The Therapeutic Relationship: In Psychoanalysis, Counselling Psychology and Psychotherapy

Product Information

In the special interest group we recognised that polarised responses often occur in people with learning disability. Examples include All-Powerful (often the therapist) / Completely Powerless (often the patient). Living with a sense of weakness and woundedness a person with a learning disability may see “normal” others, including the therapist, as clever and useful and herself as dim and useless. Kim, when choosing a button to represent herself, selected a very small button because she felt that she could not do anything, whilst she chose a very large button for me. It was as if in facing the cognitive difference between us she felt completely worthless and useless. It was good to see that when she repeated the exercise towards the end of therapy she chose buttons of much more equal size. Ideal care is often sought out and reciprocated. It is as if we need to somehow magically make up for the limitation, vulnerability and sense of woundedness, which are faced by patients on a daily basis. CAT helped me to be aware of this and to avoid colluding with it. Clarkson (1995 p181) describes the transpersonal relationship as “the timeless facet of the psychotherapeutic relationship, which is impossible to describe, but refers to the spiritual dimension of the healing relationship.” She suggests a relationship “analagous to that of the marital pair” with its potential for space and fruitfulness, writing about the “sacred space.” De Groef, J. (1999) Mental Handicaps: A Dark Continent. In De Groef, J. and Heinemann, E. (Eds), Psychoanalysis and Mental Handicap. Free Association Books. As individuals, as psychotherapists and as a society, it is healthier to learn to connect with people with learning disability and the pain that they bear for us, and the gifts that they bring us, than it is to distance ourselves or destroy. In wishing to conceal or get rid of disability we deny or destroy an essential part of our humanity. Living in a society which places such a high premium on achievements, possessions and the perfect looks of the adverts, it may be hard to be in touch with the imperfections which are part and parcel of the human condition. Connecting with disability brings us more in touch with the whole of ourselves, allowing us, if we will, to accept the strengths and weaknesses of our full humanity.

Perhaps what people with learning disability most long for and need is the experience of the person-to-person relationship in which two adults meet as equals. Much can get in the way of this, but my experience was that when we were truly able to make authentic connection as human beings of equal value, then change, growth and transformation could occur. I found that this aspect of therapy tended to grow as the therapy progressed and that it could be encouraged by limited self-disclosure which allowed the patient to have a sense of the person behind the therapist. In my practice this was initially extremely limited, for example to a personal comment about a shared experience such as the weather or noise outside the room. I found that too early or too much self-disclosure was either ignored or caused tension within the relationship. However appropriate self-disclosure could be transforming. Michael saw himself and others as being either all good, loved and accepted or all bad, blamed and rejected. When he made the “mistake” of absconding, we were also able to reflect about a “mistake” I had made when I had not taken enough notice of him saying that he did not want to talk about his father, with the consequence that he had been reluctant to come to one of the therapy sessions. Then we were able to share the reality that, as human beings, we both made mistakes and when we did, if we recognised them and tried to make amends for any hurt we had caused, then it was not the end of the relationship, rather it allowed a deepening and strengthening of the bond between us. This marked a turning point in the therapy and also in his relationships outside. Another example was when I arrived very late for one of my sessions with Claire. As well as accepting my apology she was able to say that she felt angry with me. I was no longer the idealised, nurturing mother. I became another human being who sometimes got it wrong. This allowed us to move forwards with that experience of equality and humanity woven into our work.

Transference & Countertransference Relationship

The therapeutic relationship refers to the relationship between a healthcare professional and a client or patient. It is the means by which a therapist and a client hope to engage with each other and effect beneficial change in the client. In the Humanistic approach, Carl Rogers identified a number of necessary and sufficient conditions that are required for therapeutic change to take place. Rogers stated that there are six necessary and sufficient conditions required for therapeutic change: [ citation needed]

Gelso, C.J. and Hayes, J.A. (1998). The Psychotherapy Relationship: Theory, Research, and Practice. (p. 22-46): John Wiley & Sons: New York. In many ways working with people with learning disability is just like working with anyone else. However issues of woundedness, weakness, limitation, difference and vulnerability (alongside the need for appropriate independence and autonomy) are particularly strong. The challenge is to find a way of establishing and maintaining authentic, life enhancing relatedness (Safran 1993) in the face of these issues. Let us take a brief look at each of these in more detail; Relationship Psychology – The Working Alliance

The Transpersonal Relationship

The transferential/countertransferential relationship refers to the idea that we may remind a client of someone from their past, or vice versa, and the related feelings from the past may be transferred to the present, so affecting the therapeutic relationship. If this happens, it is important to explore the issue in supervision. In my work with people who have learning disability I found that in recognising, facing, accepting and appropriately communicating our limitations, woundedness and vulnerability, in person-to-person relationship, we were brought to a part of ourselves where we could meet together, as adults of equal value, at a deeply significant level and experience a creativity which was bigger and beyond ourselves. With it there came a sense of freeing bonds that had tied us both, allowing for spontaneity, movement and change. Often this was expressed in the diagrammatic representation of the work as the patient brought this alive with their use of colour and drawings. (For examples see King 2002). I understand this to be the transpersonal aspect of relationship. Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook of Counseling Psychology (4th ed.). (pp. 267-280). In counselling we call this empathy and this is mirrored across many approaches such as person-centred and psychoanalytic theory. Carl Rodgers first said this was one of the necessary conditions required for successful therapy to take place, along with genuineness and unconditional positive regard, those were referred to as the core conditions. Awareness of personal countertransference is particularly important in work with people with learning disability. Relating to those who carry the woundedness and weakness of disability means that we must face our own disability, weakness and wounds, something which we would often prefer to ignore, conceal, deny or thrust on to others. (Symington 1981; De Groef 1999) Powerful feelings may arise in us such as contempt (Symington 1992), guilt and intense compassion (Sinason1992). A variety of responses to these feelings may occur. Disability may be denied, losing connection with what is real. There may be avoidance, distancing or rejection . Alternatively there may be an attempt to provide perfect care to make up for the weakness and pain. We may fall into judging ourselves to be inferior or superior, bringing feelings of worthlessness or contempt. Or we may put unwanted parts of ourselves into those who are different leading to denigration, contempt, rejection, abuse and exclusion. These feelings and responses will tend to undermine or destroy the therapeutic relationship or may even lead to a reluctance to offer therapy at all. (Bender 1993)

You are here: Home > Reformulation > Spring 2005 [Issue 24] > CAT, the Therapeutic Relationship and Working with People with Learning Disability CAT, the Therapeutic Relationship and Working with People with Learning Disability Consultant in Psychiatry of Learning Disability (retired). Currently clinical assistant with Salisbury Alcohol and Drug Advisory Service and CAT Therapist”. As a framework for my study I used the model of five different aspects of the therapeutic relationship described by Clarkson (1995): namely; the working alliance; the transference/countertransference relationship; the developmentally-needed or reparative relationship; the person-to-person or real relationship and the transpersonal relationship. The key idea of Clarkson’s Five Relationships was the use of a systemic integrative psychotherapeutic model. it is safe to say she was, and continues to be a major contributor to the world of psychotherapy. Relationship Psychology Relationship Psychology – The Therapeutic Relationship Miller, M. E. (2000) The Mutual Influence and Involvement of Therapist and Patient; Co-Contributors to Maturation and Integrity, In Young-Eisendrath, P, and Miller, M. E. (Eds) The Psychology of Mature Spirituality. Routledge.The therapeutic alliance, or the working alliance may be defined as the joining of a client's reasonable side with a therapist's working or analyzing side. [6] Bordin [7] conceptualized the working alliance as consisting of three parts: tasks, goals and bond. Tasks are what the therapist and client agree need to be done to reach the client's goals. Goals are what the client hopes to gain from therapy, based on their presenting concerns. The bond forms from trust and confidence that the tasks will bring the client closer to their goals. Ardito, R. B., & Rabellino, D. (2011). Therapeutic Alliance and Outcome of Psychotherapy: Historical Excursus, Measurements, and Prospects for Research. Frontiers in Psychology, 2. DOI:10.3389/fpsyg.2011.00270. Therapist unconditional positive regard: The therapist accepts the client unconditionally, without judgment, disapproval or approval. This facilitates increased self-regard in the client, as they can begin to become aware of experiences in which their view of self-worth was distorted or denied. Clarkson (1995) emphasises that these are aspects rather than stages in the relationship. However she describes a gradual development through the different aspects as therapy progresses. This was echoed in my work in which the development of the relationship seemed to evolve naturally, though at times I was aware of guiding or encouraging the process. The working alliance was established at the start and deepened as the therapy progressed. Sometimes it was threatened by transference and countertransference issues, which needed attention. Provision of the developmentally-needed relationship was required from early on. Working with these three aspects of the relationship seemed to allow for a stronger development of the person-to-person relationship in which could be found the transpersonal with all its creative energy. It was my experience that all of these aspects of relationship were grounded in the very ordinary stuff of being human.

Psaila, C.L. and Crowley, V., 2006. Cognitive Analytic Therapy in People with Learning Disabilities: an Investigation into the Common Reciprocal Roles Found Within this Client Group. Reformulation, Winter, pp.5-11. A Qualitative Study of Cognitive Analytic Therapy as Experienced by Clients with Learning Disabilities Rogers describes the core conditions of Empathy, Congruence and Unconditional positive regard, as the foundations of building an interpersonal alliance between two people. In terms of “The 5 relationship model,’ the therapist would use these conditions to facilitate the ongoing encounter with the client.Greenhill, B., 2011. "They have behaviour, we have relationships?". Reformulation, Winter, pp.10-15. Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in therapeutic change. Psychological Monographs: General and Applied, 76, 1-33. Greenson, R.R. (1967) The technique and practice of psychoanalysis. (Vol.1). New York: International Universities Press. King, R., 2005. CAT, the Therapeutic Relationship and Working with People with Learning Disability. Reformulation, Spring, pp.10-14. Humour also had a role in promoting the person-to-person relationship. With Michael we used buttons in each session to help him express his feelings and experience. Each time at the beginning of the session when he opened the tin of buttons he would comment “what no biscuits then.” It was a moment we both enjoyed.