Relational Therapy in Practice: When, Why and How Psychologists Work Relationally

An integrative psychologist's perspective on the place of relational work in psychological therapy, how it develops, and the clinical decisions that guide it.

Originally published: 2 December 2025 | Last updated: 5 November 2026

A person may seek therapy because they want to understand what happens to them in relationships. They recognise familiar experiences, such as finding it difficult to receive care, feeling uncertain about their own needs when another person matters, or becoming uncomfortable with closeness despite valuing connection. Some have already developed considerable psychological insight, yet find that understanding these experiences has not necessarily changed how they feel or respond.

Another person may begin therapy with a more clearly defined difficulty. They want help with anxiety, traumatic experiences or a particular problem affecting everyday life. The psychologist and client agree on an appropriate therapeutic approach, and the work begins. As therapy develops, however, something about the person's relational experiences may become relevant. This could arise through relationships outside therapy or through something experienced within the therapeutic relationship itself.

There are also people whose treatment progresses without the relationship becoming an explicit focus. They may benefit from structured psychological interventions while working with a psychologist who understands their needs, respects their preferences and responds to difficulties as they arise.

These situations involve different ways of working therapeutically. The relationship between psychologist and client matters in each, although its clinical purpose and the attention it receives will differ.

In my integrative psychological practice, I  consider relational work in relation to the person's difficulties, their therapeutic goals, the psychological approaches available and what we begin to understand through working together. Relational experiences may form a sustained focus of treatment, become relevant during another therapeutic approach, or remain largely in the background while other interventions address the person's needs.

I am interested in how the place of relational work is established with the person, and how our decisions change as we understand more about their experience.

Relational Therapy in Practice: Beyond the Working Alliance

Across psychological approaches, therapists attend to the relationship they develop with the people they support. Bordin's (1979) working alliance framework describes collaboration around therapeutic goals and tasks, alongside the development of a relational bond. Subsequent research has consistently identified an association between the therapeutic alliance and psychotherapy outcomes (Flückiger et al., 2018; Wampold & Flückiger, 2023).

The therapeutic relationship contributes to psychological treatment across different approaches. The psychologist remains attentive to collaboration, communication, consent and how the person experiences the work.

Relational therapy in practice involves considering whether, when and how relational experiences themselves should become part of treatment.

Different psychological approaches understand and work with relationships in different ways.

Interpersonal psychotherapy, for example, focuses on interpersonal circumstances and difficulties associated with psychological distress. Some psychodynamic approaches attend more directly to emotional experiences and relational expectations that may also become apparent within the therapeutic relationship. Although these approaches share an interest in relationships, their theoretical foundations, treatment aims and methods differ.

The therapeutic relationship itself also contains different processes. Gelso's (2014) tripartite model, for example, distinguishes the working alliance, the real relationship and transference-countertransference processes. Their relative significance can vary across therapeutic approaches and clinical circumstances.

Within integrative practice, relational work may involve understanding the person's significant relationships outside therapy, exploring how particular emotional and interpersonal experiences develop, or attending to what emerges between psychologist and client.

Someone may spend considerable time exploring their relationships with family members, partners or colleagues without needing to examine their relationship with the psychologist. For another person, something experienced within therapy may offer an opportunity to explore a familiar expectation, emotional response or interpersonal difficulty.

The therapeutic relationship can contribute to this work, although it does not have to become its central subject.

I find it helpful to distinguish relationally led therapy, where working with relational experiences forms a sustained therapeutic emphasis, from periods of relational work that become relevant within another psychological treatment.

These describe differences in clinical emphasis within my integrative practice. They are not separate treatment stages or a newly defined therapeutic model.

A psychologist may also remain relationally responsive throughout treatment without undertaking explicitly relational work. Adjusting communication, clarifying an intervention or responding to concerns about treatment can be appropriate clinical practice in its own right.

The distinction becomes important when considering whether greater attention to relational experiences would contribute something useful to the person's therapy.

When Is Relational Work Clinically Useful?

Relational experiences can be relevant to many psychological difficulties. Their presence, however, does not establish that relationally focused treatment is necessarily the most appropriate intervention.

Someone experiencing difficulties in a relationship may need practical support, clearer boundaries, safeguarding or changes in circumstances. Relational exploration might contribute to understanding their experience, but it cannot substitute for addressing an environment that is genuinely harmful.

Another person may understand their interpersonal difficulties well and wish to explore experiences that remain emotionally difficult despite that understanding.

The psychologist needs to consider the person's goals and preferences, the nature of their difficulties, the available psychological evidence, previous treatment experiences and the wider circumstances affecting their life.

An additional consideration concerns the purpose of bringing relational experiences into treatment.

We may have identified a recurring interpersonal expectation or noticed a response within the therapeutic relationship. Yet before deciding to explore it further, I would want to understand what that exploration might contribute to the work already agreed.

Would it help us understand something central to the person's difficulties? Is there an emotional or interpersonal experience that remains difficult to work with through the existing approach? Does the person recognise the concern as meaningful, and are they interested in exploring it?

We also need to consider whether relational exploration is proportionate to the person's present needs, whether another intervention would be more appropriate, and whether the practitioner has the necessary competence.

Treatment preferences are clinically relevant within these decisions. Research on accommodating client preferences has found associations with improved outcomes and lower dropout compared with providing non-preferred treatment conditions (Swift et al., 2018). NICE guidance on shared decision-making similarly emphasises considering evidence alongside the person's priorities and preferences.

Within integrative practice, relational work may enter treatment in several ways.

When Someone Seeks Relationally Led Therapy

A person may approach a psychologist already interested in relational therapy.

They might be familiar with the term through previous treatment, professional reading or a recommendation. Others may simply describe wanting to explore their relationships and emotional experiences more closely.

The request itself tells us relatively little until we understand what the person hopes the work might offer.

Consider someone who is accustomed to being the person others approach for support. They manage responsibilities, help family members and are comfortable making decisions independently. These are qualities they value, and they have served important purposes in their life.

Recently, however, they have become curious about their discomfort when another person offers care.

They appreciate the concern but often minimise what is happening, reassure the other person that everything is fine, or move the conversation towards something more practical. Afterwards, they sometimes feel alone, even when support had been available.

The person has already thought about their family experiences. They understand why independence became important and recognise some of the expectations they carry into relationships.

Yet there is still something difficult about the experience of receiving care.

As we begin working together, I would want to understand what the person hopes to explore. They may be concerned about finding it difficult to rely on others, interested in recognising their emotional needs more clearly, or seeking a different balance between independence and support.

Their understanding and preferences would help determine the therapeutic direction.

We might explore how care has been experienced across different relationships. Practical assistance may feel welcome, while emotional concern is harder to receive. Asking for help might carry expectations of obligation, or the person may worry that acknowledging a need will change how others see them.

Independence may be an important part of the person's identity, including how they express care and responsibility towards others. It would be inappropriate to begin from an assumption that their independence needs to be reduced.

A relationally led approach could involve exploring these experiences over time, recognising the emotions and expectations associated with them, and considering what the person wants from different relationships.

Much of this work may concern relationships outside therapy. The relationship with the psychologist may become relevant as treatment develops, although its significance needs to emerge from the work rather than being presumed because the person has requested relational therapy.

When Relational Work Emerges During Another Treatment

In integrative psychological practice, relational experiences sometimes become relevant during treatment that initially has a different focus.

Consider a psychologist supporting someone experiencing anxiety. They have agreed to use behavioural experiments to explore some of the person's expectations and develop greater confidence in particular situations.

The client engages thoughtfully and begins bringing detailed written accounts of what happened between sessions.

Initially, the psychologist understands these records as a useful way for the person to organise their experiences.

As therapy progresses, however, the preparation becomes increasingly extensive. The client explains that they have spent several hours arranging their notes and checking that everything has been included.

The psychologist begins wondering whether the person experiences therapeutic tasks as something they must complete correctly. This appears plausible within the existing formulation, particularly given their anxiety about evaluation.

The client explains that writing things down helps them process information and remember important details. They had also been uncertain about how much preparation the psychologist expected, following an earlier request to bring examples to therapy.

The psychologist's initial interpretation had overlooked the person's information-processing needs and the effect of their own instructions.

Recognising that their instructions contributed to the uncertainty, the psychologist can acknowledge the misunderstanding, clarify the purpose of the exercise and agree with the person on a form of recording that supports their needs without creating an unnecessary burden.

The psychologist can acknowledge their contribution, clarify the purpose of the exercise and collaboratively agree on a form of recording that supports the person without creating an unnecessary burden.

The person has described a communication and accessibility need. Pursuing the earlier interpretation of perfectionism would now risk overlooking what they have explained.

During the conversation, however, the client describes previous experiences of finding it difficult to ask professionals for clarification. They recall occasions when questions were received impatiently and have become accustomed to preparing extensively before approaching someone in authority.

We could become interested in how these experiences have shaped the person's expectations, particularly when they are uncertain about what another person requires.

They may feel that clarifying the therapeutic task has resolved the immediate difficulty and prefer to continue with the agreed anxiety treatment.

Alternatively, they might recognise that uncertainty around professional expectations has affected them in several settings and wish to explore this more closely.

A conversation about the developing formulation could help establish whether relational work would be useful and how it might sit alongside treatment already underway.

The original behavioural intervention may remain appropriate. Exploring the person's expectations of authority does not require abandoning it.

Our understanding of the person has developed, and this may create an opportunity to reconsider the therapeutic focus together.

When Relational Work Is Not the Main Therapeutic Focus

There are circumstances in which a relational focus offers little additional benefit to the person's current therapeutic goals.

Someone receiving treatment for obsessive-compulsive difficulties may undertake cognitive behavioural therapy incorporating exposure and response prevention, consistent with established treatment guidance.

The psychologist and client develop a shared understanding of the intervention, review progress and adapt the work according to clinical need.

A collaborative therapeutic relationship remains important throughout. The person, however, may not need sustained exploration of their relationship with the psychologist to benefit from treatment.

The same principle applies across other psychological approaches. Someone may need a structured intervention, wish to develop practical responses to particular difficulties, or prefer to concentrate on an agreed treatment goal.

If concerns arise within the therapeutic relationship, the psychologist can respond appropriately without assuming that a deeper relational process requires exploration.

We also need to distinguish a preference for structured treatment from an inability to engage relationally. Some people find clarity, predictability and explicit therapeutic tasks particularly helpful. These preferences can reflect how they work best, rather than something that needs to change.

The decision to maintain an existing therapeutic focus deserves clinical consideration in its own right.

What Happens During Relationally Led Therapy?

For the person who finds receiving care uncomfortable, much of the work begins after they have already developed a coherent explanation for why independence matters. They understand how their experiences have shaped them and recognise that accepting support does not necessarily mean losing autonomy.

During a session, they describe a recent conversation with a close friend.

The friend had noticed that something was wrong and offered to help. The person initially describes feeling grateful. They then explain that they reassured the friend, changed the subject and continued managing the difficulty alone.

As we explore the experience, they begin to recognise that they had wanted the friend to remain interested in how they were doing.

This is difficult to acknowledge. They remember feeling relieved when the conversation ended, yet also disappointed that the friend did not ask again.

The person values the friendship, appreciates the concern and wishes to remain independent. Being noticed may also bring an uncomfortable sense of exposure.

I would be interested in how the person experiences these different responses. What did they anticipate would happen if they accepted the friend's offer? Did the concern itself feel uncomfortable, or was there something about the possibility of another person becoming involved in their difficulty?

Perhaps practical assistance feels comfortable because the person can retain control over what happens next. Emotional concern may feel different because another person becomes aware of something they usually manage privately.

They may recognise an expectation of obligation or uncertainty about whether they would still be regarded as capable if their needs became visible.

There could be sadness associated with having managed difficulties alone for a long time. The person may recognise that they have wanted more care than they previously allowed themselves to acknowledge.

They might also discover that certain forms of concern feel intrusive, even when offered with good intentions.

Working relationally involves understanding these differences and attending to how the person experiences them. The explanation they arrived with may remain meaningful, while other aspects of the experience become more accessible through the work.

Sometimes the person can describe their experience clearly while finding it harder to remain in contact with the feelings associated with it.

We may return to a particular interaction, spend longer exploring an emotion that has become more accessible, or consider what changes when the person imagines responding differently.

Their ability to articulate an experience can also fluctuate. Something that feels clear in one session may become harder to recognise when a similar interaction occurs in everyday life.

The therapeutic work allows us to remain interested in these differences without requiring the person to reach a particular emotional response.

The person might decide to ask a trusted friend for a particular form of support. We could then consider what they expected, what actually happened and how the experience affected their understanding of that relationship.

The outcome may be reassuring, uncomfortable or mixed.

For example, the person might decide to ask a trusted friend for a particular form of support. We could then consider what they expected, what actually happened and how the experience affected their understanding of that relationship.

The outcome may be reassuring, uncomfortable or mixed.

A friend might respond sensitively, or the interaction might reveal limits to what that relationship can offer. The person may discover that they appreciate support in some circumstances while preferring independence in others.

These experiences can contribute to a more differentiated understanding of their relational needs.

Over time, they may begin recognising what makes receiving care difficult, which forms of support they value, and how they want to respond when another person notices their needs.

When Relational Responsiveness Becomes Relational Work

Psychologists routinely respond to how a person experiences treatment. We adjust communication, clarify expectations, negotiate decisions and review whether an intervention is helpful.

Evidence-informed psychotherapy also recognises the importance of adapting therapeutic relationships and interventions to relevant individual characteristics and preferences (Norcross & Wampold, 2018).

These responses are part of collaborative psychological practice. Their presence does not automatically mean that we are undertaking a relational intervention.

Consider what happens when the person who finds receiving care uncomfortable returns for another session.

The psychologist remembers a difficulty discussed previously and asks how things have been progressing.

The client appears uncertain and explains that they had not expected the subject to be raised again.

An appropriate response may be to clarify that the person can decide whether they wish to return to the subject. The psychologist might also ask how they would prefer previous discussions to be followed up in future sessions.

This addresses the person's experience of treatment without requiring a psychological interpretation.

However, the client might describe something more personally significant.

Perhaps being remembered has affected them because they are accustomed to managing difficulties without others remaining aware of them. They may appreciate the psychologist's concern while also finding it uncomfortable that their needs have stayed in another person's mind.

If the client recognises this as relevant to the experiences they are already exploring, the interaction may become part of the relational work.

We might consider what it was like to be remembered, what they anticipated from the therapist and whether the experience adds something to their understanding of receiving care elsewhere.

The therapeutic relationship has become another source of experience through which the person can explore something meaningful to them.

Within an established relational formulation, the psychologist may intentionally respond in ways that allow the person greater choice about how they seek support, communicate a preference or maintain privacy.

These responses may contribute to the therapeutic work without requiring each interaction to be discussed.

Their significance still needs to be considered through the person's experience and the developing formulation. A therapist cannot assume that a particular response has produced relational change simply because it was intended to be helpful.

The same interaction may therefore have different clinical functions depending on what has been understood and agreed within treatment.

The psychologist’s curiosity does not establish the significance of the interaction. The person’s understanding, therapeutic goals and willingness to explore the experience remain central.

Formulation, Therapist Participation and Clinical Judgement

Psychological formulation contributes to decisions about relational work before, during and after a relational experience becomes clinically relevant.

Our initial understanding may already include significant relationships, emotional experiences, cultural and family contexts, neurodevelopmental needs, current circumstances and psychological processes contributing to the person's difficulties.

Relational experiences may add to this understanding or challenge it.

The broader process of developing, weighing and revising these understandings is explored in my article on psychological formulation in clinical practice. Here, I am particularly interested in what happens when relational experiences contribute to our understanding and influence the therapeutic direction.

In the earlier example involving written therapy records, the psychologist initially considered an explanation involving perfectionism and fear of evaluation.

The client's account revealed that written preparation supported information processing and that the therapist's instructions had contributed to uncertainty.

An interpretation that initially appeared plausible became less convincing. Further discussion then revealed experiences involving professional authority that the client also considered relevant.

These aspects of the work could inform one another, although their clinical meanings remained different.

Our own participation also requires examination. The questions we ask, the assumptions we bring and the way we respond may influence the very interaction we are trying to understand. The psychologist’s own emotional responses may also affect the work.

A practitioner may notice a strong wish to reassure someone or feel increasingly responsible for ensuring that an intervention is understood correctly.

Such responses can be worth reflecting upon, especially when they begin influencing what the psychologist does.

However, the therapist's experience cannot be treated as direct evidence of what is happening for the client. It may reflect the immediate interaction, the practitioner's own history, the demands of treatment or wider professional circumstances.

Clinical judgement involves considering these influences alongside the person's account, the formulation and the purpose of the therapeutic work.

An interaction that appears relationally significant may invite exploration. Another may require a change in how treatment is being conducted. There will also be occasions when the most useful response is to continue with the agreed work.

A more specific example of this clinical discernment appears in When People-Pleasing Enters the Therapy Room, where I explore how apparent cooperation, accommodation and the therapist's own responses can become relevant to understanding a particular therapeutic process.

Culture, Communication and Professional Authority

Consider a person who responds cautiously to questions from a psychologist.

The therapist may initially wonder whether the person is concerned about being evaluated.

Yet the meaning of that caution could differ considerably depending on their experiences.

They may have encountered dismissive responses from healthcare professionals. They might be working in a language in which emotional experiences are less familiar to describe, or prefer time to consider how much they wish to disclose.

A person may also value formality, restraint or a degree of separation between personal and professional relationships.

For neurodivergent clients, explicit communication, predictable expectations and sufficient processing time may influence how comfortably they can participate.

These considerations affect what we understand about the interaction and what we decide to do next.

A psychologist who notices a prolonged pause may choose to clarify the question or allow more time rather than immediately enquiring about an emotional response.

If the person subsequently identifies an experience involving authority, trust or uncertainty that they wish to explore, relational work may become relevant.

The psychologist's professional position also carries responsibilities.

We introduce interventions, offer explanations, maintain the treatment framework and influence how the person understands their difficulties.

A client may find it difficult to challenge an interpretation because of previous relational experiences. Their reluctance may also reflect something about the psychologist's actual communication or behaviour.

At times, the appropriate action may involve acknowledging an assumption, clarifying an intervention or changing our approach. A difficulty within therapy should not automatically be understood through the client's relational history.

These considerations connect with broader questions about how professional assumptions influence our interpretation of behaviour across difference. I explore that process in Intercultural Competence in Practice, including the distinction between cultural knowledge, interpretation and responsiveness within professional encounters.

There is also a related question about whether the clinician's understanding of safety corresponds with the person's actual experience. My article on Cultural Safety in Therapy examines that distinction more directly, particularly when professional authority and expectations surrounding emotional expression affect how therapy is experienced.

These dimensions of relational practice become especially important when differences in culture, trauma experience and social position influence the person's access to care and the degree of power they hold within services. The intersection of these responsibilities is explored further in Cultural Humility in Trauma-Informed Therapy.

More complex experiences involving emotional participation, countertransference, rupture and attempts at repair require additional clinical consideration. These processes involve questions about how therapists and clients influence one another, how difficulties within the relationship are understood and what responsibilities arise when the work becomes strained.

I explore these questions in the companion practitioner article, The Power of the Therapeutic Relationship: Exploring Relational Depth in Therapy and Supervision.

Reconsidering the Therapeutic Direction

The role of relational work may change as treatment develops.

Someone who initially seeks relationally led therapy might become more interested in applying their understanding to relationships outside treatment. The work may gradually involve behavioural practice, clearer communication, emotional exploration or other interventions relevant to their goals.

Another person may begin with a structured psychological approach and later identify relational experiences they wish to understand more closely.

The clinical emphasis develops according to what we are learning about the person and what they need from treatment.

A client may feel that repeated exploration of their relationships is no longer contributing to change. They might disagree with the psychologist's interpretation, want a more practical focus or need a different intervention for a difficulty that remains unresolved.

Their feedback should influence how we reconsider the work.

The psychologist may also recognise that they have become particularly invested in a relational explanation. An interpretation can feel psychologically coherent without being sufficiently supported by the person's experience.

For the person receiving care in our earlier example, progress might involve becoming more comfortable asking for help.

It could equally involve understanding which forms of care they welcome, maintaining valued independence and recognising when a particular relationship does not offer the support they need.

These changes can be considered alongside the person's original therapeutic goals and the ways their circumstances have developed.

The role of relational work remains open to review, including the possibility that another therapeutic direction would now be more useful.

Relational Practice and Clinical Supervision

For practitioners, decisions about relational work can be difficult to evaluate while immersed in treatment.

We may recognise something in an interaction without understanding its significance, feel strongly drawn towards a particular response or find ourselves repeatedly returning to an explanation that has become familiar.

Clinical supervision offers another opportunity to examine these experiences alongside the formulation, the client's perspective and the wider clinical context.

A practitioner might bring uncertainty about whether to explore a relational interaction or continue with an existing intervention. Reflecting on their own responses may reveal an assumption that has not been sufficiently examined, while considering another psychological perspective may lead to a different understanding of the person's needs.

At times, supervision supports further relational exploration. It can also strengthen the decision to maintain a structured treatment approach or identify a practical adjustment that had been overlooked.

The supervisory relationship also deserves consideration, particularly when cultural difference, professional authority and the experience of being evaluated influence what practitioners feel able to bring into supervision.

These questions are developed further in Intercultural Supervision in Practice: Safety, Humility and the Work of Repair.

Within my integrative psychological practice, relational thinking contributes to understanding how therapy is experienced and how it may develop. Its purpose is considered alongside psychological theory, research evidence, therapeutic methods, the person's preferences and the changing circumstances of treatment.

The relationship may remain an important foundation while other interventions are central. At other times, relational experiences become part of what we are trying to understand and work with.

Clinical Supervision with Dr Tiffany Leung

I offer integrative clinical supervision for psychologists, counsellors and therapists who wish to develop their psychological formulation, reflective practice and clinical judgement.

In supervision, we can examine questions such as when a relational interpretation is clinically useful, how the therapist's own responses influence treatment, and whether a different psychological perspective might change our understanding of what is happening.

My supervisory approach considers these questions alongside culture, neurodivergence, trauma, professional responsibilities and the wider contexts in which psychological work takes place.

Explore Clinical Supervision with Dr Tiffany Leung

Further Practitioner Reading

The articles linked throughout this discussion develop particular areas of relational practice in greater depth.

• A Reflective Guide to Psychological Formulation in Practice offers questions for examining how personal assumptions, uncertainty and competing psychological perspectives influence clinical understanding.

• Intercultural Clinical Supervision: A Guide to Safety, Cultural Humility and Reflective Growth introduces the role of culture, professional relationships and reflective development within clinical supervision.

• The wider For Therapy Practitioners article collection brings together further writing on integrative practice, psychological formulation, relational processes, cultural responsiveness and professional development.

References and Further Reading

• Bordin, E. S. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research & Practice, 16(3), 252–260. doi:10.1037/h0085885

• 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. doi:10.1037/pst0000172

• Gelso, C. J. (2014). A tripartite model of the therapeutic relationship: Theory, research, and practice. Psychotherapy Research, 24(2), 117–131. doi:10.1080/10503307.2013.845920

• National Institute for Health and Care Excellence. (2005). Obsessive-compulsive disorder and body dysmorphic disorder: Treatment (CG31).

• National Institute for Health and Care Excellence. (2021). Shared decision making (NG197).

• National Institute for Health and Care Excellence. (2022). Depression in adults: Treatment and management (NG222).

• Norcross, J. C., & Wampold, B. E. (2018). A new therapy for each patient: Evidence-based relationships and responsiveness. Journal of Clinical Psychology, 74(11), 1889–1906. doi:10.1002/jclp.22678

• Swift, J. K., Callahan, J. L., Cooper, M., & Parkin, S. R. (2018). The impact of accommodating client preference in psychotherapy: A meta-analysis. Journal of Clinical Psychology, 74(11), 1924–1937. doi:10.1002/jclp.22680

• Wampold, B. E., & Flückiger, C. (2023). The alliance in mental health care: Conceptualization, evidence and clinical applications. World Psychiatry, 22(1), 25–41. doi:10.1002/wps.21035

Editorial note: The clinical situations described in this article are illustrative examples developed to demonstrate psychological reasoning. They do not reproduce identifiable client sessions.

The distinctions between relationally led therapy, periods of relational work and relationally responsive practice reflect my integrative, practice-based understanding. They draw on established psychological approaches and research but are not presented as a separately validated psychotherapy model.