02 Jan Reflections on the Importance of the Therapeutic Relationship in the Era of “Evidence Based Treatments”

Posted at 9:29 am in Individual Therapy by jlbworks

By Philip Chanin, Ed.D., ABPP, CGP
Board Certified Clinical Psychologist
Assistant Clinical Professor, Department of Psychiatry
Vanderbilt University Medical Center

“In my early professional years, I was asking the question: How can I treat, or cure, or change this person? Now I would phrase the question in this way: How can I provide a relationship which this person may use for his own personal growth?” — Carl Rogers

Recently I was having lunch with a young colleague, relatively new to psychotherapy practice. She was talking about how she had been taught in her graduate program that a focus of psychotherapy, especially given “managed care” guidelines, should be to help patients complete individual counseling as quickly as possible. I responded to her by saying that my 43-year experience as a psychotherapist has taught me that I should not be in hurry to terminate a patient’s treatment. Instead, I want to offer the patient a therapeutic relationship that she or he can utilize, often over many years, to heal past trauma and develop a fulfilling life.

Writing in the New York Times, on August 11, 2019, following the death of Toni Morrison, novelist Jesmyn Ward paid tribute to Morrison’s enormous impact on her life. Ward writes, “There was something about that absolute narrative presence that communicated this: ‘You are worthy to be seen. You are worthy to be heard. You are worthy to be sat with, to be walked beside. Even in your quietest moments, you are worthy of witness.’”

Ward’s testimony to Morrison reflects one of my goals as a psychotherapist, which is to help my patients to tell their stories, as I bear witness to their pain, and assist them in developing—often for the first time—a belief that they have worth and value. Thinking of her own life, novelist Ward continues, “I was walking the desert, waiting for a word. A word that would sound out of the wilderness to declare that it was speaking to me, for me, within me. The sonic sear of that voice: a new knowing of not only the world I walked, but of me.” In psychotherapy, during individual counseling we help our patients to find their own authentic voices, that were often long ago drowned out by the expectations and demands of other figures in their early lives.

Nancy McWilliams, writing in Psychoanalytic Case Formulation (1999), stresses the critical importance of the relationship between patient and analyst: “Although contemporary analysts consider understanding, especially the affectively charge ‘Aha!’ kind of understanding that has usually been termed ‘emotional insight,’ to be of immense therapeutic significance, they also credit numerous ‘nonspecific factors (e.g., the therapists’ quiet modeling of realistic and self-respectful attitudes, the client’s experience and internalization of the therapist’s stance of acceptance, the fact that the therapist survives the patient’s seemingly toxic states of pain and rage) with just as much power. In fact, over the past couple of decades, almost all psychoanalytic writing about what is curative in therapy stresses relationship aspects of the treatment experience over traditional notions of insight.” (p. 14).

In elaborating on this point, McWilliams goes on to say: “The analytic emphasis on understanding is partly attributable to the fact that the two participants in the work need something interesting to talk about while the nonspecific relational factors are doing their quiet healing.”

In his seminal article in the American Psychologist (February-March,2010), titled “The Efficacy of Psychodynamic Psychotherapy,” Jonathan Shedler outlines the focus in psychodynamic psychotherapy on the therapy relationship: “The relationship between therapist and patient is itself an important interpersonal relationship, one that can become deeply meaningful and emotionally charged. To the extent that there are repetitive themes in a person’s relationships and manner of interacting, these themes tend to emerge in some form in the therapy relationship.”

Shedler concludes, “The recurrence of interpersonal themes in the therapy relationship (in theoretical terms, transference and countertransference) provides a unique opportunity to explore and rework them in vivo. The goal is greater flexibility in interpersonal relationships and an enhanced capacity to meet interpersonal needs.” (p. 99)

In an NPI presentation I gave in 1996, at the end of my year as Chair of the NPI Board of Directors, I spoke about the critical importance of the “non-anxious presence” of the psychotherapist in assisting the change process. To begin this talk, I mentioned Murray Bowen, one of the founding fathers of family therapy, who put a great emphasis, for both therapist and patient, on the differentiation process. In family systems theory, differentiation is an instinctively rooted life force which propels the developing child to grow to be an emotionally separate person, with the ability to think, feel, and act for him or herself. The further our differentiation process proceeds, the more capable we are of non-reactively participating in and maintaining relationships.

Edwin Friedman was an ordained rabbi and family therapist who practiced in Washington, D.C., for more than 35 years. Friedman was an articulate voice for applying Bowen’s theories. My first exposure to Friedman was in his Family Therapy Networker article of May-June, 1987, entitled, “How to Succeed in Therapy Without Really Trying.” Friedman credits Bowen for helping him to understand that the key element in psychotherapy is the “non-anxious presence” of the therapist, functioning in a non-willful manner. According to Friedman, Bowen “believes that if one can maintain a non-anxious presence in any system, that very style of functioning in itself will have a beneficial effect, no matter what the problem.” (p. 30)

From Bowen, Friedman learned that it was his non-anxious curiosity about a patient or family which was most responsible for any change which might take place. He elaborates,

“When the therapist’s primary concern is understanding the human condition, a
natural patience emerges that enables one to out wait the resistance demons that,
like the swiftest horses, can only beat humans over a short course…if you genuinely
want to learn, you must not be willful about life, but rather let it teach you. That
means you try not to interfere too much with what you are observing, except in
a manner that will bring it more into relief…When the task of the clinician becomes
learning about life rather than imposing change, the challenge of therapy lies no
longer in the contest of will with the client, but in satisfying one’s own curiosity
about what makes people tick.” (pp. 31 & 68)

In concluding his article, Friedman returns again to the central importance of differentiation, both by therapist and patient or client. He writes,

“I am after one thing, no matter what the symptom—promoting differentiation
throughout the system. This takes me totally out of the willful position of assuming
I know what choices are best for my clients. For me, symptoms are not an enemy,
to be eliminated, but pathways that lead me in my quest to understand the system.
And I assume once people differentiate themselves, symptoms will atrophy.” (p. 68)

For the past 27 years, I have been deeply involved in The American Academy of Psychotherapists. Under “Who We Are,” on the Academy’s website, it states,

“With an emphasis on authentic ‘I-Thou’ engagement, we explore the relationship
between the person of the therapist and the process of therapy, in an ongoing
effort to develop the art and science of psychotherapy. We value the therapist-
client relationship as fundamental to the psychotherapy process, and are committed
to developing ourselves in relationship as authentic human beings. We see this as
foundational to healing in therapeutic relationships…In an increasingly technical
and manualized treatment climate, the Academy maintains a commitment to
in-depth personal engagement.”