The Therapeutic Relationship

We know from outcome research that the therapeutic relationship is an important factor. Bruce Wampold says the actions that characterize effective therapists are “warmth and acceptance, empathy, and focus on other.” But it is the colaborative nature of the work of psychotherapy that builds the relationship. Early gains create a better alliance and a better outcome.

I had a maths teacher in high school. He was old, bald and large. Kind of your stereotypical 1970’s maths teacher. He was not warm. I wouldn’t have called him empathic. If anything he was aloof and a little intimidating, but boy could he teach maths. I liked him for many reasons, particularly for the way he handled a friend of mine. This boy was smart and outspoken, and mucked up in every class. Teachers got exasperated with him and ended up losing their dignity and our respect. This guy was different. He was straight, firm and fair, no matter how provoked. He had a way of diverting the muck up and getting back on task. He was doggedly attached to teaching us maths, and I would say he was doggedly attached to us learning, my friend included. I think we all felt the investment he had in us, not for him, but for us. There was no criticism, and no praise, there was just learning maths. I liked maths. Early on my father spent time with me, I see now, in deliberate practice. Doing homework and then whipping up my enthusiasm for extra practice. Those early gains meant I was good at maths by the time I hit this man’s class.

One of my indelible memories was of learning logarithms, which we did the old way with logarithm books. I thought it was stupid and irrelevant at first. I think he must have known, because I was normally such a girly swot, and this was different. I remember talking to my mum about this and she suggested I think about it as mental gymnastics. Do it for fun, learning a skill with no relevance, just to see if you can. So I did. When he was walking around the room handing our tests back he got to mine. The look on his face scared me, and there was a slight raise of his eyebrow as he made eye contact with me. I looked at my mark of 100% and looked back up, but he was gone. It felt very good. I went on to get the prize for advanced maths at the end of high school. A good outcome.

The teacher student relationship I had with him was pivitol, but to call it warm and empathic would not only be wrong, but it would miss the best bit, which I think was the power of his belief.

One of my favourite stories that Erickson told about his work is written up in The Letters of Milton H Erickson (Zeig & Geary p 122 – 127) In 1936 he worked with a 24 year old Italian flutist who came to him demanding hypnosis for a swollen, chapped lower lip which he’d had for 6 years despite all attempts to treat it. The session reads like 2 Napoleans going head to head with binds and therapeutic double binds flying around the room. There was nothing warm or empathic about the relationship but Erickson was intensely invested in this fellows therapy, and doggedly attached to the outcome. Like my maths teacher he didn’t get triggered by the client’s bad behaviour, he didn’t get exasperated, there was total acceptance of the client and his problem dance, and total belief that the therapy would work. The man’s long history of resignation about a possible cure stood no chance in the face of Erickson’s dogged determination. It was clear though that Erickson felt light and playful, I could almost hear him chuckle as I read his words. The lip healed and the man got a job as first flutist in the W.P.A orchestra. A good outcome.

Erickson said that the client didn’t need to like him, they just needed to know that he could do therapy. He also said “Just do good work.”

I wonder if the emphasis on the warm fuzziness of the therapeutic relationship may have clouded our looking at what it really is that we do, when we do good work.

What do you think?



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