A Relational Approach to Therapy

“We are evolutionarily hard-wired to heal and be healed by human connection and social interaction’ Elkins (2016 p51)

We are living through interesting times; the rise in terrorism, interest in mental health and an increasing need for connection in our digital age, creating challenges and new possibilities in the helping professions. This article has come about from our rigorous discussion: what is effective in therapy and supervision?

There has been much debate about whether the therapy or the therapist is more significant in predicting the effectiveness of therapy. Research has now confirmed that the quality of the relationship between counsellor and client is central to the effectiveness of the therapy (Norcross 2002 and Elkins 2016).

Meta-analyses of studies examining the linkage between the therapeutic alliance and outcomes in psychotherapy (Martin et al., 2000) have also confirmed these results. Significantly, it was also indicated that the quality of the alliance was more predictive of a positive outcome than the type of intervention.

Yet currently, therapy is increasingly defined by what we offer according to medical diagnosis. ‘We need to use CBT for medical problems such as depression or anxiety or EMDR to work with PTSD’. We can feel defective if we are not trained in the latest techniques. Yet both researches into effective therapy and into neuroscience are showing that it is the relationship, not particular modalities or techniques that bring relief from the struggles.

Over that last 10-15 years, there has been a quiet revolution in our work with a significant paradigm shift, a relational approach that values the subjective experiences that we have with each other.

Within the psychodynamic schools, ‘relational theory’ has already developed (Mitchell 1988, Frawley-O’Dea and Sarnat 2001, DeYoung 2015). Transactional Analysis (Hargaden and Sills 2002, Hargaden 2016) has taken a ‘Relational Turn’ and Person-Centred theory has moved to ‘relational depth’ (Mearns and Cooper 2005). Even CBT have gone 3rd wave, looking at meaning and Compassion Focused Therapy (Gilbert 2010).

In addition, David Elkins (2016) argues that psychotherapy can best be understood as an expression of ‘social healing’ and offers a nonmedical model of emotional healing by developing a relational approach.

We are at a pivotal time in the development of therapy. At the same time as the relational approach has been developing the neuroscience are also having an impact on our profession. Most commentators on the neuroscience have come to the conclusion that the brain is a social organ (Siegel 2010), we are pack animals and our brains have developed to help each other adapt and heal each other. One person needs another person to heal. We are even told that the use of compassion can literally help clients and supervisees create healing chemicals in the body, change neural pathways in the brain and develop hormonal responses that can help heal past abuses. (Badenoch 2008) The implication of this is enormous for therapy!

So what does this mean for therapists? How can we use this knowledge to make ourselves the most effective practitioners we can be? What do we mean when we say we work relationally?

WORKING RATIONALLY

Most problems in life are relational. That is they were born out of our experiences in relationships with others. So if they arise from interactions in a relationship, then they can be healed with interactions in relationships with ‘emotionally regulated’ others; regulated in effect, being trustworthy, safe and ethical.

The relationship needs to be connected. In relational theory (DeYoung 2015) human beings are seen as part of a network of relationships, continually motivated, from birth, by the need for a relationship that shapes the internal perception of external experiences. Disconnections in relationships create psychological difficulties. A relational approach is to establish authentic and mutual connections.

The therapist needs to be in the relationship with all their passion and humanness. In our experience clients do not want someone who is disengaged, holding some idea of the ‘role of the therapist’. What they tell us is they want someone fully engaged and human.

Being subjective and using our subjective experiences in service of the client is crucial to relational work. We wish schools of therapy would get away from teaching ‘not to self-disclosure’ and teach students ‘how and when to disclose’, working with what may be useful to the therapeutic relationship.

Stark (2000) integrates different schools of thought in therapy describing three modes of how therapists relate: one-, one-and-a-half and two-person. The ‘one-relationship' is classical therapy. The therapist holds the position of wise expert, interprets the clients’ discourse, trying to keep their own personal experiences out of the relationship. ‘One-and-a-half is where the therapist is more involved with their emotions/observations/disclosures at the moment and a ‘two-person’ relationship is a therapist who will use full disclosure of self in service of the client and their relationship.

All of these modes have value, the psychodynamic ‘one-‘ and the Rogerian and Kohut ‘one-and-a-half’ are all familiar concepts to most therapists, the more contemporary relational ‘two-person’ mode is less commonly taught and the area we are interested in developing.

From the neurosciences (Badenoch 2008) to the basics of any therapeutic approach, we feel the elements below are necessary for full engagement in a relational approach.

The Interconnected Relational Elements

INTENTIONS

Intention holds all our ethical values and principles, the ethics of doing no harm. Intention within the therapeutic relationship is ‘conscious choice’. The notion of intention in this context comes from the teachings of Craniosacral Therapy (Milne 1995) and Shamanism “How we intend to listen, observe, heal or hold sacred space is a creative power second to none” (ibid p59).

If we have the assumption that we are inherently healthy and self- regulating beings; when we meet ourselves and others with this understanding, and align our intention to find ‘where the health is’. We are creating a very positive space in which to engage, allowing the whole body and brain to integrate and function at its best.

PRESENCE

When we are present with others we are receptive to what is going on with the other person and viscerally within ourselves. Our state of being constantly emerging and re-emerging as we connect with others and our inner world.

Presence is a fluid, energetic state created and developed as we exist in each other’s company. Working relationally means we need to have a clear a lens as possible, to have worked on our own issues enough to be regulated in our effect. Being relational is also then helping the client or supervisee to be fully present with us. Exploring any taboo’s and blocks in our relationship that may impede fully being together. Two beings fully present create the possibility of attunement.

ATTUNEMENT

Attunement happens when two people are coinciding with each other with respect and compassion. They become ‘attuned’ to their internal emotional states then as we bring empathy and attunement together we get a bodily and viscerally felt empathy that creates connectedness (Finlay 2016).

Thomas Merton defined compassion as being based on a keen awareness of the interdependence of all these living beings, which are all part of one another, and all involved in one another. This could be another explanation of attunement.

RESONANCE

To resonate is to ‘chime’ together, that mutuality which is so important for therapy to work, as the client feels that they are as part of what is going on, that they too have a right to exist making observations and contributions to the ‘wisdom voices’ that emerge from the work.

We can get caught in mutuality if it starts moving towards symbiosis – always agreeing with each other, that is speaking only from one mind, one model, and one approach as the only way of doing therapy; a conditioned response to each other.

In all dynamic relationships, there is a dance between intimacy and separateness which we can sometimes get wrong. But we have to do the dance and possibly get it wrong because then we can meet each other’s separateness which leads us then to reciprocity (see text box below)

RECIPROCITY

Reciprocity is the mutual action and transaction that then is agreed together in the relationship; the give/take interchange that continually builds the bridge between two fully relating beings.

In and between these elements we will pick up echoes of, and experience with, blocks and frustrations, distorted effects and mistrust, hurts and resentments that have left imprints and re-enacted in the working therapeutic relationship, ours and the clients!

For example, when shame is triggered, both can hide or get caught in ‘feeling loops’, usually triggered unconsciously. Hence the reason for the therapist to know as much about their own issues as possible, not to make sure they are free from contamination in the therapy session, but more to notice such ‘ruptures’ and work with the feelings triggered in the unconscious, in service of the relationship with the client. To hold, tolerate and explore; leading to reworking and healing the neural pathways often for both client and therapist.

Now we are starting to work relationally!

JUDY'S EXAMPLE

Once when a person arriving for supervision, wasn’t the person I expected…..

As I adjusted to the person in front of me, my supervisee clearly saw my perplexed expression, and asked: “Are you alright”. I thought I had a cancellation, and on closer examination understood my confusion when I had not put her clearly in my diary. In that initial moment, although I said I was O.K. she, an experienced counsellor, struggled to begin. I needed to address and confirm her struggle.

Taking time to explore what was happening, confirmed my confusion which she intuitively sensed. This unnerved her; her pattern is to assume she is in the wrong. I was attuned to another person in my intention before she came to my door, we were ‘mis- attuned’ and she was able to sense this. By owning my mistake, she was confirmed in her intuition. She realised her struggle to begin was because of my not being ready for her; not any problem with her. This allowed us to connect deeply and trust each other’s non-conscious messages and speak them.

References

Badenoch B (2008) Being a Brain-Wise Therapist Norton New York

DeYoung, P.A. (2015) Relational Psychotherapy: a primer (2nd ed) Routledge. Hove

Elkins D.N. (2016) The Human Elements of Psychotherapy - a nonmedical model of emotional healing American Psychological Association Press. Washington

Finlay, L. (2016). Relational Integrative Psychotherapy: Processes and Theory in Practice, Chichester: Wiley

Frawley –O’Dea, M. G. and Sarnat, J.E. (2001) The Supervisory Relationship. A Contemporary Psychodynamic Approach The Guilford Press. New York

Hargaden H (ed) (2016) The Art of Relational Supervision-clinical implications of the use of self in group supervision Routledge

Hargaden H and Sills C (2002) Transactional Analysis A relational perspective Routledge Hove

Martin D. J., Garske J. P., Davis M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. J. Consult. Clin. Psychol. 68, 438–45010.1037/0022-006X.68.3.438

Mearns, D. and Cooper, M. (2005) Working At Relational Depth in Counselling and Psychotherapy. London: Sage Publications

Milne. H (1995) The Heart of Listening: A Visionary Approach to Craniosacral Work. Berkeley, California. North Atlantic Books

Mitchell, S.A. (1988) Relational Concepts in Psychoanalysis. Cambridge: Harvard University Press.

Norcross J.C. Ed (2002) Psychotherapy Relationships that work New York: Oxford University Press

Siegel D (2010) The Mindful Therapist – A clinician’s guide to mindsight and neural integration Norton: London

Stark M (2000) Modes of Therapeutic Action Aronson. New York

KARL GREGORY

RGN, RMN, MSc Counselling, Diploma in Psychotherapy Supervision, FNCS

• Integrative relational therapist – integrating relational, existential and systems approaches across many differing professions

• Previously, 20 years’ experience as a psychiatric nurse, tutor, supervisor and manager in the NHS

• Lecturer and external examiner at various Universities and Colleges in the UK

• Co-founder of Severn Talking Therapy as a vehicle to run an annual Supervision Conference UK, an Advanced Diploma in Relational Supervision course and workshops

• 20 years in private practice.

JUDY HEMMONS

MA. Diploma Integrative Psychotherapy, Diploma Supervision Certificate in Craniosacral Therapy, Occupational Health Nursing Certificate. UKCP. RCST. CSTA Accredited Supervisor

• Integrative Relational Therapist – integrating constellations, epigenetics and neuroscience

• Worked in the NHS and business sector.

• Previously established and co-ordinated counselling agencies

• Trained Counsellors, Psychotherapists, Social Workers, Shiatsu Practitioners and Craniosacral Therapists in Trauma management.

• Course Leader on Foundation Degree in counselling.

• Has been in private practice for 24 years.