Value of the therapeutic relationship

When I first arrived at the Philadelphia VA Medical Center to practice psychology in 2001, my patients – mainly male Vietnam veterans – were leery. I had a PhD and could be viewed as an authority figure, a likely trigger for distress for those who felt mistreated by the military or the Department of Veterans Affairs.

When I suggested an intervention or put forward an interpretation of their behavior, they would bristle. Regardless, I used to say to them, “I’m planting seeds. Please don’t rake them out. I’ll water them over time.”

Week after week, year after year, I’d use psychotherapy techniques that had been shown to be effective in randomized trials to reduce post-traumatic stress disorder (PTSD) symptoms, increase effective coping and help people live more meaningful and healthy lives. My patients got better, for sure. And it might have been because of those interventions – some aspect of one or their combination. But that’s not what my patients remembered as being most effective, and that’s not what I remember either.

What they remembered more – what they gave the most credit to – was the time we spent together, the bond forged over years of therapy. This is called the therapeutic relationship. And while evidence suggests that it is a critical part of psychotherapy, the impact of the relationship often isn’t studied in clinical trials for trauma survivors with PTSD.