Written by listed counsellor/psychotherapist: Charlotte Thomas MBACP registered, BA (hons), MSc, FCIPD, Ad.Dip.CP, MNCS (ACC)
17th February, 2013
Our coalition government might be further evidence of what Petr?ska Clarkson called the ‘postmodernist’ distrust of the ‘one’ or ‘grand’ truth. As we are shifting from our political allegiances, so we have been widening the lens by opting for a greater diversity of approach through an integrative psychotherapy; bringing together the Person Centred Model with parts selected from different traditions to form a new coherent whole.
But, if there is a single truth that continues, it is that the ‘relationship’ between client and Therapist is fundamental and rather more important, in terms of outcomes, than the particular schools of therapy to which a therapist may pledge allegiance. Some therapists go as far as to say that the relationship is the therapy (Kahn 1991), for others it is the centre of gravity, the cornerstone and the core to everything else in the theory and practice of therapy. As Clarkson put it, like water is to the fish, relationship is, for many therapists ‘the very medium in which we and our clients live, breath and find our meaning’ (Clarkson 2003).
Writing in 2003, Clarkson admits that, at that time, she had not integrated her professional life in her own therapy practice and concedes that she may never do so. She says she prefers the term ‘integration’ in the verb form – ‘integrating’ – as she finds it more ‘vital, alive and interesting’. Certainly, the concept as a ‘doing word’ suggests a work still in progress rather than that the job has been completed. Indeed, it is possible that each time a therapist meets a new client they begin ‘integrating anew’. Collectively they strive to form a unique and temporary coalition of the relationship with the insights and techniques from different theoretical orientations, selected because they best meet the needs of the client as they present at that time. However, this might be closer to a definition of ‘eclecticism’ rather than ‘integration’ and critics of that model might say that it is too random and lacks theoretical discipline.
Clarkson developed a conceptual structure containing five facets of the therapeutic relationship which she offered as a reference or sorting device to be used as a guide and to measure practice. She maintained that all five relationships would be available in every therapeutic encounter and: ‘Like the keys on a piano, some of them may be played more frequently or more loudly than others, depending on the nature of the music.’ (Clarkson and Pokorny 1994)
The relationship is the foundation of the model and the crucible around which integrative therapists construct a framework, allowing them to deploy the theories and techniques that they believe will be therapeutic for the client. The purpose of this essay is to explore the theoretical and operational glue that holds the specific techniques and approaches together and in place to form a coherent and ethically competent psychotherapeutic practice.
Lapworth and Sills (2010) provide a brief history of integration in which they describe the formation of three overlapping schools of therapy: Psychodynamic, Behavioural and Humanistic. They then describe how, instead of seeking to develop further brand new approaches, the attention of therapists has turned to the creation of integrative models by combining elements of the three schools. Integrative counsellors, therefore, seek to build coalitions between compatible, workable and useful aspects of the existing schools of thought and practice.
Exploring the Relationship
Meeting for the first time, the Therapist was thrown a little when the client (we will call her Fleur) said she had ‘parked right outside’. ‘Thrown’ because, she came in carrying, and deposited on the floor beside her, a couple of carrier bags, a rucksack and a pair of well worn trainers tied together at the top of the long laces so that she could toss them back on her shoulder when she was ready to leave.
As the she sat down and undid one or two buttons she revealed that, under her coat, her small frame was swathed in multiple layers of wool, cotton and jersey.
Should the Therapist voice what she is thinking, or is it far too early in the relationship to be so bold? What purpose would it serve? If the client’s presence in the room is so ‘conditional’ would the observation, however gently expressed, just send her ‘packing’? The Therapist decides to keep it for later and until after they have established some sort of relationship and the Therapist has discussed with the client why she has come. The useful therapy assessment notes provided by the agency say that the client is 33 years old, single, with a pattern of difficult transient relationships. She also has a history of anorexia and drug and alcohol abuse that are all well managed at present and the client has the support of a Sponsor from Alcoholics Anonymous (AA).
The challenge, thought the Therapist, is for the client to stay in the room long enough to form some sort of therapeutic relationship. Once a level of trust had been established, it might be possible for the client to (literally) peel off a layer or two and create what Clarkson called the ‘working alliance’ so that client and Therapist could join together in a shared enterprise. But, for the moment, the client seems very small and highly ‘defended’ perched, as she is, on the edge of the sofa on a Friday afternoon in early December as it is getting dark outside.
The Therapist is pleased to be seeing her Supervisor; she feels that another perspective is ‘overdue’. She and her Supervisor often use Clarkson’s five facet relational model as a framework for integrating and as a helpful shared language with which to discuss an experience with a client. The Therapist tells her Supervisor that she had been acutely aware of the need to offer, and for Fleur to receive, the six necessary core conditions at their first session. But the Therapist is wondering if she managed to penetrate the heavy defenses deployed by the client and if Fleur would even return for a second session.
As she offered warm acceptance and empathy, the Therapist said that the client looked at her with a wariness that was probably the product of earlier pain. The client had a child-like quality and her vulnerability was almost palpable. The Therapist said that she felt that the client had probably been affected at an early age by a lack of unconditional positive regard from an important figure in her life. She talked of ‘arrested’ development and she dipped into the concepts and language of ‘ego states’ from transactional analysis to help her to understand and describe the emerging issues from the case. She said that she had sensed the need for a ‘nurturing parent’ and an over abundance of the ‘critical parent’ in the client’s childhood development, leaving her with internal conflict and a strong conviction that she was ‘not ok’.
The Therapist shared with her Supervisor how she began the session gently, giving the client time to get comfortable in the room, establishing eye contact and getting a feel for the pace that would be appropriate for the client. The Therapist said that she expressed her goodwill towards the client by how she listened; how she was seeking to understand fully; how she was respecting and acknowledging the experience and the insight of the client and expressing her empathy through, as Rogers said: ‘entering the private perceptual world of the other…. being sensitive, moment by moment, to the changing felt meanings which flow in this other person…’ (Rogers 1980).
The Therapist explained to the Supervisor that her instinct was to avoid too many questions at this early stage but, having welcomed Fleur she did ask: ‘How are you feeling about being here today?’ The response from the client revealed much about her expectations of the therapy, these expectations having been formed by unhappy encounters with the profession in the past from which the client had fled prematurely.
The Therapist told her Supervisor that she had noted what the client had said and then went on to describe how she had intended to use the rest of the session to continue to set the stage for a solid ‘working alliance’. The Therapist said she was listening and summarising, contracting, setting mutually agreed goals, sharing the responsibility for treatment and ensuring, as best she could: ‘that both parties had a reasonably sound sense of each other and what the journey together – however ultimately unknown – may involve’ (Clarkson 2003)
The Supervisor nodded, offering her encouragement and endorsing the approach. She said to the Therapist: ‘I can see that you have been consciously and intentionally using the ‘self’ (‘self’ - in the way Rogers used the expression as being the person of the therapist) to make therapeutic contact with this client and to establish an effective working alliance. I think that the client is being well cared for the in relationship and the question you are asking is, does she feel well cared for? You have also, I think, begun to notice some of the difficulty the client is having in responding and, in Gestalt terms, co-creating the relationship’.
The Therapist was reassured that the Supervisor was following closely as she was keen to have the benefit of her insight and an external view. The Therapist went on to say that it was at this point she asked her second question:
‘Fleur, I am interested to know what brings you to therapy today.’
Transference/Counter transference relationship
The Therapist observed how Fleur was sitting on her hands and swinging her legs just above the floor so that they skimmed the carpet. The Therapist thought that the client looked much younger than her 33 years and noticed her shoes were flat with a rounded toe and a school girl’s T-strap fastening.
‘My mother’, she began, ‘had a dinner party with some new friends and wanted me and my brother to pop in ……not to stay, but just to be introduced and then go away again.’ With evident disgust she added: ‘Paraded like prime stock at some cattle market…..’
Fleur described how she had arrived late and heard the warm hum of appreciative laughter as her brother was leaving the dining room having done his ‘turn’ for the guests. Fleur paused at the door and heard her mother’s tipsy voice above the murmur, in a conspiratorial tone she was confiding in her guests:
‘I am afraid that you will find my daughter, when she finally arrives, far less well…..you know, a bit of a disappointment really ..….so typical of her to be late.’ ‘Never mind’, she adds with a resigned laugh, ‘we all have our crosses to bear……..’
Fleur said that she did not wait to hear how the guests responded but stumbled straight back out of the house, gulping for air and feeling a familiar pain in her stomach.
The Therapist told her Supervisor how she had been completely absorbed in Fleur’s painful story. So much so that she felt her attention was drawn back only slowly to what was going on in the consulting room. When it was, she realised that Fleur had got up from the sofa, clutching her stomach and then, gathering her things, she swept out of the door, weeping and muttering her apologies. The Therapist was a little startled and was slow to react. She then found herself alone in the now silent consulting room, with a full twenty minutes of the session still remaining.
The Therapist told her Supervisor that, immediately after the intensity of the moment, she realised that her first response was to actually offer herself reassurance: ‘…….as if I had actually been Fleur’s Mother, I was saying to myself: ‘it is not your fault; you have not done anything wrong’. Then I became conscious of the transference and recognised what had happened and how I was feeling.’
‘…….and how were you feeling?’ asked the Supervisor in a soft voice.
The Therapist said she felt disappointed that she had not managed the session better and not realised in the moment that she had become a symbol for Fleur and Fleur was re-creating in the consulting room the dynamics of the problem she had with her mother. The Therapist said that she felt that she may have been captured in the dynamics of the story or it may have even touched some vulnerability of her own. She still was not sure, but she said that she had missed the signals that Fleur had given when she had said that she had ‘fled’ from earlier encounters with psychotherapy. She said that, had she picked it up, she and Fleur could have discussed in advance how they would deal with a need to escape, should it occur during one of their sessions. She felt that she had ‘missed a trick’ and in doing so she had allowed the client to repeat old patterns of behavior and she may have reinforced the client’s sense of abandonment. She went on to quote sections of the ethical code questioning her competence, whether she had promoted the well-being of the client and if she had even avoided harm.
The Supervisor was alert to the danger of creating a parallel process in supervision and wanted to avoid a relationship between herself and the Therapist which would mirror the relationship between Fleur and her mother. She also felt that the Therapist was being overly critical of herself – in Cognitive Behavioural terms, the Therapist was ‘awfulising’ and ‘catastrophising’; probably in the same way that Fleur was questioning her own worth. The Supervisor told the Therapist that she wanted to use their session as an important developmental opportunity and she was sure that they could both learn much from the Therapist’s experience with Fleur. The Supervisor encouraged the Therapist to be curious about her own vulnerabilities.
The Supervisor agreed with the Therapist’s insight and said that it may have been helpful to have picked up on the signal and to have used it to strengthen the working alliance so that it could remain intact and withstand an early crisis.
However, the client may not have been ready for therapy and may have still left the session prematurely. The Supervisor also reminded the Therapist that she was now criticising her management of the session using the benefit of hindsight and she could not have known how Fleur would respond to the question ‘What brings you to therapy today?’ She added, with genuine honesty and some humility: ‘I am not sure any of us always pick up the signals all of the time’.
The Developmentally Needed or Reparative Relationship
The Therapist, feeling a little more grounded now said that, if the client returned for a second and further sessions, they may, in due course, work together to link the past, present and future. The Therapist had a keen sense of how identity is shaped by environment and relationships – as Gestalt practitioners say – ‘at the contact boundary’ - and also by a client’s existence in time. She worked well with a temporal framework and often found a timeline useful in helping the client to see patterns of behaviour repeated over time.
The Therapist and her Supervisor referred to the multidimensional integrative framework, described by Lapworth and Sills (2010) and they used it as a guide to produce a meta-view of the client’s world and context. The Therapist was also aware that she could apply the same model to her own process. They discussed how the working alliance could be strengthened by exploring how the client would deal with her shock, distress and disturbance in the present and ‘in here’. They would also make connections between the client’s past relationships ‘back then’ and her present relationships ‘in here’.
The Therapist might be able to say: ‘I am not your Mother’ and work with the client to change unhelpful beliefs and internal conflicts and to establish relationships which would enhance her contact with the world ‘out there’ and her development as an individual. The purpose of therapy was to assist the client in reassessing how she experiences and separates her past and present relationships and how much of her time she spends setting goals for her future. ‘The Therapist’s task may be to hold in mind a potential future for the client while endeavoring to offer the kind of ‘reparative relationship’ in the present that will allow for the future formation of nourishing interactions in the wider world.’ (Lapworth and Sills 2010)
The Person-to-Person or Dialogic Relationship
The Supervisor then asks the Therapist what she has to say about the person-to-person relationship. The Therapist had not analysed this before and so considers her answer deeply before responding:
‘I think that Fleur, in her distress, was relating to herself in a critical way and trying to disown that part of herself that was desperate to escape from the painful encounter in the consulting room. I expect that, the more she tried to disown or deny the need to escape, the more difficult it became to control it. With only limited feelings of self-worth and high levels of internal conflict, I would expect that Fleur had little capacity for finding her own inner adult or of finding me in a genuine in-depth encounter. A person-to-person relationship requires both therapist and client to be ‘present’ and, as Fleur was not fully present, the relationship was more ‘monologic’ than ‘dialogic’.’
The Supervisor agreed and reassured the Therapist by saying how well she was respecting the client’s defenses and her fragile state. She congratulated her for creating a safe space that was accepting, non-judgmental and affirmative and for gently inviting the client to join her there. Having sensed an urgency from the Therapist, she advised that ‘you cannot make it happen’ and, as Means and Cooper (2005) say about working at relational depth, you must let go of your ‘aims’ and ‘lusts’ and put your own agenda to one side. You have prepared the ground and now you must wait in readiness.
The Transpersonal Relationship
The Supervisor said that they had just enough time to share a few thoughts on the transpersonal dimension in relation to the session with Fleur. The Therapist said that her reflections were about shared stories and were reminiscent of Jung’s collective unconsciousness and archetypes. She said that she felt she could connect with Fleur on a number of ‘unconscious’ levels but particularly around the universal expectations and idealised characters such as: ‘the nurturing and comforting mother’ and ‘the vulnerable child in pain and in need of support and protection’. There were also connections around concepts and symbols such as, good and evil, time, abandonment, attachment and trust.
As they approach the end of their time together the Supervisor says:
‘Let me just ask you, how will you feel if Fleur does not return for a second session?’
The Therapist says that she would like to see Fleur again so that they could work together using an Integrative approach with the Person Centred model as the core philosophy. However, since having had this supervision session, the Therapist says she feels more able to respect the client’s right to ‘autonomy’ and to be ‘self-directing’ about when and how to seek treatment. The Therapist continues to reflect and says that Fleur has a level of self-protection that has been the coping strategy she has relied on for her survival. She may not be ready yet to take a risk and join the therapeutic relationship and she may not be resilient enough to maintain that commitment. She goes on:
‘In other words I suppose I am saying that I am more able now to ‘trust the process’ and Fleur will return if the time is right for her.’
The Therapist says that her experience with Fleur will always feature in her own personal history of cases that have contributed to her continuing professional development. The Therapist concludes by saying:
‘I hope that Fleur finds the strength to return for a second session and, if she does, she will find that her Therapist has also learnt from the experience’.
Clarkson, P. (2003) The Therapeutic Relationship Second Edition
Clarkson, P and Pokorny, M (1994) The Handbook of Psychotherapy
Kahn, M.D (1991) Between the Therapist and the Client: The New Relationship
Lapworth, P and Sills, C. (2010) Integration in Counselling and Psychotherapy Second Edition
Means, D. and Cooper, M. (2005) Working at Relational Depth in Counselling and Psychotherapy
Rogers, C (1980) A Way of Being
 Rogers stated that there are six necessary and sufficient conditions required for therapeutic change: Psychological Contact, Client’s incongruence, Therapist’s congruence, Therapist’s Unconditional Positive Regard, Therapist’s Empathy and the Client’s Perception that the conditions are present.
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