An Introduction to the Therapeutic Relationship in Counselling and Psychotherapy
Publication Year: 2015
Subject: Therapeutic Relationships
The therapeutic relationship is considered to be the most significant factor in achieving positive therapeutic change. As such, it is essential that trainee and practising therapists are able to facilitate a strong working alliance with each of their clients. This book will help them do just that, by offering a practical and evidence-based guide to all aspects of the therapeutic relationship in counselling and psychotherapy. Cross-modal in its approach, this book examines the issues impacting on the therapeutic relationship true to all models of practice. Content covered includes: -The history of the therapeutic relationship -The place of the therapeutic relationship in a range of therapy settings, including IAPT -Concepts and practical skills essential for establishing and maintaining a successful working alliance -The application of the ...
- Front Matter
- Back Matter
- Subject Index
- Chapter 1: Introducing the therapeutic relationship
- Chapter 2: What the research tells us
- Chapter 3: The relationship in different modalities
- Chapter 4: A relational approach to therapy
- Chapter 5: Developmental factors in a relational approach
- Chapter 6: Establishing the relationship
- Chapter 7: Developing the relationship
- Chapter 8: Challenges to the relationship: When things get tricky
- Chapter 9: Ending the relationship
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© Stephen Paul and Divine Charura 2015
First published 2015
Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, this publication may be reproduced, stored or transmitted in any form, or by any means, only with the prior permission in writing of the publishers, or in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers.
Library of Congress Control Number: 2014936186
British Library Cataloguing in Publication data
A catalogue record for this book is available fromthe British Library
ISBN 978-1-4462-5664-0 (pbk)
Editor: Kate Wharton
Assistant editor: Laura Walmsley
Production editor: Rachel Burrows
Marketing manager: Camille Richmond
Cover design: Shaun Mercier
Typeset by: C&M Digitals (P) Ltd, Chennai, India
Printed in Great Britain by Henry Ling Limited, at the Dorset Press, Dorchester, DT1 1HD
To our clients, supervisees, and students
Whose narratives helped make this book[Page vi]
About the Authors
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
[Page xi]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
- 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
Innate movement towards realizing one’s full potential.
Selfless love towards another.
Being true to and living from one’s own self, despite external conditions.
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.
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.
The ability to be present, open and genuine in relationship with the client.
Comparing our experience with the feedback of others through interpersonal therapy.
Therapist’s ability to work and maintain the therapeutic frame with whatever the client brings.
The coherent theoretical discipline the practitioner works from, for example, psychodynamic, Gestalt, cognitive-behavioural, psychosynthesis[Page 259].
This is the process by which an individual is stimulated by the behaviour of their client and responds personally from their own material.
Literally meaning being there, to be truly present with another.
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.’
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.
A mix of theory and practice drawn from a range of models of therapy.
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.
Is the sense of our conscious ‘I’ which regulates our inner drives and our social self.
An approach based on the unique insider’s perspective and customs and beliefs; a ‘culturally-specific’ way of relating with others.
The ability to enter the perceptual world of the client and have an accurate understanding of that perceived reality.
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.
Focused on Europe or European/western people’s ideas concepts and values.
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.
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[Page 260].
A state of psychological adjustment when all conditions of worth are dissolved or removed. The individual is living fully in the moment.
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.
Associated with humanistic psychology, the ‘third force’ in psychology concerned with personal growth and self-actualisation.
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.
The Freudian unconscious; senses and thoughts below the surface of our awareness; the id is the home of our instinctual drives.
Empathic responses that are unique to an individual client.
A mismatch between self-concept and experience which results in a feeling of anxiety.
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.
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.
A strategy to stop the client in mid-process to enable them to reflect on their behaviour.
There is not one reality (the client’s) and an objective observer (the therapist) in the therapy room, but two subjective realities.
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[Page 261].
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.
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.
The brain’s ability to reproduce new neurones and reorganize itself by forming new neural connections throughout an individual’s life.
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.
A holistic way of viewing or conceptualizing; a worldview.
Perceptions of others based on our own (distorted) inner experiences.
The study of the fundamental nature of knowledge, reality and existence.
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.
The valuing of the other and their perceptual world.
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.
The act of locating one’s own thoughts and feelings on to another person.
The projection of unconscious feelings/impulses on to another in such a way as to evoke, in the other, those feelings/impulses projected.
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[Page 262].
The medical specialty dedicated to the study, diagnosis, prevention and treatments of mental disorders.
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.
The interaction of conscious and unconscious processes and emotions that determine motivation and personality; a form of therapy using psychoanalytic theory relationally.
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.
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.
Describes feelings of connectedness and relating between therapist and client. They may be moments of encounter or refer to a particular quality of relationship.
A sense of being ‘fed up’ or tired of working with clients in the therapeutic relationship.
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.
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.
A break in the agreed working alliance.
The image a person has of themselves based on experiences, beliefs, perceptions and thoughts[Page 263].
The revelation of personal rather than professional information about the therapist to the client.
Self is a central structure of the personality. It is formed over time in relation to impressions from parents or significant others.
A part of the infant’s experiencing that becomes an element of the developing self-structure.
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.
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.
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.
The container in which therapy takes place and is held. This will include the context, the contract and the therapeutic relationship.
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.
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.
The process by which aspects of the selfobjects are absorbed into the child’s self.
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[Page 264].
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.
This is the working relationship between the therapist and the client based on agreed goals and ways of working together.
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)[Page 265]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 relationship Methods of adapting
• Alliance in individual psychotherapy
• Collecting client feedback
• Reactance/resistance level
• Religion and spirituality
• Goal consensus
• Positive regard
• Stages of change
• Coping style
Promising but insufficient research to judge
• Repairing alliance ruptures
• Managing countertransference
• Attachment style[Page 266]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.
[Page 267]Products of the Task Force
- 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.
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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