An Introduction to the Therapeutic Relationship in Counselling and Psychotherapy

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Stephen Paul & Divine Charura

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    Acknowledgements

    To our clients, supervisees, and students

    Whose narratives helped make this book

    About the Authors

    Stephen Paul has recently retired as Director of The Centre for Psychological Therapies at Leeds Metropolitan University after 20 years of service. He is a client-centred psychotherapist. He is co-editor of The Therapeutic Relationship: Themes and Perspectives (PCCS, 2008) and The Therapeutic Relationship Handbook: Theory and Practice (McGraw-Hill/Open University Press, 2014). Stephen was instrumental in developing a relational approach to therapy with Geoff Pelham (1999). He has worked extensively in both adult and child and adolescent psychiatry. He has been head of a therapeutic school and was Director of the VSO programme in Bhutan. Stephen now writes, practises therapy, undertakes supervision and coaching, and provides training.

    I have practised as a therapist in a wide range of settings since the mid-1970s. I worked in a psychiatric hospital in Liverpool where there were no strategies in place for working psychologically with patients. The therapeutic ethos was focused around drugs, ECT (electro convulsive therapy) and what was loosely called at the time ‘basket weaving’. In the late 1970s I set up a counselling centre in Bradford, one of the first in the UK, and met my first client. I had no formal training in counselling, there was little around in those days in Yorkshire. We just sat and I tried to be fully present to her and offer her a helping environment. I had no techniques to use, just myself. To this day I remember that first session. In the 1980s I trained and took courses in psychodynamic, humanistic and existential modalities to help me become fully equipped as a therapist. I ran groups in a London NHS Unit using what we would now call CBT for about eight years.

    I found that the different models helped me to understand and work with my clients, but as time went by none worked exclusively for me. It became clear to me that while techniques might work well for some people, they did not for others, even those with very similar life issues. I found that it was something in the relationship that was helpful. I later trained as a client-centred psychotherapist.

    In the 1990s, while developing counsellor training in Leeds and working with colleagues from very different modalities, we discovered that so much of what we did was very similar although we conceptualized it very differently. We thus formulated a relational paradigm and an approach that focused explicitly on what happened in the session.

    Divine Charura is a Senior Lecturer at Leeds Metropolitan University in Counselling and Psychotherapy. He is an Adult Psychotherapist who works in the NHS, the voluntary sector and in private practice. He has published various papers and contributed to various books.

    I started working in mental health settings in the late 1990s. I commenced psychiatric nurse training in Leeds and I worked in the old psychiatric asylums, including St James Hospital, Roundhay Wing and High Royds Mental Hospital, which was one of the oldest asylums in the UK and was opened in 1888 as the West Riding Pauper Lunatic Asylum. In these setting I worked with clients who were experiencing acute mental ill-health. Many of them were there against their will and had been detained under the Mental Health Act for assessment or treatment. The therapeutic interventions in these settings were often giving medication to clients, and supporting clients with activities of daily living. At times, when patients became agitated or violent, they were restrained, injected, then secluded and monitored through a small window in what was called a seclusion/de-escalation room. In worst case scenarios, I escorted patients many times to the electroconvulsive therapy (ECT) suite, where electric shock treatment was administered to them. These interventions made me question the therapeutic relationship that was being offered to those experiencing mental distress.

    I decided that, as I was dissatisfied with the practice, I would train further in counselling and psychotherapy. I spent eight years training in different psychotherapy modalities. In that time I met Steve Paul, who had co-developed with colleagues a relational paradigm that focused explicitly on the relationship as being central to change. This hugely impacted on my learning and practice.

    Since I have worked as a psychotherapist, I have learnt that a good therapeutic relationship is the most central and key ingredient to client therapeutic change.

    Contact details

    Stephen Paul: www.stephen-paul.co.uk

    Divine Charura: psychotherapyinleeds@gmail.com

    Acknowledgments

    SP

    With my thanks to

    Alice Oven, who invited me to write this book, and later to Kate Wharton, whose encouragement kept it on track

    Other members of the team at SAGE including Laura Walmsley, Rachel Burrows, Camille Richmond, and Shaun Mercier, plus Sarah Bury our copyeditor and Bryan Campbell our proofreader

    Jacqui Gray from BACP

    Divine who came on board at the half-way mark and helped bring it to fruition

    Colleagues, whose advice and information helped craft both content and design: Brian Charlesworth, Joy Cullwick, Tracey Hitchcock, Geoff Pelham and Pete Sanders

    Colleagues at Leeds Met University, including, Kay McFarlane, Paul Nicholson and Jayne Godward

    Joyce Cramond, Judith Dryhurst and Nina Wright

    Kathy Paul, who read the book through and gave a layperson’s advice and guidance

    Joan Dexter and Rosie Paul who were always there in the writing of the book

    Sheila Haugh, whose guidance and insights helped sow the seeds that are evident here

    DC

    With my thanks to

    Steve Paul, a great mentor and teacher, for inviting me to help write this book and spending many hours working on it with me

    Professor Colin Lago, a wise mentor and colleague, for your inspiration and encouragement

    My parents Alois and Letisia, my wife Helen, and my siblings David, Tatenda, Talent, Elizabeth and Enock, for all your love and for always being there

    Colleagues, students at Leeds Met University and at St Anne’s community services who continually teach me so much

    Inspiring colleagues, Lynne Fordyce, Misha Fell, Anne Burghgraef, Jonathan Philpot, Anne Sunter, Stuart Gore and Andrew Hawkins

    With thanks for health, strength, faith and love, which make all things possible

    Thanks to all who have helped and inspired us whose names we may have omitted here: You know who you are

    Acronyms

    • ACT Acceptance and Commitment Therapy
    • BT Behavioural Therapy
    • CBT Cognitive Behavioural Therapy
    • CORE Clinical Outcome in Routine Evaluation
    • CT Cognitive Therapy
    • EBPs Evidence-based Practices
    • ECT Electro Convulsive Therapy
    • GD Guided Discovery
    • IAPT Improving Access to Psychological Therapies
    • MBCBT Mindfulness-based Cognitive Behavioural Therapy
    • MBSR Mindfulness-based Stress Reduction Practice
    • MRI Magnetic Resonance Imaging
    • NHS National Health Service
    • NICE National Institute for Health and Care Excellence
    • RA Relational Approach
    • RCT Randomized Control Trial
    • RFT Relational Frame Theory
    • TR Therapeutic Relationship
    • UPR Unconditional Positive Regard
  • Glossary

    Actualizing tendency

    Innate movement towards realizing one’s full potential.

    Agape

    Selfless love towards another.

    Authenticity

    Being true to and living from one’s own self, despite external conditions.

    Behaviourism

    A modality which is deterministic and assumes that people’s behaviour and self-concept is entirely controlled by their environment and their prior learning. The ‘second force’ in psychology.

    Common factors

    The core factors that research has found to be effective in all forms of therapy, regardless of theoretical model. These include extratherapeutic change, hope/expectancy, model or technique and the therapeutic relationship. The TR is considered to be the most powerful in-therapy factor.

    Conditions of worth

    As the child develops, they learn that some behaviours attract more positive regard than others. When they actively choose or avoid a self-experience because of the need for positive regard they are said to have acquired a condition of worth.

    Configurations of self

    A ‘configuration’ is a construct made up of a pattern of feelings, thoughts and behavioural responses which represent to the person different aspects or parts of their self.

    Congruence

    The ability to be present, open and genuine in relationship with the client.

    Consensual validation

    Comparing our experience with the feedback of others through interpersonal therapy.

    Containment

    Therapist’s ability to work and maintain the therapeutic frame with whatever the client brings.

    Core model

    The coherent theoretical discipline the practitioner works from, for example, psychodynamic, Gestalt, cognitive-behavioural, psychosynthesis.

    Countertransference

    This is the process by which an individual is stimulated by the behaviour of their client and responds personally from their own material.

    Dasein

    Literally meaning being there, to be truly present with another.

    Dodo effect

    Relates to the idea of psychotherapeutic equivalence – that all psychotherapies are equally effective regardless of modality. It originates from Lewis Carroll’s Alice’s Adventures in Wonderland where the Dodo said after a race, ‘Everybody has won and all must have prizes.’

    Drive theory

    Relates to the idea that humans are born with particular psychological needs and that human functioning is based upon the interaction of drives and forces within the person. A negative state of tension is created when these needs are not met.

    Eclectic

    A mix of theory and practice drawn from a range of models of therapy.

    Eclecticism

    A multi-modal approach to working effectively with clients. It mainly refers to the drawing on of a range of different techniques to get the best result for the client.

    Ego

    Is the sense of our conscious ‘I’ which regulates our inner drives and our social self.

    Emic approach

    An approach based on the unique insider’s perspective and customs and beliefs; a ‘culturally-specific’ way of relating with others.

    Empathy

    The ability to enter the perceptual world of the client and have an accurate understanding of that perceived reality.

    Etic approach

    An approach based on an outsider’s view of another and seeing them as ‘culturally universal’. The assumption, therefore, is that all should be treated in the same way in every setting regardless of their culture. It is critiqued as a dominant, likely Eurocentric, perspective.

    Eurocentricism

    Focused on Europe or European/western people’s ideas concepts and values.

    Existentialism

    A philosophical school of thought that proposes that the personal meaning of life is central to existence and that there is no objective ultimate Truth.

    Existential-humanistic

    A modality of psychotherapy which focuses on individual responsibility and self-determination. The existential-humanistic therapist is typically engaged in helping the client take responsibility for their situation and operates as a catalyst for growth. A term for the ‘third force’ in psychology including incorporating both humanistic and existential psychologies.

    Frame of reference

    The perspective an individual has of their reality.

    Fully-functioning person

    A state of psychological adjustment when all conditions of worth are dissolved or removed. The individual is living fully in the moment.

    Guided Discovery

    A process that a therapist uses to help the client reflect on the way that they process information. The therapist asks the client Socratic questions which enable the client to reflect on their thinking processes.

    Humanistic

    Associated with humanistic psychology, the ‘third force’ in psychology concerned with personal growth and self-actualisation.

    I–Thou relationship

    Buber’s concept of the I–Thou relationship relates to a way of being in the therapeutic relationship. It is essentially about a human-to-human relationship in which there is a process of authentic encounter and dialogue.

    Id

    The Freudian unconscious; senses and thoughts below the surface of our awareness; the id is the home of our instinctual drives.

    Idiosyncratic empathy

    Empathic responses that are unique to an individual client.

    Incongruence

    A mismatch between self-concept and experience which results in a feeling of anxiety.

    Interactive coordination

    This is the joint collaboration by both parties in the work of therapy.

    Internal working model

    A cognitive conceptual framework that an individual uses to make sense of the world, the self and others.

    Interpretation

    Possible explanations of a meaning in dream, behaviour, action, thoughts or feelings. Interpretation may be used to explain how the client’s presenting issues are embedded in old relationships and conflicts.

    Interruption

    A strategy to stop the client in mid-process to enable them to reflect on their behaviour.

    Intersubjectivity

    There is not one reality (the client’s) and an objective observer (the therapist) in the therapy room, but two subjective realities.

    Introjected, introjection

    The psychological process in which the standards and values of others are unconsciously and symbolically taken within oneself.

    Locus of evaluation (LOE)

    With internal LOE, self-assessment is independent of others, while with external LOE, there is a dependence on the judgement of others.

    Magnetic Resonance Imaging (MRI)

    A test using a magnetic field and pulses of radio wave energy to ‘see’ internal structures in the body.

    Meta-analysis

    A comprehensive independent review of a number of studies which identifies factors that are measurably significant. A meta-analysis employs standardized methods to evaluate, compare and review many different studies.

    Mirror neurons

    A type of brain cell activated when doing an action, and similarly when watching someone else perform the same action. Mirror neurons have been associated with our ability to be empathic. The communication of empathy by the therapist triggers and activates new mirror neurons within the client.

    Neuroplasticity

    The brain’s ability to reproduce new neurones and reorganize itself by forming new neural connections throughout an individual’s life.

    Neurotransmitters

    Chemicals that are exchanged between neurones.

    Object Relations theory

    Object Relations theory proposes that people relate to others and situations in their adult lives as shaped by family experiences during early childhood. Significant experiences are internalized as objects which form part of the self-structure.

    Organismic valuing process

    A process in which all action is directly motivated towards immediate inner gratification and fulfilment of the self.

    Paradigm

    A holistic way of viewing or conceptualizing; a worldview.

    Parataxic distortions

    Perceptions of others based on our own (distorted) inner experiences.

    Philosophy

    The study of the fundamental nature of knowledge, reality and existence.

    Pluralistic approach

    A way of practising, researching and thinking about therapy which is embedded in humanistic, person-centred and postmodern values, but also fully embraces a whole range of effective therapeutic methods and concepts.

    Positive regard

    The valuing of the other and their perceptual world.

    Postmodern Psychology

    A branch of psychology which questions whether there is an ultimate or singular version of truth. Reality is considered to be multi-dimensional and practitioners seek to avoid reducing human experiencing to a model based on past social perspectives. It reflects current social and cultural values and contexts.

    Projection

    The act of locating one’s own thoughts and feelings on to another person.

    Projective identification

    The projection of unconscious feelings/impulses on to another in such a way as to evoke, in the other, those feelings/impulses projected.

    Proxy self

    The presentation of an ‘acceptable’ front/persona by a person of diversity that helps them manage life relating to those persons and attitudes of the dominant group.

    Psychiatry

    The medical specialty dedicated to the study, diagnosis, prevention and treatments of mental disorders.

    Psychoanalysis

    The first ‘force’ of psychology, a psychological theory and therapy which aims to understand and treat psychological problems by examining the interaction of conscious and unconscious elements in the psyche and bringing repressed fears and conflicts into conscious awareness.

    Psychodynamic

    The interaction of conscious and unconscious processes and emotions that determine motivation and personality; a form of therapy using psychoanalytic theory relationally.

    Psychology

    The scientific study of the human mind and its functions, especially those affecting behaviour in a given context.

    Randomized control trial

    A study that randomly assigns subjects to two groups: a control group in which members are not subjected to any interventions, or may in some cases be treated with a placebo effect; and an experimental group in which members are subject to one or more interventions that the experimenter wants to investigate. The results are then compared to determine any significant change.

    Relational approach

    A paradigm which overarches modalities and schools. In the RA, our self is formed through relationship with others. We grow and develop through relationship, and problems are solved through relationship. A relational therapist is a facilitator and full participant in the TR. A relational approach can also be a core model of therapy.

    Relational depth

    Describes feelings of connectedness and relating between therapist and client. They may be moments of encounter or refer to a particular quality of relationship.

    Relational fatigue

    A sense of being ‘fed up’ or tired of working with clients in the therapeutic relationship.

    Researcher allegiance

    A risk of bias in psychotherapy outcome research. An example is research funded by those who want to prove that their preferred way of working is best.

    Resistance

    Considered a healthy defence mechanism for the psyche against threats to the self-structure. Traditionally considered within the analytic tradition as everything in the words and behaviours of the client that prevents access to unconscious material.

    Rupture

    A break in the agreed working alliance.

    Self-concept

    The image a person has of themselves based on experiences, beliefs, perceptions and thoughts.

    Self-disclosure

    The revelation of personal rather than professional information about the therapist to the client.

    Self Psychology

    Self is a central structure of the personality. It is formed over time in relation to impressions from parents or significant others.

    Selfobject

    A part of the infant’s experiencing that becomes an element of the developing self-structure.

    Socratic questioning

    A systematic combination of questions which facilitates the client’s ability to look at things from alternative angles that they may not have considered before.

    Super-ego

    In psychodynamic psychology, the element of our psyche which is concerned with our place in society and how we behave in relation to the expectations of others.

    Theorem of reciprocal emotion

    We gain or suffer as our needs are met in relationships.

    Therapeutic alliance

    A component of the therapeutic relationship; the agreement between client and therapist on goals, tasks and the boundaries of the TR which helps form the frame in which therapy takes place.

    Therapeutic frame

    The container in which therapy takes place and is held. This will include the context, the contract and the therapeutic relationship.

    Therapist facilitativeness

    A generic term to describe relational behaviours of the therapist to enable change.

    ‘Third Wave’ CBT

    A range of therapies, including acceptance and commitment therapy, dialectical behavioural therapy, metacognitive therapy, mindfulness-based cognitive therapy and schema therapy. The focus is on accepting and understanding thought and feelings and inner psychic relations rather than changing or controlling them.

    Transference

    A term used by therapists to describe feelings, thoughts or memories that a client has from their past that they project on to another person. This is done out of conscious awareness and can be quite innocuous or can have more complex dynamics.

    Transmuting internalizations

    The process by which aspects of the selfobjects are absorbed into the child’s self.

    Transpersonal

    The fourth ‘force’ of psychology which focuses specifically on the development of being, spirituality and a holistic view of the individual. A transpersonal therapist undertakes a guiding role in the client’s journey.

    Unconditional positive regard

    An accepting, valuing attitude to another person without condition or judgement.

    Unitary paradigm

    A way of conceptualizing that includes all perspectives.

    Vicarious traumatization (VT)

    The cumulative effect of the therapist working with clients who are traumatized or distressed. This results in the therapist becoming traumatized.

    Working alliance

    This is the working relationship between the therapist and the client based on agreed goals and ways of working together.

    ‘Zero-sum’ responding

    A global generic response as opposed to responding empathically and non-selectively to all the different aspects of the client that present.

    Appendix: Conclusions and Recommendations of the Interdivisional (APA Divisions 12 & 29) Task Force on Evidence-Based Therapy Relationships (John C. Norcross, PhD, Chair, 2 January 2011)

    Conclusions of the Task Force
    • The therapy relationship makes substantial and consistent contributions to psychotherapy outcome independent of the specific type of treatment.
    • The therapy relationship accounts for why clients improve (or fail to improve) at least as much as the particular treatment method.
    • Practice and treatment guidelines should explicitly address therapist behaviours and qualities that promote a facilitative therapy relationship.
    • Efforts to promulgate best practices or evidence-based practices (EBPs) without including the relationship are seriously incomplete and potentially misleading.
    • Adapting or tailoring the therapy relationship to specific patient characteristics (in addition to diagnosis) enhances the effectiveness of treatment.
    • The therapy relationship acts in concert with treatment methods, patient characteristics, and practitioner qualities in determining effectiveness; a comprehensive understanding of effective (and ineffective) psychotherapy will consider all of these determinants and their optimal combinations.
    Elements of the relationshipMethods of adapting

    Demonstrably effective

    • Alliance in individual psychotherapy

    • Empathy

    • Collecting client feedback

    • Reactance/resistance level

    • Preferences

    • Culture

    • Religion and spirituality

    Probably effective

    • Goal consensus

    • Collaboration

    • Positive regard

    • Stages of change

    • Coping style

    Promising but insufficient research to judge

    • Congruence/genuineness

    • Repairing alliance ruptures

    • Managing countertransference

    • Expectations

    • Attachment style

    Practice Recommendations
    • Practitioners are encouraged to make the creation and cultivation of a therapy relationship, characterized by the elements found to be demonstrably and probably effective, a primary aim in the treatment of patients.
    • Practitioners are encouraged to adapt or tailor psychotherapy to those specific patient characteristics in ways found to be demonstrably and probably effective.
    • Practitioners are encouraged to routinely monitor patients’ responses to the therapy relationship and ongoing treatment. Such monitoring leads to increased opportunities to reestablish collaboration, improve the relationship, modify technical strategies, and avoid premature termination.
    • Concurrent use of evidence-based therapy relationships and evidence-based treatments adapted to the patient is likely to generate the best outcomes.
    Policy Recommendations
    • APA’s Division of Psychotherapy, Division of Clinical Psychology, and other practice divisions are encouraged to educate its members in the benefits of evidence-based therapy relationships.
    • Mental health organizations as a whole are encouraged to educate their members about the improved outcomes associated with using evidence-based therapy relationships, as they frequently now do about evidence-based treatments.
    • We recommend that the American Psychological Association and other mental health organizations advocate for the research-substantiated benefits of a nurturing and responsive human relationship in psychotherapy.
    • Finally, administrators of mental health services are encouraged to attend to the relational features of those services. Attempts to improve the quality of care should account for treatment relationships and adaptations.
    Products of the Task Force

    Norcross, J.C.(ed.) (2010) Evidence-based therapy relationships. Module on SAMHSA’s National Registry of Evidence-based Programs and Practices: NREPP/SAMHSA Website.

    Norcross, J.C.(ed.) (2011) Psychotherapy Relationships that Work: Evidence-Based Responsiveness (2nd edn). New York: Oxford University Press.

    Norcross, J.C.(ed.) (2011) ‘Evidence-based therapy relationships’, Psychotherapy, 48 (1).

    Norcross, J.C. and Wampold, B.E.(eds) (2011) ‘Adapting psychotherapy to the individual patient’, Journal of Clinical Psychology, 67 (2).

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