Clinical Impact Statement: This manuscript provides essential information to mental health clinicians, clinicians in training, and psychotherapy trainers and educators to better teach evidence-based relationship principles. Challenges to systematically integrating evidence-based relationship principles into classroom instruction and supervision are discussed and a new initiative to help face these challenges and better integrate relationship principles into teaching and learning are discussed.
Like many of you, at the heart of my professional identity lies a psychotherapy relationship researcher. While my specific interests have changed and evolved over time, this aspect of my professional identity has always remained constant. This part of me has delivered professional talks about the relationship, has studied it under the lens of an empirical eye, and written about it from multiple theoretical vantage points. Yet, quite honestly, no part of me feels fully competent when it comes to teaching students how exactly to facilitate a “good” therapeutic relationship with patients.
While I can cite the latest research on alliance and outcome, it is a much more difficult task to actually teach beginning trainees how to facilitate a good alliance, particularly when they simply do not know how to begin. I was a collaborator on the forthcoming meta-analysis on the real relationship and therapy outcome (Gelso, Kivlighan, & Markin, 2018), but I can’t really tell you how to teach students to be “real” with a client, not exactly. As a group leader, I have experienced group cohesion or lack thereof first-hand. Yet, when it comes down to it, how exactly do we teach students to help others feel as if they belong? And, then, there is empathy. This construct haunts me as an educator because I feel at the very least I should be able to teach my students how to be empathic. I view empathy as so fundamental to the therapy process that I feel as if I really should have a systematic, well-researched, and generalizable method for teaching trainees how to experience and communicate empathy to clients. Yet, while I can help students develop their conceptualization skills, and I can ask questions to inspire their curiosity into the client’s mental world, I’m not so sure that those are the same as actually teaching someone how to do empathy and how to be empathic.
While I am embellishing here somewhat to make a point, I believe many of us encounter a similar dilemma as educators and psychotherapy trainers. We understand very well the research on the relationship and treatment outcome and are adept at facilitating good relationships with our own patients; it follows that we want to train our students in the same vain. Yet, teaching the relationship is hard to do—so often we just don’t, in least not as much and as systematically as we might like.
Challenges in Teaching Relationship
Systemically integrating evidence-based relationship principles into our teaching and training of graduate students is often hard to do for several reasons. To start, we may be in academic environments that value evidence-based treatments at the exclusion of evidence-based relationship principles. As a result, faculty, especially those going up for tenure, may feel a tremendous amount of pressure to focus more on the treatment than the individual patient and/or therapist. Related to this, at least in part, may be the current cultural emphasis on the biological basis of behavior, concrete solutions, and quick answers, leading beginning trainees more often than not to want you as the instructor to tell them how to “fix” something, not how to relate to someone. Teaching the relationship in this context can feel like an exhausting uphill battle.
However, even without real or perceived pressure from colleagues and/or students to focus on the treatment over individual or relationship factors, there still remains a significant challenge to teaching our students how to be competent in facilitating effective elements of the therapeutic relationship. In my experience, that challenge has to do with the largely abstract, complex, experiential, and nonverbal nature of the relationship. How do you teach something explicitly when that “something” is largely implicit and intuitive? How do you explain a relational experience that is largely affective and lies outside verbal language? How do you test a student’s knowledge of a construct that oftentimes has no right or wrong answer? How do you teach someone the steps in facilitating a therapeutic relationship when the steps are somewhat different every time? Perhaps most challenging, how do we teach students to facilitate a good therapy relationship when there is something about their personality or interpersonal style that is impeding the relationship? How do we teach trainees, in a didactic classroom context, relational principles that are usually learned … well, in a good relationship? In contrast, teaching students about concrete skills and well defined treatment packages starts to look pretty “good,” or at least more doable. In essence, teaching the relationship is a vulnerable place for students and instructors alike. It is an ambiguous place in which to reside, a personal place, and, sometimes, a raw one, making the teaching and learning of relationship factors that much more complex and challenging.
I believe the Inter-Divisional Task Force on evidence-based relationships similarly grasped the need for more training recommendations and guidelines on the relationship when they concluded that: (a) Training and continuing education programs are encouraged to provide competency-based training in the demonstrably and probably effective elements of the therapy relationship; (b) training and continuing education programs are encouraged to provide competency-based training in adapting psychotherapy to the individual patient in ways that demonstrably and probably enhance treatment success; and (c) accreditation and certification bodies for mental health training programs should develop criteria for assessing the adequacy of training in evidence-based therapy relationships.
Resources for Teaching Relationship More Effectively
Consistent with the training recommendations set forth by the Task Force and with my personal desire to more systematically integrate relationship factors into classroom instruction, I embarked on a project to translate evidence-based relationship principles to teaching and learning, along with my collaborator Dr. Michael J. Constantino, on behalf of Division 29. This project consists of a series of videos titled, Teaching and Learning Evidence-Based Relationships: Interviews with the Experts, and is a companion project to the third edition of Psychotherapy Relationships that Work, Edited by John Norcross and Michael Lambert. The videos can soon be found on the division’s web site (https://societyforpsychotherapy.org/teaching-learning-evidence-based-relationships/), and will be posted in installments.
The overall goal of the project is to translate relationship research to teaching and learning, from the classroom context to clinical supervision. The videos consist of interviews with experts on different aspects of the therapeutic relationship and how to apply relationship research to clinical training. They are appropriate for supervisors, instructors, and students. In these interviews, I had the pleasure of speaking with various authors in the upcoming book, Psychotherapy Relationships that Work, edited by J. Norcross and M. Lambert. These authors briefly reviewed their meta-analytic findings, gave practical suggestions on how to apply their research findings on the relationship to the classroom context and clinical training, discussed resources for relationship teaching, and suggested readings, videos, and other teaching tools. Perhaps most helpful for me personally, these authors/interviewees talked about their own struggles in teaching the relationship to trainees and how they have dealt with these challenges. They also offer future suggestions and steps for us to take as relationship researchers, practitioners, and educators.
Some common recommendations for teaching evidence-based relationship principles that have emerged from the interviews thus far include:
- Use varied didactic and experiential teaching methods including readings, videos, and role play assignments.
- Encourage students to make mistakes and explore their fears of inadequacy, failure, and loss of control.
- Instructors should consider giving personal examples of successful and unsuccessful relationships with clients.
- Encourage peer and instructor feedback on role plays and taped sessions of student work.
- Have students complete instruments that measure various relationship factors based on “good” and “bad” sessions.
- Explore through readings and case examples how the different relationship factors are inter-related in the clinical context.
We hope that these videos will help educators, supervisors, and students continue to have this conversation, as, together, we wrestle with how to best teach competencies in evidence-based relationships to the next generation of psychotherapists.
Cite This Article
Markin, R. D. (2018). Teaching and learning evidence-based relationships: A division 29 initiative to apply relationship research to clinical training. Psychotherapy Bulletin, 53(4), 13-15.
Gelso, C. J., Kivlighan, D. M., Jr., & Markin, R. D. (2018). The real relationship and its role in psychotherapy outcome: A meta-analysis. Psychotherapy, 55(4), 434-444. http://dx.doi.org/10.1037/pst0000183