The Therapeutic Relationship

Arlene Vetere

drarlenevetere@hotmail.com

Psychotherapy and Culture

Cultural and ideological diversity of clients and professionals

The multi-layered spirit of practice in modern healthcare systems

Engagement and communication: common factors in healing

Collaborative practices

The complexity of change processes

The link between entrenched social disadvantage and physical and mental health

EU Green paper on Mental Health

Bruce Wampold, 2011

“Lest we forget, it is the therapist who makes

psychotherapy, and other helping professions,

effective. Accumulating research demonstrates

that in practice, as well as in clinical trials, much

of the variability in outcomes is attributable to

the therapist, regardless of the treatment being

delivered.”

A SECURE BASE

“For not only young children, it is now clear, but human

beings of all ages are found to be at their happiest

and to be able to deploy their talents to best

advantage when they are confident that, standing

behind them are one or more trusted persons who

will come to their aid should difficulties arise. The

person trusted provides a secure base from which

his (or her) companion can operate.”

Bowlby, 1973

Diana Fosha

“The roots of resilience…….are

to be found in the sense of being

understood by and existing in the

mind and heart of a loving,

attuned, and self-possessed

other.”

What Does the Research Tell Us?

The therapeutic relationship is the key

predictor of client outcome (Elliott et al, 2011)

The therapeutic relationship accounts for

30% of the variance in client outcome

(Lambert and Barley, 2001)

The therapeutic relationship is accepted as

necessary for change in all major

psychotherapies

Empathy is the ‘evidence based component’

of the therapeutic relationship (Norcross and

Wampold, (2011)

What Does the Research Tell Us?

Empathy: A conscious perspective-taking

process (affective and cognitive), whereas

sympathy is an emotional response to

another’s affective state

Rogers ‘accurate empathy’: understanding

the other and communicating this through

reflective listening

Empathy linked to positive engagement: 10%

variance in client outcome

Alcohol use problems: higher empathic

engagement, less drinking…..

What Does the Research Tell Us?

Empathic responding helps clients identify

and modify their own affect

Empathy: acceptance and warmth

Trust: listening, being present, focused,

caring emotional risk taking

If we believe out therapist can help us

stronger commitment to therapy and

therapist’s hope in usefulness of therapy

linked to client engagement

What Does the Research Tell Us?

Therapist empathy and interpersonal skills

highly linked

Empathy trust…

Principal healing components of the

therapeutic relationship (empathy,

genuineness, positive regard and validation)

form the basis of compassion (a higher order

process?)(Kirschenbaum and Jourdan, 2005)

Empathy and curiosity = self-reflexivity

Attributes and/or learned skills??

Active Listening

Focus attention on the child without

interrupting with own thoughts and comments

Acknowledge you are listening, both verbally

and non-verbally – speaker can both see and

sense they are being listened to

Pick up the non-verbal cues – what is not

being said….

Don’t be distracted by thinking of your reply

while child is speaking

Offer an appropriate response

Listening, Speaking and Hearing

Stress responses get in the way of hearing

Anger, fear and panic produce ‘fight or flight’

or dissociation responses cognitive

functioning and memory are impaired

Repeat what has been said and check it has

been understood

Give opportunities to repeat and develop

understanding

Rehearsal helps

Attunement, Empathy & Reflective Function

Empathic and well attuned bonds greater

emotional security

Understand child’s feelings, respond in a way

that effectively communicates that

understanding, and contains distress with

sensitivity

Fonagy: a reflective caregiver increases

likelihood of child’s secure attachment which

in turn, facilitates development of

mentalisation

Attunement: Reading the Rhythms of the Child

“This is why the core of good teaching is attunement. Attunement is

being aware of, and responsive to, another. How does this child

feel? Is she interested, engaged, capable of listening to what I want

to say? What is the best way to communicate this idea, fact,

concept, or principle to her in this moment? What will engage,

encourage and excite her about this subject? What will be heard,

perceived, felt and learned – in short, what the teacher will

communicate – depends upon how receptive the child is. And how

well a teacher reads a child’s receptivity depends upon an

understanding of how humans communicate without words.”

Bruce Perry

Internal Working Models

Beliefs and expectations about

One’s own and other people’s behaviour

Views of the SELF – How loveable, worthy

and acceptable am I?

How available and interested are others in

me, and in caring for and looking after me?

ATTACHMENT STRATEGIES AS A CONTINUUM:

styles of protective & defensive processes

DISMISSING/DE-ACTIVATING PRE-OCCUPIED

Learn that expressing

emotions cannot reliably elicit

comfort or caring, defensive

strategy develops of

distancing or excluding

emotions. Cognition is relied on

and can be employed to help

omit or distort emotional

information: inhibit affect,

falsify, deny physiological

discomfort and pain:

- idealise, care for others

- deny need for others

compulsive reliance on self

Learn that cannot rely on words

and cognition, inability and

failure to predict. Increasingly

rely on affective information. Split

feelings of anger and

vulnerability so display one and

suppress the other. Cognitive

defences involves passive

thinking, reducing complexity by

blaming of others and avoiding

considering own contributions,

rationalising/justifying own

actions:

- anger towards others

- anxiety and vulnerability

ATTACHMENT ALWAYS TWO SIDED

Attachment always has TWO sides. Responses to non-availability of the attachment figures:

PROTEST - anger of hope and of despair

and

VULNERABILITY – sadness/fear/shame

One may be shown more than the other, or shown in rapid alternation. Internal conversation – potential ‘Strange Loops’

Systemic Intervention

Identify unhelpful patterns with the couple – the pattern is the

problem, not the person – unresolved hurt (NB violence needs a

different response – see Cooper & Vetere, 2005)

Validate each person’s experience – deep listening - expand

and process - help to soften a blaming position – intention vs

effect!

Encourage integration of representational systems and

reflection – coherent narrative

Support listening and curiosity about the other’s experience –

compassion, trust, soothing and affect regulation

Support re-bonding enactment in/outside the session

Assisting with other difficulties and worries

Repair, consolidation and new narratives

Implications for Therapy

Naming and regulating emotions

Standing in the emotional shoes of the other

Comforting and self soothing

Information processing

Transformations in representational systems

Secure Attachment

“…what sustains our relationship is, I’m extremely happy with her, and part of it has to do with the fact that she is at once completely familiar to me, so that I can be myself and she knows me very well and I trust her completely, but at the same time she is also a mystery to me in some ways. And there are times when we are lying in bed and I look over and sort of have a start. Because I realise here is this other person who is separate and different and has different memories and backgrounds and thoughts and feelings. It’s that tension between familiarity and mystery that makes for something strong, because, even as you build a life of trust and comfort and mutual support, you retain some sense of surprise or wonder about the other person.”

Barack Obama. The New Yorker, January 19, 2009, P50

“For Better or Worse….”

Physiological and psychological implications

Attachment and Repressive Coping Style

Cancer and the immune system

Hostile conflict and wound healing (Kiecolt-

Glaser and Glaser)

Pain and comfort

Social support networks

London Depression Intervention Trial

John Gottman: ‘divorce prediction’? Criticism,

contempt, stonewalling, defensiveness

Our Wish for Connection: Research

on Bonding

1. Emotional connection: turns on positive emotion (oxytocin) & mediates threat perception

2. Effective dependency and resilience: open systems, curiosity, & the ability to learn and play…..

3. Responsiveness and accessibility: are you there for me?

4. Emotional separation: cues panic and protest

5. Safety and emotional risk-taking: demand – anger of hope (protest); dismiss – anger of despair (shut others out): cues negative cycles, maintains felt insecurity, distorts attachment signals

(John Gottman, Mario Mikulincer, Pat Crittenden, Susan Johnson)

John Gottman: The Science of Trust 2011

Enhance your love map

Nurture fondness and admiration

Turn towards each other

Let your partner influence you

Solve your solvable problems: a) softened ‘start up’;

b) make and receive repair attempts; c) soothe self

and each other as conflict can lead to ‘flooding’; d)

compromise

Overcome gridlock – existential base of unexpressed

dreams

Create shared meanings – stories we tell about our

relationships

“Felt security” in a relationship

Affect regulation (less reactivity, hyper-

arousal & under-arousal)

Support seeking

Information processing (curiosity, open, more

toleration of uncertainty)

Communication (meta-communication,

disclosing, collaborative, assertive, empathic)

‘Sense of self’ (elaborated, articulated,

positive) (Mikulincer and Goodman)

INTERNALISED OTHER INTERVIEWING

Three people : if you can get into pairs (A & B) where you know each other reasonably well.

Person A: Gets into role of becoming Person B Person B: listens Interviewer C: interviews person A as if they were B. “Now B, can you tell me

how you are feeling today, etc..! For about 5 minutes, then Reverse: Interview B as A A, B and interviewer C discuss the conversations: What did this feel like? How accurate were they? What surprised each of them about what the other said?

Couples Therapy & Attachment Theory

Focus on attachment needs & forms of

engagement/disengagement (Minuchin,

1974)

Privileges emotion – “the music of the

attachment dance” (Johnson, 2002)

Therapy as a secure base (Byng-Hall, 1995)

Supports different bonding responses &

events: integration and reflection

Addresses impasses & ‘attachment injuries’

Working with Dynamic Systems

Focus on attachment theory guides interventions

(Dallos & Vetere; Flaskas; Johnson)

The couple relationship can either support or

undermine the sense of emotional safety: for both

partners and their relationship – mutual influences

Couple distress is understood in the context of recent

research (eg John Gottman; Mikulincer and

Goodman; Crittended; Hazan and Shaver)

Attend to key emotional responses that maintain

distress – therapy alliance as secure base

Pursuer-distancer circularities are especially relevant

to an understanding of couples’ attachment

relationships

Working with Dynamic Systems

Support for altering emotional responses and

dispositional representations in ways that enhance

and develop secure connections – reprocessing,

integrating, reflecting and doing

Transition points in families provide a particular

challenge for the couple system, as partners seek

either to re-establish familiar reaction patterns ie

falling back on old solutions, or take the risk to

develop new patterns ie corrective scripts

There is mutual influence between the couple unit

and other subsystems of the family (life cycle theory

and inter-generational family therapy)

Focus on most poignant or vivid aspect of

experience: non-verbal expression of emotions and

non-conscious relational responding

Focus on emotions that are most significant for

attachment needs and fears eg of rejection

Sadness and grief related to a sense of loss and

helplessness

Anger is often a reaction to perceived or actual non-

responsiveness (or threat of abandonment or

rejection) in an attachment figure

Support & help develop differences & interaction

Focusing on Emotions: Johnson, 2008

Shame may indicate a partner’s lack of entitlement

to share their needs and longing for closeness, and

fear that such sharing will lead to rejection

Fear and vulnerability are core aspects of human

attachment and evoke a partner’s longing for

closeness and secure connection

Focus on emotions that play a part in organising

negative cycles of interaction: therapist explores

and expands emotions that are present in couple’s

problematic patterns (Johnson, 2008)

Focusing on Emotions: Johnson, 2008

Expressing and expanding emotional experience is

central to change in interactional patterns

Accessing primary emotions (eg sadness, fear of

loss, shame) enables new meaning to be brought to

understanding family members’ behaviour

Processing the experience and the underlying

emotions that may have been on the edge of

awareness

And to challenge long held perceptions of family

members

Working with Emotions: EFT

Exploring Patterns of Comforting

When you were upset or frightened as a child – what happened?

How did you get to feel better? Who helped you to feel better? How did they do this?

What do you think your parent/s learned from their parents?

What have you learnt from this for your own family?

What do you want to do the same?

What do you want to do differently?

How do people comfort each other in your own family/relationship?

How do you comfort your children?

How do they comfort you?

What do you want your children to learn about comforting, for now, for the future, and for the future of any children they might care for?

Can be held as a family or couple interview or as a one-to-one conversation.

Reaffirming and clarifying clients’ experiences

Modelling acceptance of both partners’ experiences

Slowing down the session, enabling partners to

process their experiences

Helping to organise different aspects of clients’

experiences (action, feeling, thought and intention)

into a more integrated whole – a coherent narrative

Comforting in response to a difficult emotional

experience

Exploring the meaning of important and powerful

human experiences

Empathy & the Therapeutic Alliance

THERAPY AS SCAFFOLDING:

Emotional and cognitive

Developmental perspective: (Vygotsky)

Learning occurs though internalising conversations

‘Zone of Proximal Development’ – staying within the zone of ‘not too familiar and not too different’

What we can do with the assistance of another person/therapist

Therapy and scaffolding:

Emotional base – safety, security – reduce negative arousal

Assisting in identifying and regulating feelings

Encouraging reflexivity – standing in the emotional shoes of the other

Exploring comforting and self-soothing

Assisting integration of feelings and events

Assisting coherence: helping families/couples develop a narrative of how they healed their relationship

Attachment Narrative Therapy

with Families/Couples

Creating a secure base

Attachment Narrative Therapy with

Families/Couples

Creating a secure base

Mapping the context & talk about talk

Engaging warmly with each member of the family

Reflecting on our relationships in the room – modeling open communication

Use of self – therapist reflecting on his/her own experiences

Adopting a non-blaming approach - working together vs ‘fixing families’, purpose is not to find fault in the past or present

Externalizing Framework

Exploring the ‘problem’ - beliefs, feelings, explanations

A ‘conservative’ (paradoxical) framework - not pushing for change

Access, illuminate, expand, reprocess emotional experience

De-escalating unhelpful patterns

Creating a secure base

Reflection, containment and emotional safety

Supporting, building the therapeutic relationship

Validation and support- acknowledging emotional risks, demands of therapy,

temptation to withdraw

Clarifying, context – how we will communicate

Establishing sense of safety, pacing:

Identifying, exploring and de-escalating unhelpful patterns of interaction

Exploration - Narratives and Attachments within a

Systemic Framework

Identifying attachment dilemmas

Identifying attachment needs and wishes eg for

reassurance, underlying core patterns of feeling,

thinking and behaviour

Discrepancies: thoughts and feelings, head and

heart

Divided loyalties – ambivalences in relationships

Reflections on the therapeutic relationship:

empathy and listening

Exploring problems, emotions and competencies:

Access, illuminate, expand and re-process

emotional experiences

Considering Alternatives – emotional risks

and change

Loosening Attachment Dilemmas

Considering alternatives – unique

outcomes

Acknowledging risks of change,

Threats to perceptions of self and

others

Relational and emotional risk taking, in

therapy and outside – conflict

resolution

Re-bonding – consolidating more

satisfying interactions

The Future:

Maintaining the Therapeutic Base

Shared narratives of healing

Acknowledging possibility of relapse

– temptation to retreat to patterns of

thinking and feeling

Holding each other in mind – how we

will think about each other in the

future

What support will be able to draw on

in future – consolidating change

Creating opportunities for future

reflection

EMOTIONAL SCULPTING

Sculpting with family members themselves, or sculpting with

objects (coins, buttons, stones, figures etc ) …

PROMPTS (can use direct or circular questions…)

Map the current attachment patterns, relationships – who looks

after whom, etc.

How does it feel to be, for example, at the centre, on the edge,

between your parents, and so on?

Now that you and your brother are closer, how does that make

you feel?

If you were to get closer to your mother what would that be like?

How do you think your sister feels being that distant from your

father? And so on.....

Corrective and Replicative Scripts

This utilises ideas from John Byng-Hall that families make comparisons across the

generations in terms of similarities and differences between how our own parents were with each other and us (the children) and how this is repeated or altered in the next generation.

Importantly it allows us to work in a positive frame with the family in that we may construe the intentions of the parents positively, i.e. they have tried to repeat what was good or correct what they felt was bad about their own experiences. This can then lead to a discussion of whether these attempts have been successful or not, and possibly how they might be altered, strengthened, elaborated etc.

What are your thoughts about how similar or different your relationship with each other and your children is to your parent’s (grandparents’) relationships ?

What have you tried to make similar or different to either of these relationships?

What do you value vs feel critical about in either of your parent’s relationships?

Does what you have tried to repeat/change work? Is there anything that you want to alter, strengthen, abandon about what you have been trying to repeat or change?

Suggested Reading:

Dallos R and Vetere A (2009) Systemic therapy and Attachment

Narratives; Applications in a range of clinical settings. London:

Routledge

Dallos, R. and Vetere, A. (2014) Systemic therapy and

attachment narratives: Attachment Narrative Therapy. Clinical

Child Psychology and Psychiatry, 19, 494-502

Johnson S (2002) Emotionally Focused Couple Therapy with

Trauma Survivors. New York: Guilford

Vetere A and Dallos R (2008) Systemic therapy and attachment

narratives. Journal of Family Therapy, 30, 374-385