Components of a Therapeutic Relationship

WWW source Amended/ Extended AW

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

The Major Common Factors Leading to Therapeutic Change

• The heart and soul of change. Duncan et al

40%30%15%15%

Techniques

Hope and Expectancy

Therapeutic relationship

Clients & their Stage, Resources

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

Some types of Questions

• I keep six honest serving-men(They taught me all I knew);Their names are What and Why and When And How and Where and Who.I send them over land and sea,I send them east and west;But after they have worked for me,I give them all a rest.

Some Types of Questions

• I let them rest from nine till five,For I am busy then,As well as breakfast, lunch, and tea,For they are hungry men.But different folk have different views.I know a person small-She keeps ten million serving-men,Who get no rest at all!

Some types of Questions

• She sends'em abroad on her own affairs,From the second she opens her eyes-One million Hows, two million Wheres,And seven million Whys!

• From The Elephant's Child Rudyard Kipling.

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?