The Psychotherapy Relationship: Theory, Research, and Practice / Edition 1

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Overview

Human beings are social creatures, and from the moment we enter the world, our personal horizons are defined by our relationships with others. Parents, siblings, teachers, friends, lovers, colleagues-even the countless strangers with whom we interact during the course of any given day-we exist through them and they through us. This book is concerned with one of the most profound, yet difficult to define of human relationships, the healing relationship of psychotherapy.

There are many psychotherapeutic schools of thought, and while they may vary considerably in theory and methodology, virtually all agree that the relationship that develops between therapist and client is important to the success of treatment. But how do you define a "successful" client/therapist relationship? How exactly does the psychotherapy relationship influence process and outcome? What are its various components, and which are most important to the healing process? In this groundbreaking study, Charles Gelso and Jeffrey Hayes provide answers to these and other challenging questions about The Psychotherapy Relationship.

The authors begin by defining the three main components of the psychotherapy relationship: the working alliance, transference configuration, and the real relationship. They then consider how each is generally defined by and functions within various psychotherapeutic approaches, how each interrelates with the other two components within the context of the therapy relationship, and how relationship components and therapeutic techniques interact during treatment. Throughout, the authors draw upon their extensive clinical experience to offer advice and guidance on how to avoid and overcome major obstacles to a successful psychotherapy relationship.

The remainder of the book is devoted to a fascinating in-depth look at the psychotherapy relationship in action in four major psychotherapy schools: psychoanalytic, cognitive/behavioral, humanistic, and feminist. Ever mindful of important factional differences within schools of thought, the authors explore the role of the relationship within each approach in terms of the centrality of the relationship; whether the relationship is seen as a means to an end or an end in itself; the extent to which the emphasis is on the "real" relationship versus the transference; and the manner in which the therapist uses power in the relationship.

The most penetrating and far-ranging exploration yet of this most crucial aspect of the psychotherapeutic process, The Psychotherapy Relationship is must reading for all psychotherapists.

A far-ranging and insightful exploration of one of the most important and controversial aspects of the psychotherapeutic process

The Psychotherapy Relationship is an impartial research-based exploration of the role of the client/therapist relationship in most major approaches to psychotherapy. Drs. Gelso and Hayes break the relationship down into its component parts-including the working alliance, transference/countertransference, and the real relationship-and define the function of each, as it interrelates with both the other two and with various intervention techniques. They explore various theories about the nature and function of the therapy relationship espoused by the psychoanalytic, cognitive/behavioral, humanistic, and feminist schools of thought. And they develop a broad-based, practical synthesis of theory, research, and personal clinical experience that all psychotherapists will find helpful in their efforts to assess and improve the quality of their relationships with their clients.

The book contains no figures.

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Editorial Reviews

Doody's Review Service
Reviewer: Walter F. Burke, PhD (Northwestern University Feinberg School of Medicine)
Description: This book provides a scholarly overview of the centrality of the therapeutic relationship in the therapeutic action of psychotherapy from four prominent theoretical orientations. Citing research and practice strategies, the authors illustrate the similarities and differences among psychoanalytic, humanistic, cognitive-behavioral, and feminist orientations in their technical reliance upon the patient-therapist relationship as a driving change agent within their respective approaches.
Purpose: Through an in-depth exploration of the elements comprising the therapeutic relationship, the authors hope to stimulate the advancement of research and the practice of psychotherapy. Practitioners are encouraged to incorporate new understandings of strategic approaches to the management of the treatment relationship. Researchers are challenged to form new empirically based questions integrating the rich variety of alternative approaches to psychotherapy.
Audience: The researcher, practitioner, educator, and student will all benefit from this careful and comprehensive literature review of four theoretical perspectives on the therapeutic relationship. Each school of psychotherapy is treated with an in-depth analysis and thoughtful balance between research and clinical practice. The authors are established scholar-practitioners in who have published widely in the field of psychotherapy research.
Features: The authors have synthesized developments from several aspects of the psychotherapy literature with citations that are current and well documented. The table of contents clearly outlines the authors' overall objectives and the reader is presented with a straightforward sense of the contributing literatures and theorists.
Assessment: The authors have complied a thorough review of the research, theory, and practice of psychotherapy from the focal vantage point of the patient-therapist relationship in a single volume. The comparative framework of this book, contrasting four major theoretical schools, provides the reader an enhanced understanding of several approaches to psychotherapy as well as the potential areas of integration existing among different theoretical persuasions.
Walter F. Burke
This book provides a scholarly overview of the centrality of the therapeutic relationship in the therapeutic action of psychotherapy from four prominent theoretical orientations. Citing research and practice strategies, the authors illustrate the similarities and differences among psychoanalytic, humanistic, cognitive-behavioral, and feminist orientations in their technical reliance upon the patient-therapist relationship as a driving change agent within their respective approaches. Through an in-depth exploration of the elements comprising the therapeutic relationship, the authors hope to stimulate the advancement of research and the practice of psychotherapy. Practitioners are encouraged to incorporate new understandings of strategic approaches to the management of the treatment relationship. Researchers are challenged to form new empirically based questions integrating the rich variety of alternative approaches to psychotherapy. The researcher, practitioner, educator, and student will all benefit from this careful and comprehensive literature review of four theoretical perspectives on the therapeutic relationship. Each school of psychotherapy is treated with an in-depth analysis and thoughtful balance between research and clinical practice. The authors are established scholar-practitioners in who have published widely in the field of psychotherapy research. The authors have synthesized developments from several aspects of the psychotherapy literature with citations that are current and well documented. The table of contents clearly outlines the authors' overall objectives and the reader is presented with a straightforward sense of the contributing literatures and theorists. Theauthors have complied a thorough review of the research, theory, and practice of psychotherapy from the focal vantage point of the patient-therapist relationship in a single volume. The comparative framework of this book, contrasting four major theoretical schools, provides the reader an enhanced understanding of several approaches to psychotherapy as well as the potential areas of integration existing among different theoretical persuasions.
Booknews
Explores aspects of the healing relationship of psychotherapy, addressing questions surrounding the various components of the therapist/client relationship and their importance. Considers how three main components of the relationship function within various psychotherapeutic approaches, how each interrelates with the other two components, and how these components and therapeutic techniques interact during treatment. Annotation c. by Book News, Inc., Portland, Or.

4 Stars! from Doody
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Product Details

  • ISBN-13: 9780471127208
  • Publisher: Wiley
  • Publication date: 8/27/1998
  • Edition description: New Edition
  • Edition number: 1
  • Pages: 304
  • Product dimensions: 6.38 (w) x 9.51 (h) x 0.98 (d)

Meet the Author

CHARLES J. GELSO, PhD, is a professor in the Department of Psychology, University of Maryland, College Park. He has written extensively about the client/therapist relationship in diverse approaches to psychotherapy, and has conducted numerous empirical studies on the topic. Dr. Gelso has also practiced both brief and long-term psychodynamic therapy throughout his career.

JEFFREY A. HAYES, PhD, is an assistant professor of counseling psychology at Pennsylvania State University, University Park. His research and theoretical writing focus primarily on the psychotherapy relationship, with a particular emphasis on countertransference. He maintains a private psychotherapy practice in State College, Pennsylvania.

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Table of Contents

The Psychotherapy Relationship and Its Components: An Introduction.

Working Alliance: The Foundation of the Psychotherapy Relationship.

Transference and Its Many Faces: The Unrealistic Relationship in Psychotherapy.

Countertransference: The Therapist's Contribution to the "Unrealistic" Relationship.

The Real Relationship: Beyond Transference and Alliance.

The Psychotherapy Relationship in Operation.

Psychoanalytic Visions of the Psychotherapy Relationship: Beyond Transference.

Cognitive and Behavioral Views of the Therapeutic Relationship: Beyond Techniques.

The Humanistic and Existential Vision of the Therapeutic Relationship: The Real Relationship and More.

Feminist Therapy: Beyond the Third Force.

References.

Index.

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First Chapter

PART ONE





CHAPTER 1

THE PSYCHOTHERAPY RELATIONSHIP AND ITS COMPONENTS: AN INTRODUCTION

PSYCHOTHERAPY MAY be thought of as consisting of a technical part and a relationship part. The technical aspect includes the techniques used by the therapist in an effort to modify client behavior, and the theoretically prescribed roles taken on by the participants. The relationship aspect consists of the feelings and attitudes the participants hold toward one another, and the psychological connection between therapist and client, based on these feelings and attitudes. This latter aspect, the client-therapist relationship, is our central concern in this book. As we have seen over the years, of the two aspects, the relationship is the part that is harder to grasp theoretically and clinically. One quality of its elusiveness is that it means different things to different practitioners and theoreticians. It is an understatement to say that the relationship has been difficult to study empirically.

Psychotherapy is a highly complex and multifaceted process. Even after many years of scientific research, few assertions can be made about psychotherapy on which there would be general agreement. One assertion that can be made pertains to the relationship that develops between therapist and client or patient. Despite the elusiveness of the relationship, noted above, nearly all psychotherapy practitioners, theoreticians, and researchers agree that the relationship that develops between therapist and client is important-that is, it has a significant effect on the process and outcome of treatment.

Current beliefs about the impact of the relationship are summarized nicely by Lambert (1983), in the opening paragraph of his book on client-therapist relationships:

Human beings are social animals. They live through a series of interrelationships, forming and being formed by interactions with other people. Much of what people come to feel and be is directly and indirectly related to the quality of the associations they have had with others. Much has been written about the quality of these formative relationships. If relationships help form troubled lives (in the natural environment), then new relationships are needed to change troubled lives....the relationship that develops between patient and psychotherapist can be especially powerful in stimulating personality change. Despite the long history of successful and unsuccessful relationships the patient has had, the relationship that develops with the therapist, quite apart from the techniques the therapist uses, can facilitate the patient's growth. (Lambert, 1983, p. 1)

Although there is general agreement that the relationship importantly influences treatment, open to debate are questions such as: Just how important is this relationship? What elements of the relationship are important? How do those elements interact with each other and influence the treatment? Just how does the relationship exert its impact on process and outcome? Answers to these questions are very difficult to come by. Furthermore, the answers one gets depend to an important extent on the therapist's theoretical orientation. For example, generally speaking, psychoanalytic, humanistic, and feminist therapists will contend that the relationship is a vital element of treatment, perhaps the sine qua non of psychological intervention. On the other hand, the behavioral and cognitive therapists, while admitting that the relationship is important, will tend to view it as less vital than will the analytic and humanistic practitioners.

Similarly, as will be discussed in detail later in this book, one's theory tends to dictate conceptions of the ways in which the relationship influences treatment. Following Prochaska's (1979) observation, one may see the relationship as (a) one of the preconditions for therapy to proceed (as in the cognitive and, probably, the behavioral therapies); (b) an essential process that itself creates change (as in person-centered therapy, feminist therapy, and some versions of gestalt therapy); or (c) as a fundamental source of content to be talked about and processed in therapy (as in most psychoanalytically based therapies and some humanistic approaches). While these questions (just how important, in what ways, are what elements) are open to debate, as we have noted, the agreed-on view, well supported by research and theory, is that the relationship is indeed a very significant aspect of psychotherapy of every theoretical persuasion.

The present book seeks to extend the theoretical formulations on the psychotherapy relationship originally developed by Gelso and Carter (1985, 1994a). It has been well over a decade since publication of their first lengthy treatise on the relationship and how it works during treatments of diverse orientations (Gelso & Carter, 1985). During the intervening time, a number of empirical studies have been conducted on the components of the client-therapist relationship, and further theoretical work has been put forth. Gelso and Carter's conception of the components of the therapy relationship has been used to analyze extensively the existing research on the topic (Sexton & Whiston, 1994); and Gelso and Carter's work advanced to the point that theoretical propositions have been possible about more complex aspects of the relationship than had been previously considered (Gelso & Carter, 1994a, 1994b). Because of these developments, the time seemed ripe for a book-length treatment of this subject matter.

In the remainder of this chapter, we give an overview of the material to come. As part of our introduction to Part One of the book, the therapy relationship is defined, the conceptualization of the therapy relationship as being comprised of three fundamental components is discussed, and these components are defined and briefly examined. As part of defining the relationship, we give a brief overview of an uncharted territory-how the relationship and therapist techniques interact with one another during treatment. Subsequently, in our introduction to Part Two, we offer some general statements about how the relationship operates within the four most prominent general systems of psychotherapy. We briefly discuss each theory cluster in terms of its status on four key concepts or dimensions, along with how the theories vary in their respective visions of the client-therapist relationship.

The Relationship and Its Components

Because the therapy relationship has been given such a central place in our field over such a long period of time, one might expect that many definitions of the relationship have been put forth. In fact, there has been very little definitional work. The client-centered therapy group led by Carl Rogers (e.g., Rogers, 1957, 1975; Patterson, 1984) seemed to provide a definition when the relationship was equated with therapist-offered conditions such as empathic understanding, unconditional positive regard, and congruence. Upon reflection, though, it becomes clear that therapist-offered conditions, however important (and we maintain that they are deeply important), cannot be equated with the relationship itself. These conditions were thought of by the client-centered group as prerequisites for effective treatment or constructive client change. Relationship conditions for effective treatment cannot serve as definers of the relationship. What the therapist does to promote an effective relationship is simply not of the same order as a definition of what constitutes a therapy relationship. In addition, therapist conditions pertain to only one side of the relationship-the therapist side. Any definition of the relationship must include both sides: the client (or clients) and the therapist.

THE PSYCHOTHERAPY RELATIONSHIP DEFINED

Things are never as easy to define as they might seem at first glance, and the psychotherapy relationship is no exception. After struggling with the issue of definition for some time, Gelso and Carter (1985, 1994a) settled on the following:

The relationship is the feelings and attitudes that therapist and client have toward one another, and the manner in which these are expressed. (Gelso & Carter, 1985, 1994)

We use this as our working definition of the relationship in this book.

Just about any definition the theoretician can cook up is going to generate some controversy when the construct is as complex as the psychotherapy relationship. In response to an extensive review of empirical research on the therapy relationship (Sexton & Whiston, 1994), Hill (1994) has raised questions about the definition we use. Specifically, she takes issue with including "the manner in which these are expressed" as part of the definition of relationship, stating that this inclusion "muddies the water and opens up the relationship to include everything" (p. 90). Although we recognize the general nature of our working definition, we believe any definition must include the manner in which feelings and attitudes are expressed (or, by implication, withheld). This expression need not be clear and direct, and the manner of expression can be tremendously variable. It may be, and often is, very subtle, nonverbal, and indirect. Thus, what one experiences about the other-the feelings and attitudes one possesses-may creep out, slip out, or be directly shared; and this process both reflects and further informs the relationship. The point is: The manner of expressing what is felt and perceived is a necessary part of any relationship definition.

The complex and elusive nature of the psychotherapy relationship, and thus the difficulty in capturing it with a single definition, is beautifully highlighted by Barrett-Lennard (1985) when he states:

One may think of a [dyadic] relationship as being centered on the qualities and contents of experiencing of the two participant individuals with, and toward, one another. This covers a lot of territory but it does not fully encompass the ways in which the participants communicate with each other, the messages that are passed back and forth, the moment-by-moment or generalized image that A has of B's awareness of A, or of B's feeling toward A, and likewise in respect to B's image of A's interperceptions. Neither of these levels fully encompasses "a relationship" as an emergent entity that develops a life and character of its own, existing in intimate interdependence with the single-person components, a "we" in the consciousness of member persons and a distinctive "you" or "they," or the like, as seen from the outside. Any of these levels of relationship can be viewed in terms of what is present or typical at a given time in the life of the relationship, or from a developmental standpoint; and interest may center on the interior process of the relationship or on the ways the relationship system maintains itself or is altered under the influence of external forces. (p. 282)

Among other things, what Barrett-Lennard reminds us is that when considering what constitutes the psychotherapy relationship, the "we" of the relationship must be taken into account, as well as the two separate "I's," or the two individuals. Thus, a third force is present in a relationship, and it transcends or at least is different from the individuals who are involved.

THE RELATIONSHIP AND THERAPIST TECHNIQUES

Returning to our definition of the psychotherapy relationship, in line with Hill's (1994) concerns, the very general nature of this definition requires that we address what the relationship does not include. As Gelso and Carter (1985, p. 159) noted, "if the relationship consists of all things, then there is nothing else-and a definition would be beside the point."

At the start of this chapter, we suggested that psychotherapy has a relationship part and a technical part. The latter consists of the techniques used by the therapist in order to bring about change, as well as the theoretically prescribed roles in which the therapist and client engage. Generally speaking, therapists' techniques emanate from their theories of how to bring about constructive change. Thus, a person-centered therapist uses reflection of feeling; an analytic therapist employs certain kinds of interpretations; and a cognitive-behavioral therapist uses conditioning and persuasive techniques in order to induce the types of change dictated by the relevant theory. Regarding roles, for example, an analytic therapist and his or her client more or less follow certain roles dictated by the particular version of analytic therapy being adhered to by the therapist. In classical analysis, the analysand reclines on a couch and free associates while the analyst quietly listens and offers interpretations when the time is right. Each theory of therapy contains its prescribed roles.

Although we differentiate the technical aspects of therapy from the relationship aspects, it must be understood that, in practice, the two parts constantly interact with and influence one another. There is a profound synergism between the two. The techniques used by the therapist, for example-and certainly the manner in which they are used-influence the kind of relationship that unfolds. Likewise, how the therapist feels toward the client will have a profound effect on the techniques he or she uses and the manner in which they are used with each client. For example, if the therapist is analytically oriented and places a premium on interpretation, how and what the therapist feels toward his or her client will have an impact on the nature, depth, frequency, length, content, and emotional tone of the interpretations that are presented (Gelso & Carter, 1985; Gelso & Fretz, 1992). The client, in turn, will experience the therapist's interpretations in certain affective and intellectual ways and will react accordingly, which will affect the relationship and create the conditions for the therapist's subsequent internal reaction and technical response. This cycle will repeat itself continually as long as the relationship lasts.

COMPONENTS OF THE CLIENT-THERAPIST RELATIONSHIP

A number of years ago, the psychoanalyst, Ralph Greenson, discussed how the analytic relationship consisted of a working alliance and a "real relationship," as well as the transference relationship that was nearly universally agreed on as a vital part of psychoanalytic theory (Greenson, 1967). The view held throughout Gelso and Carter's writing, and the one that we espouse, is that all psychotherapies, regardless of theoretical orientation, consist of these three components. At the same time, the centrality of the individual components varies importantly with the theory guiding the work, as will be examined in Part Two.

In much of the remainder of Part One, we shall provide an in-depth analysis of the components: the working alliance, what we call the transference configuration (including client transference and therapist countertransference), and the real relationship. We offer here our basic definitions of these components, as well as a preliminary discussion of their operation in therapy.

THE WORKING ALLIANCE

The most fundamental component of the therapy relationship, we suggest, is the working alliance that develops between client and therapist. It is hard to imagine therapy being successful in the absence of a sound working alliance; indeed, empirical research supports the importance of the alliance to treatment outcome (Horvath & Symonds, 1991). Stronger alliances are associated with more positive outcomes.

The working alliance may be defined as "the alignment or joining of the reasonable self or ego of the client and the therapist's analyzing or 'therapizing' self or ego for the purpose of the work" (italics added; Gelso & Carter, 1994a, p. 297). The alignment or joining of these parts allows the participants to observe, understand, and do therapeutic work in the face of many obstacles and resistances that inevitably impinge on probably all therapies. Related to Bordin's (1979, 1994) seminal writing, it is suggested that the strength of the working alliance both affects and is affected by the degree to which the therapist and client (a) agree on the goals of treatment and the in-session or out-of-session tasks that are useful or necessary to attain those goals, and (b) experience an emotional bond with each other. In contrast to Bordin, we do not think that agreement on goals and tasks, and the existence of a bond constitute a definition of the working alliance. Rather, as noted, they influence and are influenced by it.

Over the years, somewhat different terms have been used to capture the alliance. Terms such as working alliance (Bordin, 1979; Greenson, 1967), helping alliance (Luborsky, 1976), therapeutic alliance (Marmar, Horowitz, Weiss, & Marziali, 1986; Zetzel, 1956), or simply alliance (Horvath, Gaston, & Luborsky, 1993) have all been employed, each with somewhat different meaning. We prefer the term working alliance because it more clearly and specifically refers to the concept of the participants' joining together to foster the working element of therapy, and it helps us separate this element from other components of the overall relationship. Of the relationship components, the working alliance has received the greatest research attention, and, during the past decade, research on the alliance has occurred at a fast pace. (Research on the working alliance will be examined in Chapter 2.)

THE TRANSFERENCE CONFIGURATION

In contrast to the general agreement that the working alliance is a key factor in treatment, the importance and role of transference remain controversial. Generally speaking, psychoanalytic therapists view transference as a key concept, whereas humanistic, cognitive-behavioral, and many feminist therapists view the concept with skepticism. Our position is that transference (and therapist countertransference) is an important element of all therapy (and probably all relationships), and, as we shall discuss in Chapter 2, we believe this position is well supported by empirical research.

Not only are the existence and importance of transference controversial, but so too is its definition. When the theoretical literature is scanned, three definitions seem most salient. The first views transference as a reliving of Oedipal issues within the therapeutic relationship. Thus, the therapist is reacted to as if he or she were any or all participants in the client's early Oedipal situation (see E. Singer, 1970). This is the conception of transference embedded in classical psychoanalytic drive theory.

The second definition of transference is broader than the first. Transference is seen as a repetition of past conflicts with significant others, so that feelings, attitudes, and behaviors belonging rightfully in those earlier relationships are displaced onto the therapist. This definition does not restrict the source to the Oedipal situation; instead, transference is viewed as a manifestation of early experience in crucial interpersonal relationships. Often espoused by interpersonally oriented therapists (e.g., Fromm-Reichmann, 1950; Sullivan, 1954), this definition is also broader than the classical view in the sense that transference is seen as entailing reactions that were appropriate and adaptive at an earlier time and place. These reactions protected the child's emerging self-esteem (rather than avoiding castration) and served to make otherwise intolerable situations tolerable.

A fundamental aspect of both of the above definitions is that transference is seen as an error. The client distorts the reality of the therapist, projecting and displacing objects (people) or parts of objects from the client's past onto the person of the therapist. The third and most recent definition goes beyond this concept of transference as distortion. Transference is seen as an intersubjective process, contributed to by both client and therapist, and the therapist's job is to understand, and help the client understand, the reality that both have constructed. Although the therapist contributes to the transference, it is still the client's

construction that is of central interest. Thus, Stolorow and Lachmann (1984/1985), the leading proponents of this third view, define transference as referring to "all the ways in which the patient's experience of the analytic relationship is shaped by his own psychological structures-by the distinctive, archaically rooted configurations of self and object that unconsciously organize his subjective universe" (p. 26). In this sense, transference is seen as an unconscious organizing activity. The client assimilates the therapeutic relationship into the thematic structures of his or her personal subjective world (Stolorow, 1991).

As Pulver (1991) has nicely clarified, within current-day psychoanalysis there is a trend to see both positions (transference as distortion, and transference as co-constructed reality) as useful and truthful, and to choose between them according to clinical circumstances. Our view, in keeping with Gill (1982, 1984), is that, although the therapist certainly contributes to the client's transference by virtue of his or her person and behavior, and although it is crucial that the therapist struggle to understand that contribution, the ways in which the client distorts the therapist (and others in his or her life) that are tied to early conflictual relationships and are still vital elements of the concept of transference and what is to be done with it. Transference is indeed an unconscious organizing activity, and it is important to understand that the portion of it that represents displacement is an error driven by unresolved issues. Thus, we maintain the traditional view of transference as distortion, while incorporating the intersubjective position in which the therapist's stimulus value is seen as vital to a full understanding of transference. Our working definition of transference is: the client's experience of the therapist that is shaped by his or her own psychological structures and past, and involves displacement, onto the therapist, of feelings, attitudes, and behaviors belonging rightfully in earlier significant relationships. As we have discussed, the person and activity of the therapist always figure into the transference (often in very subtle ways) and ordinarily must be considered when trying to understand the client's transference.

Within what we call the transference configuration also resides the construct of therapist countertransference. Like perhaps all high-level constructs emanating from psychoanalytic theory, the definition of countertransference has been controversial. The classical psychoanalytic definition essentially views countertransference as the therapist's transference to the client's transference (Singer & Luborsky, 1977). A more recent position is called the totalistic view: countertransference is seen as all of the therapist's emotional reactions to the client. Each of these definitions has serious limitations, in our opinion. The classical view seems narrow and restrictive; the totalistic view is so broad and encompassing as to have limited utility. All of the therapist's emotional reactions are important, we would offer, but to consider all of them countertransference badly muddies the construct.

We think it is useful to differentiate a therapist's reactions that are based on his or her conflictual issues from those that are a natural and realistic response to the stimulus of the client (granted that there is overlap between these two types of reactions). At the same time, we also believe that whether the therapist's reactions might be seen as countertransferential should be independent of whether the reaction is to the client's transference or nontransference material. Thus, our working definition of countertransference is "the therapist's transference to the client's material-both the transference and nontransference communications presented by the client" (see Gelso & Carter, 1994a, p. 297). As elaborated in Chapter 4, if understood and worked through by the therapist, countertransference feelings can be extremely useful to the work. If they are ignored or remain ununderstood, they can literally destroy the work.

Within these conceptions of transference and countertransference, expectations are given a key role. For example, in addition to having some feelings toward the therapist that were not "earned" by this therapist, clients will have fundamentally inaccurate, or transference-based, expectations of the therapist's feelings and behavior and of themselves with the therapist. Thus, it is not just clients' affective reactions to the therapist that compose the transference. Transference also involves what the client expects from the therapist and how the client expects to behave and feel. In response to a particular client behavior or to the client in general, a given client may expect any of a range of therapist emotional or behavioral reactions. The client may expect the therapist to love, hate, abuse, understand, attack, seduce, and so on. Clients will tend to distort their therapists so as to make them consistent with those expectations, and will alter their own behavior and feelings to conform to those expectations. In fact, based on transference expectations, clients may react to their therapist in a way that actually produces the expected reaction from the therapist. This is the basis for the defense mechanism of projective identification, which has been linked to psychodynamic therapy, with clients suffering from borderline personality disorders.

In summary, both transference and countertransference occur in all therapies, from the first moment of contact. They may even occur before actual contact and then might be called preformed transferences: the client experiences feelings, attitudes, and expectations of his or her imagined therapist, and these represent unresolved issues from the past. Both transference and countertransference may be helpful, neutral, or destructive to the therapy, depending on their nature, their valence, the central thrust of the therapy, and the therapist's beliefs about these processes and ways of handling them.

Empirical research on both transference and countertransference has progressed at an exceedingly slow pace since Freud coined the terms during the early part of the 20th century. The pace has somewhat quickened, however, since about the mid-1980s. The development of transference measures based on session evaluations by outside judges (Luborsky et al., 1993) and therapists' reports (Gelso, Kivlighan, Wine, Jones, & Friedman, 1997; Multon, Patton, & Kivlighan, 1996) should help accelerate this process. In the area of countertransference, several lines of research are emerging (e.g., Gelso, Fassinger, Gomez, & Latts, 1995; Hayes, Riker, & Ingram, 1997; Lecours, Bouchard, & Normandin, 1995; McClure & Hodge, 1987). Research on transference and countertransference will be discussed in Chapters 3 and 4, respectively.

THE REAL RELATIONSHIP

In an obvious and profound way, the client-therapist relationship is always fully real. Thus, it seems ironic that what we call the real relationship has been the most theoretically neglected and least understood of the relationship components.

In accord with Greenson's (1967) thinking, we use the term real relationship in a particular way. Real relationship pertains to "that dimension of the total relationship that is essentially nontransferential, and is thus relatively independent of transference" (italics added; Gelso & Carter, 1994a, p. 297). This usage dictates a certain philosophical position about reality-namely that, in some sense, reality does exist and is not simply a function of the perceiver. If there were no belief in reality independent of the observer, any definition of transference as a distortion of reality would be meaningless. A use of the term real relationship to connote the nontransferential part of the total relationship would also be meaningless.

Although our views on this matter have clashed most pointedly with staunch phenomenological and social constructionist positions, we must add that the perceptions and constructions of the observers and the participants are vitally important in the relationship. Perceptions of what is real and true do depend profoundly on the observers, and there is no simple reality out there. Yet we do maintain the position that there is a complex reality and that perceptions do contain degrees of accuracy and inaccuracy. Our discussion of real relationship in this book centers on those aspects of the relationship that are primarily undistorted by transference.

The real relationship, we suggest, contains two defining features: genuineness and realistic perceptions. Genuineness is seen as the tendency to be what one truly is in the relationship-honest, open, authentic, congruent with one's inner experiencing. Realistic perceptions, as implied above, refer to those perceptions that are uncontaminated by transference distortions and other defenses that may not directly implicate transference. Thus, for example, if the client is high on the realistic perceptions feature, he or she sees the therapist in an accurate, realistic way.

Gelso and Carter (1985, 1994a, 1994b) have suggested that all therapeutic encounters contain a real relationship component, although the importance of this component certainly varies according to one's theoretical orientation. For example, the humanistic therapist typically places a premium on the real relationship, whereas many psychoanalytic therapists may even question whether such a construct truly exists or is useful.

Not only do we propose that all therapy relationships contain a real relationship component, but we suggest that the real relationship has an important impact on all encounters, theoretical differences notwithstanding. Thus, even in classical psychoanalysis, which maximizes the importance of transference, a real relationship (a degree of genuineness and realistic perceptions) exists and is contributed to by both participants, and this component exerts an important influence on process and outcome.

Generally speaking, the stronger the real relationship (greater genuineness and more realistic perceptions), the more effective the treatment, although this proposition must be qualified in a number of ways. For example, many psychoanalytic treatments seek a buildup of transference, which may then be usefully interpreted and worked through. This may suggest that high transference (and perhaps low realistic perception) is a positive element at some points in some therapies. However, whether an increase in transference leads to a reduction in realistic perceptions is as yet unknown. Although transference entails distortion, it is quite conceivable that high transference and high realistic perception may occur simultaneously.

As will be discussed in Chapter 5, there has been almost no research on the real relationship as we have defined it. The genuineness element has been extensively studied in terms of therapist genuineness, and the findings have generally been supportive of its positive effects (Beutler, Crago, & Arizmendi, 1986; Orlinsky & Howard, 1986). However, research on client genuineness is virtually nonexistent. The construct of realistic perceptions, too, has been given very limited empirical scrutiny.

The Psychotherapy Relationship

and Theoretical Orientation

Each major theory of therapy has a particular vision-usually explicit but at times implicit-of the psychotherapy relationship. Thus, psychotherapists' theoretical orientations are deeply connected to their views of the psychotherapy relationship-its role in the treatment; what is to be done with and to the relationship; and the overall importance of the relationship. At the same time, it is not clear what causes what, regarding a therapist's theoretical orientation and his or her beliefs about the relationship. Each orientation contains statements about the therapy relationship, and these will affect how a therapist behaves with clients. At the same time, beliefs about the relationship draw particular therapists to particular theoretical orientations. Thus, the causal influence probably goes both ways.

RELATIONSHIP DIMENSIONS

In seeking to delineate how theories of therapy differ from one another in their visions of the relationship, we suggest that there are four salient dimensions along which formulations of the psychotherapy relationship vary (see Gelso & Carter, 1985). Following our descriptions of each of these dimensions, we will discuss how four major theory clusters (psychoanalytic, cognitive-behavioral, humanistic, and feminist therapy) may be situated and evaluated on these dimensions.

1. We call the first dimension a centrality dimension. Its defining feature is the extent to which the client-therapist relationship is seen as a crucial element of client change. Theoretical orientations vary widely in terms of how central the relationship is seen to be.

2. The means-end dimension is defined by the extent to which a theory of therapy views the relationship as an end in itself as opposed to a means to an end. Theories that view the relationship as an end in itself, or that at least lean toward that side of the continuum, tend to view the client-therapist relationship, in and of itself, as the mechanism through which client change occurs. In other words, the relationship itself, when it possesses certain desired qualities, produces constructive change.

Theories that envision the relationship more as a means to an end suggest that it is what we do about, to, or because of the relationship that produces change. The relationship itself is not the cause or mechanism of positive change. The relationship may effect change, for example, through providing an impetus for the client to follow the therapist's instructions, which themselves are the mutative elements; or the relationship that unfolds must be transformed through interpretation, the mutative element, if constructive change is to occur; or the relationship may allow the client to reveal more about self, which in turn permits the therapist to devise more effective techniques and procedures, and these are the major change agents.

3. The real-unreal relationship dimension is defined in terms of whether the real relationship or the transference relationship is given primacy in a particular theoretical perspective. As discussed below, theories differ substantially in which of the two components is most vigorously addressed in theory and treatment.

4. The power dimension is defined in terms of the manner in which power is conceptualized and used by the therapist. Therapists' power derives from many sources, including socially ascribed and legislated authority, command of a knowledge base, technical expertise, and, for some therapists (e.g., members of dominant cultural groups in a society), particular cultural characteristics. Whereas the power that therapists possess at the outset of therapy may not vary appreciably as a function of therapists' theoretical orientation, the manner in which power is conceptualized, garnered over time, shared, used to affect change, and potentially abused differs widely among the major theoretical approaches. Thus, for each theory that is examined, we shall address questions about power dynamics in the therapy relationship, such as: How is power conceived and attended to theoretically? What are the sources of power within the therapist and client? How much power does the client possess, especially relative to the therapist? How is power used and potentially misused?

THEORY CLUSTERS AND RELATIONSHIP DIMENSIONS

Depending on how specific one wants to be, the current theoretical scene may be divided into many or a few theories of psychotherapy. Some years ago, Harper (1959) wrote about 36 different systems of therapy. Others have divided the pie into even smaller slices. In considering how the therapy relationship is envisioned, we find it useful to think in terms of four general theory clusters: (a) psychoanalytic, (b) cognitive-behavioral, (c) humanistic, and (d) feminist. Each of these broad clusters contains many more specific theories, and the theories within a cluster may seem quite divergent from one another. Yet we believe that these clusters hang together in terms of their visions of the basic client mechanisms through which change occurs and, very much related to these mechanisms, the role of the psychotherapy relationship in facilitating change.

THE PSYCHOANALYTIC CLUSTER

The psychoanalytic cluster is very complex; it includes many different theories, which are often reduced to four groups: (a) Freudian drive theories, (b) ego analytic theories, (c) object relations theories (including interpersonal theory), and (d) psychoanalytic self psychology (Mishne, 1993; Pine, 1990). Within all or nearly all of these psychoanalytic theories, the central mechanism through which client change occurs is insight (Gelso & Fretz, 1992). Insight is usually described as the understanding, emotionally as well as intellectually, of how the client distorts and misperceives in his or her present life and in her or his relationships as a result of unresolved conflicts from earlier times-usually childhood, and most often early childhood.

How do psychoanalytic theories in general stack up on the four dimensions we use to differentiate conceptions of the client-therapist relationship? Given that insight, as defined above, is the key mechanism for client change in the psychoanalytic theories, it makes sense that the analytic therapist would view the relationship as highly central. Thus, the relationship, as conceived of in psychoanalytic treatments, is high on the centrality dimension. But the psychoanalytic vision of the relationship is of a particular sort. The transference relationship is key: the relationship to a large extent involves distortions of the therapist based on unresolved issues in earlier relationships. Thus, the psychoanalytic relationship clearly is situated on the "unreal" side of our real-unreal continuum. Because of this focus on the unreal (qua transference) relationship, the relationship cannot be an end in itself, but rather is a means to an end. For the analytic therapist, something must be done to the relationship if it is to be curative. In Prochaska's (1979) terms, the relationship is a "source of content" to be talked about and processed. Usually, this implies that the transference relationship must be interpreted by the therapist so that the client acquires insight into how his or her distortions occur, where they come from, and how they also occur in other relationships. These misperceptions, through repeated interpretations of how they are enacted in the therapy relationship and many other situations, are then worked through or resolved.

Regarding how power is used and conceptualized in psychoanalytic treatments, the analytic therapist generally aims to have the client run the ship. The client takes the lead, and the therapist is careful not to advise, persuade, or push the client. At the same time, and paradoxically, the therapist's or analyst's role of providing interpretations of what is causing what-in the client's psyche and in the therapeutic relationship-imbues this role with a great deal of subtle power in the relationship.

THE COGNITIVE-BEHAVIORAL CLUSTER

This cluster includes the many versions of cognitive and behavioral therapy currently on the scene. We put cognitive and behavioral theories together because of the compatibility of the two approaches, because of their very similar vision of the therapy relationship, and because, in practice, most therapists who lean toward this cluster also use both cognitive and behavioral techniques.

In virtually all cognitive and behavioral approaches, the most fundamental client mechanism through which change occurs is learning. Further, learning is usually seen as taking the form of classical conditioning, instrumental conditioning, and modeling. The therapist helps the client change through the use of techniques that revolve around these forms of learning, and techniques of cognitive persuasion, which help to change faulty or maladaptive thinking. Such cognitive change is also seen in learning terms, although conditioning and modeling are not as commonly implicated as the bases for cognitive learning.

How does the cognitive-behavioral approach rank on the four dimensions? Given the cognitive-behavioral therapists' focus on techniques, the relationship has not been seen as highly central, although its centrality to change surely has increased in recent years. In terms of the real-unreal continuum, the portion of the relationship that has been of interest to cognitive-behavioral therapists is most often the real relationship. The unreal or transference relationship is probably of less concern to the cognitive-behavioral therapist than to therapists of any other major persuasion. Furthermore, the relationship is very clearly a means to an end rather than an end in itself. A sound working alliance and real relationship are seen as somewhat helpful in themselves, but mostly as providing the therapist with leverage that will help him or her gather client information and use cognitive-behavioral techniques most effectively. If the relationship is good, the client is more likely to cooperate with the treatment regimen, to be responsive to techniques, and to carry out assignments. In Prochaska's (1979) terms, the relationship in the cognitive-behavioral therapies is a "precondition" for therapy to proceed effectively. Finally, regarding the conceptualization and use of power, perhaps more than in any other approach, cognitive-behavioral therapists explicitly use their power to educate and persuade clients and directly influence clients' behavior.

THE HUMANISTIC CLUSTER

Within the humanistic cluster are theories such as person-centered, gestalt, experiential, relationship, and some versions of existential therapy. Theories within this cluster place a premium on the client's (and therapist's) here-and-now functioning, the client's phenomenological/perceptual world, and the client's capacity for self-actualization. The fundamental mechanism through which change occurs is the client's emotional experiencing or awareness in the moment. Immediacy, a kind of emotional being in the present in the relationship, is a part of this central mechanism. The therapist and the client are to work toward genuineness, a state of being true to oneself and honest with the other.

Given the central mechanism of experiencing/awareness in the here-and-now, it makes sense that the therapist would seek to capitalize on the client-therapist relationship, particularly on the feelings that are alive in the moment, regardless of the content. In terms of our four dimensions, it follows that the relationship is highly central for the humanistic therapist. Furthermore, given the premium placed on genuineness and realness in the moment, the clearly real relationship, rather than the unreal or transference relationship, is viewed as key. Regarding the third dimension, the relationship tends to be an end in itself rather than a means to an end in most humanistic treatments. It is the relationship, not something done to it or because of it, that causes constructive change. In Prochaska's (1979) terms, in the humanistic cluster, the relationship is an "essential process" that creates change. Finally, in terms of power, a pervasive theme in the humanistic therapies is that the client and therapist are viewed as coequals in the therapy process.

FEMINIST THERAPY

Disagreement exists as to whether feminist therapy constitutes a separate system of therapy or is best viewed as a theoretical approach that can be used to evaluate and inform other approaches. We take the position that both stances are possible. Feminist therapy may be conceptualized and practiced in pure form, or, like almost any other approach, it may be integrated with other theories. When viewing feminist therapy as a system of therapy in itself, the question arises as to what, if any, central mechanism of client change is posited by this orientation. The central mechanism for each of the three theory clusters just summarized seemed relatively easy to specify, but such a mechanism is not so easily identified with feminist therapy. The feminist literature, to our knowledge, is not clear about such a mechanism. At the same time, one construct that does appear to stand out as vital in all statements of feminist therapy is client empowerment. This concept (like insight, learning, and experiencing, for the three other theory clusters) appears to represent a client process that mediates desired outcomes. The client in feminist therapy is seen as growing and changing essentially through internalizing a healthy sense of personal power and overcoming personal and internalized societal disempowerment. This internal shift itself promotes a host of desired outcomes in feminist therapy.

How does the feminist therapy vision of the client-therapist relationship rank on the four dimensions we use to assess theories? Because of the general importance of relationships to women, feminist therapists tend to view the therapy relationship as a highly central element of their treatment. The relationship tends to be situated on the end side of the means-end continuum because the relationship is one way through which feminist therapists empower their clients. That is, feminist therapists seek to "give away" their power to clients within the context of a relationship in which egalitarianism is the ideal. However, there are other ways in which feminist therapists seek to empower clients (e.g., advocacy, consciousness raising, political activism), so the therapy relationship is conceptualized as less significant as an agent of change in and of itself than in, say, person-centered therapy.

Regarding the real-unreal dimension, we would rank feminist therapy toward the real relationship end of the continuum. At the same time, whether the real relationship or the transference configuration is the focus of therapy varies greatly, depending on whether, for example, a particular feminist therapist subscribes to psychoanalytic or humanistic theory, to both, or to neither. As discussed in detail in Chapter 10, there is, within the feminist cluster, a wide range of views on the utility of emphasizing transference or the real relationship in therapy, although, as noted, there does appear to be a relatively greater emphasis on the real relationship among feminist authors. Finally, in terms of our fourth dimension, an analysis of power dynamics in the therapy relationship is one of the hallmarks of feminist approaches. More than any other theoretical system, feminist therapy attends to the ways in which power is acquired, utilized, and potentially mishandled by therapists. The fundamental goal of feminist therapy, and the central change mechanism, is client empowerment.

The role of the relationship in each of the four theory clusters will be examined in much greater detail in Chapters 7 through 10. Table 1.1 summarizes the status of these four theory clusters in terms of the centrality, real-unreal, means-end, and use-of-power continuua discussed in this chapter. Regarding our fourth dimension-conceptualization and use of power-each system is evaluated in the table in terms of the extent to which the therapist employs overt and covert power as a means of promoting change.

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Preface

Preface
THE RELATIONSHIP that develops between psychotherapists and clients or patients is, by any yardstick, a vital part of the psychotherapy experience. As we conceive of and participate in psychotherapy, a good relationship is likely to be an enormously valuable contributor to positive outcomes; conversely, good outcomes rarely occur in the context of a poor client-therapist relationship.
This book is about the client-therapist relationship in psychotherapy-what that relationship consists of, how it develops during treatment, how it varies for different systems of psychotherapy, how it operates in and affects treatment. The book consists of two parts. Part One uses previous theoretical work on the therapy relationship presented by the first author and Jean Carter (Gelso & Carter, 1985, 1994a) as a takeoff point, and refines, modifies, and extends that work. In keeping with Gelso and Carter, all therapy relationships are seen as consisting of a working alliance, a transference configuration (including therapist countertransference), and a real relationship component. After providing an introduction to the therapy relationship (Chapter 1), Part One examines each of these components in depth and explores how each operates in different therapies (Chapters 2 through 5). We conclude Part One by exploring in Chapter 6 how these components interact in the context of the therapy relationship, and how the relationship and therapist techniques interrelate during treatment.
In these chapters on the components of the therapy relationship (Chapters 2 through 6), we explicitly state theoretical propositions and discuss how those propositions are informed by theory, research, and practice. Our aim in making these statements is at once to foster research and theory while providing a theoretical guide to practitioners of therapy.
In Part Two, we examine what is made of the therapy relationship-what it looks like and how it operates-in four major theory clusters: psychoanalytic (Chapter 7), cognitive-behavioral (Chapter 8), humanistic (Chapter 9), and feminist (Chapter 10). Each organized theory of psychotherapy has its own vision of the client-therapist relationship. We analyze the vision offered by these theories in terms of four dimensions: (a) the centrality of the relationship; (b) the extent to which the relationship is seen as curative in itself versus helpful because of something done to or because of it; (c) the relative emphasis on what we call the real relationship versus the transference configuration (the "unreal" relationship, so to speak); and (d) the therapist's conceptualization and use of power in the relationship. The organization of the chapters in Part Two varies somewhat, to take into account how the four major theories themselves vary in certain ways. Specifically, for the psychoanalytic and humanistic chapters, we explore how the psychotherapy relationship is envisioned by different theoretical approaches within the general theory cluster, and then we look at the entire cluster in terms of the dimensions of centrality, relationship as a means vs. an end, real vs. transference relationship, and use of power. For the feminist and cognitive-behavioral clusters, on the other hand, we believe that the subtheories within these general clusters "hang together" in terms of visions of the relationship, so we do not analyze those subtheories separately. Instead, we examine the general theory cluster (cognitive-behavioral and feminist) with respect to its vision of the relationship on the four aforementioned dimensions.
Our most basic hope in writing this book has been to benefit both science and practice in the field of psychotherapy-to offer some clear-cut theoretical statements that would foster empirical research and theory development about the relationship, and to present material that would be useful to therapy practitioners in furthering their thinking about therapy relationships. Thus, we intend this book for, and hope it will be useful to, students, researchers, and practitioners of the art and science of psychotherapy. Because of our dual emphasis on science and practice, we have sought to incorporate research (when it exists) into all of the chapters, to express views developed from our own practice and supervision of psychotherapy, and to provide case material when it might clarify certain points. Just as we have used theory, research, and practice in writing the book, we hope, in turn, that the book serves to benefit theory, research, and practice.
Our investment in reaching both scientists and practitioners likely stems from our own involvement as scientists and practitioners. Both of us have been involved in teaching, studying, and practicing psychotherapy throughout our careers, and we have been intellectually and emotionally sustained by all of these professional activities. This book surely comes out of and reflects each of these different parts of our experience.
The focus of the book is individual psychotherapy. Although we believe that much of what we have to say pertains to other modes of intervention (e.g., group therapy, couples therapy), individual therapy is the central concern about which we have deliberately theorized.
Although the material on the components of the therapy relationship (working alliance, transference, countertransference, and real relationship) emanated from psychoanalytic theory, we have sought to be evenhanded theoretically throughout the book. In this, we were aided by the differences in our theoretical approach: one of us is psychoanalytically oriented (CJG), and the other leans toward humanistic theory (JAH). Nevertheless, both of us seek to integrate diverse perspectives into our therapy. We think we have been good at "catching" each other's theoretical prejudices-at pointing out any "cheerleading" for one or another theory, or any antagonism against a particular viewpoint. Our readers will, of course, be the final judges of whether we have succeeded in these efforts.
We are grateful to and want to acknowledge many individuals who have helped us with the book. Dr. Jean Carter's thinking and writing as part of the Gelso and Carter team have been deeply influential and are credited throughout the book. We also owe her a debt of gratitude for her thoughtful critiques of several of our chapters. Dr. Janet McCracken and Ms. Sarah Knox read and provided invaluable feedback on several chapters. We express our appreciation to the following people who each read and gave extremely helpful input into one or another of our chapters: Dr. Alicia Chambers, Mr. James Fauth, Ms. Suzanne Friedman, Dr. Shirley Hess, Dr. Clara Hill, Mr. Jonathon Mohr, and Mr. Eric Rosenberger.
CHARLES J. GELSO
JEFFREY A. HAYES
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