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The Therapeutic Pyramid: A Common Factors Synthesis of Techniques,
Alliance, and Way of Being
Article in Journal of Marital and Family Therapy · July 2013
DOI: 10.1111/jmft.12041
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Journal of Marital and Family Therapy
doi: 10.1111/jmft.12041
January 2014, Vol. 40, No. 1, 20–33
THE THERAPEUTIC PYRAMID: A COMMON FACTORS
SYNTHESIS OF TECHNIQUES, ALLIANCE, AND WAY
OF BEING
Stephen T. Fife
University of Nevada
Jason B. Whiting
Texas Tech University
Kay Bradford
Utah State University
Sean Davis
Alliant International University
Common factors in therapy such as the therapeutic alliance and client motivation have been
found to account for more change than therapy models. But common factors have been
critiqued as only lists of variables that provide little practical guidance. Some researchers
have demonstrated that certain common elements (e.g., the therapeutic alliance) account for
more variance than others (e.g., techniques), suggesting that some factors should be emphasized over others. Such findings suggest the need for alternatives to model-based therapy,
with one alternative being meta-models, or “models of models,” that focus on how therapeutic factors interact with each other to produce change. The purpose of this article is to
propose a meta-model describing the relationship between two specific common factors—the
therapeutic alliance and interventions. We also propose a new factor—a therapist’s way of
being—that we believe is foundational to effective therapy. The model is proposed in pyramid
format, with techniques on top, the therapeutic alliance in the middle, and therapist way of
being as the foundation. The hierarchical relationships between these three concepts are
discussed, along with implications for training, research, and therapy.
Fortunately, we are often guided in our professional roles more by our deep human
responsiveness to people than by our theories. As a result, good things frequently happen
(Warner & Olson, 1981, p. 501).
Decades of meta-analytic research suggest that although couple and family therapy is effective, no one model is consistently more effective than another (Shadish & Baldwin, 2002, 2009).
Common factors research suggests that elements common to all therapeutic approaches such as
the therapeutic alliance and client motivation are more responsible for change than are the unique
contributions of the model. In this view, models become the vehicles through which common curative factors are delivered (Davis, Lebow, & Sprenkle, 2012; Sprenkle & Blow, 2004b). Proposed
Stephen T. Fife, PhD, Marriage and Family Therapy Program, University of Nevada, Las Vegas; Jason B.
Whiting, PhD, Marriage and Family Therapy Program, Texas Tech University; Kay Bradford, PhD, Family, Consumer, & Human Development, Utah State University; Sean Davis, PhD, Marital and Family Therapy, California
School of Professional Psychology, Alliant International University.
Portions of this article were presented at the AAMFT Annual Conference in Atlanta, GA, September 2004 and
the NCFR Annual Conference in San Francisco, November 2009. The authors express thanks to Jaclyn Cravens of
Texas Tech University for her review of a previous version of this article.
Address correspondence to Stephen T. Fife, PhD, Marriage and Family Therapy Program, University of
Nevada, Las Vegas, Box 453045, 4505 Maryland Parkway, Las Vegas, Nevada 89154-3045; E-mail: stephen.fife@
unlv.edu
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January 2014
common factors of effective therapy include hope/expectancy, the therapeutic alliance, client
motivation, and therapist confidence, among others. Each of these common factors has varying
degrees of direct and indirect empirical support (see Davis et al., 2012; Sprenkle, Davis, & Lebow,
2009; and Sprenkle & Blow, 2004a for overviews of systemic common factors).
While common factors researchers critique models as presenting an incomplete picture of
change (Sprenkle & Blow, 2004a), common factors are critiqued as providing nothing more than
lists of variables that provide little practical guidance (Sexton & Ridley, 2004). In the search for
answers regarding therapeutic change, some researchers (Asay & Lambert, 1999; Lambert, 1992;
Wampold, 2001) have demonstrated that certain common factors (e.g., the therapeutic alliance)
account for more variance than others (e.g., techniques), suggesting certain aspects of therapy
deserve more emphasis than do others. Nevertheless, while knowing that certain factors carry
greater weight than others is interesting, understanding the clinical and training implications of
this can be challenging.
Research has typically addressed common factors independently. However, conceptualizing
common factors as independent entities fails to recognize potential relationships between factors
in practice. For instance, Sprenkle and Blow (2004b) proposed that common factors are not
islands. More specifically, Hatcher and Barends (2006) argued that “alliance is actualized when
technique engages clients in purposive work. Alliance cannot happen without technique” (p. 294).
Furthermore, the alliance may be strong because the client believes that the therapist’s techniques
are relevant (Davis & Piercy, 2007a; Simon, 2012a). Conversely, the techniques may work because
the clients like and trust the therapist (Bordin, 1979) or the therapist adapts treatment to match the
clients’ needs (Blow, Davis, & Sprenkle, 2012; Blow, Sprenkle, & Davis, 2007; Sprenkle et al.,
2009). Common factors are not independent entities, and researching or practicing one factor without
implicating others is impractical, if not impossible.
How, then, should we conceptualize therapy-assisted change? Meta-models, or “models of
models” are one possibility (Davis & Piercy, 2007a,b; Fraser, Solovey, Grove, Lee, & Greene,
2012). A meta-model focuses on how common factors interact to produce change in effective therapy
regardless of the model used. A meta-model can be superimposed over any relevant model of therapy to help a therapist know what to pay attention to and why. The emphasis of a meta-model is
on principles of therapy rather than theory or technique, which makes it easier to apply the metamodel with different theories at different stages of treatment. A meta-model can apply to therapy
as a whole or to more narrow aspects of therapy.
The purpose of this article is to propose a meta-model describing the relationship between two
specific common factors—the therapeutic alliance and techniques. We will also propose what we
believe is another common factor—a therapist’s way of being—that we claim is foundational to
most if not all aspects of effective therapy. Way of being is a theoretical construct that incorporates
elements discussed by various scholars into one influential dimension. We will discuss the hierarchical relationships between these three concepts, as well as their implications for training,
research, and therapy.
THE THERAPEUTIC PYRAMID
Our meta-model suggests that effective therapy involves not only what we do, but who we are
and how we regard our clients. The effective use of skills and techniques rests upon the quality of
the therapist–client alliance, which in turn is grounded in the therapist’s way of being, a concept
that reflects a therapist’s in-the-moment stance or attitude toward clients (described in detail later).
The hierarchical model in pyramid format visually shows the relationship between the three
aspects of the model (see Figure 1). This suggests that the effectiveness of each level of the pyramid
depends upon the level below it (Arbinger, 1998). Changes in lower levels of the pyramid will effect
change in higher levels, whereas the opposite is not necessarily true. The pyramid reminds therapists that therapy entails more than the use of models and techniques, and the hierarchical relationship between the levels suggests that therapists should emphasize the lower levels as they consider
their work with clients.
The meta-model developed out of a perceived need to address the attributes and attitudes of
the therapist in a more deliberate way. Scholars have long argued the importance of some of these
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21
Figure 1. The therapeutic pyramid.
difficult to define aspects of successful therapy, including therapist warmth and genuineness
(Rogers, 1957), character (Peterson & Seligman, 2004), self of therapist (Aponte et al., 2009;
Simon, 2006), and fundamental goodness/kindness (Kottler, 1991). Many of these areas are captured by philosophical work that argues for the primacy of relational obligation and connection.
For example, Levinas (1961/1969) suggests that all relationships should be grounded in the respect
and acknowledgement of the “Other,” and Wetzel (2005) argues that this may be the most apt philosophy for family therapists to operate from. Martin Buber’s (1958) work also emphasizes our
fundamental relatedness and suggests two different ways of being with others (i.e., seeing people as
people or as objects), the former of which seems to represent many of the traits valued in therapists. In addition to the impact of these ideas on our thinking, another significant influence in the
development of our meta-model was The Parenting PyramidTM (Arbinger, 1998) that uses a
pyramid structure to suggest a connection between who we are, our interpersonal relationships,
and our parenting behavior and situates parents’ way of being at the foundation. These ideas are
considered in context of an MFT profession that is wrestling with influences of managed care, the
medical model, evidence-based treatment models, clinical competencies, and training to the licensure test (Nelson et al., 2007). These influences tend to focus primarily on models, techniques, and
intervention, to the exclusion of other elements of therapy. We will first discuss the role of techniques, but then will articulate how they rest upon the therapeutic relationship, which is in turn
grounded in the way of being of the therapist.
Level 1: Skills and Techniques
Wampold (2001) found that at most 8% of the outcome variance in therapy is due to the
unique contribution of model-based techniques. His meta-analysis is particularly relevant when
discussing the effects of techniques on outcome because he includes a review of component analyses
or studies that measure differences based on adding or subtracting key components of a model
(e.g., empathic attunement in emotionally focused therapy, EFT; Johnson, 2004). In our model,
knowledge of therapy approaches and the utilization of techniques are essential to effective practice as they are employed within the context of the therapist–client relationship.
Historically, MFT has placed great emphasis on the curative powers and uniqueness of our
models (Nichols, 2009; Sprenkle & Blow, 2004a), and graduate and postgraduate training
programs have focused extensively on the development of knowledge and skills of MFT models.
Additionally, beginning therapists are often anxious about being in the room with clients, so they
may rely heavily on concrete techniques. Furthermore, beginning therapists may not have developed enough clinically by the time they graduate to consider how other factors influence their therapy. Integrating issues related to the relational stance of the therapist earlier into training may
influence effectiveness of MFTs by helping students develop a deeper understanding of the process
of therapy.
Unfortunately, meta-analytic findings such as Wampold’s (2001) are often interpreted to mean
that technical proficiency is inconsequential or that therapists do not need to be well-versed or
skillful in using techniques; they can simply follow intuition or fly by the seat of their pants and
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achieve the same outcome as someone who has carefully studied and developed proficiency in
MFT models. Scholarship does not support this conclusion. Wampold’s study suggests that an
effective therapist (a) offers a credible rationale for understanding the client’s symptoms and (b)
offers a plausible procedure—including relevant and effective techniques—for addressing the
symptoms (see also Davis & Piercy, 2007a). Likewise, Lambert’s (1992) research indicates that
models and techniques represent an important aspect of successful therapy outcomes. Technical
proficiency in models and techniques are necessary, but not sufficient, for successful therapy.
To illustrate this conclusion, consider that most clients do not seek a therapist or refer a friend
to one based on how proficient that therapist is in a model. There are deeper elements at work that
affect how confident and connected a client feels about a therapist. Clients need a human being
more than they need a technician, for “it is as people rather than as experts and manipulators of
lives that we help others” (Warner & Olson, 1981, p. 501). We suggest that theoretical and technical
mastery is therapeutic when grounded in factors related to the therapeutic alliance and the therapist’s way of being.
Level 2: The Therapeutic Alliance
Both meta-analyses and quantitative reviews of therapy outcome literature find that the therapeutic alliance accounts for roughly 30% of the variance in client outcome (Lambert & Barley,
2001; Wampold, 2001), while therapy techniques account for between 5% and 15% of outcome
variance (Beutler & Harwood, 2002). Moreover, there is evidence that a significant part of that
variance is attributable to the clinician’s therapy allegiance (Luborsky et al., 1999). Thus, the therapeutic alliance has been documented as the most important therapist-influenced condition for
client outcomes (Safran & Muran, 2000)—at least in individual psychotherapy. Again, the importance of the therapeutic relationship does not mean that models and techniques are immaterial
(Davis et al., 2012; McHugh, Murray, & Barlow, 2009). Models are implemented amidst therapist
qualities, client qualities, relationship factors, and contextual issues (Beutler & Harwood, 2002).
Historically, psychoanalysts viewed interactions between client and therapist as projection,
whereby acceptance from the therapist provided a foundation for positive transference (Horvath,
2000). Because the interpretation of transference was a primary task of analysis, the therapeutic
relationship itself was based on projection and was thus subject to interpretation rather than being
seen as a genuine interpersonal relationship. In contrast, early behavioral interventionists focused
on observable client behaviors, believing the therapeutic relationship to be largely unnecessary to
the goal of helping clients change (Horvath, 2000).
Although Freud advocated engaging collaboratively with patients (Gelso & Samstag, 2008),
Rogers (1957) was the first to articulate nonmedical healing as a relationship issue. The humanistic
psychotherapy movement (e.g., Bugental, 1987; Jourard, 1971; Rogers, 1957) advanced the importance of the therapist–client relationship, as well as the self of the therapist. Conceptualization and
research on the therapeutic relationship have gone beyond Rogers’ original facilitative conditions
of empathy, warmth, and congruence. The therapeutic relationship has many overlapping facets
and has multiple conceptualizations, but it can be described as being influenced by at least three
components: (1) the client’s characteristics and personal attributes; (2) the relationship between
therapist and client, including the working alliance; and (3) the person of the therapist, including
the therapist’s facilitative conditions and the therapist’s interpersonal attributes and style. These
components become even more complex in family therapy with multiple clients and therapist–
client relationships (Pinsof & Catherall, 1986). In individual psychology, the therapeutic relationship has been defined as “the feelings and attitudes the therapy participants have toward one
another and the manner in which these are expressed” (Gelso & Samstag, 2008, p. 268). It has been
seen as consisting of three components: the working alliance, a transference–countertransference
configuration, and a “real relationship” (Gelso & Samstag, 2008, p. 267; see also Gelso, 2009).
The alliance refers to the quality and strength of the collaborative relationship between client and
therapist, and a positive therapist–client alliance is essential for optimal client outcomes regardless of
the therapy model used (Horvath, 2001). Bordin (1979) articulated two aspects of the therapeutic alliance: (a) interpersonal liking, respect, and trust, and (b) the therapist–client bond that facilitates
engagement in therapeutic work. It also includes consensus about and commitment to goals.
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In terms of the working alliance, a meta-analysis of 90 clinical investigations of the linkages
between alliance and therapy outcome yielded a weighted mean overall effect size (r-value) of .21
(Horvath, 2001). The therapist’s style of relating is important, and experienced therapists possess a
wider range of styles of relating than do newer therapists (Norcross, 2002). Developing a therapeutic relationship is an important part of engaging clients in treatment. Norcross stated: “The power
of being asked and of co-creating the therapy relationship is tremendously effective… I prefer
clients telling me in the first session what they don’t want than suddenly not showing up for the
sixth session” (Cooper, 2004, p. 17).
The person of the therapist as experienced by clients is also a key part of the therapeutic alliance. One meta-analysis of the linkages between the therapist’s empathy, warmth, and genuineness
and client outcomes yielded an overall correlation of .43 (Greenberg, Elliott, & Lietaer, 1994).
Therapist’s attributes of being flexible, respectful, trustworthy, confident, interested, affirming,
relaxed, and open were found to contribute positively to the therapeutic alliance (Ackerman &
Hilsenroth, 2003). Other literature describes a facilitative therapeutic stance in terms of genuine
openness, humility, kindness, mutuality, mindfulness, and lack of contrivance (Safran & Muran,
2000). Thus, although the therapeutic relationship is rightly seen in a professional light, it is clear
that some of its components are innately personal.
When addressed by scholars, the therapeutic relationship is sometimes cast as something that
can be created by the correct application of relationship-building skills or techniques. However,
certain qualities or characteristics are required for the creation of a relationship that is truly therapeutic. A genuine relationship with a client is no more the result of an application of skills than is a
romantic relationship. Indeed, couple process research suggests that personal “attributional” characteristics support relationships skills (in couple relationships, at least). For example, Fowers
(2001) argued that good communication in couples goes beyond skills; it rests upon a foundation
of personal virtues (Fowers’ Aristotelian term) such as compassion and generosity. Recent empirical research suggests that relationship-enhancing communication is not likely to occur without
such virtues, regardless of how skilled partners are (Carroll, Badger, & Yang, 2006; VeldoraleBrogan, Bradford, & Vail, 2010). These studies suggest that virtues are correlated with communication skills and that both underpin positive relationship quality. Yet many therapists coach
couples on communication or problem-solving skills without any consideration of the condition of
underlying attitudes or characteristics essential to communication. Couple relationships are
obviously different from therapist–client relationships, but facilitative therapist–client relationships may share similar foundations—that is, good personal attributes that support the effective
use of skills. Because more client change is due to the therapeutic relationship than to techniques,
this is likely to be the case.
Clients prize the same characteristics in therapists that they value in personal relationships.
Research linking the importance of therapist’s empathy, warmth, genuineness, and positive regard
with client outcomes underscores the personal nature of therapy and suggests that both deep
understanding and the “prizing of the person” (Rogers, 1957, p. 101) are key curative parts of therapy (Farber & Lane, 2001; Orlinsky, Grawe, & Parks, 1994; Greenberg et al., 1994). Although
there is disagreement as to how to train therapists in fostering therapeutic relationships, it is clear
that the importance of the alliance should be viewed in tandem with empirically supported treatments (McHugh et al., 2009). Taken as a whole, however, these findings underscore the innately
personal nature of therapy. There is clear evidence that who the therapist is as a person plays a central part to the professional role.
Level 3: Way of Being
Way of being refers to the in-the-moment attitude that therapists have toward clients and
provides a foundation for the therapeutic alliance. This attitude can be genuine and open to the
humanity of the client, or it can be a stance that is impersonal and objectifying. Our way of being
will influence how clients experience us. As Boyce (1995) said: “People respond primarily to the
way we feel toward them. More important than our knowledge, our skills, or our education, is
simply our goodness – the quality of our hearts” (p. 31). Anderson (2006) uses the term “way of
being” to describe how a therapist “conveys to the other that they are valued as a unique human
and not as a category of people; that they have something worthy of saying and hearing; that you
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meet them without prior judgment” (p. 44). This is communicated to clients through attitude, tone,
body language, word choice, and timing. Therapists who value the personhood of clients and put
the clients’ needs first are demonstrating a way of being that is conducive to a good therapeutic
relationship.
Corey (2005) similarly argued that the humanity of the therapist is critical for connecting with
clients and suggests that if “we hide behind the safety of our professional role, our clients will keep
themselves hidden from us” (p. 17). Because therapy is a human rather than technical endeavor, it
requires an authentic human relationship facilitated by “our own genuineness and aliveness” with
our clients (Corey, 2005; p. 17).
This connection with others is well articulated by the philosophical work of Martin Buber. He
suggests that it is only in relation to another person that the “true” self is manifest, and it is within
our relationships that our way of being is found (Buber, 1965). In other words, who we are, is who
we are with others—whether in or out of the therapy room. Our way of being is developed and
demonstrated through our relationships. This means that one’s way of being is not static, but may
change from moment to moment or person to person.
Buber (1958) discussed two types of relationship stances: I-Thou and I-It. He proposes that in
any given moment with another, we are in one of these two ways of being. To be I-Thou is to be
“aware of the full, irreducible otherness of the partner” (Fishbane, 1998, p. 42). It is to see others
as we see ourselves, recognizing that they have hopes, fears, desires, and independent views about
life (Boyce, 1995). Their needs are as real to me as are my own. A therapist who “really has in
mind” his or her client will have “the intention of establishing a living mutual relation between
himself [sic] and them” (Buber, 1965; p. 19). Sometimes being I-Thou or open to another’s humanity
occurs spontaneously, as when we feel compassion or concern for another’s distress, but other
times it is a conscious choice to try to see the other’s reality (Wetzel, 2005). In contrast, to be in an
I-It mode is to see the other as an object. In I-It, we relate to the other as something either helping
or hindering us. We see them as means to our own ends or as obstacles to these ends.
Many therapists have indirectly referred to the importance of the therapist’s way of being.
As mentioned, Carl Rogers advocated unconditional positive regard (Rogers, 1957), and
Virginia Satir emphasized valuing clients and appreciating their strengths (Satir, 1988). Constructivist thinkers have attempted to elevate collaborative and supportive attitudes that were
deemphasized in early family therapy models (Freedman & Combs, 1996). For example, Maturana defined love as “opening space for the existence of another” (Wright, Watson, & Bell,
1996; p. 88). Some have argued against diagnosis on the basis that it forces the rich complexity
of a person into a set of diagnostic criteria, which leads to the objectifying of the client
(Andrews & Clark, 1998).
The way of being level is relevant for self of therapist work. For example, one’s personal issues
and areas of reactivity can cloud one’s ability to see the other clearly. It is also important to
acknowledge the influence of gender and power among other contextual issues. Therapists are
inherently in positions of power, and those in power are more inclined to see their own perspective
as correct and ignore others’ reality (Whiting, Oka, & Fife, 2012). Therapists can choose to put the
humanity of the client first, even when personal reactivity might influence otherwise. Accomplishing this takes a high degree of awareness of one’s motives and thoughts. This type of self-responsibility is at the heart of engaging in an I-Thou manner.
While self of the therapist work can help facilitate an I-thou way of being, a psychologically
and emotionally well-adjusted therapist may still view others from an “I-it” perspective.
Conversely, a therapist can adopt an “I-thou” attitude but have potentially problematic personal
issues of which they are unaware. We therefore view efforts to develop a therapist’s way of being as
complementary but different than self of therapist work.
Although therapy is a human interaction, the terms used to describe this process have often
been drawn from scientific traditions that have a hard time speaking to the idea of way of being
(e.g., Fife & Whiting, 2007; Fowers, 2001; Slife, 1993). Researchers write in “objectifying” ways,
ostensibly removing themselves from the knowledge they are presenting (Knapp, 2002), and clinical
literature is often constructed for exactitude and scientific credibility rather than richness and ambiguity (White & Epston, 1990). While this may result in scholarly precision, it also strips some of the
humanity from therapeutic discourse. Scholars have recognized this gap, and many have argued
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that cold, scientific terms are insufficient to describe the rich, moral, and interactive nature of therapy (Stern, 2004). Approaches emphasizing ideas about relational interdependence and obligation
have addressed this deficiency (e.g., Fishbane, 1998; Gantt & Williams, 2002; Wetzel, 2005).
In clinical work, clients may be seen with an I-It or I-Thou way of being. Therapists shift into
an I-It mode when they regard clients as annoying, take sides, are suspicious, or pathologize client
behavior. These subtle accusations are likely to be perceived by the client. Accusing clients is different, however, from legitimately challenging or inviting them to be responsible for their own I-It
behavior (Jenkins, 1990; Jory, Anderson, & Greer, 1997). Being I-Thou is not just an empathetic
supporting of whatever the client does. It may be more difficult for a therapist to authentically
challenge the client about their behavior than to neutrally support them in harmful decisions (Doherty, 1996). In an I-Thou mode, clients are challenged because that is what the therapist genuinely
thinks will benefit them (Buber, 1999).
On the surface, an I-Thou and I-It challenge could look like the same intervention, but the
motivation will be different, and that is likely to come across to the client (Arbinger, 2006; Boyce,
1995; Warner, 2001). One client who worked with several therapists related the following:
One guy I saw … it seemed like … I wasn’t really that important. I felt like I was a test
case to them. Like they were seeing if they could win this one, seeing if they could fix this
problem, and then ok, on to the next…. And so that also made me feel like … their ego
would go up if they could fix me or something. Whereas with [current therapist], it feels
like he actually cares, you know. I’m sure the others cared a little bit, but I think their
satisfaction came from themselves being: “Oh, I’m so good, you know, and I can fix blah
blah blah.” (Whiting, Nebeker, & Fife, 2005, p. 50).
This client’s experience shows how a person can be reduced from someone to something. A
therapist cannot have an authentic relationship with a thing. A therapist who is regarding clients
as objects might become bored or frustrated and see them as an obstacle to his or her own satisfaction. Or a therapist might force clients’ experiences into favorite theoretical models or diagnoses,
selecting and disregarding sections of their stories to support the therapist’s conclusions. Therapists might worry about what their clients think about them or try to gain their clients’ affection.
This keeps the therapists’ focus upon themselves, which will hinder their view of the client and
therapy. Therapists might see their clients as threats to their professional competence, such as
when the client makes no progress or challenges the therapist. Other ways of objectifying clients
include using flattery to obtain approval, sexualizing or flirting with a client, becoming defensive
or accusing with clients, or seeing them as a puzzle to be solved. To the extent we regard our clients
as objects, our interventions become manipulations (Warner & Olson, 1981).
With an I-Thou way of being, the client is primary and the model and/or plan for the session
is secondary. Therapists with an I-Thou stance toward clients will hold their plans in a tentative
manner such that they are willing to modify or even abandon the plan if their sense of the clients’
needs invites them to do so. The first author was once working with a couple who was feeling stuck
and became convinced that a solution-focused approach was needed. This was planned for and
vigorously tried in the next session, but it fell flat, and even seemed to engender a power struggle
between the therapist and husband. Upon reflection with colleagues, one wondered whether the
approach became an attempt to “solution-focus them into submission.”
Ways of being are not model-dependent. A cognitive therapist may approach a client with an attitude of elitism, believing that their expertise will help fix the distorted beliefs and automatic thoughts
in the client. Or, they could approach their client in an open and respectful way of being, recognizing
the fullness of the client and maintaining a humble, respectful approach. This therapist may use the
same cognitive techniques as the first, but their use would arise out of the therapist’s responsiveness to
the client, and they would be used because the therapist judged the techniques to be the best thing for
the person, rather than therapist convenience or a priori theoretical commitments.
Even therapists who are known for technical mastery practice in ways that demonstrate their
humanity and caring, although many of them do not explicitly discuss this aspect of their work.
Jay Haley, who is well-known for his virtuosity as a strategic therapist, is a good example of this.
In November 2000, three of the authors attended an informal question and answer session with
Haley. Much of the discussion centered on his clinical work and the strategic therapy model.
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However, as the session drew to a close, a graduate student asked, “What do you think is the most
important thing an MFT student should learn during their graduate studies?” Without any hesitation, Haley answered, “Kindness.”
DISCUSSION
Suggesting that MFTs should be authentic and caring may at first seem redundant. Don’t
most therapists see their clients as complete, real, and important? Are not most “helping professionals” helpful and kind? MFTs in particular have been shown to value both their clients and
their client’s relationships (Wall, Needham, Browning, & James, 1999). Although it may seem
natural to see our clients as persons and respond accordingly, it is also easy to shift into objectifying and self-centered ways of being. While it is unrealistic to constantly remain in a fully I-Thou
way of being in all of our relationships, it is important to increase our awareness of our way of
being when engaging in clinical work and training.
Clinical Implications
Although we have discussed many applications of the pyramid as we outlined the three levels,
there are global implications as well. As a meta-model, it is applicable across theoretical and
professional orientations and can inform therapist’s work with individuals, couples, and families.
The hierarchical configuration of the pyramid has implications for therapists, especially in cases
that do not seem to be going well. Namely, when problems exist in one level of the pyramid, the
solution is often found at the underlying level (Arbinger, 1998, 2006). For example, when clients
are not making progress or seem resistant to the interventions offered, instead of changing models
or interventions, the model suggests that therapists should first evaluate the quality of the alliance
they have developed with their clients and consider whether there is a way to strengthen it. Therapists may ask themselves: How is my relationship with the client(s)? Have I given enough time and
attention to building a therapeutic relationship? Do my clients feel I have heard and understood them?
Is there anything that has damaged the relationship or hindered the relationship from developing?
Similarly, when stuck, clinicians may benefit by examining their way of being toward clients,
both in general and in specific moments during therapy sessions. Therapists might ask themselves:
How am I feeling about my clients? How do I regard them—are they objects to me or real people? Are
the clients’ needs as real to me as my own? Am I responsive to my clients, or am I forcing them to fit
my agenda? Do I have any personal reactions or issues that are getting in the way of seeing my client?
Relationships (including therapist–client relationships) have a mutual quality to them. How
one person feels toward the other often invites a reciprocal response. Intimate partners tend to
respond in the way that they are treated. A therapist’s way of being may influence the way of being
of the client, including (in the case of couples therapy) the way in which couples regard each other
as partners. It can therefore be helpful for a therapist to model an I-Thou way of being, particularly in response to clients who are I-It with the therapist or their partner.
In accepting the notion that the therapist’s way of being constitutes the foundation of successful
therapy, some might conclude that a therapist only needs to be nice, warm, compassionate, and
accepting to be successful. However, knowledge and proficiency in models, skills, and techniques
are essential to successful practice. Situating way of being at the foundation of the pyramid is not
an excuse for laziness or a lack of study, knowledge, or preparation. Our model suggests that all
aspects of the pyramid are critical in providing effective therapy and that a therapist should attend
to each level. Consider an analogy. A basketball player who seeks to excel must work hard and
practice to learn the skills of the game but must also have a trusting relationship with teammates,
at least part of which comes from an underlying attitude of generosity and success. The player’s
motivation (part of way of being) must combine with a willingness to put the team first and have a
congruent and trusting relationship with them. The individual’s attitude and the team’s relationship will then be expressed through the actual skills displayed on the court. We have all seen skilled
players fail due to poor teamwork or lack of desire, and likewise, we have seen a winning attitude,
teamwork, and determination make the difference in success between similarly skilled teams.
In a recent debate on common factors, Simon (2012a) argued that a therapist would be most
effective when he or she had congruence between his or her model and worldview (see also Simon,
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2006). Blow et al. (2012) argued that the needs of the client should drive the selection of a model,
and that a therapist could conceivably be passionate about most models if they believed doing so
would be in the service of clients. While it could be argued that an I-Thou way of being would presuppose worldview/model congruence, it could also be argued that a therapist working from an
I-Thou stance would privilege client’s needs above his or her model preference. We believe that the
way of being dimension of the pyramid model transcends both of these approaches, as a therapist
coming from either angle could either view clients as people or objects. In our meta-model, therapists can regard a client from an I-Thou perspective regardless of whether their or their client’s
preferences drive the selection of a model. Regardless of approach, however, a therapist with an
I-Thou way of being would be responsive to the client’s needs.
Training Implications
Ongoing trends in the assessment of MFT students and training programs emphasize the knowledge of MFT models and the mastery of certain clinical skills (AAMFT, 2004; AMFTRB, 2009; Perosa & Perosa, 2010). The focus of accreditation guidelines, licensing exams, licensing laws, and
preparation for clinical work naturally leads educators to focus training on the major models of marriage and family therapy. In addition to these key components, we support the inclusion of other fundamental aspects of therapy. We believe that MFT training programs can teach models while also
incorporating a greater focus on the self of the therapist (Simon, 2006), therapists’ way of being
toward their clients, and the therapeutic alliance. As noted by Asay and Lambert (1999), “Changing
the emphasis in graduate training toward the development of the therapist as a person who prizes others can only make the enterprise of therapy more valuable, meaningful, and effective” (p. 49).
There are a number of ways in which MFT educators can present the concepts that make up
the therapeutic pyramid. The pyramid structure is fairly intuitive, and we have found that including the model early in students’ training helps sensitize them to the relative importance of the
different factors, specifically that the foundation of therapy practice is grounded in who we are,
rather than in models and techniques.
Many graduate programs offer one or more courses in the major models and techniques of
family therapy, and such courses may be an optimal setting to explore the therapeutic alliance and
way of being. One way we have done this is to introduce the model at the beginning of the class
and then work through the different levels during the course. This approach helps students understand the significance of the therapist’s way of being and the therapeutic alliance in the overall
process of therapy. Additionally, when the aspects of the meta-model are presented at the beginning, they are more easily identified in the theoretical writings and application of the major MFT
models. As noted, Anderson has discussed way of being specifically in her explanation of collaborative therapies (2006), but many other MFT models allude to these ideas even when they are not a
formalized part of the approach. The importance of thoroughly instructing students in the major
MFT models and techniques may limit the time available for the lower levels of the pyramid.
Nevertheless, the time spent focusing on the therapeutic relationship and way of being is often a
highlight of the course.
Certain books and articles are helpful in facilitating discussion on these topics and inviting
reflection from students about their way of being with clients and others. Books such as The Anatomy of Peace (Arbinger, 2006) and Leadership and Self-deception (Arbinger, 2000) focus on the
I-It/I-Thou concepts and the impact of way of being on relationships. The ideas are very accessible
to students because they are presented within the context of a story, rather than as abstract or philosophical ideas presented in a didactic manner. Some articles that discuss the importance of underlying attributes and relational stances include Arbinger (1998), Boyce (1995), Davis (2005), Fishbane
(1998), Fowers (2001), Warner (1999), Warner and Olson (1981), and Whiting et al. (2005).
As part of the instruction on the pyramid model, we ask students to write about their experiences with the different ways of being. Most can easily recall experiences in which they felt treated
as an object or as a person. We also invite them to reflect on times in which their way of being was
more I-It or I-Thou in relation to others. Although it is not required, we ask willing students to
share these experiences with the class, and we share ours as well. These stories help facilitate
further dialog on the relational impact of our way of being. We ask them to consider questions
such as: When you were treated as an object/person, were you more or less open to the other’s
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January 2014
influence? Were you more or less likely to hear what the other had to say? Was there an increase or
decrease emotional closeness or connection?
Being treated as an object tends to push people apart, creating emotional distance and closing
them off from the influence of the other. Being regarded in an I-Thou way, on the other hand,
tends to draw people together and invites openness and mutual respect. We ask students to
consider the application of these ideas in therapy and the impact of the therapist’s way of being
with clients. For example, when therapists objectify clients, perhaps regarding them a problem to
be fixed or an obstacle to overcome, we may provoke resistance and are less likely to be a positive
influence with them. On the other hand, clients may respond differently as we regard them in an
other-affirming manner, and they sense our sincere interest in them and their needs.
One of us has students read The Anatomy of Peace (Arbinger, 2006) or Leadership and SelfDeception (Arbinger, 2000) and then attempt to view everyone as a person rather than an object for
a week. Students then discuss this experience in a term paper and during class. Many students
invariably describe this as one of the most difficult and impactful assignments of their graduate education. Students commonly report feeling more connected, aware, centered, and empathic to those
around them. Worldviews and stereotypes are often challenged. For example, when teaching this
concept during a study-abroad opportunity, one of us was walking to dinner with a student after
class. We were discussing how challenging it can be to develop an I-thou way of being, and (in retrospect) somewhat smugly noting our progress on this, when we noticed a homeless man walking
slowly our way. We each briefly slowed as he approached, realizing we had an opportunity to put
the concept into practice with a kind word or even eye contact. We resumed walking just as quickly,
though, and failed to acknowledge the man until we heard him say “Se
nores!” soon after he passed.
We paused again then kept walking until we heard “Se
nores!” even louder and heard him walking
toward us. We turned around and realized he, with a big smile, was returning the student’s wallet,
which had fallen from his backpack a half-block earlier and contained several hundred dollars. The
humbling lesson was not lost on us. Students encounter meaningful experiences frequently throughout the week and report that the effect spreads to their clinical work as well.
Although these ideas may be presented in a single course, the pyramid concepts can be integrated throughout the curriculum. For example, as clinical supervisors, we often find that individual
and group supervision discussions naturally provide opportunities to focus on therapist’s efforts to
develop therapeutic relationships. Likewise, these discussions may also include reflecting on the
ways in which therapists are regarding clients, how they are balancing their commitments to a particular therapy approach or treatment plan and the client’s needs, and the influence of their own
way of being on the therapy process.
An exercise that one of us uses to facilitate reflection on these ideas involves students reading
quotations from therapists about their experiences with clients and then discussing the questions
(in italics) below (quotes taken from Fife, 2004; Whiting et al., 2005). For example:
Therapist A: “It’s a struggle for me between being selfish and not being selfish…. I don’t
want to put [my client] in the hospital… it’s work, just so much work. And so that’s why I
don’t want to put her in the hospital, and that’s selfish. That means it clouds my judgment.”
What are some things that might “cloud therapists’ judgment” with clients?
What might be some good or bad reasons for steering sessions deliberately?
Therapist B: “For me, [it] means putting my own needs second. And my needs are to be
competent and professional and to look in charge, and when I’m with her, I will have to
be the expert, that’s important. But I will have to be vulnerable…. And it opens me up to
having to say like, things like ‘I don’t know what you’re talking about, I’m lost, ‘ or, ‘Oh
yeah, I guess that was pretty harsh, I apologize. ‘”
What sorts of things can get in the way of therapists’ relationship with their clients?
Is it appropriate for therapists to admit mistakes in sessions with clients? What would be
instances where it might or might not?
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29
Therapist C: “I ask[ed] them what is good that’s going on right now. And so it moved
from ‘what’s bad that we need to change’ to ‘what’s a good thing that’s going on.’ And so
right away they became very vocal…. They both spoke up, and they had things to say.
And I decided to just let them lead instead of going with what I had planned.”
What are clues in session that the clients are not happy with the direction of therapy?
How can you know when a shift in direction or approach is needed?
How do you balance letting clients lead the session with your own agenda of what might be
most helpful?
Movies can also be used to teach the way of being concept and the relationship between the
different levels of the meta-model. For example, Patch Adams (Kemp et al., 1998) depicts a medical
student who demonstrates a genuine regard for the humanity of the patients at the hospital, which
contrasts with his training that focuses solely on objective diagnosis and treatment. In one scene,
the Dean declares that the faculty will train the humanity out of the students and make doctors out
of them. Although the Dean suggests that a human relationship with patients is at odds with providing sound medical treatment, Patch demonstrates that a ‘both-and’ approach is possible. In the
final scene of the film, Patch asserts before the state medical board that if you treat a disease, you
win or lose, but if you treat a person, you win every time. Other films such as Les Miserables (Gorman, Radclyffe, & August, 1998), the musical adaptation of Les Miserables (Bevan, Fellner, Hayward, Mackintosh, & Hooper, 2012), The Help (Columbus, Barnathan, Green, & Taylor, 2011),
The King’s Speech (Canning, Sherman, Unwin, & Hooper, 2010), and A Man for All Seasons
(Zinnemann, 1966) can be used to show I-It and I-Thou ways of being and the contrast between
regarding people as objects and regarding them as people.
Research Implications
We agree with recent calls for research that looks more specifically at therapist factors and
what effective therapists do in therapy (Blow et al., 2012; Gelso, 2009; Simon, 2012b). Although
perhaps difficult to operationalize and measure, we believe that future research should also
consider training implications for the pyramid model and how a therapist’s way of being with clients is related to therapy outcomes. Possible research questions include: “What are the most effective ways to train students in the concepts of therapeutic alliance and way of being, and how do
students perceive this training?” “How do factors related to way of being fit within manualized
treatments and how can they be incorporated into empirically validated treatments?” “How does a
therapist’s way of being influence clinical outcomes?”
CONCLUSION
We have proposed a meta-model in which the effectiveness of clinical techniques rests on the
strength of the therapeutic alliance, which in turn rests on the quality of the therapist’s way of
being. We anticipate that these ideas will be welcomed by some and challenged by others. Our hope
is that the ideas stimulate additional reflection and broader dialog on the foundations of therapy
and conceptualizations of therapy-assisted change.
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