The real relationship in psychotherapy: The hidden foundation of change

As with most matters psychotherapeutic, it was Freud who first wrote about the therapeutic relationship or alliance. Although he stated, in one instance, that ‘‘The physician should be impenetrable to the patient, and, like a mirror, reflect nothing but what is shown to him’’ (1912, p. 331), he also wrote: ‘‘The first aim of the treatment consists in attaching him to the treatment and to the person of the physician’’ (1913, p. 360). Along these lines, we know that Freud was often friendly and informal with his patients, even lending them money on occasion. In general, from early on, Freud (1913) understood that the uncovering work he considered essential to successful psychoanalytic treatment required an attitude of collaboration and cooperation between patient and therapist. The term Freud used to refer to this important aspect of the patient-therapist relationship was rapport, which he called the vehicle for success in treatment. Greenson (1967), an ego psychologist, expanded on this view, suggesting a tripartite division of the therapeutic relationship into the working alliance, transference and real relationship. (For reviews of the psychoanalytic history of the therapeutic relationship, see Messer and Wolitzky, 2010, and Safran and Muran, 2000.) Enter Charlie Gelso, who knows as much about the ins and outs of the therapeutic relationship as anyone around. His previous books, co-authored with Jeffrey Hayes, are on the theory, research and practice of the psychotherapeutic relationship (Gelso & Hayes, 1998) and the perils and possibilities of countertransference (Gelso & Hayes, 2007). In the current book, Gelso turns his considerable analytic skills (in both meanings of that term) to the real relationship, remarking that it has been the neglected piece of Greenson’s three-part schema, especially when considering the paucity of research in this domain. He has come to the conclusion that the real relationship is the cornerstone of the three even if they tend to be interwoven in patient-therapist interactions, albeit with varying degrees of salience at any one moment. Gelso defines the real relationship as ‘‘the personal relationship existing between two or more persons as reflected in the degree to which each is genuine with the other and perceives and experiences the other in ways that befit the other’’ (p. 58). That is, Gelso posits that there are two key elements in a real relationship: genuineness and realism. Genuineness includes elements such as immediacy (being in the here and now), intimacy (mutual empathy and acceptance) and affective authenticity (avoiding deception and self-deception) (Frank, 2006). Readers will recognize the term ‘‘genuineness’’ or ‘‘congruence’’ as one of Rogers’s necessary and sufficient conditions for constructive personality change in psychotherapy. The requirement of genuineness immediately raises a concern about how honest or self-disclosing a therapist ought to be. After all, being authentic may be seen as requiring full disclosure by the therapist just as one expects of the client. Greenberg (2002), for example, cautions the therapist about being too disclosing, recommending that such selfdisclosures should be made in a disciplined way. The therapist should also check in with clients to see how they are handling their therapist’s disclosure. Gelso refers to this tension between being authentic, yet not too self-disclosing, as the humanist’s paradox and offers his own solution. He is not one to duck such thorny conundrums. Gelso first points out that authenticity is only one feature of genuineness so that one can still be considered genuine without being disclosing, as long as one is not being phony. He then cites his own research (Ain & Gelso, 2008) that ‘‘clients’ retrospective recall of their therapists’ overall amount of self-disclosure was only modestly related (r .33) to these clients’ ratings of the genuineness aspect of their real relationship with their therapists’’ (p. 33). In addition, we are reminded that there is always a certain degree of information about therapists conveyed via their physical presence, choice of words, temperament, and so forth. Turning to the realism dimension of the real relationship, it is defined as ‘‘perceiving and/or experiencing the other in ways that befit the other’’ (p. 41). Although this realistic perspective is often viewed as the opposite of transference, Gelso, following Greenson, prefers to consider each as being part of the total relationship, with elements always being contributed from the two sources. That is, although the transference and real relationship exist on separate continua, where one can be high and the other low, they are not mutually exclusive. Psychotherapy Research, May 2012; 22(3): 363 365