of assessment

methods to measure the quality of the relationship

(i.e. patient or therapist reports or observational

ratings). These studies, which used diverse

patient groups (children and adults, in-patients

and out-patients) treated for all types of problems

(i.e. depression, anxiety, drug abuse, work and

social problems), all show the importance of the

therapeutic relationship on treatment outcome.

Our mission is to strengthen and heal families

from all walks of life through clinical service,

community outreach, education and research.

A T N O R T H W E S T E R N U N I V E R S I T Y

T H E F a m i l y I N S T I T U T E

Clinical Science Insights

Knowledge Families Count On

Volume 1

“A little over half of the beneﬁcial effects of

therapy accounted for [in previous research] are

linked to the quality of the alliance,” according

to Dr. Adam Horvath, a professor at Simon Frasier

University and a leading expert in research on the

patient-therapist relationship.

Interestingly enough, patients and therapists

often (but not always) agree on the quality of their

relationship. However, it is the patient’s perception

of the quality of the relationship that is the strongest

predictor of treatment success. Patients’ ratings

of their relationship with the therapist, even very

early in the treatment – after the ﬁrst session or

two – predict their improvement over the course

of treatment. However, patients who report poor

relationships with their therapists are more likely

to drop out of treatment early.

What exactly is a “good” therapeutic relationship?

Since the relationship between the therapist and

patient appears so crucial to treatment success,

experts have tried to deﬁne a “good relationship.”

One pioneering expert, Dr. Edward Bordin, deﬁned

a good therapeutic relationship as consisting of

three essential qualities: an emotional bond of trust,

caring, and respect; agreement on the goals of

therapy; and collaboration on the “work” or tasks

of the treatment.

A shared sense of ownership for the treatment

also appears essential. Do the therapist and patient

trust that the other is working hard to contribute

to the treatment’s success? Do they collaborate

together on decisions that need to be made about

the way the treatment is being conducted and what

intervention strategies are used?

Every close relationship has problems, difﬁculties

or misunderstandings, and the relationship

between the therapist and patient is no exception.

However, the manner in which the therapist and

patient handle these difﬁculties together is another

crucial component of the success of the

Clinical Science Insights: Knowledge Families Count On v.1 The Importance of the Relationship With the Therapist

Qualities of a good therapeutic

relationship:

- Mutual trust, respect, and caring

- General agreement on the goals

and tasks of the therapy

- Shared decision-making

- Mutual engagement in “the work”

of the treatment

- The ability to talk about the

“here-and-now” aspects of

the relationship with each other

- The freedom to share any

negative emotional responses

with each other

- The ability to correct any

problems or difﬁculties that

may arise in the relationship

T H E F a m i l y I N S T I T U T E AT N O R T H W E S T E R N U N I V E R S I T Y

relationship. When difﬁculties arise, can the

therapist and patient share any negative feelings,

hurt or anger that may have resulted? And, can

they work together to resolve any problems that

may occur in their work together?

The importance of an expanded conceptualization

of the “therapeutic relationship”

Historically, study of the therapeutic relationship

has focused solely on the patient’s relationship

with the therapist. However, research conducted

at The Family Institute at Northwestern University

by myself and Dr. William Pinsof demonstrates

the importance of expanding this deﬁnition to

include the inﬂuence of signiﬁcant other people

in the patient’s life. For example, in individual

therapy, support of the treatment by the patient’s

signiﬁcant others (family members, spouse,

close friends) was associated with successful

outcome. In couple therapy, the extent to which

the couple agreed with each other on treatment

tasks, goals and bonds predicted whether therapy

would be successful.

What do therapists do to establish a good

therapeutic relationship?

Research shows that the ability to form good

relationships with patients is not simply a

function of therapist training or experience level.

Many beginning therapists are as skilled as their

more experienced counterparts at forming good

therapeutic relationships. However, studies

show that experienced therapists are better at

forming relationships with those patients who

have struggled in past relationships. In addition,

experienced therapists are better than novices

at identifying and resolving problems in the

therapeutic relationship.

Therapists make important contributions to the

establishment of a good therapeutic relationship.

The therapist’s ability to communicate empathy

and understanding to the patient is very important.

Another essential component is the therapist’s

openness, ﬂexibility and willingness to adapt the

treatment to the patient’s needs. Skilled therapists

actively solicit patients’ input about the goals

and methods of treatment, in order to facilitate

collaboration.

What helps patients establish a good therapeutic

relationship?

Research shows that patients are more likely to

establish a good therapeutic relationship when they

have good interpersonal and communication skills.

For example, patients are more likely to form good

relationships with their therapists when they are

open and honest about their needs.

What should I do to try to improve my relationship

with my therapist?

If you are having difﬁculties with your therapist,

it is important to talk about that directly with

your therapist. If you have questions or concerns

about any part of the treatment, do not hesitate

to discuss them with your therapist. Open, honest

communication is a very healthy strategy for

resolving difﬁculties. In fact, studies show that

engaging in this kind of “talking about the

relationship” is a very effective therapy strategy for

improving the relationship, thus improving your

chances of treatment success.

References

Hatcher, R.L. (1999). Therapists’ view of treatment alliance and collaboration

in therapy. Psychotherapy Research, 9, 405-423.

Horvath, A.O. (2001). The alliance. Psychotherapy, 38(4), 365-372.

Martin, D.J., Garske, J.P., & Davis, K.M. (2000). Relation of the therapeutic

alliance with outcome and other variables: A meta-analytic review. Journal of

Clinical and Consulting Psychology, 68, 438-450.

Author Biography

Lynne Knobloch-Fedders,

PhD, is a licensed clinical

psychologist and Assistant

Director of Research

at The Family Institute at

Northwestern University.

She has conducted several research studies on the

effect of the therapeutic relationship in individual,

couple and family therapy.

Clinical Science Insights: Knowledge Families Count On v.1 The Importance of the Relationship With the Therapist

A T N O R T H W E S T E R N U N I V E R S I T Y

T H E F a m i l y I N S T I T U T E

The Family Institute at Northwestern University is the

Midwest’s largest center for marital and family therapy,

education, research and community outreach. The Institute

provides counseling and psychotherapy throughout the

Chicago metropolitan area, including community-based

mental health services for low-income, at-risk families.

It also conducts important research projects that lead to

a better understanding and treatment of mental health

issues and operates nationally-renowned graduate programs

in marital and family therapy and counseling psychology

in afﬁliation with Northwestern University.

For more information on The Family Institute, visit

www.family-institute.org or call 847-733-4300.

FSC Recycled