Two well known and utilised views of the therapeutic relationship include the transference/countertransference model and the reparative model, both of which . “The developmentally needed or reparative relationship is an intentional provision by the psychotherapist of a corrective, reparative. These are (a) the working alliance, (b) the transference/countertransference relationship, (c) the developmentally needed/reparative relationship, (d) the.
My aim is to reintroduce these important theoretical concepts, but set them in the relational and developmental frame, which is integrative psychotherapy. I consider that all therapists would benefit by understanding regression to dependence, whether they choose to work with it or not.
In my book I highlight these theories and identify their application to practice. I also explore the implications of working at this depth, for both client and therapist and the necessity of flexibility and availability on behalf of the therapist.
I also address the traumatic aspects of childhood neglect and deprivation. Erskine and Trautmann describe the process of integrative psychotherapy referring to the integration of theory with a perspective of human developmental tasks and needs. The theoretical foundation focuses on child psychological development, the understanding of attachment patterns and the lifelong need for relationship. When working with regression to dependence, I may adjust the boundaries of my usual therapeutic stance, particularly those around contact outside sessions and touch, I must stress the importance of supervision when working in this way.
Stewart considers that work on this area of analysis has not received the recognition it deserves because of the adaptation of technique that it requires, and the necessity of the therapist living without knowing for long periods. In my experience, rather than seeing a regressive phase which is clear and distinct, which clients approach and then move away from, I have experienced an overarching movement to deeper levels of regression over the course of therapy and I have also noted that clients may move in and out of regressed states within any session.
Bollas describes working with patients in the process of breakdown and the difficulties for the analyst when patients tip into psychosis. Professional therapists are trained and motivated to expand and develop their knowledge and experience.
Since Van Sweden wrote this, experience, knowledge and understanding have continued to evolve. Some of this evolution has been towards understanding the intersubjective nature of the relationship and its healing potential, and some has been towards treating the majority of patients minimally, where cost is the prime consideration, as in the upsurge in CBT.
Whilst I have no doubt that for some people these minimal interventions are relevant and effective, for others the complexity of their presentation requires other, more significant forms of help. This book is useful for practicing psychotherapists and supervisors, trainee psychotherapists, psychotherapy training programmes, and those with no formal training, but having an interest in the subject.
CAT, the Therapeutic Relationship and Working with People with Learning Disability
Researchers who are interested in the heuristic process and reflexivity may also benefit. My research has contributed to the theory and practice of psychotherapy and will be of interest to a range of audiences. Members of other disciplines may also have an interest in these findings, such as social scientists involved in understanding the development of personal identity, identity process and the development of self.
Ryle ;Ryle and Kerr As a framework for my study I used the model of five different aspects of the therapeutic relationship described by Clarkson Clarkson 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. In many ways working with people with learning disability is just like working with anyone else.
Key psychotherapeutic theries
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 in the face of these issues. It is increasingly accepted that CAT can be used effectively with people with learning disability.
Experience, gathered by a few practitioners working in the field and pooled in a special interest group has been summarised by Ryle and Kerr p In this article I will consider each aspect of the therapeutic relationship in turn, linking each with the theory and practice of CAT and my experience of working with people with learning disability.
The clinical material quoted in this article is derived from six completed CAT therapies, which I have undertaken with people with mild or borderline learning disability The Working Alliance The working alliance has been described as involving the reasonable, rational part of the patient and therapist, allowing them to be part of a shared undertaking.
This enables the work to proceed even when difficult transference and countertransference feelings occur by allowing them to be recognised and worked on. Gelso and Carter Bordin proposes three essential aspects of the working alliance, the collaborative setting of goals; the joint agreement on tasks and the development of a human relationship or bond. Ryle This concept is of particular importance in work with people with learning disability. One way of addressing the difference in cognitive ability is in modifications of the CAT tools.
I found that simplifying the wording of the Psychotherapy File King ; taping the Reformulation and Goodbye Letters and using simplified SDRs incorporating colour and drawings King were all helpful. It is suggested that the tools of CAT all serve to create and maintain the working alliance. Ryle ; Ryle and Kerr p Joint identification of Target Problems, Reciprocal Roles and Reciprocal Role Procedures facilitates the formation of a strong working alliance early on in therapy.
The Reformulation Letter is described as often strengthening the emotional bond between patient and therapist. The prose and diagrammatic reformulations bring understanding, which will help prevent or repair disruptions to the therapeutic alliance.
It is now generally understood to be a valuable therapeutic tool, which can give insight into the experience and responses of the patient. Clarkson Different types of countertransference have been described by Ryle and Kerr p as personal countertransference what the therapist brings to the encounter and elicited countertransference the reaction induced in the therapist by the patient the latter being either identifying or reciprocating.
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.Reparative Relationships
Symington ; De Groef Powerful feelings may arise in us such as contempt Symingtonguilt and intense compassion Sinason 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.
KEY PSYCHOTHERAPEUTIC THEORIES | Crowe Associates
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.
This is of particular value in work with people with learning disability who may have difficulty in recognising, naming and expressing their feelings.
For example in this work I often felt confused and overwhelmed which I understood as an indication of what the patient might have been feeling. Another time my strong feeling of being rejected and contemptible proved to be an invaluable aid in understanding what the patient was feeling. Both are examples of identifying countertransference. CAT understands transference and countertransference in terms of Reciprocal Roles RR being played out within the therapy.
In one case I found myself being uncharacteristically neglectful over an agreed arrangement.
CAT, the Therapeutic Relationship and Working with People with Learning Disability
In the special interest group we recognised that polarised responses often occur in people with learning disability. 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.
This first stage is very much about building a shared understanding and a foundation, so if the relationship falters, both parties can return to the contract and try to repair the therapeutic alliance. As I understand it the working alliance is the basis of the client—therapist relationship that enables both the client and the therapist to work together and would include such things as the contract, the presenting issues and maybe a realisation of both people that in other circumstances they may not be kindred spirits, or even necessarily like each other.
There are some synergies here with Coaching practice with a contracting process, and examination of presenting versus underlying issues; it leads to my sense that Coaching has beg, stole and borrowed from therapeutic theory!
Most of us have at some time or another met a person for the first time and found ourselves either strongly attracted or repelled by them. Given time the client begins to trust their own judgment and the need to use the therapist as an emotional support lessens, at this point therapy usually comes to an end.
Counselling and psychotherapy relies to a great extent on building a human connection with clients, where a deep level of trust is established, this transcends any modality, this is seen to a great extent in the work of Carl Rogers. Rogers describes the core conditions of empathy, congruence and unconditional positive regard, as the foundations of building an interpersonal alliance between two people. The person-to-person relationship is the core or real emotional connection — as opposed to a professional relationship with say your doctor or dentist.
Research by Affleck has shown that it is significant to the client that there be a real relationship from within which environment the therapists can use whatever modality of therapy she or he is trained in. Perhaps one way of describing it is the feeling you have after going to a concert you enjoyed or a really special evening with friends. Whilst I am careful in my Coaching practice about maintaining boundaries between coaching principles and deeper therapeutic approaches and in some cases referring clients on where we both feel it appropriate, the emerging interest in therapy over the last few years has taken me in working with clients into a more psychological way using approaches like the autobiography exercise, which encourages clients to reflect on how they have become the people they are before starting to look at how the future might unfold.
- Petruska Clarkson – 5 Relationship Model