This article originally appeared in the April 2006 Harvard Mental Health Letter and is provided courtesy of Harvard Health Publications.

The therapeutic relationship: What patients want
Two studies in a journal exploring the theory and practice of psychotherapy show that therapists and their patients or clients don’t always agree on what makes for a good working relationship.

In the first study, 40 psychotherapy patients ranging in age from 18 to 62 described “critical incidents” that they thought helped establish a strong therapeutic relationship and promote successful psychotherapy. The interviewers requested specifics — something either the patient or the therapist did or said, something they did together, or something else that happened in connection with the therapeutic sessions. Patients were asked why and how the critical incident helped to form or strengthen the relationship.

Using tapes of the interviews, the researchers divided the responses into 25 categories. Examples:

   Nonverbal communication. The therapist made eye contact, leaned forward in her chair.
   Active listening. He remembered and repeated what I said in an earlier session; she paraphrased what I said.
   Self-disclosure. She said she had had an experience similar to mine.
   Encouraging comments. He congratulated me for what I was doing to help myself; she said I was intelligent.
   Emphasis on choice. She said, “You know yourself best.”
   Greetings and farewells. He greeted me with a smile; she opened the door for me to leave; he introduced himself in the waiting room.
   Openness to personal criticism. She responded well when I said she used too much perfume.
   Validation of feelings. He gave me a tissue when I cried; she supported me when I criticized a previous therapist.
Humor and laughter were important as well. And one class of critical incidents involved technical therapeutic procedures: “He got me to make a list of my goals.” Patients also mentioned clothes and grooming and the lighting, decorations, and books in the therapist’s office.

Some of the actions that patients endorsed might be thought questionable by some therapists: hugging, meeting after hours, offering food and drink, walking out of the office with the patient, giving a home phone number. Patients rarely mentioned anything they themselves, as opposed to therapists, did to establish the working relationship.

The authors believe psychotherapists may be insufficiently aware of the “deceptively simple” actions and comments that patients may regard as critical for cementing a therapeutic alliance.

The second study examines patients’ views of what helps and hurts in psychodynamic (psychoanalytic) psychotherapy. The participants were 22 young adults, mostly women aged 18–25, who had been in individual or group psychodynamic psychotherapy for an average of 18 months with problems like depression, anxiety, low self-esteem, and conflict with their parents.

When investigators analyzed their interview responses with the help of a computer, certain themes emerged as most significant. On the value of therapy:

   Talking about oneself. Patients found it helpful to express and label their feelings, reflect on them, and remember and review personal history. When they did this, they regarded the therapist as mainly a background presence or witness rather than an active participant.
   A special place and a special relationship. Patients spoke of the therapy as a neutral zone, outside the usual context of family, friends, and work, in which they could express themselves freely, without choosing their words carefully, to a respectful and supportive person.
   “A new relational experience.” Therapy created an atmosphere in which they could try out new ways of relating to other people: “I started to influence my family to talk about deeper feelings.”
   Exploring together. Patients used words like “asked questions,” “summarized,” “linked,” “pointed out.” It meant finding patterns in their lives, defining problems, and sometimes setting goals. Finding patterns in present behavior and connecting them with the past is a central feature of psychodynamic therapy. It is often described in terms of transference — the influence of early emotional ties on responses to the therapist. But these patients did not describe pattern-finding that way. They rarely mentioned feelings about the therapist that suggested transference.
   Expanding self-awareness. This was the main result of exploration and talking about oneself. Patients said they had sorted out something about their lives, linked the present to the past, and were able to continue a therapeutic dialogue with themselves after treatment.
There were also difficulties and disappointments. Talking about oneself could be anxiety-provoking, and it was some time before patients were able to feel complete trust in the therapist. Another common theme was summarized as “self-knowledge is not enough” or “something is missing.” Therapists were described as too passive. Patients wanted more guidance and advice. Some wanted the therapist to act as “good parent”; some wanted homework.

Finally, there was a situation described as a mismatch. Some patients had been unhappy with the treatment. They thought they might do better with medication, another kind of therapy, or another therapist. But they often continued anyway, sometimes for a year or more. The theme of exploring together was rarely mentioned in the same context with worries about a mismatch or the feeling that something was missing. Apparently patients were reluctant to bring up these troubling issues with the therapist.

The authors suggest that psychodynamic therapists check their understanding of the collaboration against their patients’ views by periodically asking what is helpful and what isn’t.