What matters most in therapy? | by Asma Suedan

Oftentimes, clients starting psychotherapy wonder if their investment of money, time, and effort will be worthwhile. This is especially the case for individuals who are new to this human endeavour. To try and ensure that psychotherapy works for them, clients may have a lot of questions initially. Psychotherapy can be a powerful process. Effective psychotherapy can lead to clients improving their relationship with themselves and other people. It can provide the insight needed to overcome significant psychological difficulties. Given how enticing these treatment goals sound, it is critical to highlight the factors that facilitate change in psychotherapy. With this blogpost, I hope to do just that.

Achieving positive outcomes in treatment depends on several factors. For example, the specifics of the client’s problem, the client’s belief of whether therapy works, and the therapist’s level of skills (Horvath, 2001). However, most importantly, the effectiveness of treatment depends on the relationship between the client and the therapist (Horvath, 2001).  This relationship is often referred to as the therapeutic alliance. Through interactions with the therapist, clients are able to address ways of managing and coping with symptoms. More importantly, clients are able to uncover what is beyond their awareness. As such, the therapeutic alliance serves as a catalyst in transforming the lives of clients.

Since the quality of the therapeutic relationship is of great significance to treatment outcome, experts have examined and defined what is considered a strong relationship (Bachelor, 2013, Knobloch-Fedders, 2008). Listed below are a few of the essential ingredients for a quality therapist-client relationship. Firstly, sharing a bond of trust, respect, and caring. Secondly, agreeing on goals for therapy. Thirdly, sharing the decision-making process. Fourthly, committing to the work of treatment. Fifthly, discussing here and now aspects of the relationship together when needed. Sixthly, sharing negative emotional responses. Lastly, solving problems that may arise.  Clients are not passive but are active in the development of the therapeutic relationship. In addition, these essential ingredients help facilitate the therapy process.

It is important to note that as Hovarth (2001) demonstrates, the ability to establish a strong therapeutic relationship is not always dependent on the therapist’s level of experience or specific therapeutic approach.  Clients can rest assured knowing that many therapists early in their professional journey are just as skilled as the more experienced therapist in forming strong therapeutic bonds. Still, the level of therapist expertise matters more when forming a relationship with clients who have struggled repeatedly in past relationships.

To ensure that a strong therapeutic alliance exists, the therapist needs to make specific contributions. Of these contributions is conveying empathy and understanding. Also, the therapist's ability to adapt and tailor treatment to the client's needs is essential. In doing so, the therapist conveys openness and willingness to work collaboratively with the client. As such, a skilled therapist consistently asks the client for their input about treatment goals and methods of treatment. These contributions further emphasize Carl Rogers’ three key attributes of a therapist in creating a climate of growth for clients.

  • The first attribute is congruence; this means that the therapist is genuine and authentic with clients. The therapist’s inner experience and outward expression align. This trait conveys to the client trustworthiness and serves as an indication of how they can express themselves, freely.
  • The second attribute is unconditional positive regard, this attribute entails accepting and valuing the client. The therapist neither judges nor evaluates the client’s experiences.
  • The last attribute is accurate empathic understanding. Treatment success is made possible when the client is fully understood in a compassionate manner; this happens when the therapist conveys an understanding of the client’s perspective.

These fundamental attributes are further built upon in the foundation of the distinct quality of presence. The therapeutic presence is experienced when therapists bring their whole selves into their encounter with each client. The therapist is completely in the moment on a physical, emotional, cognitive, spiritual, and relational level. Prescence also consists of therapists being grounded in themselves as they actively take in the expressions (verbal and nonverbal) of the client in the moment.

Clients also contribute to the effectiveness of the therapeutic relationship. When clients communicate effectively, then they are actively developing and maintaining a therapeutic alliance. It is important that clients are open and honest about their needs because it plays a key role in resolving any difficulties. To answer the question proposed in the title of this post, for change to happen in therapy, the most important tool is the quality of the relationship between the therapist and the client, in other words, the therapeutic alliance.

Throughout my training and experience, I have come to have a strong interest in the therapeutic alliance. I enjoy doing my best to establish strong working alliances with the clients I work with.

Asma Suedan, M. A. is a former clinical associate at Karey Wilson Therapy.



Bachelor, A. (2013). Clients' and therapists' views of the therapeutic alliance: Similarities, differences and relationship to therapy outcome. Clinical psychology & psychotherapy20(2), 118-135.

Geller, S. M. (2013). Therapeutic Presence: An Essential Way of Being. In Cooper, M.,Schmid, P. F., O'Hara, M., & Bohart, A. C. (Eds.). The Handbook of Person-Centred Psychotherapy and Counselling (2nd ed.), pp. 209-222. Basingstoke: Palgrave.

Horvath, A.O. (2001). The alliancePsychotherapy, 38(4), 365-372.

Knobloch-Fedders. (2008, January 31). The Importance of the Relationship with the Therapist. Family Institute. https://www.family-institute.org/behavioral-health-resources/importance-relationship-therapist

Rogers, C. R. (2007). The necessary and sufficient conditions of therapeutic personality change. Psychotherapy: Theory, Research, Practice, Training, 44(3), 240–248. https://doi.org/10.1037/0033-3204.44.3.240