Relational Therapy: How It Works & What to Expect

What Is Relational Therapy?

Relational therapy (also called relational-cultural therapy) is a relationship-focused form of psychotherapy that draws heavily from psychoanalytic therapy. Defined as the shift from “Freud’s [neutral] blank screen,” RT therapists use the therapeutic relationship to identify and address the client’s psychological issues.^1,2

The relational therapist will consider the client’s past and current relationships, race, gender, social economic class, sexuality, and political orientation. A primary goal of RT is for clients to leave their therapy sessions feeling connected, understood, rejuvenated and revived rather than empty, vulnerable and exposed.^2,3 As one prominent RT therapist Jon Mills states, “We imagine the analytic encounter aspiring toward an interpersonal, ideal of relational fulfillment and mutual recognition that serves a nurturing and validating function for both the patient and the therapist.”³

The History of Relational Theory

Relational therapy is credited to the work of Dr. Jean Baker Miller, a psychiatrist who worked in the 1970’s and 1980’s. The theory was influenced by many existing forms of therapy, including Karl Rogers’ person-centered therapy, multicultural therapy, feminism, and Freud’s psychoanalytic therapy. Using these theories, RT therapists work to form strong bonds with clients and try to understand the influence of their past experiences and interactions, and when possible, resolve these through specific positive interactions.

How Does Relational Therapy Work?

A strong relationship between a client and therapist is necessary for clients to make progress in therapy, but when it was developed, this idea was not widely accepted. Core concepts of relational therapy are relatedness, transference and countertransference between the client and therapist, enactment, projective identification, intersubjectivity, and self-disclosure.

Relatedness

Relatedness means that the drive to have social relationships takes precedence over all other motivations. This idea challenged Freud’s Drive Theory, that suggested basic instinctual and biological desires are the primary motivator and driver of human behavior.³

Transference & Countertransference

Transference and countertransference happen when either the client or therapist imposes or transfers his or her feelings or opinions on the other person. For instance, the client may relate to the therapist as a sister, mother, or best friend from early formative years (transference), or the therapist might dislike a client because of their past experiences (countertransference). This phenomenon can create good or bad feelings between the client and therapist. Originally a classical Freudian concept, relational therapists have utilized this concept to build on their own work and theory.^3,4

Enactment

Enactment is the acting out of problematic behavior that perhaps even sent the client to therapy, which allows the analyst to heal and resolve feelings in real time, thereby undergoing a corrective emotional experience.⁵ According to Mitchell Relational Center, enactments “provide special opportunities for gaining access to the ways in which the unconscious life of the patient and the therapist emerge and interact, creating special challenges and special opportunities for deepening and furthering the work.”²

Projective Identification

This is a concept where the good or bad attributes of one individual are subconsciously transposed to another individual or object, often referred to simply as projection. For instance a person who is excellent at their job, but lacks confidence may project their own successful traits onto a supervisor who they idealize. Often this happens in reverse, when an undesirable trait is projected on to another party or object.^6,7

Intersubjectivity

Intersubjectivity is the person’s ability to simultaneously hold both their inner world and perceptions along with another’s experience. The client’s experiences may be directly observed and discussed with the therapist to help bring a deeper self-awareness and gain insight. This can be processed and practiced through the safe yet challenging observations of a relational psychotherapist.^1,3

Self-Disclosure

This is when a therapist chooses (for therapeutic reasons) to disclose something personal to their client. When used appropriately, self-disclosure can create more trust, closeness and connection in the relationship, as well as improve client’s insight. An example would be a client feeling great shame about a job loss and the therapist offering their own experience of emotionally overcoming and finding new professional success following their own lay-off.^8,9,10,11

What’s the Goal of Relational Therapy?

The goal of relational therapy is to help people who are struggling to develop and maintain stable, healthy, and secure relationships. A lack of fulfilling relationships in a client’s life is believed to cause a number of common psychological issues, including mood instability, social anxiety, addiction and higher susceptibility to trauma. Relational therapy helps people become more aware of the past experiences and patterns of behavior that prevent them from developing healthy relationships, as well as helping them develop the needed skills to improve their relationships.

Relational Therapy Examples

Relational therapy can be used to treat a variety of issues, from generalized anxiety disorder and depression to PTSD. Because of the primary emphasis on relationships, relational therapy will often include questions and discussions about a client’s previous and current relationships.

Relationship Instability & Insecure Attachment Styles

Relational therapy helps the client learn about healthy boundaries and consistent, secure attachments to others through the therapeutic relationship. These teachings are observed in therapy and are also reinforced by the experience of developing a healthy and stable relationship with the therapist. By setting healthy standards that include consistent session start and end times, fees, and keeping professional boundaries, therapists help clients with insecure attachments learn to have healthy boundaries within their own relationships.^10,11

Relational Therapy for Social Anxiety

The transparent nature of the therapeutic relationship in relational therapy can assist individuals struggling with social anxiety. The therapeutic relationship provides predictable space for clients to learn how to authentically connect and relate to others. By using warmth, empathy, and non-judgmental approaches, relational therapists create a safe environment for clients to feel free to express themselves. The more they practice doing so in sessions, the more likely they will be able to do so in their personal relationships as well.

Relational Therapy for Mood Instability

Client’s are encouraged to act out difficult and intense emotions like rage in a relational therapy setting. This free emotional expression can be relieving and cathartic, and can also help provide an outlet for repressed emotions which can lead to mood swings.

Relational therapy for Trauma & PTSD

Trauma can create a loss of trust in others, which can be restored with empathy and careful pacing of treatment.⁶ The therapist can also use self-disclosure to gain trust, “reveal themselves,” and think out loud.¹² Relational therapy would not be recommended as a first line of defense for PTSD, which is better treated with EMDR or ART, but it can be in used conjunction or immediately after more regimented approaches.

Relational Therapy for Addictions

The lack of close relationships or inability to maintain healthy relationships can lead people to seek out comfort in alcohol or illicit drugs, workaholic tendencies, over-exercise, or food addiction. A relational therapist can assist the individual struggling with addiction to uncover their painful relationship history and see how this relates to their addiction. Some addictive behavior may be dangerous and require immediate medical attention or intensive treatment programs. Relational therapy would not be an appropriate resource in these instances.

How to Find a Relational Therapist

The best way to find a relational therapist is to go directly to an institute such as Mitchell, Jean Baker Miller, or William Alanson White, which all specialize in relational therapy. Another approach is to search specifically for relational therapy through an online therapist directory, where you can sort by specialty and insurance coverage. You can also review the therapist’s biography page to verify they currently provide RT.

You do not need a special referral to see a relational therapist, but it is important to find someone who is a good match for your needs, which may require you to talk to several therapists.

Who Is Able to Offer Relational Therapy?

Relational therapy is practiced by licensed counselors, social workers psychologists, and other professionals providing professional counseling services. At a minimum, counselors obtain a graduate degree and go through an additional licensure process.

Aside from these requirements, there are no licenses or certifications required to apply this method, though years of experience and training are beneficial. Ideally, however, relational therapists have additionally obtained a minimum year long certification from a post-graduate Institute such as Mitchell Relational Center or William Alanson White.

Key Questions to Ask a Relational Therapist Before Beginning

Finding a counselor who is a good match is important, especially in relational therapy, where the entire treatment is centered around the bond between the therapist and client. Many counselors offer free consultations to potential new clients to answer questions and provide information that will help them make an informed choice.

Questions to ask a relational therapist before starting include:

• What licenses and credentials do they have?
• How long have they been practicing relational therapy?
• What drew them to this approach? Why is RT effective, in their opinion?
• Who is their biggest influence in relational therapy and why?
• How do they apply the RT method?
• What is the evidence that RT is successful, either anecdotal or research based?
• What is the cost per session? Do they take insurance? What is the length of treatment?

How Much Does Relational Therapy Cost?

The typical cost of therapy can range from a small co-payment to $150-250 or more per session for those paying out of pocket. Insurance may approve coverage of these sessions for up to 1-2 times per week if your therapist is in-network. Even if they are out of network, some mental health insurance plans provide partial reimbursement for services. If you are unsure about insurance coverage and costs, check with your provider about in-network and out of network coverage for behavioral health services.

What to Expect at Your First Appointment

Your first therapy appointment with a relational therapist will typically involve a 60-minute intake session. In addition to the usual information gathering process, the therapist will probably ask questions about your childhood, family history, and current relationships. To a relational therapist, human connection and experience is relational by definition, making this information highly relevant to your treatment.¹³

Questions about your gender, cultural and racial background may also be asked.

Is Relational Therapy Effective?

It is difficult to prove the efficacy of relational therapy because much of the research is qualitative in nature. Also, relative to other types of therapy, relational therapy is less commonly used, and less research has been done to establish its efficacy with different populations. However, relational therapy draws from several therapies that are evidence-based, including psychoanalytic, person-centeredness, and attachment therapy. In addition, the primary focus on the therapeutic relationship also lends credibility to the therapy, as this is consistently found to be more important than the specific kind of therapy being used.

Risks & Critiques of Relational Therapy

Like any therapy, relational therapy comes with an assumption of some risk. Feeling exposed in the client chair may be a challenge enough for some, but in addition to the general risks in therapy, there are a few that are more specific to RT. The open-ended nature and lack of specificity can leave room for bias and loose interpretations over objectivity.

Another risk of relational therapy is the use of the therapist’s discretionary use of self-disclosure, which can be harmful if not properly applied and can result in “boundary violations.”³ Under RT, analysts can openly discuss almost anything, including sexual countertransference which has clear potential to be traumatic for certain clients. Also, since RT is based on theory without much structure in technique, the development of standardized training for students and treatment protocol can be challenging.¹⁴

Relational therapy is not evidence-based and can not rapidly treat a mental health concern.¹⁵ RT is a long-term treatment where individuals must be stable enough to tolerate it for the duration without instantaneous relief. For this reason, RT may not be the ideal option to treat severe and acute-onset mental illness, where intensely symptomatic individuals need immediate stabilization. Treatments such as inpatient rehabilitation, day treatment programs and behavioral therapy might be better options.

Some critics feel that the relational therapist can get carried away in participating in the dyad. If focus is routinely shifted back to the manner of relating between the therapist and client, then the client’s individual needs and sense of self become overshadowed. While careful training should ensure this does not happen, it is a risk of the therapist participating in the treatment.³

How Is Relational Therapy Different From Other Forms of Therapy?

Relational therapy is most closely related to Classical Freudian Psychoanalysis from which it stemmed, but also attempts to distance itself from this theory by emphasizing relational aspects rather than instinctual drives. In Freudian therapy, dreams and the subconscious psyche are accessed to analyze, diagnosis, and treat the client.³ A relational therapist will interpret the client’s relatedness, communication, body language and social/environmental history to assess and treat.³

Relational therapy mostly differs from it’s evidence-based short term counterparts, EMDR, CBT, and DBT, which are 6-12 week behavioral treatments meant to target a specific behavior or trauma. There is usually a very specific syllabus with each session pre-determined and outlined, whereas RT is flexible and adaptive to the unique needs of each client.³ There is significantly less focus, if any, on the developing relationship between client and therapist. While these are vastly different approaches, all methods can lead to healing and sometimes can be used in conjunction with each other depending on the client’s needs.