A significant shift has taken place in psychotherapy over recent years.
Based on continuing research, it has become clear that the client and therapist are equal partners, and there must be a move toward a greater degree of mutuality (DeAngelis, 2019).
Crucially, it is about the therapist committing to be a partner rather than a director in the relationship (DeAngelis, 2019).
As a great deal of therapy continues to move online, the therapeutic relationship remains essential to the outcome of the process, perhaps even more so (Kamphorst, 2017).
This article looks at the critical elements of that relationship and how it can be improved using digital techniques and communication methods.
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What Is the Therapeutic Relationship? 4 Examples
The connection between patient and therapist is crucial. Indeed, the “therapeutic relationship is as powerful, if not more powerful, than the particular treatment method a therapist is using,” says professor John Norcross, part of a task force set up by the American Psychological Association (APA; DeAngelis, 2019).
The task force found that even if the therapy is correct for the problem a client presents with, the client will not get the most out of the treatment if the connection is not a good one.
After all, “different types of psychotherapy often reveal similar results,” suggesting that there are common, non-therapy-specific variables coming into play, such as the therapeutic relationship (Ardito & Rabellino, 2011, p. 2).
As far back as 1990, studies have confirmed the association between good therapeutic relationships and positive therapeutic outcomes (Horvath & Marx, 1990).
In the early phases of the therapeutic relationship, the client must see the therapist as supportive. In later sessions, the relationship with the therapist must be viewed as a collaborative approach to overcome the patient’s problems. Shared responsibility and communion are essential in achieving the goals of therapy (Ardito & Rabellino, 2011).
But why is the therapeutic relationship so meaningful?
Research and anecdotal evidence confirm that the therapeutic relationship is a defining factor in treatment success.
- A 2018 meta-analysis of 21 studies found that when therapists share their feelings about the client or the therapeutic relationship, the client’s degree of self-insight and mental health functioning improves (Hill, Knox, & Pinto-Coelho, 2018).
- Another review of 107 studies identified that improved collaboration when setting patients’ goals led to enhanced therapy outcomes (Tryon, Birch, & Verkuilen, 2018).
- Clinical researcher Orya Tishby provides the example of a patient treated for a social phobia who repeatedly failed to follow through with exposure protocol, such as initiating a conversation with a stranger.
Tishby began an open dialogue with the client to discuss how they felt about being rejected by a stranger and not complying with the treatment. The solid therapeutic relationship they shared led to better outcomes through a more nuanced approach that slowed the pace of the treatment and increased the number of check-ins (DeAngelis, 2019).
- Author and university professor Marvin Goldfried warns that clients also pick up on cues from the therapist. If the therapist is bored or frustrated, it will show in nonverbal signals (tone of voice, lack of eye contact, posture, etc.). Unless the therapist can move from a sense of blame to realizing that the client is “stuck in some uncomfortable way of living,” it could impact the therapy outcome (DeAngelis, 2019).
6 Components of a Positive Therapeutic Alliance
Relationships with patients are a crucial factor in the therapeutic outcome.
Therefore, therapists need to foster the development of the therapeutic alliance early in the process (DeAngelis, 2019).
The APA suggests an emphasis on six valuable components to build a beneficial therapeutic relationship (DeAngelis, 2019; Hill et al., 2018; Tryon et al., 2018).
While many of these points have been written with face-to-face coaching in mind, there is no reason to consider them any less relevant to online or blended care. As long as regular contact is maintained, perception regarding the therapeutic alliance can be highly positive with little difference in outcomes compared to face-to-face therapy (Tremain, McEnery, Fletcher, & Murray, 2020).
1. Fostering mutuality and collaboration
Psychotherapy is a two-way relationship. The therapist and client are equal partners in the process and benefit from shared commitment and openness. If the therapist remains open regarding their feelings concerning both their relationship and the client, it leads to greater mutuality.
Along with perceiving the alliance as collaborative, mutuality improves the direction the therapy and therapeutic relationship take and the chance of actualizing therapy goals.
2. Remaining flexible and responsive
The therapist must remain cognizant of the client’s individual characteristics (gender identity, spiritual beliefs, cultural background, etc.) while tuning into their specific motivations and personality traits to tailor treatment and build an appropriate relationship.
If successful, the therapist will be better able to identify what works well and what is being resisted during therapy.
3. Incorporating feedback
Gathering and including feedback in the therapeutic process can be valuable for identifying red flags that require immediate action, including substance abuse, the potential for violence, and the risk of suicide.
Questionnaires completed before each session have proven successful at identifying patients at risk of dropping out of therapy or of harmful behavior. Once analyzed, the answers can also form part of a practical feedback loop that can help the therapist avoid blind spots and learn from their mistakes.
4. Repairing breakdowns in therapy
Like any other relationship, the therapeutic relationship can break down. Yet, repairing disagreements or ruptures (regarding therapy goals, mistrust of the treatment, misunderstandings, etc.) can lead to a stronger alliance and ultimately better outcomes.
The therapist can recognize confrontation ruptures from the client’s anger and repeated challenges, and withdrawal ruptures from the client pulling away from what they perceive as the therapist’s criticisms or a painful discussion.
While facing up to and working through conflict can be difficult, it can, in time, aid the patient’s growth and strengthen the therapeutic relationship.
5. Handling negative emotions
Unsurprisingly, clients often have painful, upsetting, and negative feelings to work through. Managing such negative states throughout multiple sessions can be frustrating for the therapist. However, if the client picks up on nonverbal or verbal indications of the therapist’s feelings – possibly brought on by their own background – it could harm the relationship.
It is crucial for therapists to remain self-aware and continue to examine their feelings and how they may impact discussions.
6. Promoting a positive end to therapy
Termination can be helped through open and regular mutual discussion.
Conversations about how the therapy went, the gains the client has made, and how they will cope with future challenges can promote better outcomes. Talking about what ending the treatment means and expressing pride in the progress and the relationship formed can be affirming and offer a sense of closure.
Improving the Therapeutic Relationship Digitally
Ribbers and Waringa (2015, p. 4) describe digital therapy (also known as e-therapy) as offering “therapy that is potentially time and location independent.”
Counselors and clients may interact through both asynchronous and synchronous channels, including any of the following (Ribbers & Waringa, 2015):
- Phone call
- Online chat
Digital or blended therapy is so successful that initial indications suggest that it is as effective or more than regular, face-to-face therapy (Ribbers & Waringa, 2015).
Inevitably, therapists and clients may have some concerns over whether it is possible to grow and maintain a therapeutic relationship digitally (Kanatouri, 2020).
Organizations such as the Samaritans, which offers a crisis hotline in the United Kingdom, have provided psychological support by phone (and more recently email and instant messaging) for over 65 years (Kanatouri, 2020).
In recent years, digital coaching has become an increasingly common and effective mode of coaching. The use of digital methods has many of the same benefits for both coaching and therapy in terms of building effective relationships between professionals and clients (Ribbers & Waringa, 2015; Kanatouri, 2020).
Here are some examples:
- Therapists and clients can communicate more frequently from the convenience of the office, home, or elsewhere.
- Direct communication (phone, video, online chat) can be scheduled for short catch-ups, performed in close proximity (time or location) to the troubling or upsetting situation.
- Indirect communication (email or dedicated digital therapy tools such as Quenza) enables messages, support, and homework to be sent and received at a time that suits both client and therapist. Quenza allows for automated, scheduled sending of psychoeducation and homework at predefined intervals.
- With the potential of digital technology to help scale services, therapy support can be provided more regularly to more clients, maximizing the time and resources of the therapist.
- Quenza, a professionally designed and implemented therapy platform, provides structure and increased access to knowledge sharing while supporting learning between sessions.
Individually and combined, the advantages offered by digital media, communication, and online platforms can support the components of a positive therapeutic alliance discussed above. And crucially, digital mental health interventions appear highly effective for a range of mental health outcomes (Tremain et al., 2020).
10+ Virtual Techniques for Building a Positive Relationship
The value of digitally delivered homework in developing the therapeutic alliance was recognized as far back as 2000.
Murdoch and Connor-Greene (2000) identified the potential of email as a virtual therapy to enhance the involvement and engagement of patients in treatment and the power of computer application to strengthen adherence.
Twenty years on and the potential for digital mental health interventions to revolutionize mental health is becoming self-evident. A review of the literature performed in 2020 found that an improved therapeutic alliance is associated with “increased engagement and adherence to digital interventions, through which it appears to influence outcomes” (Tremain et al., 2020, p. 1).
There are several digital attributes at play (Kanatouri, 2020):
- Asynchronous communication
Email, sending and receiving messages, and homework within an online therapy tool can enhance the client’s reflection, but requires appropriate well-thought-out interventions.
- Improved auditory-verbal communication
Can increase focus on the subject matter.
- Increased visual communication
Encourages building trust and rapport.
- Texting tools
Such as online chat and SMS to guide clients through problem solving.
- Visual aids
Infographics, slides, and diagrams to aid the client’s understanding and ability to see things from other points of view.
Factors that may affect the therapeutic alliance in digital environments include (Tremain et al., 2020):
- Digital availability
How freely available and convenient is the digital intervention?
- Digital interactivity
What degree of personalized feedback is provided? To what degree does the user feel in control?
- Degree of human support
What degree (and type) of support is available in the digital environment?
Well-thought-out digital therapy platforms, such as Quenza, have implemented such factors to provide therapists and clients with an interactive experience where timely feedback can be given.
To extend the degree of virtual immersion further, virtual reality offers varying degrees of mirroring reality and simulating the real world, and it is increasingly being used in therapy. Placing clients in controlled, modifiable environments has become part of exposure therapy to treat patients with phobias (Maples-Keller, Bunnell, Kim, & Rothbaum, 2017).
Immersive virtual reality has also proven successful in coaching, providing clients with the opportunity to learn new skills and interact with others (including groups) receiving treatment or the professional coach or therapist (Kanatouri, 2020). It is easy to imagine the therapist’s avatar accompanying the client to situations that typically cause distress and providing in situ support and interventions.
Avatars and coaching chatbots offer the perception of human presence, helping to strengthen (human or AI) therapeutic relationships, which shapes the experience of the therapy and potentially its outcome (Kanatouri, 2020).
In summary, whatever form the digital tools and techniques take, it is essential that the therapist consider the following medium-specific guidance (Kanatouri, 2020):
- Adapt to the relevant sensory cues.
- Make good use of listening skills (phone or video).
- Increase the use of powerful questions to guide client’s cognitive processes.
- Use vivid, descriptive language, potentially using analogies and metaphors (primarily when text based).
- Adopt visual aids such as emoji, pictures, and avatars.
When used in combination, to the right degree, and with appropriate feedback, it is possible to tailor techniques to build and maintain positive therapeutic relationships.
Using Questionnaires & Scales to Measure Your Relationship
There is a range of measures and instruments available for scoring the therapeutic alliance between client and therapist; they include (Simpson & Reid, 2014):
- Working Alliance Inventory: This is a 36-item measure of a client’s psychotherapy experience, including trust and empathy with the therapist.
- Penn Helping Alliance Scale: This 10-item instrument includes scoring of the helpful attitude of the therapist and the sense of forming a team together.
- Agnew Relationship Measure: This tool has a straightforward format and easily understood language and is therefore practical with all forms of therapy.
- Session Evaluation Questionnaire: Psychotherapy sessions are scored on multiple dimensions, including whether they were powerful and valuable versus weak and worthless, and relaxed and comfortable versus tense and distressing.
- Distance Communication Comfort Scale: This 27 item self-report questionnaire captures the degree of comfort in face-to-face, videoconferencing, and phone communications.
Each scale varies in the number of questions and the information it provides. Find one appropriate to your needs without being so lengthy that it leads to clients’ failure to complete.
A Take-Home Message
In psychotherapy, the therapeutic alliance between client and therapist greatly influences treatment outcome. According to the APA, it is as influential as choosing the correct treatment method (DeAngelis, 2019).
The wealth of research that confirms the link between the quality of that alliance and positive outcomes in both youth and adult psychotherapy warrants therapists’ extra focus on building and maintaining that relationship throughout treatment (Ardito & Rabellino, 2011).
To build such a successful relationship, you might consider Quenza as your digital platform of choice. Quenza was created by the founders of PositivePsychology.com with the help of the wider positive psychology community. It was designed from the ground up to assist therapists and improve the client–therapist relationship.
We recommend Quenza as the best tool to build digital therapeutic relationships because it offers therapists a powerful and flexible online platform to focus on the needs of their clients. The wealth of digital tools provided by Quenza enable the therapeutic alliance to be developed and remain central to therapeutic success.
Digital interventions typically have a greater degree of adherence and engagement and are particularly helpful for managing procrastination and motivational issues (Tremain et al., 2020).
Quenza fosters essential client trust and confidence via immediate one-to-one conversations through chat functionality and asynchronous communication, including email, automated homework, and psychoeducation.
As more and more therapists turn to digital technology to communicate, assess, and share psychoeducation and homework, it remains crucial to consider its potential for strengthening the therapeutic alliance and improving the likelihood of positive outcomes.
Why not try out Quenza’s tools to promote regular knowledge sharing and support learning between sessions to build new and strengthen existing therapeutic relationships? A 30-day trial is offered for $1, allowing you to see the value of this powerful application.
We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free.
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- DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes. Monitor on Psychology, 50(10). Retrieved May 11, 2021, from https://www.apa.org/monitor/2019/11/ce-corner-relationships
- Ardito, R. B., & Rabellino, D. (2011). Therapeutic alliance and outcome of psychotherapy: Historical excursus, measurements, and prospects for research. Frontiers in Psychology, 2.
- Hill, C. E., Knox, S., & Pinto-Coelho, K. G. (2018). Therapist self-disclosure and immediacy: A qualitative meta-analysis. Psychotherapy, 55(4), 445–460.
- Horvath, A. O., and Marx, R. W. (1990). The development and decay of the working alliance during time-limited counseling. Canadian Journal of Counselling and Psychotherapy, 24(4), 240–259.
- Kamphorst, B. (2017). E-coaching systems. Personal and Ubiquitous Computing, 21, 625–632.
- Kanatouri, S. (2020). The digital coach. Routledge.
- Maples-Keller, J. L., Bunnell, B. E., Kim, S. J., & Rothbaum, B. O. (2017). The use of virtual reality technology in the treatment of anxiety and other psychiatric disorders. Harvard Review of Psychiatry, 25(3), 103–113.
- Murdoch, J. W., & Connor-Greene, P. A. (2000). Enhancing therapeutic impact and therapeutic alliance through electronic mail homework assignments. The Journal of Psychotherapy Practice and Research, 9(4), 232–237.
- Ribbers, A., & Waringa, A. (2015). E-coaching: Theory and practice for a new online approach to coaching. Routledge.
- Simpson, S. G., & Reid, C. L. (2014). Therapeutic alliance in videoconferencing psychotherapy: A review. Australian Journal of Rural Health, 22(6), 280–299.
- Tremain, H., McEnery, C., Fletcher, K., & Murray, G. (2020). The therapeutic alliance in digital mental health interventions for serious mental illnesses: Narrative review. JMIR Mental Health, 7(8).
- Tryon, G. S., Birch, S. E., & Verkuilen, J. (2018). Meta-analyses of the relation of goal consensus and collaboration to psychotherapy outcome. Psychotherapy, 55(4), 372–383.