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Key points
- Successful psychotherapy depends on an alliance between client and therapist.
- The therapeutic alliance is a kind of chemistry, analogous to romantic chemistry.
- Psychotherapeutic chemistry emerges from perceptions, emotions, behaviors, and conscious experiences.
- Conscious experience emerges from neural representations, binding, coherence, and competition.
A major predictor of successful psychotherapy is the establishment of an alliance between the therapist and the client. The therapist and client need to have good chemistry, which is the experience of feeling an intense connection. Psychotherapeutic chemistry is analogous to romantic chemistry, which I explain as a conscious experience resulting from the interaction of perceptual, emotional, emotional, and behavioral components. Harry Reis, Annie Regan, and Sonja Lyubomirsky explain chemistry as an emergent property of these components, which meshes well with my theory of consciousness as resulting from four brain mechanisms: neural representation, binding, coherence, and competition. These mechanisms also operate in the psychotherapeutic alliance.
Representation
From the first meeting, the relationship between the therapist and client is influenced by their visual and auditory perceptions of each other. The therapist notices the dress, grooming, posture, movements, and eye contact of clients, which may be relevant to understanding their emotional states. For example, dishevelment may be a sign of emotional distress. Facial expressions and tone of voice can indicate emotional problems such as anxiety. Crying is a visual and auditory observation implying intense emotions such as sadness, shame, and/or guilt. Touch can also provide information about emotional states, for example, through a damp, flaccid handshake or a desperate hug.
Conversely, the client perceives the appearance of the therapist, which may affect the degree of confidence that the therapist will be helpful. If the therapist is shabbily dressed or has a decrepit office, the client may wonder about the therapist’s capabilities. In contrast, the perception of a friendly smile and warm voice can encourage clients to expect that the therapist will be helpful.
Concepts are mental representations corresponding roughly to words. When therapists and clients think about each other, they use concepts to describe and explain what is going on in the other. The therapist tries to identify the situation, wants, needs, and problems of the client using concepts such as husband, wife, family, job, lonely, love, and self-esteem. At the same time, the client is trying to understand the therapist by applying concepts such as helpful, experienced, friendly, educated, and expert. An alliance would be difficult to establish if the client instead applies concepts such as distant, aloof, arrogant, cold, and slow-witted.
These client concepts show that they are not merely cognitive descriptions but often have an evaluative component. Values are concepts that have associated emotional attitudes, which clearly operate in the contrast of friendly versus distant. For diagnostic purposes, the therapist may also draw on theoretical concepts taken from psychodynamic, cognitive-behavioral, emotion-focused, or other therapeutic approaches. Relevant concepts available to psychotherapists but not initially to the client include narcissist, insecure attachment, and inner critic.
Therapy is successful when it produces desired emotional change, such as alleviation of anxiety and depression. Therapists also have emotions ranging from interest and excitement concerning how to help an afflicted client to disappointment when therapy is not working. Therapists can use their personal experiences with emotions, such as sadness from bereavement, to help clients make similar emotional transitions. For therapy, the emotions that generate a bond between therapist and client include mutual liking, respect, appreciation, and even affection. Trust is a crucial reaction that involves emotion as well as an expectation of future reliability.
Binding
Beliefs are sentence-like representations formed from perceptions and concepts, for example, the therapist’s belief that the client is potentially suicidal or the client’s belief that the therapist is too expensive. The formation of beliefs requires the operation of binding that builds complex representations out of simple ones. Rules are an important class of beliefs with an if-then structure. The therapist’s rules might include practices such as If clients are anxious, then calm them. The client’s rules might include general expectations such as If the therapist is listening, then I can get help.
Coherence
Therapists and clients make inferences about each other. Therapists may consider hypotheses that explain why a client is crying, such as that the client is depressed, is consumed with shame or guilt, or has some other combination of emotions. Similarly, therapists make inferences about their clients’ perceptions, beliefs, and metaphors in order to come up with the best explanation for their utterances and other behaviors. For the sake of the development of an alliance, it helps if the therapist can infer that the client is honest and genuinely wants to be helped.
Such inferences are based on explanatory coherence, where people pick the best explanations for each other’s behavior. For example, a therapist may infer that a client is crying because of depression resulting from the death of a family member. Mental health assessment is better viewed as a process of explanatory coherence than as matching to patterns of symptoms such as those in the DSM-5.
Inferences about clients and therapists can also be based on analogies, such as when a therapist notices similarities between a current client and a previous one. The quality of the analogy depends on its coherence with the full range of information about the client.
Empathy is an important kind of analogical inference where a therapist gains understanding of a client by comparison with previous experience. The therapist identifies the client’s situation and resulting emotion, such as a depressing romantic breakup, and recalls a similar situation, such as a divorce. The emotion that the therapist feels as the result of recalling that situation is then an approximation of the emotion experienced by the client. Here, empathy is not just providing a coherent explanation of the client’s emotion but actually feeling an approximation of it.
Competition
The therapist and client will not develop much chemistry unless they pay attention to each other. The major brain mechanism for attention is competition between neural representations based on inhibition between them. If either the therapist or client suffers from mind-wandering or interest in other matters, such as phone messages, then their conversation will be unproductive.
Reis, Regan, and Lyubomirsky do not mention psychotherapy in their insightful paper on interpersonal chemistry, but their insights extend well. The extension is aided by the recognition that chemistry in therapy, as well as romance, is a conscious experience resulting from neural representations, binding, coherence, and competition.
References
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.
Nienhuis, J. B., Owen, J., Valentine, J. C., Winkeljohn Black, S., Halford, T. C., Parazak, S. E., . . . Hilsenroth, M. (2018). Therapeutic alliance, empathy, and genuineness in individual adult psychotherapy: A meta-analytic review. Psychotherapy Research, 28(4),
Norcross, J. C. (Ed.) (2011). Psychotherapy relationships that work: Evidence-based responsiveness. New York: Oxford University Press.
Reis, H. T., Regan, A., & Lyubomirsky, S. (2022). Interpersonal chemistry: What is it, how does it emerge, and how does it operate? Perspectives on Psychological Science, 17(2), 530–558.
Thagard, P., & Larocque, L. (2018). Mental health assessment: Inference, explanation, and coherence. Journal of Evaluation in Clinical Practice, 24(3), 649-654.
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Thagard, P., & Stewart, T. C. (2014). Two theories of consciousness: Semantic pointer competition vs. information integration. Consciousness and Cognition, 30, 73–90.
Zilcha-Mano, S. (2017). Is the alliance really therapeutic? Revisiting this question in light of recent methodological advances. American Psychologist, 72(4), 311-325.
