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. 2023 Jul 5;26(2):678. doi: 10.4081/ripppo.2023.678

The real relationship: the Portuguese version of the Real Relationship Inventory-Client form

Pedro Rodrigues Ribeiro 1,✉, David Dias Neto 1
PMCID: PMC10481421  PMID: 37403924

Abstract

The Real Relationship is a relational construct that has influenced other constructs, like the working alliance, although empirically neglected. The development of the Real Relationship Inventory provides a reliable and valid way of measuring the Real Relationship in research and clinical applications. This study aimed to validate and explore the psychometric properties of the Real Relationship Inventory Client Form with a Portuguese adult sample in the context of psychotherapy. The sample includes 373 clients currently in psychotherapy or concluded recently. All clients completed the Real Relationship Inventory (RRI-C) and the Working Alliance Inventory. The confirmatory analysis revealed the same two factors in the RRI-C for the Portuguese adult population, Genuineness and Realism. The observation of the same factor structure suggests the cross-cultural value of the Real Relationship. The measure demonstrated good internal consistency and acceptable adjustment. A significant correlation was found between the RRI-C and the Working Alliance Inventory and significant correlations between the Bond and Genuineness and Realism subscales. The present study reflects on the RRI-C while also contributing to the importance of the Real Relationship in different cultures and clinical contexts.

Key words: real relationship, therapy relationship, Real Relationship Inventory, alliance

Introduction

Psychotherapy is a multidimensional and complex process in which the relationship between therapist and client plays an important role (Barkham & Lambert, 2021; Norcross, 2019). The therapeutic relationship has consistently accounted for as much, and probably more, of the outcome variance as particular treatment methods (Norcross, 2019). The therapeutic relationship can be defined by the feelings and attitudes the therapist and client have toward one another and how these are expressed (Gelso & Carter, 1985, 1994). Research has been focusing on other relational constructs and the dichotomy transference/countertransference. As noted by Gelso (2011), the real relationship, among all the relational constructs, has been the most empirically neglected possibly because of the lack of reliable and valid ways to measure it.

Real relationship: a brief review

As emphasized by Gelso & Carter (1985, 1994) and by Gelso & Hayes (1998), the modern transtheoretical definition of the real relationship has been the personal relationship between therapist and patient marked by the extent to which each is genuine with other and perceives/experiences the other in ways that befit the other (Gelso, 2009, p. 119). The basis for the real relationship can be traced to the beginning of psychoanalysis when not every relation between an analyst and his subject during and after analysis was to be regarded as transference; there were also friendly relations which were based on reality and proved to be viable (Freud, 1937). From Anna Freud’s perspective, the real relationship was seen as the counterpoint to transference, meaning a realistic involvement of each participant in perceiving and experiencing the other in ways that befit the other, rather than through transference (Freud, 1954).

Another aspect of the real relationship was referred to by Ralph Greenson (1967), and it concerns the genuineness of the analytic dyad, where the analyst and patient can be themselves in the relationship rather than holding back or being artificial. With a focus on realism and genuineness, Greenson’s views seem to be connected by humanistic/experiential therapies that placed congruence or genuineness as the central treatment point (Gelso et al., 2019; Pearls, 1969; Rogers, 1957). Current thoughts and research consider this conception of realism and genuineness crucial for understanding the real relationship (Gelso, 2014; Wampold & Budge, 2012). Gelso sustained that the strength of the real relationship should not vary according to the therapist’s theoretical orientation, supporting the current focus of the real relationship as being transtheoretical, applying to all theoretical orientations in psychotherapy (Gelso, 2009, 2011; Gelso & Carter, 1985, 1994; Gelso & Silberberg, 2016; Wampold & Budge, 2012).

Both therapist and patient contribute to the real relationship. From the therapist’s perspective, direct self-disclosure of thoughts, feelings, and information, but also the therapist’s sense of humor, attire, office decoration, facial expressions, body posture, and the like, enables the patient to build an image of the therapist as a person. Also, the therapist contributes to the strength of the real relationship by being genuine and real and perceiving/experiencing the patient as they are instead of a projection based on the therapist’s past and present unresolved conflicts (Gelso et al., 2019).

From the patient’s perspective, the enacting role contributes to forming and developing the real relationship, which is built and strengthened by the patient getting in touch with inner experiences and through both verbal and non-verbal exploration and communication that shows who they genuinely are (Gelso et al., 2019).

The real relationship is then presented from the first contact between therapist and patient, perceived as immediate, probably to varying degrees (Couch, 1999; Gelso, 2009, 2011, 2014; Greenson, 1967). It is suggested that as the therapeutic relationship deepens, the strength of the real relationship increases throughout the work (Gelso, 2014).

Since the real relationship is a relational construct, it seems related to others such as the working alliance. Gelso (2014) has theorized that the real relationship and the working alliance are highly interrelated concepts. Initially, the most significant difference established by Greenson (1967) and Gelso (2014) between the real relationship and the working alliance is that, while the real relationship is more foundational, the working alliance is seen as an artifact of treatment, with the sole purpose of getting the work accomplished.

Bordin’s pantheoretical view of the working alliance (1975, 1989, 1994) based on Greenson’s (1965) and Rosenzweig’s (1936) ideas, was a collaborative stance in therapy supported by 3 components: agreement on the therapeutic goals, consensus on the tasks that make up therapy, and a bond between the client and the therapist (Flückiger et al., 2019). The bond established in the working alliance is a working bond, a connection between therapist and client that reflects directly on their therapeutic work (Gelso, 2014, 2011). Whenever either the therapist or the client feels a connection to the other on a person-to-person basis or feels liking or caring for the other as a person, the bond resides in the real relationship, thus there is an overlapping between the working alliance and the real relationship (Gelso et al., 2019).

Research supports that when therapists rate the working alliance and the real relationship, they are found to be moderately correlated, but each adds unique aspects to the session prediction and treatment outcome (Bathia & Gelso, 2013; Fuertes et al., 2007; Gelso et al., 2005; Lo Coco et al., 2011; Marmarosh et al., 2009). When clients do the rating, the real relationship and working alliance are highly related (Fuertes et al., 2007; Kelley et al., 2010; Lo Coco et al., 2011; Marmarosh et al., 2009; Owen et al., 2011).

Although the correlation value may suggest that these constructs might be the same, from a client’s perspective, Kelley et al. (2010) found that the relationship was substantially stronger for the bond subscale than for the agreement on goals and tasks sub-scales (Gelso, 2014).

Measuring the real relationship

The measurement of the real relationship has only been conducted in recent years since no reliable instrument had been created before 1990 (Gelso et al., 2019). Eugster and Wampold (1996) developed the first measure of the real relationship. It consisted of a patient-rated, 8-item scale of the therapist’ and patient’s real relationship. It assesses patients’ feelings and reactions toward their therapists, and their therapist’s perceptions, feelings and reactions toward them (Gelso et al., 2019).

At the same time, Eugster and Wampold (1996) developed a therapist-rated scale with the same 8-item for the therapist and patient’s real relationship. These items focused more on the genuineness and liking elements, with little attention to the realism element (Gelso et al., 2019). Eugster and Wampold (1996) and Kelley et al. (2010) found modest internal reliability, with Cronbach’s a coefficients ranging from the .60s to mid .70s., and significant correlations with several other measures expected to be associated, providing support for the constructs and convergent validity.

Since then, quantitative research on the real relationship has been done using 2 measures specifically developed: the real relationship inventory-therapist version (RRI-T; Gelso et al., 2005) and the real relationship inventory-client version (RRI-C; Kelley et al., 2010). While the RRI-T measures the therapist’s perception of the real relationship, the RRI-C measures the client’s perceptions (Gelso et al., 2019).

The RRI-C is a 24-item self-report questionnaire with a 5- point Likert scale (strongly agree-strongly disagree). According to the psychometric study by Kelley et al. (2010), this inventory consists of 2 dimensions of 12 items each, representing genuineness and realism. This inventory can be used to assess the client’s perception of the real relationship, regardless of the theoretical model of psychotherapy. In this study, the responses of 187 adult clients were accessed and correlated with the working alliance inventory (WAI). As expected, the bond scale of the WAI was found to be significantly more highly correlated with the RRI than the task and goals scales.

After the initial study of the RRI, Hill et al. (2014) presented an abbreviated version of 12 items, with 6 items in each scale, realism, and genuineness. Because of high internal consistency and inventory completion time, the items that better represented the 2 measures were chosen. The short-version is correlated with the RRI-C (.91) and further studies demonstrated its reliability and validity (Kivlighan et al., 2017).

Present study

Research shows that the therapeutic relationship generally accounts for at least as much as the treatment method in terms of successful psychotherapy (Norcross, 2019). Measures that can access different theoretical dimensions of the therapeutic relationship are essential for psychotherapy research and informed clinical applications. Although Portuguese adaptions for measuring the working alliance are available (Machado & Horvath, 1999; Paixão & Nunes, 2008; Ramos, 2008), measurements for the real relationship are still lacking. This study aims to provide a Portuguese version of the RRI-C (Kelley et al., 2010) and contribute to further the understanding of relational concepts, such as the real relationship. We will explore the psychometric properties of the Portuguese version by confirming his factorial structure. Also, we intend to demonstrate convergent validity with the working alliance.

Methods

Participants

This study was conducted in Portugal, with a convenience sample of 373 participants. Recruitment was done online and from societies and associations of psychotherapy. Inclusion criteria were: 18 years or older, participating or having completed individual psychotherapy. Participants were primarily female (n=326). The mean age was 36.7 (SD=9.2), aged range between 20 and 70. 93% of the participants were undergraduates and graduates from university, 6.2% concluded high school and 0.8% finished middle school. 64.6% were on psychotherapy. The main reasons for seeking psychotherapy were family difficulties, professional difficulties and personal development. 26% were diagnosed with a mental diagnosis. The most frequent mental diagnoses were anxiety disorders and depression. Regarding the main models of psychotherapy, 96 (25.8%) indicated Psychodynamic/Psychoanalytic Therapy, 79 (21.2%) indicated Cognitive-Behavioral Therapy, and 33 (8.9%) indicated Psychoanalysis. Sample characteristics are described in Table 1.

Instruments

Real relationship inventory-client version

RRI-C (Kelley et al., 2010) comprises 24 items consisting of statements on how the client perceives the relationship with the therapist, with a 5-point Likert scale from 1 (strongly disagree) to 5 (strongly agree). Along with the global score of the relationship, RRI-C has two subscales: realism and genuineness. Items nº 3, 6, 8, 12, 14, 21, 22, and 24 are reversedscore. Internal consistency analysis indicates the RRI-C α=.88, realism α=.84, and genuineness α=.88. In the present study, the total score (α=.91) showed high internal consistency and all the subscales showed good internal consistency: realism (α=.82); genuineness (α=.86). Additional psychometric properties of the RRI-C will be presented in the Results section.

Working alliance inventory-short form

The working alliance inventory-short form [(WAI-S), Tracey & Kokotovic, 1989; Machado & Horvath, 1999 (Portuguese version)] consists of a short version of 12 items of the original 36 items version statements on how the client perceives the therapeutic alliance with the therapist, with a 7-point Likert scale from 1 (never) to 7 (always). Along with the global score of the alliance, the WAI-S also has three subscales: bond, tasks, and goals. Items nº 3, 5, 6, 7, 9, and 12 were reversed-scored. In the present study, the total score (α=.91) showed high internal consistency and all the subscales showed acceptable to good internal consistency: bond (α=.78); tasks (α=.84); goals (α=.86).

Procedure

Ispa – Instituto Universitário’s Ethical Committee approved the present study (Nº D-052-06-22). Permission was sought and obtained from Charles Gelso for the Portuguese adaptation of the RRI-C. The RRI-C (Kelley et al., 2010) was translated by one of the authors and retro-translated back to English by an experienced psychotherapist proficient in English. Despite language differences, the item’s meaning is maintained because of the in universal qualities of relational constructs and cultural similarities in Western countries. Semantic, idiomatic, experiential and conceptual equivalence was achieved as best as possible. Following Beaton et al. (2000), a pretest was made with 10 participants who had previously experienced a psychotherapy process. Each participant’s remarks were taken into consideration for further enhancements. A group of expert psychologists were consulted so cross-cultural equivalence could be achieved.

Table 1.

Sample characteristics of the participants (N=373).

Variable Frequency Percentage
Gender
   Female 326 87.4
   Male 47 12.6
Age
   20 1 0.3
   >20-30 110 29.5
   >30-40 144 38.6
   >40-50 82 22
   >50-60 28 7.5
   >60-70 4 1.1
Education
   University Undergraduates 16 4.3
   University Graduates 331 88.7
   High School 23 6.2
   Middle School 3 0.8
Psychotherapy
   Where in process 241 64.6
   Family difficulties 73 19.6
   Relational difficulties 111 29.7
   Personal difficulties 160 42.9
   Mental diagnosis 63 26
   Anxiety disorders 38 10.2
   Depression 30 8
Psychotherapy models
   Psychodynamic/psychoanalytic 96 25.8
   Cognitive behavioral 79 21.2
   Psychoanalysis 33 8.9
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Data was collected online through the Qualtrics platform. All participants signalled their informed consent, which was anonymous and voluntary. The order of application of the instruments was as follows: socio-demographic variables, RRIC and WAIS-S. The study was disseminated via social networks and Portuguese associations of psychotherapy.

Data analysis

We verify the factorial structure of the RRI-C, following a similar strategy to the one adopted by Kelley et al. (2010) using confirmatory factorial analysis. The adjustment quality of the factorial model was evaluated according to indexes with empirical statistical support (Marôco, 2014), specifically: Chisquare of adjustment (χ2/df); Tucker-Lewis index (TLI>.90); comparative fit index (CFI>.90); root mean square error of approximation (RMSEA). Finally, we performed convergent validity analysis, referring to the analysis of scales constituting the same or an identical construct, and so it is expected that these measures present positive and high correlations between them (Marôco, 2014). For this study, we explore the correlation between the RRI-C and WAI-S, using Pearson correlation. All of these analyses were performed on Jamovi version 2.3 (Sydney, Australia).

Figure 1.

Figure 1.

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Path diagram of a confirmatory model of real relationship inventory - client version with two-factor model with acceptable adjustment indices {χ2 (251)=679, p .001; comparative fit index=.810; Tucker-Lewis index=.791; root mean square error of approximation (RMSEA)=.084; P[rmsea≤.05] .001.

Results

Confirmatory analysis

Confirmatory factor analysis was performed with the current sample to evaluate the theoretical model’s adjustment quality to the observed correlated structure between latent items (Marôco, 2014). The results of the confirmatory factor analysis indicate an acceptable adjustment model {χ2(251)=679, p<.001; CFI=.810; TLI=.791; RMSEA=.084; P[rmsea≤.05]<.001}. This model confirmed the 2 factors: the realism factor, constituted by 12 items and the genuineness one, which includes 12 items (Figure 1).

Convergent validity

Convergent validity analysis was performed between the RRI-C and the WAI-S. We found different correlations between global scores and respective subscales from the RRI-C and WAIS. Associations where r<.25 are considered weak, associations with .25≤|r|<.5 are considered moderate, associations of.5≤|r|<0.75 are considered strong, and associations of |r|≥.75 are considered very strong (Marôco, 2018).

We found a statistically significant and strong association between the global scores of the RRI-C and WAI-S (r=.75, p<.001), the RRI-C and the goals subscale (r=.62, p<.001), the RRI-C and the tasks subscale (r=.63, p<.001), the genuineness subscale and the WAI-S (r=.71, p<.001), the genuineness subscale and the goals subscales (r=.57, p<.001), the genuineness subscale and the tasks subscales (r=.63, p<.001), the realism subscale and the WAI-S (r=.72, p<.001), the realism subscale and the goals subscale (r=.62, p<.001), the realism subscale and the tasks subscale (r=.62, p<.001), the bond subscale and the RRI-C (r=.73, p<.001), the bond subscale and the genuineness subscale (r=.72, p<.001) and finally the bond subscale and the realism subscale (r=.67, p<.001).

Discussion and Conclusions

In this study, we intend to adapt the RRI into the Portuguese context, so that therapists and researchers can have a reliable way to measure the real relationship. Measurements for relational constructs had been previously adapted, such as the WAI (Machado & Horvath, 1999), the California psychotherapy alliance scale (Paixão & Nunes, 2008), and the alliance negotiation scale (Galvão et al., 2019). However, until now, an instrument measuring the real relationship had not been adapted. Moreover, we aim to explore and investigate the psychometric properties of the RRI-C for the adult Portuguese population in clinical practice. Finally, we intend to explore the convergent validity between the RRI-C and the WAI-S.

Our results suggest the RRI-C for two factors, one for genuineness and one for realism, similar to what was found in the original validation study (Kelley et al., 2010), including the same items for each factor. While our adjustment model value was lower than the original study, it is still acceptable and confirms the factorial structure of the RRI-C. Although there is insufficient information to extrapolate the cause of the difference, one theory is that some of the items may have lost some of their meaning during translation.

As for the convergent validity, the results align with the research and the original study. We found strong associations between the bond subscale of the WAI-S and the global score of the RRI-C, and also between the bond subscale and the genuineness and realism subscales. As previously noted by Kelly et al. (2010), the bond aspect of the working alliance seems to emerge from the real relationship not only from a theoretical perspective but also from a research one. Not only does the real relationship seem to be a common factor in psychotherapy, but it can also transcend different cultures. Genuineness, reflecting one’s authenticity and honesty (Bohart, 2005), is considered to be an essential part of the real relationship (Gelso, 2011) and a necessary condition for change in the psychotherapy context (Rogers, 1957). It is an essential element of psychotherapy relationships, and it seems that in the cultures where studies of efficacy outcomes have been done, mainly Western ones, outcome improvement increased the more therapists were seen as genuine by their clients (Kolden et al., 2018). Despite some cultural and language differences, our results show that this Portuguese version can measure the client’s perspective of the real relationship, considering that psychotherapy is supported by a therapeutic human encounter in which the client can be in a state of incongruence, vulnerability, or anxiety, and the therapist is in a state of congruence and integrated into the relationship (Rogers, 1957). Through a personal and genuine relationship, the therapist and client can work on what they perceive in reality that benefits the client (Gelso, 2009).

The main focus of this study is to develop a Portuguese version of the RRI-C and compare our psychometric properties with the original version (Kelley et al., 2010). Since this is the first study involving the Portuguese population, further studies are suggested. All the instruments that were used in this study had a self-report format, reflecting only the client’s subjective experience, which may not show all aspects of the relational experience if the client does not recognize them or decides not to share them with the therapist. Participants also completed the questionnaire at their time, which could have been across more than one therapy session. Because of this, it was difficult to standardize the researchers’ control of the data collection.

The study has several limitations. Firstly, the adaptation was based on a convenience sample. The sample size limited our analysis. Further research is suggested using the itemresponse theory to improve the measure. The item-response theory (Bond & Fox, 2001) is a method that analyzes the properties of items and scales and their relationship to the underlying dimension the scale is intended to assess. This method has several advantages over the classical psychometric theory and has been successfully used in WAI (Hatcher & Gillaspy, 2006).

Following Ronkko and Cho (2022), we suggest more cross-cultural adaptations of the RRI-C to access the strength of the factorial structure to ensure better discriminant validity. Consistent factorial structures, in different languages and cultures, may offer a validation for the Real Relationship.

Despite these limitations, our findings support that this Portuguese adaptation of the RRI-C is suitable for further research concerning relational constructs in psychotherapy and especially for exploring the real relationship. In clinical settings, the RRI-C can be used to measure the real relationship in the adult population and provide feedback for the therapist on the development and quality of the real relationship.

Acknowledgments

The authors would like to acknowledge the help of psychotherapy societies for sharing and encouraging participation in this research, namely the Portuguese Association for Behavioral, Cognitive and Integrative Therapies, PsiRelacional, the Portuguese Institute for Body Psychotherapy and the Portuguese EMDR Association.

Funding Statement

Funding: none.

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