How to Create a Healthy and Effective Therapeutic Relationship

As with medical emergencies, the 'golden' first hour of a therapeutic relationship can be critical

It was a tragedy, but I didn’t know it at first.

In the long-shadowed gloom of a winter evening, as barely formed snow shyly brushed the window pane, Mary painted the painful picture of what had happened to her husband Dave.

Dave was depressed. His much-loved brother had recently been killed in a car accident.

He was plagued by worry about a court case with an ex-business partner. He was staring down the barrel of bankruptcy.

But worst of all, his feelings about himself had changed.

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As he hit middle age, he felt he had “nothing to show” for his life. He started to talk bitterly of being a “lousy husband”, a “bad father”, and a “failure”. “But he was so good in so many ways…” Mary told me, her tone almost pleading. Eventually she had urged Dave to see a therapist.

“Knowing Dave, he must have been desperate to agree to see a counsellor”, Mary said. “He never liked to talk about anything emotional. It was a big deal for him to go see someone.”

But go see someone he did.

“How did it go?” I asked.

“Well, he only saw her the once.”

Now, like a distant but shrill distress signal in a wind-blasted sea, something deep within me whispered that Dave was dead.

“And? Did the therapy help?”

“Help! After his session with her he just couldn’t stop weeping. He told me that the therapist hadn’t even really looked at him. That it was just 50 minutes of information taking. He filled out one form after another without either speaking or being spoken to. I remember him telling me he didn’t think the therapist liked him very much. More than ever, he seemed to believe that it really was hopeless, that even therapy couldn’t help him.”

“Oh” was about all I could manage. Mary continued.

“I reassured him that it was just the first session, that she was there to help him. But I think he had been so prepared to talk that he was completely thrown when he didn’t get the chance, and it made him even more despondent. Or maybe it was just the way he saw it.”

The room darkened as the snow began to fall harder, flakes thudding audibly against the glass in the chill wind. For a few moments, there was nothing but foreboding silence. Eventually Mary spoke again.

“Three days after the therapy session Dave killed himself.” I could see how hard it was for her to even form the words. Decades on, the pain still cast a shadow over Mary’s eyes and mouth.

“He threw himself from Beachy Head.” The words caught in her throat. “Suddenly I had no Dave…” Now the tears came. “All I wanted to do was to… talk to him. Tell him he was a good man… and that he was loved so, so much…” She trailed off.

Don’t just do no harm

Now, Mary was my client. She felt terrible that she had recommended Dave seek help in that way. Yet she knew that it wasn’t really her fault, and no one could actually blame the therapist for being ‘cold’ or bureaucratic when she could have been warm and human. If that’s how it even went down.

Maybe Dave would have killed himself anyway.

We can’t know for sure what happened in that session or how connected it was to Dave’s suicide. I’m not saying we should never be judgmental – without judgment there can be no volition or free thought – but we don’t have enough information to be judgmental about that therapist in this instance. Not really.

But there may be something to be learned from this tragedy. What we do know is that the therapist wasn’t able to prevent Dave’s suicide. One thing it seems that therapist didn’t supply was that most powerful antidepressant on Earth: hope.

The doctor’s Hippocratic Oath urges us to “first do no harm”. But what if that isn’t enough? Maybe we can improve on Hippocrates and say “first do actual good.” And establishing a therapeutic relationship with your client is the first step.

The therapeutic relationship is important because therapy isn’t just about what we do but also who we are with our clients.

If the therapist has an outmoded ideology, lacks flexibility or is too steeped in ‘being the professional’ or bureaucratic note-taking over actual human connection, then the therapeutic relationship – if it can even be called that – may do no good. It may even be counterproductive.

Conversely, if the therapeutic principles are good enough, then even computerized therapy can be highly effective without the therapeutic relationship being necessary ⁽¹⁾.

But in the majority of cases, a strong, well cultivated therapeutic relationship is the best – perhaps the only – basis for healthy, effective therapeutic outcomes.

So what do we really mean by a therapeutic relationship?

What is a ‘therapeutic relationship’?

There’s little doubt about the power of a warm human encounter. Clients need to feel safe, listened to, relaxed and able to voice ideas and opinions without feeling the need to please the therapist, nor the fear of displeasing them.

In some ways the therapeutic relationship has become somewhat sanctified, a hallowed contract of trust between client and therapist. Psychology textbooks heave and strain to contain its almost holy pact.

We hear about ‘boundaries’ and ‘ethics’, and sometimes of ‘transference’ (the client meeting their needs for intimacy through the therapy, not outside of the therapy). Therapeutic nomenclature almost fetishizes this ‘holy communion’.

But on a very basic level we have one troubled primate sitting down with another who can help them feel better, think healthier and meet their emotional needs in life. This ‘therapeutic relationship’ is not new. In fact, it existed long before therapy was even a word.

At its heart the therapeutic relationship is simply an exchange of decency, openness and friendliness between one human being and another, hopefully in both directions. The relationship is the container in which the skills of the therapist can best be used to help the client.

Most relationships require an exchange of one person’s needs with the other’s needs at least some of the time. If you give me attention, you expect me to ask about you. If I steal all the attention by speaking endlessly about myself, never asking you anything, then the relationship shrivels.

People who are good at relationships intuitively know about this exchange aspect to all personal relationships – give and take of human needs.

But the modern therapeutic relationship is a little different. Within the therapeutic relationship the exchange of needs doesn’t work in the same way, because money is being exchanged, and the emotional needs of the client need to, of course, take precedence.

We don’t need our clients’ adulation or respect any more than is useful for their therapeutic progress. We shouldn’t draw our natural human needs for attention from them either. We are paid in money, we don’t need to be ‘paid’ in any other way.

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Empathy, space to talk, encouragement, and prioritizing client experience are all part of a good therapeutic relationship. And if we have a relationship of trust and warmth then within that relational framework we can sometimes work in unconventional ways that might not superficially seem so nurturing; we can be a little harsh or paradoxical or contrary because we have good rapport.

This is an area not often discussed but nevertheless important. For therapy to happen learning has to take place, and sometimes, in order to learn, the client needs to be challenged.

Like all relationships, the therapeutic relationship needs more than one tone. Here’s why.

Don’t get stuck on therapy mode

Some therapists may slip into sympathy mode and have trouble getting out. They may look slightly pained when they talk to you (like an adult comforting a child with a stubbed toe), talk in hushed tones and nod sympathetically to anything and everything you say. They may believe this is the best and only way to instigate therapy.

But there’s a danger here. The subliminal message is “you are damaged” and “you are vulnerable and fragile.” I’m not saying this mode of communication isn’t useful sometimes, but it shouldn’t be used exclusively, even in the presence of real client resilience and personal resources. All communication is more of a fluid ‘dance’ than a one-size-fits-all mode.

We risk unconsciously reinforcing clients’ limiting beliefs with every well-meant nod of the head. Besides, if someone can only do sympathy we will soon tire of their company.

Take them on a practice run

Moving on from these perhaps seldom-explored considerations, the therapeutic relationship should never replace real-life relationships for the client.

But sometimes, when clients feel safe with us, they can use us as practice – ‘training wheels’ for the development of healthier relationships in their wider life. A client can learn to relate to a whole gender or type of person simply by developing a healthy, fair and respectful relationship with their therapist.

For example, if you are a member of Uncommon Practitioners TV, you’ll see my sessions with Frances, a client needing help with long-term depression resulting from an abusive past. After several sessions she tells me how she feels. As she has learned to trust me, she has realized she no longer fears men.

And that is, at least in part, thanks to the therapeutic relationship we have established. Maybe I am the first man who hasn’t let her down.

Talking with me has become, in some small way, ‘practice’ for Frances. Practice to build her confidence and feel more comfortable around all men, and start to let go of her blanket preconceptions about men on the whole.

So, with all this in mind, here are my Do’s and Don’ts when establishing the therapeutic relationship.

4 Tips for a Healthy and Effective Therapeutic Relationship

1. Make the most of the ‘Golden Hour’

It breaks my heart when I hear that the first hour, maybe the client’s first hour ever, of therapy, is misspent simply gathering information or bogged down in bureaucracy. This is the time to build rapport with our clients. The time to listen to them, to encourage them, but also to inhabit their perspective so they feel uniquely understood.

This is the opportunity they’ve been waiting for to lay down their emotional burden for a while, to be treated with respect, like a person not a number.

We have a massive opportunity in a first session precisely because it’s the first session. The newness of the session creates an intensity of focus – a trance – that can be used to help instil hope (see below) and make changes. This opportunity should never be missed.

In fact, this may be the only chance we get to help the person – because if we don’t, they may only attend one session. We need to do as much as we can as fast as we can. And we need to do one thing above all else.

2. Do give them hope

“Hope is like the sun, which, as we journey toward it, casts the shadow of our burden behind us.”

– Samuel Smiles

Dave didn’t have hope, and it seems his one and only therapy session didn’t give him any. In fact, according to Mary, he seemed to have lost hope after his form-filling session with the therapist he felt “didn’t like him.”

Positive expectation is so vital. It doesn’t have to be huge. Just a smidgen of hope. A small flicker can light a path out from a dark cave.

Even if the hope stems from the simple fact that someone cares about them. Someone is there to listen. But we can often do better than that. And we should do it straight off the bat.

The placebo effect is immense. It’s easy to pass the effect off as some ghost-in-the-machine inconvenience that occurs in physical medicine. But the fact that placebo pills have been shown to be as effective in treating depression as drug products is glowing evidence of just how important positive expectation really is for depression ⁽²⁾.

Cognitive Behavioural Therapy seems to be about half as effective at treating depression as it used to be. Researchers were left scratching their heads as to why this might be until it was considered that the newness of the technique had subsided. The placebo element to the therapy may have worn away ⁽³⁾.

The placebo effect isn’t smoke and mirrors. It’s real. It mobilizes powerful inner healing mechanisms, both psychological and physical ⁽⁴⁾.

A skilled therapist knows how to utilize this natural healing response in their clients and build positive expectation around therapy within a reassuring framework. Client beliefs and expectations and trust in the process are a major factor in how well they actually do in therapy.

Hope is so vital that it can override damaging emotional habits. We know that over-analysis and brooding rumination is emotionally toxic and can produce and maintain clinical depression and anxiety conditions ⁽⁵⁾.

But if someone ruminates while they have hope the toxic effects of dwelling seem to be mitigated ⁽⁶⁾. That’s how powerful hope is.

The time we have with our clients is a unique chance to learn what troubles them and help them feel heard and understood. But it’s also a time to listen to what they want. For clients with negative bias we can’t instil hope by being too positive as this risks breaking rapport and seeming not to understand their perspective.

But we can begin to light a spark in more subtle ways. We can help them to feel they might, just might, have a chance of feeling better.

But if a client comes for therapy multiple times, you need to be aware of a very real danger.

3. Don’t let therapy fossilize

“You can never awaken using the same system that put you to sleep in the first place.”

– G I Gurdjieff

Any recurrent experience can lose its ‘juice’, become predictable, and come to feel like simply ‘going through the motions’.

The tendency for repeating experiences to become fossilized, to ‘put us to sleep’ is an oft-overlooked phenomenon. From attending class to going to church to being with the person we love to therapy sessions, repetitive experiences can lose their capacity to help us change and grow.

This happens when a situation becomes too mechanical and predictable. Focus dissipates and weakens, and so does the opportunity for learning.

This happens because of the basic emotional and physical principle of ‘pattern matching’, in which environmental triggers produce a repeating emotional response in a mechanical way. Think same-old commute to work.

People who’ve had lots of previous therapy may have been trained by that therapy (depending on the ideology of the therapist) to cry during sessions. This Pavlovian response may get mechanically wheeled out simply because this person is once again sitting on a therapy chair.

Therapists who don’t understand the mechanical nature of experiences like this may look for causes of the tears and forget that the client may be subconsciously producing a learned response.

The now-legendary psychiatrist Dr Milton Erickson would see clients in different places, move the furniture around in his office, and generally keep the client awake to change and therapeutic reality. We are all put to sleep by habit. And repeating cues – same office, same chair, same type of conversation – may take the living heart out of the experience.

So intensity and dynamism are required to keep therapy from becoming a staid and dead thing. Surprise and conversational reframing, in which feelings are reframed, are ways of keeping therapy ‘live’.

Part of the therapeutic relationship is also in knowing when it must end and how that needs to happen.

But there’s one more risk to the client.

4. Don’t become a replacement for real-life needs

The therapeutic relationship can certainly for a while start to fulfil a need that may never before have been met for the client. Maybe you are the first person who has ever seemed to have understood them, cared about them, and helped them to feel psychologically robust, to believe in themselves and to feel free to explore their life more positively.

But therapy should help the client meet these kinds of needs not just during the time they are with the therapist, but also outside of the therapy situation. When this happens, the client is less likely to get hooked on the therapy or therapist.

So if the therapist and/or client is not clear about the basic emotional needs we all share then the client may meet their needs for meaning, purpose, self-esteem, giving and receiving attention, and even love and emotional intimacy purely from the therapy. And they may never move on from that.

For therapy to be ‘clean’, the practitioner needs to understand this and help the client get these needs met outside of therapy, so that dependency doesn’t happen. As the great Human Givens psychologist Joe Griffin once said, “A good therapist should not leave footprints in the lives of their clients.”

But it works both ways.

Every therapist should meet his or her needs outside of their therapy practice to a large degree. They should have enough friends, outside opportunity to feel good about themselves, intimacy and so forth that they have ‘spare capacity’ to help their clients without being tempted to unconsciously try to draw their needs from their clients.

When we are hungry we will try to find food anywhere. But attempts to meet emotional ‘hungers’ are often unconscious. One client told me his old therapist would talk for hours about himself. He said, “I used to feel sorry for him [the therapist] because I had the feeling I was the only one he spoke to in the whole week!”

To sum up

The therapeutic relationship should be open, relaxed (and relaxing), caring, and above all effective in creating the right environment for developing client wellbeing and sustainable health.

Words like ‘boundaries’, ‘ethical’ and ‘nurturing’ are only as good as the reality behind the words and the extent to which the purposes of those realities are understood.

A therapeutic relationship may last as little as a few moments, or as long as many months for some clients who may have few of their needs met in their current life or have psychological damage from the past to sort out.

The therapeutic relationship is unlike real-world relationships in that it is caring but impartial. The therapist doesn’t play games in order to meet their own emotional needs. The relationship shouldn’t contain its own ‘baggage’ from the past and lacks many of the feelings and associations of everyday relationships.

Maybe you or I couldn’t have helped Mary’s decent, caring, beloved Dave.

But maybe, just maybe, we could have.

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About Mark Tyrrell

Psychology is my passion. I've been a psychotherapist trainer since 1998, specializing in brief, solution focused approaches. I now teach practitioners all over the world via our online courses.

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