The Therapeutic Relationship

Crucial Importance

“The maintenance of a realistic, friendly relationship with the psychotherapist is thus of crucial importance in the treatment of the psychoses and borderline states, and the current emphasis on the significance of the so-called therapeutic alliance or working alliance is justified with regard to these cases.”

- Kohut: The Analysis of the Self

Karl D. LaRowe

Feeling Safe Within Ourselves

• How/why we can feel unsafe• Personal issues get activated • Personal history of trauma• Degree of exposure to trauma issues

• Developing safety• Knowing yourself/feeling comfortable in your body• Feeling safe in your work environment• Relationships with supervisor/coworkers• Social support - support from family and friends

The “Holding Environment”

• The safety of boundaries• Self-organization and

consolidation

• As an “Organizing Principle”• Structure and support • Information and education • Consistency, clarity, reliability

Karl D. LaRowe

Engagement

• Encountering the client• The process of engagement

• Engagement challenges

• Engagement techniques

Karl D. LaRowe

Encountering The Client

• How does your mood and stress level impact your

perception of your client?• Emotion is Energy in MOTION

• Stress is contagious

• Before every contact with clients• Checking in with your own body

• Clearing energy residue

Karl D. LaRowe

The Process of Engagement

• Every session requires (re)engagement• Both client and therapist have changed

• Participant/observer perspective• Suspending attention• Being present• “Attuning” yourself to your client

• Mirroring (verbal and non-verbal)• Breath, motion, rhythm, eyes, voice, body tension

and movement, flow, verbal tone and intensity, use of language

Mirror, Mirror

• Wired for empathy• Somatic empathy• Empathic resonance• Neural WiFi & emotional

contagion• Mirror Neurons

• Motor, vision, memory areas of the brain

• Sensing actions and reading intention

• The felt-sense

Felt-Sense Mirroring Exercise

• Utilizing your feelings/sensations/intuition in a flow of energy/communication• 2 person non-verbal communication-relationship

exercise• Be curious, open your heart and mind• Sense, feel, follow and flow with another person’s

energy• Experience synergy and synchrony• Allow your natural self to come out and play

What Was Your Experience?

• Your overall sense-feel• Your connection to your body/mind• Your connection with your partner• Your feeling of synchronization• Your sense of energy• Your experience of “flow”

Karl D. LaRowe

Engagement Challenges

• The experience of being a client

• Client is brought/mandated to counseling

• Client does not trust you/mental health

• Client is internally distracted and unable to

process information very well

• Client does not believe you can help them

or does not believe they need your help

Engagement Techniques

“Engagement, or the development of a helpful, working or therapeutic alliance, has a strong impact on treatment outcome in clients with

psychosis” (Frank et al., 1989). • Recognize that the client may be nervous, wary or not want to see you

• Be aware that the client’s psychosis may distort their mode of interaction and their ability to process information

• Acknowledge and respect the client’s viewpoint identify common ground

• Listen carefully to the client and take their views seriously

Engagement Techniques

• Consider what is appropriate body language when interviewing a client who may be extremely paranoid, aroused or manic– sit side by side with the client (not too close) rather than face

to face– avoid too much eye-to-eye contact– allow personal space, for example walk around while talking

• Be helpful, active and flexible• Carefully explain the procedures involved in the assessment

• Gather information gradually, at the same time fostering a good relationship

Role Play

• Partner A: Role play a new client, first visit, recently discharged from Woodbridge, diagnosis of schizophrenia, first break, living with family, now stabilized on medication, not convinced s/he has a mental illness, is ambivalent about treatment and medications, was convinced by family to come to the agency. S/he is unemployed, is in recovery for alcohol/drugs, is not suicidal. Not actively psychotic but is anxious, suspicious, slightly paranoid.

• Partner B: Utilize the process just discussed to engage the client in an initial assessment• Feedback • Reverse roles

The Power of Listening

• The heart of listening• The need to be heard• The art of being present• The “felt-sense”

• The process of listening• Reflecting• Focusing• Confirming• Integrating

“Nobody cares how much you know until they know how much you care”

Reflecting (Mirroring)

• Attuning yourself to the overall “tone”• Listening to the music and not just words• Suspending attention/judgment• From the client’s perspective• Sensing underlying emotional currents

• Responding/acknowledging/connecting • Verbal and non-verbal• Expressing acceptance/non-judgment

Focusing

• Utilizing the “felt sense”• “Connecting” with your client through connecting with

your own body• Sensations/feelings/intuition• Sensing the message of the feeling• Expressing the feeling verbally• “I sense a reluctance to talk. Your not feeling very

understood right now”

It is only with the heart that one can see rightly; what is essential is invisible to the eye."

- The Little Prince

Confirming

• Identifying/clarifying what has been sensed, felt and said:• Acknowledging your understanding of what has been

said and why• Doesn’t mean agreement• Non-judgmental acknowledgment• “In other words you’re reluctant to talk with me. You

don’t think I can really understand you because I’ve never been hospitalized. Is that right?”

Integrating

• Helping the client make sense of and “metabolize” parts into a whole

• Facilitating integration - putting the “pieces” in a context that makes sense and develops more of a sense of self/wholeness

• Confirming the integration• “So, from your perspective counselors have never really understood

what its like for you because they’ve never experienced what you have.”

The Therapeutic Alliance

• Highly associated with positive outcome• The “holy grail” of therapist competency• More important than technique/orientation• Predictive of therapy outcome

• Corrective emotional experience• The opportunity to correct (heal) the broken trust of

abusive relationships• Initiates re-integration in the structure of the self• Re-establishes self-acceptance, self-trust, positively

influences self-esteem.

Development of the Therapeutic Alliance

• The therapeutic alliance develops over time• Based on an agreement to work together to achieve

specific goals

• Development of therapeutic alliance can be influenced by:• Residual symptoms

• Personality Disorders

• Depression

• Substance abuse

• Pre-morbid deficits

• Developmental issues

The “Vehicle of Psychotherapy”

• Mutual construction• A “collaborative relationship”

• Shared goals• Gives direction and motivation to counseling

• Accepted recognition of tasks• Client and therapist recognize their part in counseling

• Attachment bond• A “genuine liking”• Transference and counter-transference

“…a mutual construction between patient and therapist that includes shared goals, accepted recognition of the tasks each

person is to perform in the relationship, and an attachment bond.”

Transference

“New additions or facsimiles of the impulses and fantasies which are aroused and made conscious during the progress of analysis; but they have this peculiarity, which is characteristic for their species, that they replace some earlier person by the person of the physician"

- Sigmund Freud: "Fragment of an Analysis of a Case of Hysteria," (p.116).

Types of Transference

• Transference Neurosis and Transference Reactions

• Positive transference reactions• Basis of the therapeutic alliance• Can develop into “inappropriate” idealization• Expectations of entitlement, wish to merge

• Negative transference reactions• Avoidance/dis-engagement• Misdirected anger• Increased disorganization

Development of Transference Reactions

• Transference reactions can develop immediately or over time• Immediate, intense transference reactions may be

the result of:• “Unfinished business” with former therapist, provider or

institution• Identification with a (past/current) abuser• Instability within the sense of self

• The more intense/immediate development usually indicates self-weakness/instability

Qualities of Transference Reactions

• Inappropriateness• Reactions out of context to the situation

• Intensity• Usually overly intense

• Tenacity• Resistant to change

• Ambivalence• Idealization/devaluation

Counter-transference: A Tool for Understanding

“Counter-transference provides therapist with invaluable information to inform and shape their clinical interventions.”

- Trauma and the Therapist

• As a tool for understanding• Counter-transference is a reality of working with

SMPI and trauma clients;

• Counter-transference is not a sign of personal weakness or something the therapist is doing wrong

• Paying attention to counter-transference can give the therapist crucial information

Factors Contributing to Counter-Transference

• The therapist’s response to the reality of trauma and psychosis;

• The therapist’s responses to the client’s transference;

• The therapist’s defenses against his/her own affects or intrapsychic conflicts aroused by the client and his/her material in the session

• The therapist’s history, personality, coping style, and transference to the client

• The therapist’s response to his/her own vicarious traumatization

Utilizing Counter-Transference

• Self-honesty• Transparency and “in-sight”

• Personal responsibility• Taking ownership

• Self-expression• Addressing counter-transference

• Clinical supervision

“We do not see what we look at, we see what we look for”

The “Real” Relationship

• A realistic relationship based on a more stable, cohesive, resilient sense of self• It is more reality oriented. • There is a greater capacity for introspection. • There is a greater capacity for objectivity. • There is greater tolerance and ability to accept and

forgive the shortcomings of self and others. • There is a greater ability to empathize with others.• There is greater resilience