The “right” relationship in assessment and treatment: What does it look like?

By David S. Prescott, LISCW

It’s a little late for this to be a 2018 year in review post, but if I had to pick a single study from the last year with maximum implications for professionals working with people who abuse (whether sexually or otherwise), it would be one by Brandy Blasko and Faye Taxman. They found that “when the community supervision process was perceived [by the client] as procedurally fair, individuals under community supervision demonstrated positive criminal justice outcomes, that is, less self-reported criminal behavior, fewer official arrests, and fewer technical parole violations” (p. 414). Their measure of fairness included the client’s perception of being listened to by their probation officer.

Why is this study so important? For starters, it adds to what over 1,100 studies have found outside of forensic treatment circles: that the therapeutic alliance (also known as the working alliance) is fundamental to making treatment effective. And yet, too few in our field can even define it. Of course, developing any kind of professional relationship with people whose actions have been reprehensible can be a challenge, especially for those starting out in the field.Bill Marshall and his colleagues found that the most effective treatment providers are warm, empathic, rewarding, and directive, but translating these qualities into one’s own practice can be a challenge.

Questioning the nature of professional relationships is not merely an academic point. Sexual and other forms of violence can cut deeply into the hearts and souls of professionals, as anyone who has followed the recent media attention to R. Kelly can attest. Virtually anyone who works in the areas of abuse and trauma has experienced those cases that leave a lasting mark on our souls, often with apparently indelible imagery. As some have recently noted, when the person who perpetrates violence has been a hero or practically wrote the soundtrack to one’s adolescence, the resulting anguish can be hard to escape and even contribute to burnout.

Recent discussions within and outside of ATSA circles have focused both on the impact of doing this work and the extent to which we should “like” our clients. To outsiders, one of the surprises of working in our field is how likable some of our clients can actually be. In some cases, this can become disconcerting, leading to questions as to where the boundaries are in developing the best working relationship. Complicating matters are the moral judgments professionals can have about their client’s actions, as well as concerns that their clients may be engaged in manipulation processes that resemble the approach behaviors used with those they’ve harmed. With all of these factors in the mix, how could we not wonder about what kind of relationship is most effective? Even beyond likability, many of us remember that the teachers, coaches, and colleagues we learned the most from were not necessarily those that we liked the best, but we respected them.

“What is the right relationship” may not, however, be the best question. Just as there are “treatments of choice”, there can also be “relationships of choice” … And these can vary based on who the therapist is. Implied within the Blasko and Taxman study is that it’s not a question about what kind of relationship you have as much as do you have agreement and buy-in as to the nature of your relationship. Very often, this centers on to what extent you have built up agreement on the goals you are working towards and the approaches used in treatment. This agreement on the nature of the relationship as well as the goals and tasks of treatment are the three areas originally defined byEdward Bordin in 1979. Although mentioned frequently in trainings and social media (including this article by Scott Miller and me, and a blog post with our colleagues), it often appears to be an idea whose time is yet to come in the forensic arena.

One way to think about building the “right” relationship with clients might be to think about it one client at a time. You can ask yourself:

1.      What are this client’s goals and how can I best align them with the goals set out in his (or her) treatment plan and/or assessment reports?

2.      What kind of approach works best with this particular client and how can we develop agreement on the best way forward?

3.      Who am I to this client and how does s/he view my role within it? Do we have agreement on who I am to this person?

4.      Finally, how can I provide services in a way that are aligned with this person’s unique culture and strongly held values?

Seen through this lens, the question of the right relationship (and the boundaries within which it exists) may be easier to negotiate.

Of course, what is missing from this mix can be as important as what is there. In this way of working, professionals must strive to keep whatever moral judgements they have about clients’ actions separate from the assessment or treatment process itself. Likewise, it can be easy to overlook the importance of establishing agreement in these areas to begin with; all too often, professionals view the working alliance as something to establish at the start of treatment rather than an essential component throughout the experience. Finally, it can be tempting to think that we already have a good enough working alliance, and that we don’t need to ensure this on an ongoing basis. Unfortunately, Beech and Fordham found otherwise in our field. Finally, it assumes that professionals are willing to take into account their clients’ experiences, are able to think flexibly about their clients, and be willing to switch up their styles as needed.

In the end, however, I’ve always found that the additional attention to these areas pays dividends in terms of time saved trying to sort out why treatment isn’t moving faster.