In the opening chapter of the sixth edition of Counseling and Psychotherapy: Theories and Interventions (published by the American Counseling Association), David Capuzzi, Mark Stauffer and Douglas Gross make the case that the helping relationship is central to all effective counseling. Not many counselors would argue with this idea. Nevertheless, many counseling practitioners still feel pressure to implement empirically supported or evidence-based mental health treatments. Consider this case:
Darrell is a 50-year-old Native American. He identifies as a male heterosexual. In his first counseling session, he talks about feeling “bad and sad” for the past six months and meets diagnostic criteria for a depressive disorder. Darrell’s counselor, Sharice, is trained in a manualized, empirically supported cognitive-behavioral model for treating depression. However, as a professional counselor, she values collaborative counseling relationships over manualized approaches. She especially emphasizes relational connections during initial sessions with clients who are culturally different from her.
The question is, how can Sharice be relationally oriented and still practice evidence-based counseling? The answer: She can use evidence-based relationship factors early and throughout the counseling process.
Evidence-based relationship factors
Back in 1957, Carl Rogers wrote that “a certain type of relationship between psychotherapist and client” was “necessary and sufficient” to produce positive change. In contrast, if you immerse yourself in contemporary research on counseling and psychotherapy, you might conclude that relationship factors in counseling are passé and that, instead, cutting-edge (and ethical) practitioners must use empirically supported treatments. But you would be wrong.
Most reasonable people recognize that both relationship factors and techniques contribute to positive outcomes. However, it is also true that relationship factors in and of themselves have strong empirical support. More than 60 years of scientific evidence supports Rogerian core conditions of congruence, unconditional positive regard and empathic understanding. In fact, counseling relationship factors are just as scientifically potent (and maybe more so) as so-called empirically supported treatments.
Newer terminology for acknowledging the research base for therapeutic relationships has been coming for about 15 years. In 2001, a task force from Division 29 (Society for the Advancement of Psychotherapy) of the American Psychological Association coined the phrase “empirically supported therapy relationships.” The task force’s purpose was to place therapeutic relationships on equal footing with empirically supported treatments. Despite those efforts, many (and perhaps most) psychologists value technical procedures (for example, cognitive behavior therapy) over relational factors. In contrast, because of counseling’s emphasis on therapeutic relationships, in some ways, empirically supported therapy relationships are much more relevant to professional counselors.
In this article, we use the broader phrasing of “evidence-based relationship factors” (EBRFs) to represent ways in which professional counselors can integrate research-based relationship knowledge into counseling practice. But what is an EBRF, and how can counseling practitioners implement them in ways that are more specific than simply saying, “I value the therapeutic relationship?”
EBRFs include the three Rogerian core conditions and other purposefully formed and implemented relational dimensions. Below, we provide concrete examples of 12 EBRFs that are empirically linked to positive counseling and psychotherapy outcomes. For each EBRF, we use the case of Sharice and Darrell to illustrate how Sharice can work relationally with Darrell and still engage in evidence-based practice.
Evidence-based attitudes and behaviors
Rogerian core conditions of congruence, unconditional positive regard and empathic understanding are foundational EBRFs. Although Rogers described them as attitudes, they also have behavioral dimensions. Additionally, counselors bring other relational factors into the room, such as role induction, cultural humility and scientific mindedness. Together, these EBRFs create a welcoming, safe and transparent environment that fosters therapeutic relationship development. Simultaneously, counselors are responsible for managing their countertransference throughout the relationship development process.
Congruence implies counselor self-awareness and involves holding an attitude that values authenticity. Clients typically experience counselor congruence as the unfolding of a genuine relationship with their counselor. Genuineness involves counselors striving to be mindfully open and honest in their interactions with clients. This usually, but not always, involves self-disclosure, immediacy and offering feedback.
Sharice displays congruence in several ways. First, she presents Darrell with an informed consent document that is written in her unique voice and that includes information on how she works with clients in counseling. She also greets Darrell with clear interest in learning more about who he is and what he wants. To focus on him, she might sit and emotionally center herself before going to meet him in the waiting room.
During the session, when Darrell talks about details of his professional work, Sharice openly expresses curiosity, “Oh, you know, I’m not sure what you mean by that. Could you tell me more so I can better understand what you’re experiencing in the workplace?” After Darrell shares details, she says, “Thank you. That helped me understand what you’re up against
Role induction is the process through which counselors educate clients about their role in counseling. Role induction is necessary because clients do not naturally know what they should talk about and because they may have inaccurate expectations about what counseling involves. When it goes well, role induction is interactive, and counselors simultaneously exhibit Rogerian core conditions (“I hope you’ll always feel free to ask me anything you want about counseling and how we’re working together”). Role induction begins with the written informed consent form.
Sharice includes in her informed consent document what her clients can expect in counseling. She also explores these topics with Darrell in their first session.
Sharice: I’d like to share a bit with you about what we’ll be doing in this first session. To start, I want to hear about what’s been happening in your life that brings you to counseling now. As you talk, I’ll ask a few questions and try to get to know you and your situation better. We’ll talk about what’s happening now in your life and, if it’s relevant, we’ll talk some about your past. Then, toward the end of our session, I’ll share with you some ideas on how we can work together, and we’ll start to make a counseling plan together. Please ask me questions whenever you like.
Unconditional positive regard
Unconditional positive regard involves the warm acceptance of clients. Rogers himself noted that unconditional positive regard was an “unfortunate” term because no counselor can constantly experience unconditional positive regard for clients. However, to the extent that it can be accomplished, unconditional positive regard involves acceptance of the client’s self-reported experiences, attitudes, beliefs and emotions. Unconditional positive regard allows clients to feel the safety and trust needed to explore their self-doubts, insecurities and weaknesses.
Throughout their time together, Sharice shows Darrell unconditional positive regard by listening to his experiences, attitudes, beliefs and emotions without showing judgment. She’s open to whatever he brings into the session and encourages him when they encounter subjects he finds difficult to explore. She not only listens nondirectively but also asks questions such as, “What’s your best explanation for why you’re feeling down now?” and “What are you thinking right now?” These questions show acceptance by supporting and exploring Darrell’s self-evaluation rather than focusing on Sharice’s judgments.
Empathy is one of the strongest predictors of positive counseling outcomes. However, there is one interesting caveat. It doesn’t matter if counselors view themselves as empathic; what matters is for clients to view their counselors as empathic.
Although measuring empathic responding is challenging, there is consensus that using reflections of feeling and engaging in limited self-disclosure are effective strategies. Also, there is evidence from neuroscience research that resonating with or feeling some of what clients are feeling is part of an empathic response.
When responding to Darrell, Sharice uses her facial expressions, posture, voice tone and verbal reflections in an effort to comprehend Darrell’s unique thoughts, feelings and impulses. She expresses empathy as he talks about work stress.
Darrell: I feel pressure coming at me from everywhere. Deadlines that need to be met, clients to make happy, bills that need to be paid, and I need to maintain this image in the community, you know?
Sharice: That sounds stressful. You have people counting on you, and it feels overwhelming.
Following an initial reflection of feeling, Sharice uses what Rogers referred to as “walking within” to emotionally connect on a deeper level.
Darrell: It’s starting to get to me in ways stress hasn’t before. Like, I can’t sleep, it’s harder to focus, and I feel like I’m going to burn out soon.
Sharice: It’s like you’re saying, “I don’t know how much more of this I can take, and I don’t know what to do.” Do I have that right?
Later, Sharice uses a reflective self-disclosure (which combines congruence with empathic understanding) in an effort to deepen her empathic resonance.
Sharice: As I listen to you, Darrell, and as I try to put myself in your shoes, I feel physically anxious. It’s almost like this pressure and pace make me feel out of breath. Is that some of what it feels like for you?
Just like Carl Rogers would do, Sharice intermittently checks in with Darrell on the accuracy of her reflections (“Do I have that right?”). Additionally, if Darrell indicates that Sharice is not hearing him accurately, she uses paraphrasing to refine her reflection and sometimes apologizes while correcting herself.
Cultural humility is an overarching multicultural orientation or perspective that includes three dimensions:
1) An other-orientation instead of a self-orientation
2) Respect for client values and ways of being
3) An attitude of equality, not superiority
Like the Rogerian core conditions, cultural humility is an attitude that counselors adopt before entering the counseling office, but there are also behavioral manifestations of cultural humility.
In their first session, Sharice creates a space for Darrell to speak about what his culture means to him. She notes that even though they come from different cultures, understanding his culture is important to her.
Sharice: Thank you for filling out the intake form, Darrell. I know it can be daunting with all the personal information we ask for. I see that you are Native American. I’m a mix of German and Swiss and grew up outside of Denver. What this means to me is that I’ll be trying my best to understand your life experiences. If at any point you think I’m not getting your perspective, I hope you’ll tell me. Sound OK? (Darrell nods.) Thanks. Also, whenever you’d like, I’d be interested in hearing more about your culture and how it informs your way of being in the world.
Scientific mindedness is a concept and skill originally described by Stanley Sue. It refers to the process of counselors forming and testing hypotheses about clients rather than coming to premature, and potentially faulty, conclusions.
As Sharice gets to know Darrell and the issues that brought him to her office, she uses scientific mindedness to hypothesize how culture may (or may not) be a salient factor in his experience of stress in the workplace. When he talks about “immense pressures” that he puts on himself, she’s reminded of how some individuals from minority groups can feel added stress because they view themselves as representing their entire minority community. Sharice keeps this hypothesis in the back of her mind and, eventually, when the time seems right, uses a reflective listening response to test her hypothesis.
Sharice: When you talk about the pressure you put on yourself to perform, it sounds like you’re performing not only for yourself but also for others.
Darrell: Absolutely. I can’t help but worry because my family depends on me to generate income. (Somewhat to Sharice’s surprise, Darrell doesn’t identify his tribe or the reservation community as an additional source of pressure to perform, so she explores the issue more directly.)
Sharice: I’ve read and heard from some of my other Native American clients and students that it’s possible to feel added stress because they might view themselves as representing their tribe or other Native American people. Is that true for you?
Darrell: I always tell myself that that’s not an issue for me. But if I’m totally honest with myself and with you, I’d have to say that being an Indian man in an intense business environment makes for more stress. In some ways, I think it has less to do with representing my people and more to do with how I think my colleagues — and even my friends at work — somehow expect me to be less competent. I don’t know exactly what they think of me, but I feel I need to work twice as hard to earn and keep their respect. (After listening to Darrell’s disclosure, Sharice updates her hypothesis about how race and culture might be adding to his stress at work.)
Sharice: So, it’s not so much that you feel like a representative for your people. It’s more that you’re thinking and feeling that you should do double the work to prove yourself to your colleagues. I can imagine how feeling discounted compounds the everyday workplace stress you feel.
Countertransference is unavoidable. Countertransference includes the counselor’s emotional reactions to any or all clinically relevant client material (transference, client personality, content presented by the client, client appearance and so on). These reactions may be related to the counselor’s unresolved personal conflicts or the client’s interpersonal behaviors. Countertransference can be a hindrance or a potential benefit to the therapeutic process; it can distort your perceptions of your client, but it can also inform your relationship with the client.
During their work, Sharice notices that she gets impatient with Darrell’s pace of speech and finds herself feeling annoyed with him. She brings this to her consultation group to understand why this is happening and how it is affecting her work with Darrell. Talking about it with her supportive group helps her deal with her emotional reactions more effectively and build understanding for why she is experiencing frustration and how to adjust so she can provide the best service possible to Darrell.
The evidence-based therapeutic alliance
The therapeutic alliance was a psychoanalytic construct until Edward Bordin described it in pantheoretical terms. Alliance factors include three dimensions:
1) The emotional bond
2) Mutual goals
3) Collaborative tasks in counseling
Additionally, progress monitoring and rupture and repair can be viewed as EBRFs related to the alliance.
The emotional bond
Although it can be difficult to measure an emotional bond, in the counseling context it is usually defined as clients showing a positive affective response toward their counselors. In many ways, the counselor-client emotional bond is a natural byproduct of the Rogerian core conditions and of the work that counselors and clients do together. However, counselors lead in this process by greeting clients with a positive affect and consistently showing interest in what clients talk about.
When Darrell arrives at Sharice’s office, she is visibly happy to see him. In addition, she expresses her interest in working with him and her belief that he possesses the ability to overcome the issues with which he is struggling.
After a few sessions, Darrell begins to show trust in Sharice. He no longer looks anxious to be in her office, his speech is less guarded and he smiles more during their interactions. He mentions that although counseling is difficult at times, he appreciates having time every week with Sharice to talk about his life and sort out what is troubling him. He has become emotionally bonded to Sharice and looks forward to counseling sessions.
In the first few sessions, counselors and clients explicitly discuss clients’ personal problems and corresponding counseling goals. Eventually, and sometimes even in the first session, clients and counselors agree on which goal or goals to focus on in counseling.
Sharice (after discussing Darrell’s presenting problems and possible solutions): Darrell, we’ve identified several goals that we can work on together: stress management, managing the negative or critical thoughts you have about your work performance and getting better sleep. Which of these would you like to focus on first?
Collaboration on tasks linked to goals
After working with clients to decide on counseling goals, counselors introduce tasks or activities in session (or as homework) that are meaningfully related to the agreed-upon goals. These collaborative tasks often constitute the “technical” part of counseling.
When applying techniques, relationally oriented counselors:
- Are careful to listen closely to what clients have already tried
- Use reflective listening to gain a mutual understanding of what has worked worse or better
- Jointly brainstorm new options with clients
- Ask permission to try out technical procedures
- Jointly monitor client reactions to new strategies
Sharice: We’ve been talking about everything you’ve tried to help yourself sleep better. It sounds like you’ve been working on this for years. How about we rank which strategies have worked better for you and which have worked worse?
Darrell: Sure. (Sharice and Darrell work on Darrell’s rankings.)
Sharice: One of the things I’ve noticed that seems to work better for you is
when you’re able to distract yourself from your thoughts about work. Does that sound right?
Darrell: Absolutely. It’s so hard for me to get my brain to stop problem-solving.
Sharice: One thing I’d add to your list of possible strategies is mindfulness meditation. It can be a powerful technique to deal with racing thoughts. What’s your reaction to that idea?
After counseling goals are established and collaborative tasks identified, counselors and clients work together to evaluate counseling progress. There’s a robust body of research attesting to the positive effects of progress monitoring.
Sharice consistently checks in with Darrell in two ways. First, she uses the Session Rating Scale after each session to gauge her therapy alliance with Darrell. Second, she directly asks Darrell about his reactions to the counseling strategies they are working on together.
As a part of her progress monitoring efforts, Sharice asks Darrell to keep a log of his mindfulness meditation activities, along with his sleep quality and quantity. Each week, they discuss what went well and what was challenging. She offers empathy and makes adjustments to his homework as needed.
Rupture and repair
Rupture is defined as tension or a breakdown in the counselor-client collaborative relationship. Repair involves counselors making statements and taking actions to restore the therapeutic relationship. Rupture can happen at any time during counseling. Usually it involves clients withdrawing or showing irritation.
After a few weeks of logging his mindfulness meditation, Darrell appears agitated. When Sharice asks about the log, Darrell says, “This is a waste of time, and I don’t know why you thought it was going to help. I’m done with this stupid meditation.”
Sharice responds empathically and then explores with Darrell the source of his frustration. She discusses how embracing a passive attitude during meditation can be extremely difficult, especially because of the pressured and problem-solving orientation he has at work. She apologizes for pushing the idea of mindfulness meditation.
Darrell’s response is paradoxical. He spontaneously shares how important it is for him to find time to get out of his hard-driving mentality. Sharice then tweaks the mindfulness approach they have been using. The new emphasis moves away from formal logging and embraces small moments of progress.
The relationally focused, scientifically based counselor
Beginning with Rogers and moving forward into the 21st century, counseling practitioners have embraced the therapeutic relationship as central to positive counseling outcomes. However, at times, allegiance to and emphasis on the counseling relationship has been viewed as anti-science. The good news is that, now, more than ever, we have growing empirical evidence to support the efficacy and effectiveness of a relational emphasis in counseling. In this article, we reviewed and illustrated specific ways in which you can emphasize the therapeutic relationship and be evidence-based. This is welcome progress for the counseling profession in general and counseling practitioners in particular.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
John Sommers-Flanagan is a professor in the Department of Counselor Education at the University of Montana. He has co-authored many books, including Tough Kids, Cool Counseling (published by the American Counseling Association) and Counseling and Psychotherapy Theories in Context and Practice (published by Wiley). Contact him at firstname.lastname@example.org or through his blog at johnsommersflanagan.com.
Kindle Lewis is a doctoral student in counselor education and supervision at the University of Montana. She is a national certified counselor, holds a license in school counseling and has 10 years of experience working with youth in education and counseling settings both locally and internationally. Her areas of focus are youth and school counseling, community building and holistic wellness. Contact her at email@example.com.
Letters to the editor: firstname.lastname@example.org
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.