The Therapeutic Relationship

The Therapeutic Relationship

We have known for a long time that the strength of the therapeutic relationship between the therapist and the patient is the biggest single factor in bringing about positive change in the patient over a course of therapy. It is a non-specific factor in that this holds true no matter what type of psychotherapy is used. The other main factors of next importance are related. These are the positive regard the therapist has for the patient and the joint expectation by both the patient and the therapist that there will be positive change and recovery. I will add two other factors. The first comes from studies in post-traumatic stress disorder. It has been shown that the therapy is more effective when the patient moves from relatively low arousal to a higher arousal then back down to a lower arousal within the session. Another way of putting it is it is the pendulation from a relative parasympathetic state to sympathetic arousal then back to parasympathetic. Why might this be? It has to do with the fact that trauma results in dysregulation of the nervous system, so changes in this system need to be involved in the session. The other factor I add is the ability of the patient to give feedback to the therapist at the end of every session. This is an aspect many of us don’t deal with at all. It is difficult to get feedback without making it be about ourselves. We will go into detail on ways to do this later on.

The five non-specific factors are focused on the process of the therapy. While all our types of therapy – the content - is important, the research is clear that the process is more important than the content. When I first went into practice, I did not understand this. I thought if I learned a wide variety of therapeutic techniques and used them well, I would be a good therapist. I was wrong. I learned over time what Babette Rotschild said, “The best thing we can bring to therapy is ourselves”. This also meant a self with a personal knowledge of my own past and how that past continues to affect me. And also, a self that is autonomically well regulated. So, if we know the therapeutic relationship is so such a critical factor in good therapy how do we improve it? In school and training they don’t teach us a lot about this. Much of the Somatic Resiliency approach is about strengthening the therapeutic alliance.

The most important task is Get therapy yourself.

If you have not been in personal individual therapy or are not in it now, I highly recommend you begin the process of facilitates self-discovery. I will go as far as to say if you have not or are not doing this you are dangerous as a practitioner and you won’t even know it. We unintendedly hurt and shame our patients from time to time. If you have not done or are not doing your own work you will hurt and shame your patients frequently. Christine Courtrois, PhD, put it well when she said, “Only therapists who have had the opportunity to experience and work through their own trauma will be able to accompany patients on the path to truth and not hinder them on the way”. Alan Schore, PhD, put it this way. “At the fundamental level the work of psychotherapy is not defined by what the therapist explicitly says to the patient. Rather, the key mechanism is how

to implicitly and subjectively be with the patient”.

I do believe the more I know about myself, my strengths, weaknesses, shame etc., the better I am for my patients. Practicing psychotherapy without having dealt with your own issues is like playing the violin in an orchestra without tuning it.

A related issue is nurturing your spiritual life. All genuine healing has a spiritual component. All my mentors, both personal ones and great writers on psychotherapy say the same thing.

I think we must be grounded in our spirituality. Trauma wounds the souls and spirits of our patients, so to guide them on the difficult path of recovery we must ourselves be connected to a spiritual source of goodness, love, and joy. Our traumatized patients often have a lot of confusion and uncertainty in their spiritual lives. Also, many have experienced religious trauma. At times we will encounter great evil that has been done to our patients. We will hear almost impossible to imagine horror stories which some of our patients have experienced and lived through. This includes victims of child pornography rings, sex trafficking, those who have been slaves, and in some cases ritual abuse. Our faith in humanity can be severely challenged when doing trauma work. It is easy to become depressed, despairing, burned out, chronically angry, or indifferent. If we do not have a strong spiritual life, or are not grounded in our own spiritual source, or if we believe that evil is an abstract concept and does not really exist, then it is better if we don’t try to work in this field.

Another aspect of our work in maintaining a positive working therapeutic alliance is the willingness to say, “I’m sorry” when we are wrong or have inadvertently hurt or shamed the patient in some way.

The last aspect of the therapeutic alliance is the tremendous benefit to us as clinicians and to our patients when we solicit feedback after every session. I did not do this for the longest time as I did not know how to do this without making it about myself. Some colleagues suggested “What was this session like for you”? or “What was helpful to you in this session”? or “What did you find troublesome or unhelpful about this session”? or “What type of work did we do today that you want more of”? I tend to like the fist one above which I try to use although sometimes forget. When we do this, it is a great boost to the therapeutic alliance and it is one more way of working collaboratively with our patients.