Psychotherapy Research

ISSN: 1050-3307 (Print) 1468-4381 (Online) Journal homepage: http://www.tandfonline.com/loi/tpsr20

The time has come: The real relationship in

psychotherapy research

Charles J. Gelso

To cite this article: Charles J. Gelso (2009) The time has come: The real relationship
in psychotherapy research, Psychotherapy Research, 19:3, 278-282, DOI:
10.1080/10503300902777155

To link to this article: http://dx.doi.org/10.1080/10503300902777155

Published online: 06 Jul 2009.

Submit your article to this journal

Article views: 246

View related articles

Citing articles: 6 View citing articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=tpsr20

Download by: [Universidad de los Andes] Date: 18 May 2017, At: 06:29
Psychotherapy Research, May 2009; 19(3): 278
282

REAL RELATIONSHIP

The time has come: The real relationship in psychotherapy research

CHARLES J. GELSO

Department of Psychology, University of Maryland, College Park, Maryland, USA

(Received 6 January 2009; revised 22 January 2009; accepted 24 January 2009)

Let me begin by expressing my appreciation to Drs.
Leigh McCullough, Robert Hatcher, and Adam
Horvath for preparing such high-quality reactions
to my article. All three reactions, it seemed to me,
were thoughtful, respectful, and useful. I could not
have asked for more. It was clear that these three
scholars each had some views that were similar to
mine and some that were different. Regardless of the
degree to which we differed, I found each comment
to be intellectually exciting, and each gave me new
ideas to explore. In this rejoinder, rather than reply
to each and every reaction, I shall focus mostly on a
few points of contention that seem central and seek
to provide clarifications of what may be misunder-
standings.
Semantics that Will Not Go Away
Before replying to substantive theoretical and mea-
surement matters, I do want to reiterate that the
term real relationship does carry its share of
problems. I have considered alternative terms over
the years. None fully fit the processes to which the
term applies without carrying controversial excess
baggage, although, as I have also noted, I have been
adding the term personal relationship more often
in recent times. This term, too, has its share of
problems, as Leigh McCullough highlights. Inter-
estingly, whereas McCullough preferred the term
real relationship and believed that personal
relationship had undesirable connotations, Adam
Horvath (2009) strongly disapproved of real rela-
tionship, preferring the term personal relation-
ship. To wit, in searching for a better term, Frank
(2005) mentioned the new relationship, which to
my mind is even more problematic. I think we shall
just have to settle for the likelihood that there is no
widely appealing term for what I refer to as the real
or personal relationship. I suspect the field can live
with this, while staying mindful of the idea that the
substance or processes the term depicts are of far
greater significance than the term itself.
Some Theoretical Matters
Must the Good Real Relationship Be Positive?
McCulloughs (2009) observations about real rela-
tionships and the three distinctions that need further
attention seem very important. That is, the distinc-
tions between realness versus genuineness, real
relationship versus therapeutic alliance, and real
relationship versus transference are all crucial to
the clarification of what constitutes a real relation-
ship. These distinctions are worthy of a careful
reading by anyone interested in the real relationship
construct. Despite my sense that McCullough and
I seem to be of a like mind about the therapeutic
relationship, there is one clinical/theoretical differ-
ence between our views that may fruitfully be high-
lighted. McCullough takes me to task for suggesting
that positively valenced ratings are needed if the real
relationship is to be considered strong. Instead, she
believes that the real relationship allows the freedom
(presumably for therapist as well as patient) to
confront conflictual and negative feelings toward
one another, which, in turn, may strengthen the real
relationship.
I actually am in close agreement with these
assertions. In fact, in one of the studies that was
part of the Maryland Psychotherapy Relationship
Research Program (Woodhouse, Schlosser, Crook,
Ligiero, & Gelso, 2003), we found that clients who

Correspondence concerning this article should be addressed to Charles J. Gelso, Department of Psychology, Biology-Psychology Building,
University of Maryland, College Park, MD 20742-4411, USA. E-mail: gelso@psyc.umd.edu

ISSN 1050-3307 print/ISSN 1468-4381 online # 2009 Society for Psychotherapy Research
DOI: 10.1080/10503300902777155

were more securely attached to their therapists
(indicative of a strong real relationship) exhibited
greater overall transference and negative transfer-
ence toward their therapists, as judged by these
therapists. To my mind, these findings imply that a
secure attachment to ones therapist, and by im-
plication of strong real relationship, gives patients
the freedom to explore negative feelings toward the
therapist. Also, in a qualitative study (Gelso, Hill,
Mohr, Rochlen, & Zack, 1999), therapists who
described cases of successful, long-term psychody-
namic psychotherapy typically viewed a positive real
relationship in these cases as creating a secure base,
which allowed patients negative transference to
emerge and be worked through. At the same time,
it seems to me that in order for the real relationship
to be strong, it must be largely positively valenced
from both the therapists and the patients perspec-
tives. A positively valenced, strong real relationship
will likely provide the patient with a secure base from
which negative feelings (both transferential and
realistic) may be dealt with and resolved.
I do tend to agree with McCullough that the real
relationship may be even more important, or at least
more prominent, in brief therapy than long-term
treatment (see Gelso & Hayes, 1998, pp. 125
126).
However, its import in longer term treatment should
not be underestimated. For example, the Gelso et al.
qualitative study hints at the major significance of
the real relationship in long-term dynamic therapy in
terms of the resolution of transference.
What Is the Best Unit of Analysis?
In a theoretical statement that has implications for
research, Hatcher (2009) explores in some detail the
extent to which the real relationship ought to be
framed as a way of looking at what happens in each
and every therapy transaction, in contrast to a
phenomenon that shows itself at certain times in
concrete aspects of the therapy exchange. Hatcher
strongly and clearly favors the former manner of
formulating the real relationship. The latter, which
he refers to as the component point of view, before it might have such an impact.
narrows and limits our potential understanding
because any given activity, attitude, etc. in therapy
serves multiple purposes, and thus cannot in general
belong in an exclusive category (p. 269). In other
words, the component approach is problematic
because it measures the strength of a given compo-
nent at a particular time or on the whole, whereas
Hatcher believes it best to analyze, for example, the
real relationship element in every transaction.
Although I agree with Hatcher that there are real
relationship (and transference) aspects in virtually all
transactions, and further agree that his suggested
The time has come 279
manner of studying constructs will be fruitful,
I believe that the exclusive use of that approach,
and the elimination of the component point of view,
will itself narrow and limit our understanding. This
is so because, although the real relationship, for
example, may be part of everything that happens in
therapy, including the enactment of techniques,
there are times when one or another component
(e.g., relationship or technique; real relationship,
working alliance, transference, and countertransfer-
ence) will be clearly the most prominent phenom-
enon that is being exhibited and, further, at times
studying mutually exclusive components is quite
useful. As an example, although Hatcher appears
to think that it is not useful to study the importance
to outcome of the working alliance versus technique,
or the real relationship versus the alliance, or
transference versus nontransference, I could see
where each of these comparisons might be extremely
enlightening. Would such a component approach be
sufficient? I agree with Hatcher that it would not.
Should it be done away with in favor of what might
be termed his all-in-everything approach? In my
view, it should not. Instead, here we have a great
situation for theoretical and methodological trian-
gulation. We can theorize about and study phenom-
ena from multiple perspectives, with, I believe, a
superior yield.
What Is Real Anyway?
Adam Horvath (2009) offers a number of interesting
and potentially fruitful ideas about the therapeutic
relationship. For example, his conception of layers of
constructs (ranging from feelings at the first level
and relationship processes at the highest level of
abstraction) is intriguing, and I could easily see it
developing into a general structure for understand-
ing the therapeutic relationship, a structure that
would take the field beyond the excessively global
conceptualizations of the therapeutic relationship
that both he and I lament. Of course, the conception
would need much refinement and development
Regarding the real relationship, Horvaths remarks
represent the most fundamental challenge to a
theory of the real relationship in psychotherapy as
I have formulated it. Specifically, Horvath is critical
of the concept of realism within the real relationship.
He sees my solution to the question of what is real
as involving the notion of fit. In other words,
whether ones experience and perception of the other
is realistic depends on how closely that perception
matches the self-perception of the other. Although
I can understand why Horvath thinks that this is
what I think because of a couple of examples
280 C. J. Gelso
I offered in the main article, this is actually not my
solution to the age-old ontological question of what
constitutes real or reality. In my view, there is
indeed a self, a mind, a psychic reality, and a basic
personality of the patient (and the therapist, too)
that transcends perceptions held by the other. Thus,
for example, the person exists as an entity and is far
more than merely the result of coconstructions by
patient and therapist in their work together, as Eagle
(2003) has aptly argued. There is indeed a reality of
the patient (and the therapist), and a strong real
relationship involves each participant grasping or
sensing that reality. (Of course, this too is a matter of
degree.) At the same time, in our measurement
approach, we do rely on patient and therapist reports
(of self, other, and relationship). That is why I
have termed our approach constructive realism.
There is a reality of the patient and the therapist, and
the participants perceptions of self and other are
extremely important in attempting to capture that
reality. Can a given participants perceptions be
inaccurate? They certainly can and indeed always
are to one degree or another. We need to stay
mindful of this fact when we measure realism
through patient and therapist reports (or reports of
others, for that matter).
Transporting Constructs Across Theories
Another very significant criticism offered by Horvath
is that because the constructs of transference and real
relationship originate from psychoanalytic theory,
and because transference in particular is addressed
much more frequently in psychoanalytic than other
treatments, the concepts of transference and what
Horvath views as its twin, the real relationship,
cannot be framed as general elements of all ther-
apeutic relationships. To the contrary, in my view,
although transference is, of course, not central to
nondynamic theories, it is still legitimate to theorize
that transference is part of all treatments (and all
relationships), whether dealt with directly or not by
the therapist in any given treatment. The originators
of key nonanalytic theories such as gestalt, client-
centered, rational-emotive, and cognitive therapies
all believed that transference does exist, and research
evidence supports such views, even, for example, in
behavioral therapies (see Gelso & Hayes, 1998, for
discussions of transference in nonanalytic therapies),
although it is not centrally worked with as such in
these treatments, unless it becomes a problem. Of
course, this is a matter of degree, and therapies
espousing the importance of transference are more
likely to infer more transference and bring more of
it to the surface. Moreover, I am suggesting
that transference is usefully seen as existing in all
therapies, although how it is handled depends on the
particular theory and therapist
patient pair. More
generally, constructs originating in one theoretical
system may be extrapolated to another theory if it
makes sense that these constructs apply to the other
theories. To the point of my main article, although
the real relationship is a concept originating in
psychoanalysis (as is the working alliance, by the
way), considering how it has been defined, it is hard
to imagine this component of the overall relationship
not existing to one degree or another in all ther-
apeutic and all human relationships.
Measuring the Real Relationship
Item Generation and Refinement
Perhaps based on my brief summaries of the projects
that have been completed by our research teams, it
seems to me that the comments evidenced a few
misunderstandings of our instrument development
research. For example, McCullough states that her
main concern about the instrument development
work that my collaborators and I have done is that
we bypassed the standard approach to measure
development. Although our measures are theory
driven rather than empirical, such as the Minnesota
Multiphasic Personality Inventory, we actually did
follow a fairly standard path for theory-driven
measures. For example, for the therapist version of
the Real Relationship Inventory (RRI; Gelso et al.,
2005), we generated 130 items aimed at capturing
theoretically determined subscales of Realism and
Genuineness and within these subscales, magnitude
and valence. Further, we wrote items focused on the
therapist, the client, and the relationship within
genuineness, realism, magnitude, and valence. We
then used standard item-reduction methods (e.g.,
back-translation, reduction in alpha when item
deleted, inspection for redundancy, and item
total
correlations) to pare down the measure to the 12
best items within the Realism and Genuineness
subscales, with at least one item representing mag-
nitude and valence related to self, client, and
relationship for the two subscales. We conducted
confirmatory factor analysis, and we assessed inter-
nal consistency and both convergent and discrimi-
nant validity. As you can see, this gets pretty
complex, and in writing the original article, I hoped
to avoid such complexity for fear of both putting the
reader into a state of terminal numbness and making
the article much longer than it ought to be.
Hatcher makes several valuable suggestions about
measurement. For example, he suggests the kinds of
items that might better fit his preference for studying
the real relationship as it exists in all experiences and

transactions in therapy. Although it was unclear to
me how his exemplified items would capture his
ideas better than our existing items, I could see
where a measure based on his views would be
potentially quite useful.
Do Realism and Genuineness Predict
Differentially?
Both Hatcher and McCullough were interested in
the possible differences in how the Realism and
Genuineness subscales of the RRI might correlate
with other important variables, despite the very high
intercorrelation between realism and genuineness.
Hatcher was puzzled as to why I did not report the
subscale correlations with other measures more
often, and McCullough expressed the view that
further research might reveal differences between
the Realism and Genuineness subscales. I am in full
agreement that the subscale correlations with other
variables should be reported and that we should
maintain an interest in how realism and genuineness
may differentially relate to other variables. In fact, in
three of the four studies I have summarized, my
collaborators and I did indeed conduct separate
analyses according to the two subscales. Because
the two subscales were so highly correlated (rs ].75
in three studies) and, again, to avert excessive detail
in the article on which McCullough, Hatcher, and
Horvath comment, I presented primarily our find-
ings about the total score. However, despite their
high intercorrelation, we have found some intriguing
differences in how the Realism and Genuineness
subscales of the RRI behave. For example, in Gelso
et al. (2005), we found that therapists responses to
the RRI
Genuineness subscale were more strongly
correlated with working alliance (r .55) than were
responses to the RRI-Realism subscale (r .32),
t(89) 5.13, p B.01. At the same time, in another
one of our studies (Marmarosh et al., in press), we
found that on the therapist measure of the RRI,
Realism scores predicted treatment outcome,
whereas Genuineness scores did not. Given the
high intercorrelation of realism and genuineness, it
is entirely possible that these differences may have
been chance findings. However, I agree with McCul-
lough that the question of whether the two subscales
should be combined merits the tolerance of ambi-
guity for some time longer (p. 266).
Validity and the Choice of Measures
Horvath makes many good points about instrument
development. For example, we clearly need to
study further the discriminant validity of the RRI-
Therapist and the RRI-Client. He suggests that to
The time has come 281
do so, evidence is needed of nonoverlapping variance
with proximal relational variables such as positive
transference, secure attachment, and alliance. In
response, we have indeed accumulated evidence of
such nonoverlapping variance in the four studies on
which I report, except for the correlation of the RRI-
Client with the Working Alliance Inventory
Bond
subscale. As Horvath aptly notes, when we correct
for unreliability of coefficients, it looks like the RRI-
Client is essentially the same thing as the Bond
subscale of the Working Alliance Inventory (short
version). In inspecting the four-item subscale, it
looks like three of the items tap to a substantial
extent the personal or real relationship and are
different from the working collaboration that seems
theoretically to define a working alliance. In this
sense, the Bond subscale of the Working Alliance
Inventory appears to be a mixture of working
alliance and real relationship, whereas the RRI may
be a cleaner measure of real relationship.
Although Horvath believes that the concept of
genuineness has greater appeal than does realism, he
suggests that the research community might be
better served by using the Barrett-Lennard Relation-
ship Inventory (BLRI; Barrett-Lennard, 1962) than
the RRI. The problem with this suggestion is that the
BLRI taps only perceptions of the therapists genu-
ineness. Although this is important to tap, and the
BLRI is an effective measure of it, I believe the real
or personal relationship is better viewed as a
bipersonal construct, which includes assessments of
both therapist and client genuineness as well as the
genuineness of their relationship. Thus, measures
completed by both therapist and client, with items in
each measure pertaining to both therapist and client
(and their relationship), are needed. The RRI
measures do reflect this bipersonal perspective.
Finally, in contrast to Horvath, I do believe that
we very clearly have accumulated sound reliability
and validity data on the client and therapist RRI
measures, such that research using these measures is
viable and will advance knowledge. Thus, as indi-
cated in Gelso (2009), research using the current
measures ought to be done simultaneously with
research aimed at measure refinement, such as, for
example, the research Hatcher and Gillaspy (2006)
conducted on the Working Alliance Inventory
(Horvath & Greenberg, 1989). As for the other
constructs Horvath believes should be considered as
components of a personal relationship (e.g., respon-
siveness, warmth, and sincerity), these all seem like
interesting candidates. However, for these candi-
dates to be accepted, someone needs to develop a
different theory of the real relationship than I have
presented and construct a different measure or two.
Doing so would certainly move the science of the
282 C. J. Gelso
real or personal relationship in psychotherapy for-
ward.
Conclusion
Where are we with respect to the real relationship? In
the words of Lewis Carrolls Walrus, The time has
come. However, although the time has come to
talk of many things about the real relationship, at
this point what will be especially helpful is actual
empirical research aimed at addressing the many
questions that have been pointed to by McCullough,
Hatcher, Horvath, and me. Vigorous empirical study
of the real relationship will itself lead to more refined
theory. We all understand that the construct that has
been termed the real or personal relationship is
maddeningly complex. So are transference, techni-
que, and working alliance for that matter. The latter
construct may not seem so complex now because
Horvath and Greenberg (1989) did the hard work of
developing a reasonable, if fallible, measure based on
a highly fallible but heuristically rich theory of
working alliance offered by Bordin (1979). It seems
to me that we are at a point, unlike when Jean Carter
and I offered our initial theoretical propositions
about the therapeutic relationship (Gelso & Carter,
1985, 1994), where research on real relationship is
quite practicable. We have the psychometrically
sound initial measures and an array of good ques-
tions based on theory, practice, and beginning
research efforts; and there has been a growing
awareness, as implied in Horvaths comment, that
it is time to move beyond a highly global concept of
the therapeutic relationship and beyond the view
that the therapeutic relationship is the equivalent of
the working alliance. Vigorous empirical study of the
real relationship will serve to refine theory, allow us
to learn more about the place of real relationship in
the overall therapeutic relationship, and ultimately
help facilitate effective real relationships and more
efficacious psychotherapy.
References
Barrett-Lennard, G. T. (1962). Dimensions of therapists
response as causal factors in therapeutic change. Psychological
Monographs, 76(Whole No. 43).
Bordin, E. S. (1979). The generalizability of the psychoanalytic
concept of the working alliance. Psychotherapy: Theory,
Research, and Practice, 16, 252
260.
Eagle, M. N. (2003). The postmodern turn in psychoanalysis: A
critique. Psychoanalytic Psychology, 20, 411
424.
Frank, K. A. (2005). Toward conceptualizing the personal
relationship in therapeutic action: Beyond the real relation-
ship. Psychoanalytic Perspectives, 3(1), 15
56.
Gelso, C. J. (2009). The real relationship in a post-modern world:
Theoretical and empirical explorations. Psychotherapy Research,
19(3), 253
264.
Gelso, C. J., & Carter, J. A. (1985). The relationship in counseling
and psychotherapy: Components, consequences, and theore-
tical antecedents. The Counseling Psychologist, 13, 155
243.
Gelso, C. J., & Carter, J. A. (1994). Components of the
psychotherapy relationship: Their interaction and unfolding
during treatment. Journal of Counseling Psychology, 41, 296
306.
Gelso, C. J., & Hayes, J. A. (1998). The psychotherapy relationship:
Theory, research, and practice. WileyNew York.
Gelso, C. J., Hill, C. E., Mohr, J. J., Rochlen, A. B., & Zack, J.
(1999). Describing the face of transference: Psychodynamic
therapists recollections about transference in cases of success-
ful long-term therapy. Journal of Counseling Psychology, 46,
257
267.
Gelso, C. J., Kelley, F. A., Fuertes, J. N., Marmarosh, C., Holmes,
S. E., Costa, C., & Hancock, G. R. (2005). Measuring the real
relationship in psychotherapy: Initial validation of the therapist
form. Journal of Counseling Psychology, 52, 640
649.
Hatcher, R. L. (2009). Considering the real relationship: Reaction
to Gelsos The real relationship in a post-modern world:
Theoretical and empirical explorations. Psychotherapy
Research, 19(3), 269
272.
Hatcher, R. L., & Gillaspy, J. A. (2006). Development and
validation of a revised version of the Working Alliance
Inventory. Psychotherapy Research, 16, 12
25.
Horvath, A. O. (2009). How real is the real relationship?
Psychotherapy Research, 19(3), 273
277.
Horvath, A. O., & Greenberg, L. S. (1989). The development and
validation of the Working Alliance Inventory. Journal of
Counseling Psychology, 36, 223
233.
Marmarosh, C. L., Gelso, C. J., Markin, R. D., Majors, R.,
Mallery, C., & Choi, J. (in press). The real relationship in
psychotherapy: Relationships to adult attachments, working
alliance, transference, and therapy outcomes. Journal of Coun-
seling Psychology, 19(3).
McCullough, L. (2009). The challenge of distinguishing figure
from ground: A reaction to Gelsos work on the real relation-
ship. Psychotherapy Research, 19(3), 265
268.
Woodhouse, S. S., Schlosser, L. Z., Crook, R. E., Ligiero, D. P., &
Gelso, C. J. (2003). Client attachment to therapist: Relations to
transference and client recollections of parental caregiving.
Journal of Counseling Psychology, 50, 395
408.