Often the client is unable to take steps to avoid the undesirable emotional attachment. The therapist must take the initiative in maintaining proper distance and personal space. However, it is important to be aware that a positive therapeutic relationship could become too much of a good thing. When it does, a positive relationship can become toxic to the therapeutic outcome.
Comparing and Contrasting the Therapeutic Relationship and Client-Therapist Attachment
The therapeutic relationship and client-therapist attachment have many common elements, but the are major differences as well. Both the therapeutic relationship and the client-therapist attachment develop from the relationship between a therapist and their client. Research cited earlier, tells us that the development of a relationship is necessary for the success of the treatment plan. The more intimate the relationship becomes, the more likely it is to result in the type of shared secrets that result in positive therapeutic outcomes. However, it appears that this relationship can go too far and cause more harm than good.
When one talks about the therapeutic relationship, it is mentioned in a positive light. It is a natural part of the therapy process and should be encouraged. However, as we learned in our discussion of client-therapist attachment, one must be careful to keep proper distance and to avoid overt closeness. It would appear that there is an obscure line that cannot be crossed in the intimacy of the client-therapist relationship. When the relationship changes from a positive interaction to an attachment, it can be damaging to both parties and can have a negative, rather than a positive impact on the treatment process.
There are many differences that distinguish a therapeutic relationship from client-therapist attachment. The first is that studies have demonstrated that the therapeutic relationship develops early in the treatment cycle. It begins to develop during the initial assessment phase of the treatment continues to grow throughout the treatment process (Hilsenroth, Peters, & Ackerman, 2004). This differs from client-therapist attachment that typically only develops after a long-term treatment plan where a significant level of intimacy develops between the client and therapist (Woodhouse, Schlosser, & Crook, et al., 2003).
The most significant difference between a therapeutic relationship and client-therapist attachment is that the therapeutic relationship can be nurturing for the client. A positive therapeutic relationship has a positive outcome on the treatment outcome. A client-therapist attachment stems from this nurturing relationship, but has a negative impact on the treatment outcome. In the end, the relationship will end, which can lead to more trauma for the client and potentially even damage to the therapist as well.
Client-therapist attachment develops from a positive therapeutic relationship. During the course of treatment client-therapist attachment may have a positive influence on the treatment progress. It may lead to greater intimacy and ability to share with the therapist. It may lead to increased feelings of trust and a willingness to follow treatment prescriptions. This may be the result of feelings that the client does not wish to disappoint the therapist, so they follow the treatment as prescribed. These are all positive affects that stem from client-therapist attachment. However, these affects are short-lives and in the end, client-therapist attachment can lead to feelings of mistrust, anger, and resentment on both sides of the couch.
It is important to understand the differences between a positive therapeutic relationship and client-therapist attachment. It can be generally agreed that when the line is crossed and the relationship evolves into attachment, a good thing turns bad. However, the most difficult aspect of the differences in these relationships is knowing exactly when this line has been crossed. Often the transition from relationship to attachment progresses slowly, as feelings gradually increase. Due to this gradual increase in feelings, it is sometimes difficult, even for a seasoned professional, to recognize the signs that too much intimacy has developed in the relationship.
The ability to maintain professional distance from clients is an important ethical consideration for therapists. They must be able to recognize the signs of too much intimacy from their clients and must be able to devise a way to transition the relationship back into a healthier state without harming the client. The most difficult aspect of this professional skill is to be able to recognize the early signs of a relationship gone wrong.
This study will explore the ability to therapists accurately assess the status of their relationship with their clients. It will explore their ability to recognize a negative relationship from a positive relationship.
It will also examine their ability to determine when the client is transitioning from a positive therapeutic relationship into a more harmful client-therapist attachment. If therapists are unable to accurately distinguish these elements of the client relationship, they could cause more harm than good by continuing the therapy.
Part 2: Assessing Measurement Instruments
The purpose of this research is to develop a means to measure the factors that influence a therapists ability to accurately assess the status of their client relationships. This study will lead to the development of criteria that therapists can use as a guideline to assess their client relationships and make certain that they remain healthy ones for all parties involved. The development of a meaningful measurement procedure is paramount to the ability of these guidelines. The following will explore various factors that are involved in the development of an appropriate measurement device for the study.
In the first part of this research study, we explored studies that addressed the therapeutic relationship. We explored the impact of the relationship on therapeutic outcomes and various factors that can affect its development. Over fifteen scales have been used in studies to assess the therapeutic relationship (McCabe & Priebe, 2004). However, it was found that no single scale was widely used in psychiatric research. These scales assessed various components of the therapeutic relationship and few used the same scale (McCabe & Priebe, 2004). This makes it difficult to measure the reliability and validity of the scale in research. This is the problem that will be confronted in the remainder of this research.
Relationship Measurement Instruments
As the importance of the client-therapist relationship became better understood, it led to the development of several early measures to assess the quality of this relationship. One of the first instruments was the Barrett-Lennard Relationship Inventory (BLRI) (Barrett-Lennard, 1962)
This instrument measures three factors that are important in the development of relationships. These factors are empathy, regard, and congruence (Ganley, 1989). This instrument is typically used to measure family relationships and marriage relationships (Ganley, 1989). It does not specifically address the issues that are specific to the development of the client-therapist relationship. However, these elements are reflected in the HAQ-2. One of the key drawbacks of the BLRI is its length.
Another instrument frequently used in the assessment of relationships is the California Psychotherapy Alliance Scales (CALPAS) (Gaston, 1991). This instrument is often used instead of the BLRI as a shorter alternative. The scale contained five subscales: patient working capacity, patient commitment, goal consensus, working strategy consensus, and therapist understanding and involvement (Gaston, 1991). This instrument consists of a 7-poitn scale in which the subject rates various items in Likert-type responses. This instrument is administered to both patients and therapists after every few sessions. This scale can be used to measure changes in the client-therapist relationship and has wider possibilities for application than the BLRI.
These scales are useful for the measurement of relationship factors in various situations, but they have drawbacks in relation to the proposed research. For instance, the BLRI is lengthy, which may deter potential clients from participating in the study. In addition, it does not specifically address the topic of client-therapist relationships. The CALPAS more closely addresses the topic of the study and is shorter in length. However, this scale is weighted towards factors that influence patient satisfaction. The focus of the proposed research study focuses on therapist perceptions, rather than patient perceptions. These are the primary reasons for deciding not to use either of these studies for the proposed research studies.
The Working Alliance Inventory (WAI) (Horvath & Greenberg, 1989) is another widely used questionnaire that measures the strength of the therapeutic alliance. It bears significant resemblance to the HAQ-2, only it has 12 items and uses a 7-point Likert scale. However, the HAQ-2 is more widely used. This means that much more is known about the reliability and validity of the HAQ-2.
The HAQ-I was one of the first scales to assess the therapeutic alliance between client and therapist. This early version of what would later evolve into the HAQ-2 included some question that reflects how much the patient benefited from the therapy (Luborsky, Crits-Christoph, & Alexander et al., 1983). These questions were later dropped from the scale, as some researchers did not feel that this represented a good condition from which to assess the relationship. These questions were more likely to address the quality of the treatment, rather than the relationship.