The surprising ways you can come unstuck in therapy

This article will look at how we might come unstuck in psychological therapy. That is by remaining in reciprocal roles (Ryle, Kellett, Hepple, & Calvert, 2014). A role is a term used for the way we respond to other people. Roles are reciprocal when they form pairs that reinforce each other. In some situations, this pairing creates a useful complementarity. For example, if we want to stop change occurring and perpetuate a beneficial status quo. However, in therapy adopting reciprocal roles can mean a person remains stuck in the distressing patterns of relating that brought them to therapy in the first place. As such, this article will examine how these reciprocal roles occur, provide examples of these roles, link particular roles to common mental health problems and detail practical changes we can use to shift roles in therapy. So reducing the client's distress and increasing their health.

How might reciprocal roles come about? 

People develop a range of roles from infancy onwards in relation to others, usually starting with our parents. In therapy, the initial preferences of each person may suggest or imply roles. However, our preferred roles may also be unconscious. Bringing them into awareness can help us examine their usefulness and if we want to change them. As an introduction some common reciprocal roles are listed below:

Role A: Intellectualising/emotional
Role B: Unthinking/unfeeling

Role A: Helpless/irresponsible
Role B: Helping/responsible

Role A: Rebellious/bullied/masochistic
Role B: Controlling/bullying/sadistic

Role A: Seducing/manipulating
Role B: Seduced used

Role A: Always sad
Role B: Always angry

Role A: Withholding/reactive/rejecting
Role B: Disclosing/proactive/defensive

Role A: Parent/judging
Role B: Child/judged

Role A: Narcissistic/demanding
Role B: Acolyte/placating

Role A: Doer/expert/prescribing
Role B: Done too/novice/recipient

As you can see each role represents a part of reality. Allowing the other person to represent a different aspect of reality. Meaning that when operating as a pair the individuals can more effectively deal with life.

As with all depictions of human relationships, these are necessarily simplified. Caricatures to emphasise a particular part of relating. I hope it is clear from the examples that when roles fit together (are reciprocal) we get a lock of complementarity. This means they become harder to break out from because the roles reinforce each other. Another way to characterise the impact of reciprocal roles is to place them in the context of common mental health problems. These are generalisations from my twenty years experience. However, they are all ways we can get stuck in distressing patterns of relating.

Relational roles, therapists and clients may adopt, in the context of common mental health problems

Generalised anxiety -  reciprocal roles which either over, or under, value the benefits of worry, focus on the future, and/or the value of therapy.

Social anxiety -  reciprocal roles which differ in their fears of being authentic or causing offence, people-pleasing, finishing the session early, arriving late, talking about other things. Acting as if we were ming vases. Seeing therapy as completely typical rather than a partially different experience of life.

Health anxiety - reciprocal roles which disagree about how desirable it is to accept uncertainty/mortality/vulnerability, where expertise lies and a realistic speed of change.

Grief - roles which contrast in their views of endings, the period of time which is most salient and/or marking the passing of time.

Depression - roles with a variety of approaches to experiencing sadness/anger. Critical, shaming, demanding or punitive interactions. Comparisons of status, education and/or income.

Anger - roles which disagree about the value of expressing sadness, passive aggression, not saying if we are hurt by the other and/or a denial of other feelings. 

Paranoia - roles where there is a suspicion of motives, and/ or unquestioning interactions.

Violence - roles which include submission, masochism, a lack of boundaries, a lack of explanation, symbolic abrupt interaction, non-verbal communication and/or rupture.

Medically unexplained symptoms - roles which vary in their experiences of uncertainty, lack of control, confusion, anger, exclusion and/or discrimination.

Chronic fatigue -  roles which divide about their experience of energy, helplessness, dissociation from other emotions, sensitivity and/or disconnection from others.

How can a therapist help clients come unstuck from unhelpful reciprocal roles? 

I think the job of a therapist is to create experiences useful to the client. Engaging in repeated, healthy and conscious interactions with reality. Making conscious shifts in practise to change unhelpful reciprocal roles.

In our favour, is any motivation we have to repair the past and change our roles. These shifts are made more difficult by any motivation we have to repeat unhelpful roles and experiences of our past. To illustrate how this can work in practise below are examples of conscious shifts I have made to break unhelpful reciprocal roles from my clinical career.

Persistence. Often it is not clear how I can help someone. Persistence in the face of this uncertainty has been the most effective means to make therapeutic progress. Proving I really mean it when I say you want to help.

Talking more about my experience of the here and now. The difficulties, joys and feelings. Me modelling what it is like to do so in that context has often taken the pressure off the client to talk first.

Changing my approach to treatment. In sum ‘I have sat down and put the pen down’. So turning exercises into an option rather than an agenda. Letting paperwork follow the evolving relationship and using my training and experience as a resource, not an instruction manual. Often clients have responded positively to being trusted to create a good enough process together.  

Using less strong emotions. For example in my facial expressions and using less eye contact.  

Acknowledging my failures. In particular apologising when I seem to have hurt someone's feelings even if unintentionally.

Allowing myself to be cared for as a way of caring for others.

Sitting with silence, stopping asking questions. 

Not feeling totally responsible for the outcome. I can only do my best. Sharing responsibility for the process.

Not placing myself between two significant relationships (e.g. father and son).

Stop trying to get everything right e.g. saying I don't know but will try.

Offering choices over how we work together, about the level of structure, homework, past/present/ future focus, challenge, theory and /or practice.

I have learnt these lessons the hard way. Through my own mistakes. I know shifting practise, in response to the reality of each relationship, can help prevent harm. Beginning with acknowledgement of our part in difficulties. These shifts also signal to the other person that the therapist could feel, and know, as they do. Avoiding my way or your way struggle. Communicating that our opposing experiences, and roles, can be both respected and added to.

These changes may be seen as a dilution of effort in therapy. I think this is no coincidence. To work, therapy has to feel real but not too real. This difference allows for play instead of just drama. So the interactions in therapy are consequential but without the usual consequences. All aiding the participants to tolerate a wider range of emotional experiences than outside therapy. Dilution for therapeutic effect (Benjamin, 2019.) 

Conscious and healthy interactions with reality

In summary, we have seen how we can easily slip into ways of responding to other people that are unhelpful. These reciprocal roles in therapy can prevent us from reducing distress and increasing our health. These roles are multiple and complex. However, there are patterns we can recognise and shifts we can make to change the reality of the relationship. I suggest effective therapy involves the therapist consciously adjusting practice to create useful additional roles for the client.

References

Benjamin, J. (2019, Apr, 1). Enactment and the theory of the third. Retrieved from: https://www.youtube.com/watch?v=GA0dcQ13rt8&list=LLSr6fHMgXhGzrFJ1qwcKfJA&index=2&t=0s

Ryle, A., Kellett, S., Hepple, J., & Calvert, R. (2014). Cognitive analytic therapy at 30. Advances in Psychiatric Treatment, 20(4), 258-268.