For this column, we focus on a counseling feature that has been shown to consistently promote positive outcomes. It is the counseling relationship (Beutler et al., 1994; Lambert & Bergin, 1994; Sexton et al., 1997; Hubble et al., 1999; Volpicelli & Szalavitz, 2000; Najavits et al., 2000; Chambliss, 2000; Miller & Rollnick, 2002). Failure to form this relationship is related to poorer outcomes, higher drop out rates, and more client noncompliance (Sexton et al., 1997).

How influential is this relationship?
For some time, there has been talk of common factors that seem to transcend theoretical doctrine or techniques — and are more effective at getting results. Following an extensive analysis of the research, a fellow named Lambert indicated that four common factors account for the principle outcomes of therapy (Lambert, 1992; Lambert & Bergin, 1994). He also assigned percentages of change that each contributed to outcomes. These four elements are:

1. Client/extra-therapeutic factors. These are composed of the things clients bring with them to treatment, including elements such as duration of complaints, strengths, resources, support system, environment, as well as chance events. This complex factor, according to Lambert, accounts for approximately 40 percent of treatment outcome.

2. Relationship factors. These are the classic Rogerian elements of empathy, acceptance, caring, warmth, and understanding. In terms of influence on therapy, this comes in second with a score of 30 percent.

3. Placebo, hope, and expectancy factors. If clients come to therapy believing it will help, the belief will move therapy in that direction — this accounts for 15 percent of the total outcome.

4. Model/technique factors. These constitute the doctrines and interventions we apply to our clients. Examples of doctrines are 12-step groups, cognitive-behavioral therapy, insight-oriented therapy, and solution-oriented therapy. Examples of techniques include inventories, reinforcement procedures, resolving defense structures, and the miracle question. According to Lambert, this factor only amounts to 15 percent of outcome.

Increase the sway
Counseling outcome is related to various factors. However, since the professional relationship accounts for 30 percent of outcome (double the hope, or theory factors), this is where we must focus our energy. Given that this element is so persuasive, the big question is what constitutes a good professional relationship?

Note that a professional relationship deals with the feelings and attitudes each person has for the other. One important element in this relationship is empathy. Now don’t confuse empathy with enabling. Many in the addiction field do, but these two phenomena are light-years apart. Grasping the thoughts and feelings of someone (empathy) is nowhere near shielding or covering for someone (enabling) (Taleff, 2002).

If empathy is associated with anything, it is probably understanding — often a deep understanding (Rogers, 1980). Here is where some counselors make a mistake. They assume that if they understand a client then this offered empathy contributes to a better outcome. Thinking you understand (empathize with) a client is not what seems to correlate to better outcomes. The correlation to better outcomes is associated with the client who perceives the counselor to be empathic (not the other way around) (Sexton et al., 1997).

To repeat, just because you come out of a session believing you understand the client will not generally foster progress in treatment. What is important, and what the research supports, is that the client needs to walk out of the session believing he/she was understood (Chambliss, 2000).

How do you check on that? Debrief your sessions, consult or interview your clients as to how the relationship is going. Studies have shown that asking clients about the therapeutic process reduces the misperceptions that can exist between the client and counselor. The debriefing will clarify things. Being in sync with your client fosters a better collaborative relationship, and hence a better outcome (Sexton et al., 1997).

Developing a strong relationship means you need to create a clinical atmosphere that accurately reflects a genuine understanding of the client. Remember, it is the client who needs to feel warmth, respect, non-judgment, and trust. But, there is a little problem with this. To apply these important elements in the same way to all clients would be an error — because all clients experience these factors differently. Counselors need to adjust the amount, intensity, and duration of these factors to each client. That way your expression of the relationship properties will be in line with the client’s definition of empathy, warmth, trust, and respect (Chambliss, 2000). Consequently, you need to be on your toes, sharp, and adjust to the subtleties of each of your clients.

Some of the core elements of any solid professional relationship include (this is not an exhaustive list):

• Skill in accurately interpreting a client’s emotional state.
• Skill in delivering a specific therapeutic technique (no shoddy applications).
• Skill in being empathic.
• Skill in projecting warmth.
• Skill in demonstrating regard and as well as respect.
• Skill in really listening.
• Skill in being non-judgmental.

To a certain degree, supervisors can help evaluate these core abilities, but no supervisor can tell you if the message is really getting through, because they are not the clients. A more reliable indicator of these skills may lie in the treatment progress. If progress is being made you are onto something. If not, the first suggestion might be to assess the strength of the professional relationship. Again, ask clients how things are between you and them. If they are perceived as good, keep on doing what you’re doing. If not so good, modify the relationship so the client begins to feel understood.

Benefits of a quality professional relationship
The advantages to treatment that result from the best professional relationship you can build include:

• Allowing the client to experience firsthand how it is to talk to another human without the need to resort to drugs or alcohol.
• Allowing the client to experience a healthy relationship and mend damage from old troubled ones through modeling from the counselor.
• Allowing (inviting) the client opportunities to experiment with and learn different forms of chemical-free thoughts and behaviors.
• Allowing clients to experience a place that is safe so that they can deeply reflect on their life, make mistakes, and still move forward.
• Improving the odds of a client making a step toward change, recovery, and a better life.
• It is important to establish the best relationship you can early on (first session or two). A window of opportunity exists here that may not be available later (after judgments have had a chance to harden).

A few parting thoughts
First, just because you improve your relationship-building ability does not mean you will be able to engage or be successful with every client who walks through your door. Should you be unable to develop a relationship with a client, talk it over with your supervisor or trusted colleague and consider transferring the case. Second, a good relationship is not only empathic but challenging if need be. Do not fall into the trap of believing an empathic relationship passively stands by and tolerates problem behavior and attitudes. It doesn’t. If well formed, the relationship can be used to “get to” clients who have chronically used poor past relationships as an excuse to continue destructive behaviors. Finally, while a good relationship can get you into the troubled world of the client, the warning is to step carefully. You are in sensitive, vulnerable territory.

The professional relationship you develop with your client may not be sufficient for success. Research, however, has established it as one of the most, if not the most important elements necessary for a positive treatment outcome.

The “try it yourself” section
Time for a little experiment. This test may give you some insight on how good your relationship-building skills are pre-sently. First, establish a baseline of outcomes (e.g., number of clients who are abstinent, or who relapsed) from a list of clients you have discharged in the last three months. At the same time, assess from the skill list above those skills in which you feel you do well (e.g., develop a likert scale for the skills to be measured). Next, ask a small sample of your present clients for their impressions of your skills (use the same likert scale). Should the client feedback be different from your list, modify those particular skills. Continue to ask your clients about your relationship skills and make modifications as necessary. Then document the outcomes from the next three months based on the modifications you made. Finally, compare that list to your first one. Keep this little experiment simple, no need for fancy experimental designs.

Michael J. Taleff, PhD, CSAC, MAC, is the Coordinator of the Center for Substance Abuse for the University of Hawai’i at Manoa. He can be reached at This e-mail address is being protected from spam bots, you need JavaScript enabled to view it

References
Beutler, L.E, Machado, P.P.P., & Allsterrer Neufeldt, S. (1994). Therapist variables. In A.E. Bergin & S.L. Garfield (Eds.). Handbook of psychotherapy and behavior change (4th ed., pp. 229-269). Wiley: New York, New York.
Chambliss, C.H. (2000). Psychotherapy and managed care: Reconciling research and reality. Allyn and Bacon: Boston, MA.
Hubble, M.A., Duncan, B.L., & Miller, S.D. (1999). The heart & soul of change: What works in therapy. American Psychological Assocation: Washington, D.C.
Lambert, M.J. (1992). Implications of outcome research for psychotherapy integration. In J.C. Norcross, & M.R. Goldfield (Eds.). Handbook of psychotherapy integration (pp. 94-129). Basic Books: New York, New York.
Lambert, M.J. & Bergin, A.E. (1994). The effectiveness of psychotherapy. In A.E. Bergin & S.L. Garfield (Eds.). Handbook of psychotherapy and behavior change (4th ed., pp. 143-189). Wiley: New York, New York.
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing: Preparing people for change. Guilford: New York, New York.
Najavits, L.M., Crits-Christoph, P., & Dierberger, A. (2000). Clinician’s impact on the quality of substance use disorder treatment. Substance Use and Abuse, 35, 2161-2190.
Rogers, C. (1980). A way of being. Houghton Mifflin, Boston, MA.
Sexton, T.L., Whiston, S.C., Bleuer, J.C., & Walz, G.R. (1997). Integrating outcome research into counseling practice and training. American Counseling Association: Alexandria, VA.
Taleff, M.J. (2002). Let’s clear the air: The difference between professional enabling and empathy. Journal of Chemical Dependency Treatment, 8, 57-65.
Volpicelli, J. & Szalavitz, M. (2000). Recovery options: The complete guide. John Wiley & Sons: New York, New York.

This article is published in Counselor, The Magazine for Addiction Professionals, June 2003, v.4, n.3, pp. 48-50.

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