An exploration of how therapists judge the quality of their therapeutic relationships in clinical practice

Abstract

In a systematic review of the existing literature exploring how therapists measure the quality of the therapeutic relationship, twelve quantitative articles deemed relevant and to have enough scientific rigour were examined and appraised. These included observational studies, and partially-controlled or uncontrolled clinical trials, all of which differed greatly in their methodology. A number of predictors of therapists' judgments of the quality of their therapeutic relationships were identified during the narrative synthesis. These fell into three main categories: therapist factors, interpersonal factors and client factors. These findings are consistent with previously reported patterns relating to the links between the quality of the therapeutic relationship and specific therapist characteristics, including the impact of their views of the relationship (e.g. Zilcha-Mano et al., 2015). Results also suggested therapists and clients differ in both their views of the relationship (e.g. Hatcher et al., 1995), and the information they use to judge its quality (e.g. Bachelor, 2013). However, datasets were highly variable, and methodological weaknesses affected the extent to which conclusions could be reliably generalised. Furthermore, the largely correlational designs meant that only associations between the above factors were made. As advocated by Elvins and Green (2008), more qualitative research attempting to explain how therapists assess the quality of the therapeutic relationship is warranted.

There is an accepted evidence-based link between the quality of the therapeutic relationship and clinical outcomes. However, this is set in the context of a lack of clarity around how therapists actually measure their therapeutic relationships, and whether this differs with experience. The present study recruited 71 Trainee Clinical Psychologists across the UK, who completed an online questionnaire exploring their experiences in their therapeutic relationships. Utilising QSR NVivo 10.0 (Silver, 2014), Braun and Clarke's (2006) six-phase iterative thematic analysis process organised data into three domains: 'Conceptualising the Relationship', 'Managing Challenges' and 'Measuring the Quality'. Among the superordinate themes, Trainees discussed what makes a 'Good Relationship' and its 'Perceived Role', alongside 'Strategies' used to manage difficulties in the relationship, which generated themes of 'Open Discussion', 'Formulation', 'Reflective Practice' and 'Adapting Approaches'. Trainees also described a superordinate theme of using 'Quantitative Approaches' to measure the quality of the relationship, but tended to use more 'In-Vivo Indicators' in this judgement. Indicators included 'Attunement and Congruence', 'Client Feedback', 'Trust, Honesty and Openness', 'Motivation and Attendance', and 'Intuition, Feelings and Gut'. Conversely, some Trainees reported having no experience of therapeutic ruptures, which could reflect either a lack of clinical experience, or could point to potential insecure attachment styles among some Trainees. Implications include (i) the potential benefits of increasing and possibly standardising approaches in using both quantitative and qualitative methods of measuring the quality of therapeutic relationships on UK Clinical Psychology training programmes, and (ii) that most Trainees currently prioritise the therapeutic relationship, practice reflexively and understand and appreciate the link between the quality of their relationships and clinical outcomes.

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