The Benefits Of A Strong Therapeutic Relationship

When I started Seven Health back in 2009, I had no idea how it was all going to pan out. I’d qualified as a nutritionist in the middle of 2008 but still felt like I knew nothing (which, in fact, was true). 

Over the last decade, my ideas have evolved and my practice looks very different now from what it did at the start. Along the way, I’ve gone through many iterations (and will continue to) as my knowledge and experience have changed.

While there are definitely things that I would do differently, it is easy to say that with hindsight. Because it is typically by going through an experience that you learn the lessons.

But if there is one thing I wish I had done differently from as early on as possible it is to focus more of my time on how to be a better practitioner.

Now, I’m very grateful for all the time I spent learning about physiology and biology. It’s clearly helped and is knowledge I constantly use when working with clients. But in the early days, this was really where all my focus was going.

Over the last 5 or 6 years, this has drastically changed. Realising how much I enjoyed being a practitioner and that one on one work had become the core of what Seven Health is about, I really knuckled down on figuring out how to be better as a coach and to help people change.

Motivational Interviewing

Motivational Interviewing by William R. Miller and Stephen Rollnick is probably the book that has influenced me more than any other in the area of how to be in relation with a client.

Motivational Interviewing or MI is an approach that focuses on eliciting behaviour change within a client. Rather than forcing motivation on someone (which typically backfires and leads to resistance), the goal is to elicit change within the client.

The word “interviewing” in the name can be somewhat misleading and actually, it would make more sense to be called motivational conversation. In the book, it is defined as “a collaborative conversation style for strengthening a person’s own motivation and commitment to change” 

Ambivalence 

A big part of MI is the concept of ambivalence, which is a state of having mixed feelings. It’s the ability to hold two contradictory ideas about something at the same time. 

It’s knowing all the reasons why you want to make a change AND knowing all the reasons why you are better off staying as you are.

This is completely normal. If someone 100% wants to make a change, then change would have already occurred as nothing is holding them back.

But the reality is that with every choice there are pros and cons and ambivalence is the little balance sheet in your mind that is seeing this ledger and knowing that change isn’t as straightforward as it may appear.

So, MI is about exploring this ambivalence and understanding why there is apprehension, so that change can occur (something I cover in more detail here).

The Therapeutic Relationship

There are several guiding principles or foundational ideas that are at the core of MI. At the centre of it all is the therapeutic relationship. This is the relationship between the practitioner (myself) and the client.

In fact, research has shown that, more than any other factor, a strong therapeutic relationship is most associated with successful treatment.

Which makes complete sense. You’re going to be opening up about some of your biggest struggles, often sharing things you’ve never shared with anyone else before. For this to work there has to be mutual trust, respect and caring.

But it’s not just about being caring and compassionate, it’s also trusting that the practitioner has the knowledge, skillset and desire to help you get to a place of recovery.

I always talk about Seven Health being about “science and compassion,” which is shorthand for what I’ve described above. The ability to meet a client where they are at in an empathic and understanding way, as well as the know-how to help them change and get to a place of recovery (or whatever their goal may be).

While many aspects go into a strong therapeutic relationship, MI has identified four main components.

Collaboration 

The first idea is that the relationship should be a partnership or collaboration.

While I have knowledge and expertise in many areas, clients are the experts of themselves. And not just in understanding themselves but in having skills and strengths that are vital to change occurring. 

Rather than doing something “to” or “on” someone, MI is done by working “for” and “with” a person. It is about using our individual skills to complement each other.  

In the book, they use the metaphor that MI is like dancing with someone instead of wrestling with someone. We are in this together to figure out what the change process looks like. Sure, at points, I can have more of a guiding role. But this guidance can only happen if someone wants to go in that direction.

An example of this is that during each session we work out what will be the goal for the next two weeks (which is the usual gap between sessions). Choosing the goal is up to the client. We discuss it and if a client wants my input, I will give it. But the final decision rests with them.

This is important for several reasons:

• The client gets to pick the pace that feels right for them
• They are more likely to follow through on a goal they have chosen rather than one that is forced upon them
• They have a stronger feeling of control and autonomy. And when they hit their goal, it is about them improving, rather than feeling like they are impressing me.  

(This is actually something I talk about in detail in this conversation)

In the early days of practice, this would have felt strange. I wanted to be more directive because supposedly that was my role. I was meant to be the expert and the one setting the agenda. But over time, I’ve realised that this doesn’t lead to long-lasting change (or even change in the first place) in the way that a collaborative approach does.

(Note: As I covered in my conversation with Emily Troscianko, the change or intervention that one makes is incredibly important. Not all goals are equal and many changes won’t actually amount to anything. So while the client is the one that gets to pick the goal, we will always explore how much upside they will see if they meet this goal and if this is a fair trade-off for the amount of anxiety and struggle this change will take.) 

Acceptance

The second component of the therapeutic relationship from an MI perspective is acceptance. There are four aspects of acceptance:

Absolute Worth

This is about unconditional positive regard. That every human has inherent worth and potential. The opposite of this is judgement and putting conditions on who should be valued and who shouldn’t.

This can seem paradoxical, especially in a society in which shame is thought of as a motivator. But when someone feels unaccepted (by themselves or others) change can be blocked or diminished. Alternatively, when acceptance occurs, they are freed to change.

Accurate Empathy

This is the interest and effort to understand another person’s way of seeing and experiencing the world; to know someone else’s thoughts, feelings, motivations and intentions. This is also known as perspective-taking. 

Autonomy Support

This is honouring and respecting another person’s autonomy and their freedom to be and to choose. At the core of this is the belief that people are doing the best they can and that human nature is essentially positive, forward-moving and constructive. Given the right therapeutic conditions, people will change for the better. 

This links back to the example I gave earlier about clients picking their own goals and why this is so important.

Affirmation

This is about finding the strengths and abilities that a person already possesses. So often there is a focus on what is wrong with someone so we can work out how to “fix it” or “fix them”. But people are already incredible and have strengths and resolves that when used in the service of making changes, will get them to the place they want to be. (Something we cover in this episode when we speak about the “upward spiral”).

Compassion

The third component of the therapeutic relationship within MI is compassion.

Compassion in this context means, to quote the book,

“to actively promote the other’s welfare, to give priority to other’s needs. Our services are, after all, for our clients’ benefit and not primarily for our own…Compassion is a deliberate commitment to pursue the welfare and best interests of the other.”

Evocation

The final component of the therapeutic relationship is evocation or the ability to call forth.

So often when someone needs help, there is this idea of an information deficit. The client is coming to an expert who is going to tell them what to do to fix their problem.

Their head will metaphorically be opened up, new ideas and beliefs will be poured in, and then they’ll go off and live in a new way.

But in MI the goal is about drawing out rather than filling up. People already have the strengths and motivation within them, the role of the practitioner is to help call this out.

 To quote from the book

“the conversation is a bit like sitting together on a sofa while the person pages through a life photo album. You ask questions sometimes, but mostly you listen because the story is the person’s own. Your purpose is to understand the life before you, to see the world through this person’s eyes rather than superimposing your own vision”. 

Other Benefits Of An Enhanced Therapeutic Relationship

Since incorporating MI into the way I practice, things have drastically improved.

It’s a more enjoyable experience for the client (and for me). We’re not combative, where I’m trying to force some change on them and they’re then telling me all the reasons it won’t work.

It leads to long-lasting change. Because they’ve been the ones making decisions along the way, rather than simply bowing to and following all my ideas. 

They feel seen and heard. When I listen to any of the client interviews I’ve released on the podcast (here, here and here are recent examples), I’m obviously ecstatic to hear all the changes and improvements that clients have experienced in all aspects of their health.

But what I feel most proud of is that clients talk about how they felt listened to, and that I was empathetic and compassionate, that I didn’t ask them or force them to do anything they weren’t ready for.

It can be easy to feel like the end justifies the means; that if someone reaches recovery, who cares how they get there. But for me, that doesn’t sit right.

Because what someone learns through the process of collaboration, acceptance, compassion and evocation is what leads to full recovery. Where you value your own worth, you learn the strengths that have always been in you, and you see the power you have in your own life.   

Would You Like To Be Supported In This Way?

So many of the people I work with have seen many practitioners in the past. Or they’ve had multiple stays at in-patient facilities. But the changes have never seemed to stick. And a big reason for this is that they haven’t experienced a strong therapeutic relationship and everything this means from an MI approach.

I’m a leading expert and advocate for full recovery. I’ve been working with clients for over 15 years and understand what needs to happen to recover.

I truly believe that you can reach a place where the eating disorder is a thing of the past and I want to help you get there. If you want to fully recover and drastically increase the quality of your life, I’d love to help.

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