Therapeutic Relationships: What Do Clients Need From Clinicians In Counseling?

Therapeutic relationships are the foundation for effective, helpful, healing counseling to take place. At least that has been my experience during 38 years of clinical practice. If we, as clinicians, cannot build and maintain a therapeutic relationship with our clients, then little can be accomplished. Sometimes building a therapeutic relationship feels effortless, as when clients just seem to “click” with us. But at other times, this process is a like pulling teeth.

I truly appreciate working with clients who engage in counseling easily. But, strangely, I appreciate even more working with clients who struggle and battle with the process and come out in the end finding help and hope. In those battle won cases I sometimes feel weary. In the end, however, I believe we’ve accomplished something that is truly meaningful. A therapeutic relationship, although unique to the counseling process, is still a relationship. And, if clients can develop therapeutic relationships in the therapeutic environment, there is hope that they can nurture and improve relationships outside of the counseling office…where the real problems exist.

What is a therapeutic relationship?

“The therapeutic relationship necessitates certain qualities in order to be effective and include; kindness, acceptance, warmth, non-judgement, and empathy.”

Psychology Today

Over the years I have been drawn more and more to the work and philosophy of Irvin D. Yalom, MD. Dr. Yalom is an eminent psychiatrist who is probably best known for the development of the field of Existential Psychotherapy. I feel that my beliefs, as I matured in my clinical practice, are much aligned with his philosophies. I have enjoyed reading his books (and hope to read his collective works in their entirety.) In his book Creatures of a Day: And Other Tales of Psychotherapy Dr. Yalom writes about the therapeutic relationship:

“The most important thing I, or any other therapist, can do is to offer an authentic healing relationship from which patients can draw whatever they need.”

Irvin D. Yalom, MD

10 things clients need from clinicians

I can’t emphasize enough how important the therapeutic relationship is in order to do good work with our clients. Through my years of clinical practice, I feel I have gathered some key ideas that are essential in both developing and maintaining a therapeutic rapport with my clients. My hope is that they will be helpful to you, whether they be new ideas or simple reminders of how you already practice.

1. Need for a consistent therapeutic approach

Clients need and deserve a positive, authentic therapeutic relationship with their clinician. Many clients have little consistency in their lives, which may contribute to their emotional instability and need/desire for therapy. Clients may have difficulty with trust in relationships. And when there is no trust it is difficult to share feelings. In the outside world clients may not trust others. Relationships can be strained, destroyed and even non-existent.

You need to remember that you may be the only consistent person in a client’s life. I often told new clients that they would come to know that I am the same person each time they see me in session. This was a way to build trust in the therapeutic relationship. Each time we met they would see for themselves that what I said was true. Thus, it was very important for me to be as consistent as possible with each client. I tried to demonstrate that consistency in session, no matter my own personal problems or mood at the time. This was a skill that I had to develop in myself over time.

2. Creating a safe place for clients to share their thoughts and feelings

In my years of clinical practice I worked in different areas of the country and in different settings. Overall, however, I found myself working with clients of all ages, from youngsters to senior citizens. Most of my clients lived in rural environments, some in more urban settings. Many of my adult clients were hard-working people. Some struggled with disabilities and/or chronic pain issues.

So the type of office I tried to set up was fairly relaxed and comfortable. A bit like coming to a home, but still resembling an office where it was obvious important work was to be done. Some seating was included to offer extra support to help clients who had difficulty with sitting or standing. I tried to avoid overhead lighting, as this sometimes created issues with headaches (mine included!) There was always a deck of cards or a game or two to play with children and teens (this helped promote conversation.) I enjoyed having a variety of books on the bookshelf, which were often used as food for thought regarding common problems arising during therapy. And because I used Music Therapy and Interactive Guided Imagery_sm in session, I always had the ability to play music when needed.

3. Active listening and “being still”

One of the most frequent comments I’ve heard from clients over the years was that they didn’t feel “heard” when they were in therapy in the past, and how much they appreciated feeling “heard” while in therapy (with me.) I don’t say this to toot my own horn, but to stress the importance of this concept that is at the heart of the therapeutic relationship. There is a time for clinicians to speak and a time for clinicians to listen. When I first began my career I was so eager to get out there and help people. I thought I had so much to share. But I came to learn that listening is probably as important, or more important, than sharing valuable information with my clients.

We need to remember that often clients have difficulty being understood by others. We live in a society where everybody has a thought or opinion to share. Sometimes we don’t listen. We just try to talk over each other to get our points across. Interruptions abound. Talk is fast. We don’t seem to have time to listen. Sure we can talk, but that doesn’t mean that we will be heard or understood. And not being heard or understood can lead to major communication and relationship problems. It can contribute to already existing anxiety, anger, or depression.

So, clinicians, please practice being still and listening. By this I am referring to active listening. You know this kind of listening…where we lean forward, nod our heads, and make good eye contact (where appropriate.) Really listen, so that your clients feel heard. And when we really listen to our clients we can know so much more about them, and how to help them.

4. The therapeutic session is a microcosm of the outside world

Many clients make progress in session but feel that they cannot carry that progress out the therapy office door into their world. I have found it helpful to remind clients that they are working on relationship building while in therapy. The skills developed and insights gained in the counseling session can be practiced with the clinician. And then those same skills and insights can be transitioned into their real-life world. The therapeutic session is just a microcosm of the outside world.

5. Do clients expect clinicians to know it all?

I’ve had many clients who have confessed that they became angry with me in session when I didn’t give them the answers for their problems. But, for those clients who stayed in therapy after this feedback, they also said that they came to learn that it was their job to find the answers. They were in the driver’s seat and I (the clinician) was the passenger…asking questions, making suggestions, being encouraging, and only being directive when absolutely necessary!

Conversely, some clients have told me that they were happy that I didn’t know it all. It’s difficult for clients to grow and make progress in counseling when they are constantly told what “to do” or “how to do it.” Clinicians, we do have expert knowledge to share with clients. We just need to be careful with our presentation of that knowledge. I’ve found that it’s helpful to find your own unique ways to “show” your message versus “telling.”

6. Clients need clinicians to be genuine

Similar to the need for a consistent therapeutic approach (see #1 above), being genuine is a key component to making clients feel safe and comfortable with a clinician. When I first began my career I tried to dress in what I thought was a professional manner for the time (early 80’s – oh my!) That meant dresses and suit jackets and blouses that tucked in. Well, if you know me, you would know that dressing like that was definitely out of my comfort zone. Plus, at the time I was working in a rural community mental health center. Over time (thank heavens) I relaxed my dress code. I still dressed in an office casual manner, but I no longer felt completely uncomfortable in my clothes.

I had to learn over time that my clients came to see me, not my clothes. What was important was my genuineness. And, in addition, I learned that clients feel more comfortable in approaching clinicians who are not trying to “put on airs.” Again, this is where knowing your client demographic is important. Should you work in a sophisticated urban area, your appearance may be different than mine, and that’s perfectly OK. (I’m just thankful that I never worked in a highly professional and formal setting. I think I’m a country girl at heart!)

7. Set healthy boundaries

It’s important to set healthy boundaries with our clients to develop and maintain therapeutic relationships:

• Clients often have difficulties with boundaries. Practicing boundaries in the counseling setting encourages boundary setting in the client’s real world.
• Set expectations for healthy boundaries in sessions when you first meet with new clients. This will include issues regarding appropriateness of behavior in sessions and confidentiality, etc.
• Clinicians, please be on time for your sessions. It conveys respect to your clients. Consistently being on time helps to build trust. And you serve as a role model for their behavior.
• End your sessions on time. Allow for a brief period of time to wrap up at the end of the session. Avoid opening up new subjects toward at session’s close. More manipulative clients may try to end a session with dramatic, attention-seeking statements like, “I’ve had thoughts of suicide.” Of course, if this happens you will need to assess for suicidality. But if the client’s drama-filled statement is not life-threatening, then ending the session on time may still be appropriate. If you are consistent in doing this, clients usually learn to respect the session’s time limits. This can lead to a conversation with the client about progress made in healthy boundary setting…which may improve his/her relationships in general. By ending sessions on time you are also being respectful to yourself and to that next client waiting for you.

8. Find the good/truth in our clients

I understand that it is our job in counseling to help our clients with their problems. But our clients come to us as human beings. We are there to help to heal what is broken. But we must be mindful that our clients are not just their problems. All people have goodness and truth in them. We need to remember that.

Sometimes we need to remind our clients of their goodness and truth too. To help them see who they are as human beings. When clients have difficulty seeing or accepting their truths we need to hold onto those truths for them until they come to a point where they can embody them. In order to do this, we must have a strong therapeutic rapport with our clients. We must have trust, consistency, and genuineness.

9. Don’t discount returning clients

I remember working as a clinical supervisor many years ago and learning that some of my clinical staff would discount returning clients. In this particular setting we saw many “revolving-door” clients. In the mental health field this is not unusual. But some of our clients had multiple previous admissions. So, when they would come for treatment again and again, it became very discouraging for my clinical staff. The expectation would be that these clients would seek treatment and then shortly discontinue. I can understand how frustrating this would be for clinicians.

But we need to remember that this admission, this time might just be their real time for change. And how wonderful that would be. So clinicians, please don’t discount returning clients.

10. Don’t be afraid to talk about death and dying

Death and dying are very difficult topics to talk about. Difficult for clients. Difficult for clinicians. But they are very important topics, and often may be a component of why a client is seeking treatment in the first place. Talking about death and dying is normalizing. The more we talk about death and dying, as a part of life, the more comfortable we will be with it. And your clients will appreciate your willingness to approach this topic.

Similarly, don’t be hesitant to discuss suicide risks with your clients. When you normalize such discussion, clients can feel more comfortable sharing their thoughts and feelings. This helps to build and maintain that desired therapeutic relationship and helps to keep our clients safe.

Conclusion…and a video!

I want to take this opportunity to thank you for choosing to read this article. My hope is it’s helpful to you and your clients in your work. As always, I’d appreciate your feedback (there’s a Comments Section below the post.)

And now, CLICK HERE FOR THE THERAPEUTIC RELATIONSHIPS VIDEO. (Music: https://www.bensound.com) Hope you enjoy it!

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