Therapeutic Relationships

When patients first come to a psychotherapist, they have in mind some
things about their lives that need to be changed. The psychotherapist recognizes
that before this can be accomplished, a trusting relationship must be established with patients. This has been termed the “therapeutic alliance”
or a “collaborative relationship.” Establishing this relationship becomes the
first goal of therapy. Patients must learn that the therapist understands them
and can be trusted with the secrets of their lives. They must also learn about
the limits of the therapeutic relationship: that the psychotherapist is to be
paid for the service, that the relationship will focus on the patients’ concerns
and life experiences rather than the psychotherapist’s, that the psychotherapist
is available to patients during the scheduled sessions and emergencies
only, and that this relationship will end when the psychotherapeutic
goals are met.
The therapist looks early for certain recurring patterns in what the patient
thinks, feels, and does. These patterns may occur in the therapy sessions,
and the patient reports about the way these patterns have occurred in
the past and how they continue. These patterns become the focal theme for
the therapy and are seen as a basic reason for the patient’s troubles.
For example, a patient may complain that he has never had the confidence
to think for himself. He reports that his parents always told him what
to do, without explanation. In his marriage, he finds himself unable to feel
comfortable with making any decisions, and he always looks to his spouse for
the final say. This pattern of dependence may not be as clear to the patient
as to the psychotherapist, who looks specifically for similarities across past
and present relationships. Furthermore, the patient will probably approach
the psychotherapist in a similar fashion. For example, the patient might ask
for the psychotherapist’s advice, stating that he does not know what to do.
When the psychotherapist points out the pattern in the patient’s behavior,
or suggests that it may have developed from the way his parents interacted
with him, the psychotherapist is using the technique of interpretation. This
technique originated in the psychodynamic models of psychotherapy.
When patients are confronted with having such patterns or focal themes,
they may protest that they are not doing this, that they find it difficult to do
anything different, or that they cannot imagine that there may be a different
way of living. These tendencies to protest and to find change to be difficult
are called “resistance.” Much of the work of psychotherapy involves overcoming
this resistance and achieving the understanding of self called insight.
One of the techniques the psychotherapist uses to deal with resistance is
the continued development of the therapeutic relationship in order to demonstrate
that the psychotherapist understands and accepts the patient’s
point of view and that these interpretations of patterns of living are done in
the interest of the achievement of therapeutic goals by the patient. Humanistic
psychotherapists have emphasized this aspect of psychotherapeutic
technique. The psychotherapist also responds differently to the patient
from the way others have in the past, so that when the patient demonstrates
the focal theme in the psychotherapy session, this different outcome to the
pattern encourages a new approach to the difficulty. This is called the corrective emotional experience, a psychotherapeutic technique that originated
in psychodynamic psychotherapy and is emphasized in humanistic
therapies as well.
For example, when the patient asks the psychotherapist for advice, the
psychotherapist might respond that they could work together on a solution,
building on valuable information and ideas that both may have. In this way,
the psychotherapist has avoided keeping the patient dependent in the relationship
with the psychotherapist, as the patient has been in relationships
with parents, a spouse, or others. This is experienced by the patient emotionally,
in that it may produce an increase in self-confidence or trust rather
than resentment, because the psychotherapist did not dominate. With the
repetition of these responses by the psychotherapist, the patient’s ways of relating
are corrected. Such a repetition is often called working through, another
term originating in psychodynamic models of therapy.
Psychotherapists have recognized that many patients have difficulty with
changing their patterns of living because of anxiety or lack of skill and experience
in behaving differently. Behavioral therapy techniques are especially
useful in such cases. In cases of anxiety, the patient can be taught to relax
through relaxation training exercises. The patient gradually imagines performing
new, difficult behaviors while relaxing. Eventually, the patient
learns to stay relaxed while performing these behaviors with the psychotherapist
and other people. This process is called desensitization, and it was originally
developed to treat persons with extreme fears of particular objects or
situations, termed phobias. New behavior is sometimes taught through
modeling techniques in which examples of the behavior are first demonstrated
by others. Behavioral psychotherapists have also shown the importance
of rewarding small approximations to the new behavior that is the
goal. This shaping technique might be used with the dependent patient by
praising confident, assertive, or independent behavior reported by the patient
or shown in the psychotherapy session, no matter how minor it may be
initially.