Components of a Therapeutic Relationship

1. Components of a Therapeutic Relationship Psych 260 January 13, 2003

2. 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

3. What is a counselling relationship? • Time limited • Clear purpose • Not a friendship relationship • Central to success of therapy

4. 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

5. Therapy Also characterized by intimacy, caring and support BUT One-way focus Client's emotional needs are central Power differential inherent (imparts responsibility) 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

6. 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

7. 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

8. Phase II: Beginning • Develop rapport • Begin to build trust • Outline purpose / contract • Limit confrontation in this phase, work on empathy and support

9. 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

10. 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

11. 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

12. 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?)

13. 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)

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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?