Components of a Therapeutic Relationship

Psych 260January 13, 2003

Components of a Therapeutic Relationship

What is a counselling relationship? Overview of counselling process Core conditions Contracting with clients Transference and Countertransference Content versus process Termination of therapy Listening skills Barriers to good listening

What is a counselling relationship?

Time limited Clear purpose Not a friendship relationship Central to success of therapy

Centrality of the Relationship

The perceived importance of the therapeutic relationship differs somewhat based on approach, but is generally accepted as central

PSYCHOANALYSIS BEHAVIOURAL THERAPY INTERPERSONAL THERAPY

Difference between a Therapy Relationship and a Friendship

Close Friendships Characterized by

intimacy, caring and support

Mutually reciprocal Both parties'

emotional needs are met

Equitable power

Therapy Also characterized

by intimacy, caring and support

BUT One-way focus Client's emotional

needs are central Power differential

inherent (imparts responsibility)

Overview of Counselling Relationship

The counselling process and relationship has a developmental or cyclical component to it – a beginning, middle and end

Each stage has different relationship tasks and challenges

Different theorists place different emphasis on importance of various stages or number of stages

Shebib characterizes the cycle as one with four phases: Preliminary, Beginning, Action, and Ending

Phase I: Preliminary

Create the necessary physical and psychological conditions for relationship to begin

First impressions are critical in any relationship, and clients often come to therapy highly anxious

Includes physical setting Also contacts that occur by phone, via a third

person Need to impart professionalism and warmth

Phase II: Beginning

Develop rapport Begin to build trust Outline purpose / contract Limit confrontation in this phase, work on

empathy and support

Phase III: Action

Relationship continues to grow Therapist more actively confronts and

challenges client E.g., may push client to see something in a way

different from their typical worldview Therapist needs to be able to tolerate tension,

potential disappointment as client is sometimes disillusioned with “ideal”

The maintenance of this relationship may be a corrective experience in and of itself

Phase IV: Ending (Terminating)

Specific phase, not just a cessation EXTREMELY important... can undermine

previous work Emphasis on reviewing, consolidating,

saying goodbye, shifting success to client A good termination may be another mastery

experience, especially for people who have experienced much loss

Core Conditions

Carl Rogers (humanist perspective) identified importance of non-judgmental acceptance of clients

These have been operationalized as three core conditions Warmth Empathy Genuineness

Contracting with Clients

Important to have an agreement / mutual expectations outlined at beginning

Lots of misconceptions about therapy Empowerment versus expert model Contract maps out process, responsibilities Encourages clients to take ownership from start The degree to which the contract is formalized

differs depending on the approach (benefits?)

Elements of a Contract

Definition of objective or purpose of the counselling relationship

Discussion of roles and expectations of participants

Discussion of the methods and routines of counselling

Practical details (time, place, fees, confidentiality)

Transference and Countertransference

Introduced by Freud – parallel process between how you relate to key figures in your life and how you relate to your therapist

Conversely, your relationships as a therapist effect how you relate to your clients

Although transference and countertransference are key in some approaches (psychoanalysis, psychodynamic approach), they are recognized by most theorists

Transference

Client may infer your reaction or thoughts (e.g., I know what you are thinking...)

Client may have a greatly exaggerated response compared to what would normally be expected Example of “Danny”

Eventually come to realization that therapy is not really about you

Countertransference

Can include intense feelings of attraction or repulsion

More than just reminding you of someone Can be increased by having a client with a

similar history / difficulties to yourself Need to be aware of your own process and

seek consultation as needed Custody and access example

Content Versus Process

What is actually said in a session The meta-communication (how something

is said, nonverbal communication, dynamics, etc.)

Can reflect some of this back to a client (particularly in certain types of therapy)

Talking about the process can be as or more important that the content

Termination of Therapy

Can be a difficult / powerful experience Sometimes clients deny difficult feelings Sometimes clients “dump you first” Sometimes clients regress / go into crisis Working through a termination with good

preparation and proactive approach can be an extremely positive experience for people

Can talk about mourning a relationship Examples

Listening Skills

Listening is a complex process What is said How it is said What isn't said Contradictions between verbal and nonverbal Emotional reaction Incongruity

Not easy or automatic

The “I know exactly how you feel” Trap

Often, the natural response is to try to convey empathy by indicating that you have felt the same way / had the same experience

Hollow listening Problems

Can invalidate uniqueness of experience Often a transition to talking about your story Shifts focus to your reaction, not the listener's

experience

Active Listening

Cluster of skills used to increase the accuracy of our understanding

Includes: Attending, Silence, Paraphrasing, and Summarizing

Although we often think of someone being a “good listener” as a personality trait, these are skills that can be taught

Attending The way you convey that you are available, ready to

listen, and willing to focus on someone else's experience

Non-verbal cues / body language – stance, eye contact, smile, etc.

Professional behaviour Avoiding fake enthusiasm When you are starting out, it can be tough to attend to

your client because you are so freaked out about what is going to happen next and whether or not you will be left speechless and looking like an idiot

Silence

Using and interpreting silence is not a value inherent in western / North American culture

Can mean different things for the client Client is thinking Client is confused an unsure of what to say or do Client is encountering painful feelings Client is dealing with issues of trust Silence is the client's usual way Client has reached closure

Encouraging Silence

Clients (and therapists!) who are impulsive and reactive can benefit from being encouraged to use silence I think it might be useful if we took a quiet minute or two... Let's pause for a moment It's okay with me if you want to think about it for a while When you're ready, we can talk about it. In the meantime,

I'm comfortable if we don't say anything Occasional silence is something that might occur during our

time together. Sometimes one or both of us will need time to think

**can also be assigned for homework

Paraphrasing

Way of testing your understanding by rephrasing client's own words

Client can then confirm or correct your understanding

Also indicated attending and focus Can be harder than it sounds

Example from high school curriculum training video

Summarizing

Way to check your understanding and assumptions

Way to organize complex information – may provide a framework for the client

Can focus on whole interview or parts Non-judgmental Check on accuracy / completeness of your

summary

Overcoming Listening Obstacles

Being patient Encouraging trust Controlling noise Staying focused – concept of mindfulness Controlling assumptions Managing personal reactions

(countertransference!) Knowing that listening does not mean agreeing Being aware of blind spots

Evaluating Ethics, Therapeutic Relationships and Listening Skills

For the following video examples Ethical considerations (what is done well,

what isn't?) Therapeutic relationship – are the core

conditions evident? Would you feel comfortable in this relationship? Can you tell what stage of the therapeutic process is represented?

Is the therapist using good listening skills?