Am I Actually Doing Anything? Why the Therapeutic Relationship Is Clinical Work
There is a particular kind of anxiety that often appears early in a counsellor's career. A client has spent the session talking about something painful. The counsellor has listened carefully, reflected what they are hearing, helped the client find words for feelings that were difficult to articulate and perhaps noticed something important that the client had not quite been able to say themselves.
The client leaves saying the session was helpful.
The counsellor comes to supervision and says, "I don't think I actually did anything."
I have a theory where this might be coming from. Counselling training introduces us to theories, treatment models, formulations and interventions. As our knowledge grows, it is easy to develop an idea that competent therapy should contain more visible evidence of our expertise. Surely we should be challenging a belief, teaching a strategy, completing an exercise or applying a technique?
Against that backdrop, listening can feel just too simple.
It isn't!
The relationship has a substantial research base
Psychotherapy researchers have been studying the contribution of the therapeutic relationship for decades. The evidence does not support treating relationship as merely the pleasant backdrop against which the "real" intervention occurs.
Norcross and Lambert's (2018) review of evidence-based psychotherapy relationships concluded that the therapeutic relationship makes substantial and consistent contributions to psychotherapy outcomes across different forms of treatment. Similarly, a large meta-analysis of the therapeutic alliance, drawing on 295 independent studies and more than 30,000 clients, found a robust association between alliance and treatment outcome (Flückiger et al., 2018).
Empathy itself has also been studied. Elliott et al. (2018) examined 82 independent samples involving 6,138 clients and found therapist empathy to be a moderately strong predictor of therapy outcome.
None of this means that modality, formulation and technique are irrelevant. Different clinical problems require different knowledge and interventions, and a warm relationship does not compensate indefinitely for therapy that has no direction or is failing to address the client's needs.
It does mean that we should stop treating the relationship as what happens while we wait to do something more clinical.
The relationship is part of the clinical work.
What are you actually doing when you listen?
One reason beginning counsellors underestimate listening is that counselling microskills look deceptively similar to ordinary conversation.
A reflection might consist of one sentence. A paraphrase might take ten seconds. Sometimes the most useful thing the counsellor says in several minutes is, "I think there was something particularly painful about nobody noticing what was happening to you."
While the sentence is simple, the listening it took to arrive there is not.
While listening, the counsellor is tracking the client's words, affect, body language, contradictions, changes in energy, recurring themes and what appears difficult to say. We are trying to understand the client's experience from inside their frame of reference while simultaneously maintaining enough perspective to think clinically about what we are hearing.
We then communicate some part of that understanding back to the client and watch carefully to see whether we have got it right.
Sometimes the client says, "Yes. That's exactly it."
Sometimes they correct us.
Both responses give us useful information.
Accurate empathy is therefore much more active than simply being kind or sympathetic. It is an ongoing process of perceiving, hypothesising, communicating and checking our understanding of another person's experience.
There may also be something happening at the level of regulation
Neuroscience research supports the broader idea that putting emotional experience into words can change the way distress is processed. Lieberman et al. (2007) used functional MRI to examine what happened when people labelled emotional stimuli. Affect labelling was associated with reduced activity in the amygdala and other limbic regions and increased activity in the right ventrolateral prefrontal cortex. The researchers proposed a pathway through which putting feelings into words may reduce emotional reactivity.
This is particularly interesting for counsellors because helping people put experience into words is something we do constantly.
A client might tell us:
"I don't know. I just get really angry when she doesn't text me back."
We could immediately investigate the thought, challenge an assumption or teach an emotional regulation strategy.
Sometimes those will be useful interventions.
But we might first say:
"When you don't hear from her, it sounds as though something shifts very quickly. It isn't only irritation. There's almost a panic that you've stopped mattering to her - is that how it is?"
If we have understood accurately, the client's experience has just been named and organised in relationship with another person.
While we should be careful about claiming that we know exactly what has happened neurologically in that individual client's brain, we do have reasonable grounds for saying that naming emotional experience and experiencing responsive interpersonal contact can contribute to emotional regulation.
So when your client takes a breath and says, "Yes. That's it", don't be too quick to dismiss the preceding thirty seconds because you didn't feel like you contributed very much.
Something may have changed.
So what are all those counselling microskills actually for?
Students sometimes learn microskills as a list of things they are supposed to demonstrate in a role-play: reflection, paraphrasing, summarising, open questions, clarification and silence.
Once the assessment is over, there can be a temptation to regard them as beginner skills that will eventually be replaced by more sophisticated therapy.
I think that gets counselling development backwards.
As counsellors become more experienced, the microskills become less conspicuous. We get better at knowing when to use them, what to listen for and when not to speak. The sophistication lies increasingly in the judgement behind the response.
Here is what that can look like in practice.
Reflect feelings rather than simply repeating content
If your client says, "My boss criticised me in front of everyone and I just smiled and said it was fine", repeating the events adds little.
Listen for the experience underneath them.
You might say:
"That sounds like it could have felt really embarrassing or humiliating - is that how it is?"
Then stop.
Watch what happens. The client's response tells you whether you are getting closer to their experience.
Paraphrase to check understanding and support exploration
A paraphrase briefly puts the essence of what the client has just said into your own words, often beginning with “It sounds like…” or “So, you’re saying…”.
A client might say:
“Work’s been relentless, Dad’s been sick, and I’m trying to keep everything going at home. Other people manage all this. I don’t know why I can’t.”
You might respond:
“It sounds like you’re managing several demands at once and questioning why you’re finding it so difficult.”
Then give them room to respond.
Hearing their experience reflected back can help the client clarify what they mean and decide what to explore next. They might say, “Yes, I feel like I’m failing”, or, “Actually, I think I’m just exhausted.” That brief paraphrase has helped the conversation move towards a clearer understanding of their experience.
Clarify when you think you understand
This is one of the easiest skills to neglect as experience grows.
If a client says, "My family never supported me", we can easily assume we know what "support" means. Emotional support? Money? Protection? Approval? Contact? Believing them?
Ask.
"What would they have done differently if you had felt supported?"
Clarification protects us from providing excellent therapy to an experience the client isn't actually having.
Use summaries to identify patterns
A summary can do more than finish a session.
It brings together the main issues, thoughts and feelings from a longer stretch of conversation, using some of the client’s own key words. It can also include something you have noticed as you have listened.
For example:
“Just to pull together what you’ve been describing: with your partner, your sister and then your manager, you knew what you wanted to say, but changed your position when they seemed unhappy. Afterwards, you felt frustrated with yourself and said you wished you’d spoken up. Have I understood that correctly?”
Now something that occurred as three separate stories becomes available as a possible pattern for the client to examine.
Give them time to consider it. They may recognise a connection, explain how the situations differ or identify something you have missed.
A summary can also help when the conversation feels scattered or you are both losing track of what matters most. Bringing the important threads together gives the client an opportunity to hear their experience as a whole and decide where they want to go next.
Let silence do some work
Counsellor anxiety can motivate us to fill silence.
If the client has just contacted something important, give them time to experience it. Watch whether they are thinking, feeling, becoming overwhelmed, withdrawing or waiting for you.
Silence is useful when it serves the client's processing. Sitting silently because we have no idea what to do next is a different clinical situation, and one worth taking to supervision.
Ask fewer questions, but make them better
Beginning counsellors can become excellent interviewers.
Question follows question because asking something creates movement and relieves the counsellor of the discomfort of not knowing where the conversation is going.
Before asking your next question, consider whether the client needs another question or whether they need you to respond to what they have already told you.
Sometimes:
"What happened next?"
is useful.
Sometimes:
"It sounds like you were terrified."
takes the therapy somewhere much more important.
How do you know if your empathy is actually accurate?
There is an important catch in all of this. As counsellors, we don't get to decide by ourselves that we have been empathic.
The empathy research makes this particularly interesting. In their meta-analysis, Elliott et al. (2018) found that clients' perceptions of therapist empathy predicted outcomes more strongly than therapists' own ratings of how empathic they had been. In other words, intending to understand someone and believing that we have understood them are not the same as the client experiencing us as understanding them.
This gives us a very practical way to think about empathy. Offer your understanding as something to be tested rather than as a conclusion about the client.
If you say, "It sounds as though underneath the anger you were actually frightened that she might leave", pay attention to what happens next.
The client might immediately say, "Yes", and elaborate. Their body may relax, their speech may slow, or they may become more emotionally engaged with what they are describing. Sometimes there is that unmistakable moment when a client says, "That's exactly it. I haven't known how to explain that."
Those responses suggest that you have found something that fits their experience.
But the client might hesitate. They might say, "Not really." They might become less engaged or simply agree politely and move on.
Don't work harder to persuade them that your reflection was insightful.
Try something like, "No, I've got that wrong. What was happening for you?" Or, "There's something about the way I'm understanding this that doesn't quite fit."
Being corrected is not evidence that you are bad at empathy. The correction is part of the empathic process. You offered a hypothesis about the client's experience and they gave you better information.
This is also why tentative language matters. "I wonder if...", "It sounds as though..." and "Have I understood this correctly?" leave room for the client to remain the authority on their own experience. Statements such as "What's really happening here is..." make disagreement a lot harder, particularly for clients who are already accustomed to accommodating other people.
There is another complication worth watching for. Some clients are very good at agreeing with therapists!
A client who fears conflict, wants approval, has learned to defer to authority or worries about disappointing people may tell you that you have understood when you haven't. A quick "yeah" is therefore not necessarily confirmation. Notice what follows it. Does the client expand on the reflection? Does it help them contact something more clearly? Does the conversation become richer and more specific? Or does your interpretation sit there while the client waits for you to say the next clever thing?
Accurate empathy is iterative. We listen, make sense of what we are hearing, offer some of that understanding back, notice the client's response and adjust.
That is one reason counselling microskills remain difficult to master. The skill is not simply knowing how to make a reflection.
The skill is being sufficiently attentive to notice whether it landed.
Relationship also makes other interventions possible
There will be times when listening and empathic responding are not enough.
A client with severe avoidance may need help approaching what they have spent years escaping. Someone who is depressed may benefit from behavioural activation. Trauma therapy may involve carefully structured processing. Other clients will benefit from skills training, psychoeducation, cognitive work or another specific intervention.
The relationship helps us do those things well.
It allows the client to tell us, "This isn't helping." It makes it more possible for them to admit that they didn't do what we discussed last week, it allows them to disagree with our formulation, it helps us notice when an intervention is moving too quickly, when avoidance is taking over, or when we have misunderstood something important.
And, ideally, it means that when we get something wrong, there is enough trust for the client to tell us.
When "I'm not doing enough" comes into supervision
When a supervisee tells me they feel as though they are not doing enough, I’m not going to offer reassurance but curiosity.
A strong therapeutic relationship can become comfortable but directionless. Sessions can become weekly conversations in which the same material circulates without anything changing. A counsellor can empathise well, all the while colluding with avoidance. There are clinical presentations for which specific knowledge and treatment approaches matter. And all of this deserves honest consideration.
But I am equally interested in why the counsellor has concluded that nothing happened.
What did the client understand by the end of the session that they did not understand at the beginning?
Did they say something they had previously struggled to say?
Did an emotion become clearer?
Were they able to stay with an experience they usually move away from?
Did you notice a pattern together?
Did the client correct your understanding?
Did their level of distress change during the conversation?
Did something happen between you that gave you new information about how they relate to other people?
And perhaps most importantly: what were you expecting yourself to do that would have counted as "real therapy"?
Sometimes the urge to intervene tells us something about the client's needs and sometimes it tells us something about the counsellor's anxiety.
Learning to distinguish between the two is part of becoming a therapist.
You are allowed to become very good at listening.
Counselling microskills should be taught early because everything else depends upon them. Learning a sophisticated modality does not make accurate empathy obsolete.
Over time, good listening becomes more clinically informed. We hear patterns we would once have missed, notice affect beneath content, become more willing to check our assumptions. We learn when to stay with an experience and when the client needs something more active from us.
So after a session, instead of asking yourself, "What intervention did I do?", try asking:
What changed in the client's experience during our conversation, and what did I do that supported that?
If the answer is consistently "nothing", bring that to supervision. Something in the therapy may need to change.
But if a client has understood themselves differently, put language around something previously difficult to articulate, tolerated an emotion they usually avoid, recognised a pattern or experienced being accurately understood by another person, don't dismiss that work because there wasn't a worksheet involved.
You were doing therapy.
Explore online individual and group supervision at The Counselling Supervision Centre
References
Elliott, R., Bohart, A. C., Watson, J. C., & Murphy, D. (2018). Therapist empathy and client outcome: An updated meta-analysis. Psychotherapy, 55(4), 399–410. https://doi.org/10.1037/pst0000175
Flückiger, C., Del Re, A. C., Wampold, B. E., & Horvath, A. O. (2018). The alliance in adult psychotherapy: A meta-analytic synthesis. Psychotherapy, 55(4), 316–340. https://doi.org/10.1037/pst0000172
Lieberman, M. D., Eisenberger, N. I., Crockett, M. J., Tom, S. M., Pfeifer, J. H., & Way, B. M. (2007). Putting feelings into words: Affect labeling disrupts amygdala activity in response to affective stimuli. Psychological Science, 18(5), 421–428. https://doi.org/10.1111/j.1467-9280.2007.01916.x
Norcross, J. C., & Lambert, M. J. (2018). Psychotherapy relationships that work III. Psychotherapy, 55(4), 303–315. https://doi.org/10.1037/pst0000193