A tripartite model of the psychotherapy relationship

Today, I address two articles looking at this tripartite model. I am presenting the earlier one first.

Gelso, C. J., & Samstag, L. W. (2008). A tripartite model of the therapeutic relationship. In S. D. Brown & R. W. Lent (Eds.), Handbook of counseling psychology (4th ed., pp. 267–283). John Wiley & Sons, Inc. Here’s the edited abstract:

It is an understatement to say that there are many ways of framing the relationship that exists between a client and therapist in counseling and psychotherapy. The frame that we have selected for this chapter divides the relationship into three interrelated components: a working alliance, a transference-countertransference configuration, and what may be termed a real relationship. This view of the therapeutic relationship was first proposed by the great psychoanalyst, Ralph Greenson, in his treatise on classical psychoanalysis and psychoanalytic psychotherapy (Greenson, 1967). Thus, the tripartite conception of the therapeutic relationship examined here originated from psychoanalysis. However, the model and its components have been extrapolated to psychotherapy in general, and in the present review, we focus on theoretical and empirical findings that stem from nonanalytic as well as psychoanalytic treatments. The tripartite model, as it is formulated here, rests on the assumption that each and every psychotherapy relationship consists, to one degree or another, of a working alliance, a transference-countertransference configuration, and a real relationship. In the reality of the psychotherapy hour, however, the components are intertwined and often not sharply distinguishable elements of the gestalt, or whole relationship. The degree to which each of these components emerges, and the importance of each, varies according to the individual relationship and the therapist's theory of treatment. This chapter focuses on the tripartite model. First, we present definitional issues and offer our preferred definition of each major component. We then summarize theoretical controversies and key empirical findings related to each component. We conclude by briefly discussing the operation of the relationship components in practice and pointing to useful future directions for work on the tripartite model. Throughout the chapter, our emphasis is on how the key components of the therapeutic relationship operate transtheoretically, despite their psychoanalytic roots. 

I thought this was helpful in illustrating that Gelso and colleagues are not leaning on a strictly psychoanalytic model. The article that captured my attention applies the model. Hill, An, Kivlighan, Jr. & Gelso (2024) published “A Tripartite Model of the Psychotherapy Relationship: Interrelations among its components and their unfolding across sessions” in Psychotherapy.  Here are the edited abstract and impact statements:

The tripartite model of the therapy relationship, which includes the working alliance, real relationship, and transference-countertransference configuration, has been a useful way to conceptualize the complexity of the connection between a therapist and a client. However, little research has focused on the interrelationships between these three components over time. This study sought to replicate the findings of Bhatia and Gelso (2018) by examining the between-person relationships among each of the three elements averaged across all sessions. Additionally, we extended earlier work by examining the within-person relationship between the working alliance, the real relationship, and transference–countertransference with themselves as well as with each of the other elements across sessions. Using 5,931 sessions across 142 clients and 36 therapists, we examined time-ordered associations among the cocreated working alliance, cocreated real relationship, and the therapist-rated transference–countertransference configuration using latent variable dynamic structural equation modeling. Results replicated the findings of Bhatia and Gelso (2018), demonstrating that in one session, the working alliance and the real relationship were positively related, and both the working alliance and the real relationship were negatively related to the transference–countertransference configuration. Regarding the interrelations over time, the findings revealed that the working alliance in the previous session had a significant and positive relationship with real relationship in the current session, and the real relationship in the previous session was related to reduced transference–countertransference in the current session. These findings provide support for complex interrelations among the components over time. 

How do the components of the tripartite model (the working alliance, real relationship, and transference/countertransference configuration) relate to each other and how do these interrelations unfold across sessions? Within a session, the real relationship and working alliance are positively related, and both are negatively related to the transference/countertransference configuration. Across sessions, the real relationship appears particularly important as it is the sole component that is related to the two other components across sessions. A session with a higher-than-usual real relationship was negatively related to working alliance and transference/countertransference in the next session. The components of the tripartite therapy relationship relate to each other in complex ways over time and are conceptualized as forming a dynamic system. Researchers should identify mechanisms for these interrelations over time by investigating how specific interventions impact the relationships and how therapists can best attend to them in ways that facilitate client growth. 

I found this work helpful in applying the model which makes intuitive sense to me. I also find it a nice reminder that referring a client to therapy is just the beginning of a complex, dynamic process. Elsewhere, Gelso defines the real relationship as "the personal relationship between therapist and patient marked by the extent to which each is genuine with the other." It seems to me that we are facing a world in which therapists are frequently hard to find, there are often insurance-constrained options provided, and telehealth is sometimes necessary, it’s critical to remember that the quality of the therapist-client relationship matters.