The positive psychology of relational depth and its association with unconditional positive self-regard and authenticity

ABSTRACT Relational depth (RD) refers to moments in a therapeutic relationship in which a person has feelings of aliveness, satisfaction and immersion. However, no research has yet tested for the association between RD and concepts closely aligned with Carl Rogers’ hypothesis of how people change in a growth-promoting relationship. In this study, 55 therapy clients completed the relational depth inventory (RDI), the unconditional positive self-regard scale (UPSR) and the authenticity scale (AS). It was found that higher scores on the RDI were associated with higher scores on the UPSR and the AS. These results provide initial evidence for the growth-promoting effects of RD. Further prospective research is now warranted.


Introduction
According to McCabe and Priebe (2004), the level of therapeutic relationship between the therapist and patient is the curative factor in those with severe mental health difficulties.
However, while the importance of the therapeutic relationship has long been recognized in the mainstream psychotherapy and mental health literature, its definition and operational measurement have only recently come under empirical investigation (Priebe, Richardson, Cooney, Adedeji, & McCabe, 2011;Welch, 2005). This empirical literature has been concerned with whether the therapeutic relationship is related to therapeutic outcomes as conceptualized from the medical model, such as depression, anxiety and psychosis (Priebe et al., 2011).
The therapeutic relationship has, however, always been central to person-centered theory and therapy. For Rogers (1957), the effects of therapy were seen from within a potentiality model rather than a medical model. According to Rogers' (1957) statement about the necessary and sufficient conditions, the therapeutic relationship is growth promoting leading to constructive personality change. In that way, people become more fully functioning (Rogers, 1963). By fully functioning, Rogers (1963) was referring to, for example, how clients become more congruent and self-accepting. The more that Rogers' (1957) conditions for a therapeutic relationship are present, the more such positive psychological growth is expected.
Seen this way, Rogers' focus on potentiality can be seen as a forerunner to the contemporary positive psychology movement with its emphasis on optimal human functioning. Rogers' approach to therapy was based on the theoretical notion that people are intrinsically motivated toward becoming fully functioning. For Rogers, fully functioning meant more than simply the absence of distress and dysfunction but the presence of positive states. In this way, Rogers' approach was a positive psychology before the term was invented (Joseph, 2015).
Following the interest in the mainstream psychiatric literature into the topic of the therapeutic relationship, Mearns and Cooper (2005) introduced a new person-centered conceptualization of the therapeutic relationship which they termed 'relational depth' (RD). RD refers to moments that occur in person-centered therapy in which participants feel deeply connected, immersed and alive. From the more traditional person-centered literature, RD can be conceptualized as those moments of experience that are increasingly likely to occur in therapy characterized by Rogers' (1957) six necessary and sufficient conditions. Since Mearns and Cooper (2005) introduced the notion of RD, some scholarship has investigated these moments of relationship, mostly employing qualitative methods to understand its nature and experience (Knox & Cooper, 2011). For example, Cooper (2005) initiated research on RD by interviewing therapists about specific times in which they felt they had experienced RD. Results indicated that therapists experienced moments of RD with their clients and that there were many commonalities among therapists' descriptions that are consistent with the positive psychological potential of RD.
Such commonalities included heightened feelings of empathy, acceptance and receptivity toward clients; powerful feelings of immersion in therapeutic work; being real; increased perceptual clarity; and greater levels of awareness, aliveness, openness and satisfaction. Therapists also reported that during such moments of RD, they experienced their clients as highly transparent; articulating core concerns and issues; and reciprocating the therapists' acknowledgment of them in a flowing bidirectional encounter. Cooper (2005) proposes that such experiences and descriptions of RD can be categorized into a tripartite system consisting of self-experiences, perceptions of client and experiencing the relationship. This research showed the characteristics of RD between therapist and client. However, it only does so from the counselor's perspective.
To shed more light on clients' experiences of specific moments of RD, Knox (2008) focused on clients' experiences of the moment; then later Knox and Cooper (2010), with a completely different sample, focused on the relationship qualities associated with moments of RD. In both of these studies, a phenomenological approach was used where clients were interviewed using semi-structured interviews. In the former study, 14 therapist-clients (clients who were also therapists or trainee therapists) were interviewed, and in the latter, 14 'bona-fide' clients (non-therapist clients who were not trainee therapists) were interviewed. In both studies, clients reported that they identified one or more experiences of a moment of RD with at least one therapist. The experience of the moment itself was described as in another dimension, with a sense of spirituality, healing and empowerment.
Also, addressing the need for research into clients' experiences of RD, McMillan and McCleod (2006) focused on clients' experiences of RD within the therapeutic relationship as a whole (as opposed to specific times, experiences or specific moments) by interviewing 10 therapists who drew on their experiences from having been a client. They then analyzed interview data using a system of open coding as well as consultation with colleagues to enable a consensus of opinion concerning the categorization of descriptions. Their results concluded that 'letting go' was an important aspect of a deeply therapeutic relationship, and consequently, this emerged as a core category in their analysis. With regard to the term 'letting go', McMillan and McCleod (2006) state that they found significant evidence that in a deeply therapeutic relationship the decision to let go can almost be like a 'leap of faith'. 'Experiencing a deeply therapeutic relationship' and 'Experiencing an inadequate therapeutic relationship' were key subcategories. In the former, they found that clients' experiences of a therapeutic relationship were concerned with 'being ready to engage with the therapist', and in the latter, they found that clients experiencing wanting 'to get out of the relationship' also reported feelings of anger toward the therapist. The categorization of their data is very different to Cooper's (2005) categorization of therapists' descriptions, suggesting that clients' experiences of RD are different from therapists'. It could also suggest that the enduring quality of RD is experienced quite differently to specific moments or times of RD.
The concept of RD has now become part of the theoretical architecture of personcentered theory and therapy. It is the moment as a unique connection within a therapeutic relationship that two individuals are authentic and understanding each other (Mearns & Cooper, 2018). According to Wiggins (2011), the experience of RD is probably or clearly present in 34% of the significant events in therapy as identified by clients.
While such qualitative research as described above shows that RD is experienced as valuable by clients and therapists and points to the positive psychological potential of RD, there is as yet no quantitative research into the positive psychology of RD. Theoretically driven research is now needed to test for the statistical association between RD and other variables. There is no research to date which addresses the question whether RD leads to changes toward becoming a fully functioning person, as hypothesized in Rogers' (1957) person-centered theory. Specifically, the therapeutic relationship as defined in personcentered therapy by Rogers (1957) is predicted to lead to positive psychological changes in the client, who would be expected to move toward greater self-acceptance and congruence (Joseph, 2015).
As such, the aim of this research was to test whether the experience of RD was related to two key variables indicative of fully functioning behavior, namely unconditional positive self-regard and congruence (authenticity). It was hypothesized that those who were in therapy for longer periods of time would be more likely to develop stronger therapeutic relationships with their therapist, and thus experience RD, and that experiences of RD would be associated with greater unconditional positive self-regard and authenticity in clients.

Method
Participants and procedure Data were collected from 55 individuals aged over 16 years who reported having been clients in psychotherapy or counseling. All participants were volunteers and were recruited by the invitation of online survey through various Internet routes such as Facebook, Twitter and online forum posted on the psychotherapy and counseling centers pages, psychotherapist's groups and also universities forums particular to Korean and British clients. There were 23 British (41%), 20 Koreans (36%) and 12 others (21%).
The study was conducted for the dissertation component of the first author's MA in personcentered counseling under the supervision of the second and third authors. Respondents participated in the research via an electronic survey system with a two-month period. Ethical approval was obtained from the University of Nottingham, School of Education Research Ethics Committee. Participants provided the consent form via an electronic sheet on which they had to indicate agreement before proceeding. They were informed that their responses were anonymous and that they had the right to withdraw at any time during the survey. In an attempt to try to minimize assumptions on the part of participants about the purpose of the study, and thus social desirability bias, participants were simply informed that the purpose was to investigate: 'The client's experience of psychotherapy or counseling'.
The study was a cross-sectional survey, and therefore, data were collected at one time point only. At this time, participants were asked to indicate if they knew, what type of therapy they had experienced (by ticking a checklist of 'do not know', 'person-centered therapy', 'psychoanalysis or psychodynamic therapy', 'cognitive behavior therapy', 'Gestalt or other humanistic therapy approaches') and how long they had been in therapy for (by ticking a 5-point checklist: 'less than 3 months' = 1; '3-6 months' = 2; '6 months to a year' = 3; '1-3 years' = 4; and 'more than 3 years' = 5). We did not collect further information on gender or age.
Following this, participants were asked to complete three different psychometric selfreport measures to assess their experience of RD as clients in therapy, and their own unconditional positive self-regard and authenticity, in that order.

Measures
Three self-report measures were completed by participants.

Relational depth inventory
The 29-item relational depth inventory (RDI: Wiggins, 2011;Wiggins, Elliott, & Cooper, 2012) was used to measure the experiences of RD. Each of the 29 items (e.g. 'I felt my therapist respected me') is rated on a 5-point Likert scale (1 = not at all, 2 = slightly, 3 = somewhat, 4 = very much and 5 = completely). Scores on the RDI, therefore, have a possible range of 29-145, with higher scores indicating greater feelings of relational moments.
Unconditional positive self-regard scale The 12-item unconditional positive self-regard scale (UPSR: Patterson & Joseph, 2006, 2013 was used to assess the unconditionality of self-regard. Each of the 12 items (e.g. 'How I feel toward myself is not dependent on how others feel toward me') is rated on a 5-point Likert scale (1: Strongly agree, 2: agree, 3: neutral, 4: disagree and 5: strongly disagree). Scores on the UPSR, therefore, have a possible range of 12-60, with higher scores indicating greater unconditional positive self-regard.

Authenticity scale
The 12-item authenticity scale (AS: Wood, Linley, Maltby, Baliousis, & Joseph, 2008) was used to measure authenticity. The AS was developed to assess the concept of congruence. Each of the 12 items (e.g. 'I always stand by what I believe in') is rated on a 7-point Likert scale (1 = Does not describe me at all to 7 = Describes me very well). The AS can be used to produce three subscale scores of self-alienation, accepting external influence, and authentic living, but for the current study, we used only the total score (i.e. the eight negatively worded items are reverse scored, and then, all 12 items are summed to produce the total score). Scores on the total AS, therefore, have a possible range of 12-84, with higher scores indicating greater personal authenticity.

Analysis
In order to test our hypothesis, we undertook correlational analysis between scores on the above self-report scales to determine if there was an association between RD and unconditional positive self-regard and authenticity. We were also interested in testing for the association with time in therapy as it might be expected that those in therapy longer would score higher on the RDI. We were not concerned with differentiating between therapeutic modalities as Rogers' (1957) statement is an integrative one; i.e. the therapeutic relationship is important regardless of the type of therapy; the more it is present, the more the therapy will be effective. As such, we were purely interested in respondents who had had some experience of therapy regardless of the type in order to assess individual differences in the experience of RD. Our analyses involved the use of Pearson correlations as generated by the use of the statistical package SPSS (Version 23). We estimated that we needed a sample size of at least 50 in order to detect associations of a moderate size.

Results
Data were collected from 55 individuals aged over 16 years who were in psychotherapy or counseling (19 respondents answered they do not know what type of counseling they were receiving − 35%; 21 were in person-centered therapy -38%; 6 in psychoanalysis or psychodynamic therapy -11%; 5 clients in cognitive behavior therapy -9%; and 4 in Gestalt or other humanistic therapy approaches -7%).
Of those who responded to the question about length of time in therapy, 11 had been in therapy for less than 3 months -20%; 16 were in for between 3 and 6 months -29%; 13 between 6 months and a year -24%; 11 between 1 and 3 years -20%; and 3 for more than 3 years -6%; and 1 did not say -2%).
Each of the measures was found to have acceptable internal consistency reliability as used with the current sample of participants (Cronbach's alpha = 0.96, 0.92 and 0.83, for the RDI, UPSR and AS, respectively). Correlation analysis was used to investigate the association between length of time in therapy, RDI, UPSR and AS (see Table 1). As predicted, it was found that those who had been in therapy longer scored higher on the RDI, and higher scores on the RDI were associated with higher scores on UPSR and on the AS.
We also conducted partial correlations to test for the differential relations of the UPSR and AS variables to the RDI. It was found that with AS partialled out, the association between the RDI and UPSR was no longer statistically significant (r = 0.03, ns), but with UPSR partialled out, the association between the RDI and AS remained statistically significant (r = 0.37, p < 0.01).

Discussion
We found that greater client's experience of RD in therapy was associated with higher scores on unconditional positive self-regard and authenticity. These variables were chosen specifically to test for the positive psychological potential of RD. While there has been much research on the therapeutic relationship, it has focused on the alleviation of distress and dysfunction. Rogers' theory, however, was a form of positive psychology, hypothesizing that person-centered therapy leads to more than the absence of distress and dysfunction, but to greater congruence and unconditional positive self-regard (Joseph, 2015). Our results are consistent with predictions derived from Rogers' (1957) theory on the growth-promoting effects of the therapeutic relationship. This is the first study to show the statistical association between RD and unconditional positive self-regard and authenticity. These findings will be of interest to person-centered therapists but also to positive psychologists concerned with understanding what therapeutic factors lead to more optimal functioning.
Our partial correlation results also suggested the possibility that authenticity mediates the association between RD and unconditional positive self-regard. The main limitation of the current study is its correlational design; hence, its inability to provide evidence for causality and mediation. An initial correlational pilot study such as this is helpful in demonstrating evidence for an association before embarking on more expensive and sophisticated prospective research. Our results now suggest such research is warranted. Further prospective research is needed to test whether RD leads to higher unconditional positive self-regard and authenticity in clients. It is likely that there are bidirectional relationships between these variables and that greater client unconditional positive selfregard and authenticity also lead to greater RD, but only using more sophisticated statistical designs, we can show these effects over time in such a way as to provide evidence for the therapeutic value of RD.
Although a relatively small sample, we found that it was sufficient for us to detect the moderately strong associations between RD and both unconditional positive selfregard and authenticity. This was a mixed sample in terms of the type of therapy that was received, but this did not affect our hypothesis that regardless of the type of therapy, greater RD would be associated with unconditional positive self-regard and authenticity.
It is important to note that Rogers' (1957) statement about the quality of the relationship was an integrative statement that applied to all therapies. The fact that participants attended different therapies was not relevant to the hypotheses. We wanted to obtain a wide range of individual differences in the experience of RD. It may be that there are differences in RD across types of therapy but that was not the focus of our study, and our relatively small and unrepresentative sample would not permit meaningful statistical generalizations to be made from these data. However, further research might specifically wish to investigate this further with representative samples from each grouping to consider the association between RD and UPSR and authenticity. A larger sample would allow for analyses to test whether associations with RD are influenced by other variables such as the type and length of relationship.
We did not have details on the respondents' gender to investigate differences. However, Wiggins et al. (2012) found no statistically significant gender difference in levels of RD and concluded that there seems to be a 'limited role for gender as a determinant of relational depth' (p. 11). However, while gender was not a focus for our investigation, future larger studies might investigate this again.
Our sample was also mixed in terms of it being composed of Korean and British participants. Again, this did not affect our hypothesis as we have no reason to think that the prediction does not hold in both countries. Rogers' (1957) theory was not intended to be culture specific, but it would be important to be able to evidence that it does apply across cultures. It may be that there are linguistic and behavioral differences across cultures in the expression in RD. As such, we would encourage further research to develop on our preliminary work with larger samples in order to confirm these findings and to extend them across different therapeutic contexts.
In conclusion, our research is the first such study to test for a statistical association between RD and unconditional positive self-regard and authenticity, which are two variables specifically chosen to reflect Rogers' (1957) hypothesis about the positive psychological effects of the therapeutic relationship. Our results support the prediction that greater RD is associated with higher scores on these variables. As a cross-sectional study, we are not, however, able to provide evidence for the causal effect of RD, and further prospective research is now needed.

Disclosure statement
No potential conflict of interest was reported by the authors.

Notes on contributors
Jiyea Kim is a registered psychotherapist with BACP Accreditation. Jiyea graduated with a Masters degree in person-centered experiential therapy from the University of Nottingham in 2018. She is a psychotherapist in the Ministry of Health and Welfare at the Seoul St. Mary's Hospital in the Catholic University of Korea. Currently, she is working with clients who have problems with substance use and specializing in smoking cessation.
Stephen Joseph is a registered coaching psychologist and a senior practitioner member of the British Psychological Society's register of psychologists specializing in psychotherapy and an HCPC registered health and counseling psychologist. He is a professor at the University of Nottingham in the School of Education where he is part of the human flourishing research group and convener of the counseling and psychotherapy teaching group.
Sue Price is a lecturer and a member of the Center for Research in Human Flourishing at the University of Nottingham in the School of Education. Sue is a practising counselor and psychotherapist with BACP Accreditation. She completed her PhD at The University of Strathclyde in 2012 under the supervision of Professor Robert Elliott and Professor Mick Cooper. Her PhD focused on the development of an inventory designed to assess relational depth in counseling and psychotherapy.