Therapist and Client

A Relational Approach to Psychotherapy

Patrick Nolan

• Publisher: Wiley-Blackwell
• Year: 2012
• ISBN:
  9781119942238
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Therapist and Client: A Relational Approach to Psychotherapy provides a guide to the fundamental interpersonal elements of the therapeutic relationship that make it the most effective factor in therapy.

• Presents the fundamental interpersonal elements that make the therapeutic relationship the most effective factor in psychotherapy
• Explores and integrates a range of approaches from various schools, from psychoanalysis to body-oriented psychotherapy and humanistic psychotherapies
• Offers clear and practical explanations of the intersubjective aspects of therapy
• Demonstrates the pivotal need to work in the present moment in order to effect change and tailor therapy to the client
• Provides detailed case studies and numerous practical applications of infant research and the unified body-mind perspective increasingly revealed by neuroscience

1

Applying Findings from Infant Research

There is no such thing as an infant.

Winnicott, 1965, p. 39

Introduction

There is an active, vibrant interpersonal field between the child and mother from the start. This forms the cornerstone of all relationships throughout life. Contemporary research paints a picture of an infant actively engaged in lively person-to-person contact. The newborn has an impressive array of cognitive, emotional and relational abilities that help them deepen their attachment to their caregiver. We now know, too, that ‘An infant can develop an early sense of self’ as they discover the world around them (Nugent et al., 2009; Rochat, 2001, p. 32).

One of the most important developments for psychotherapy over the last 40 years is the compelling evidence from developmental psychology, neurobiology and attachment research that cognitive and emotional development depend on interpersonal relationships from infancy (Schore, 1994; Stern, 1985; Piontelli, 1992). Findings from infant research are becoming increasingly incorporated in psychotherapy and in psychoanalysis and analytic thinking. They provide an extensive understanding of the essentially relational nature of people and how this plays out in psychotherapy. Infant development research also helps us understand the consequences of developmental disruption from trauma. Because arrested development limits an individual's ability to reflect, sense, express, respond, defend and repair, we need in psychotherapy to address the developmental capacities of our clients.

Psychoanalyst Esther Bick is famous for her introduction in 1948 of infant observation as part of training in psychoanalysis, a part still required today. She saw observation of babies and mothers in their own homes as an objective way to ‘understand the earliest experience patients bring with them into therapy’ (Sayers, 2000, p. 139). Direct observation of caregiver–infant interactions can counter or support traditional theories about the development of the infant that are based on hypotheses drawn from the clinician's understanding of the adult. The result of such theories is what Stern (1985) calls a ‘clinically constructed child’. Clearly there are limits to such a construction and its attempt to show early processes of experience, function and expression and the way they develop. Fonagy (2001) questions the assumption that experience drawn from the consulting room corresponds to an actual infant's early life. He states that ‘to accept clinical data as validating developmental hypotheses flies in the face not only of ferocious opposition from philosophers of science … but also of common sense’ (Fonagy, 2001, p. 8). In contrast, infant research from the latter half of the twentieth century uses advances in technology to observe both the capacities of the infant and the finely tuned interaction between the infant and the caregiver as they are happening and even from the inside.

We know now from close observation that babies sense and engage with the other in much less disorientated ways than previously thought. This has led to key concepts in developmental theory such as Stern's Representations of Interactions that have been Generalized (RIGs)¹ and reports by scientists like Rochat and ‘schema-of-being-with’² on research showing that an infant probably has the ability to differentiate between self and non-self stimulation from birth. Rochat concludes that ‘rather than being absolutely separate from their environment or confused about it, infants are attuned to it from the outset’ (Rochat, 2001, p. 32). As the trend towards inclusion in psychotherapy of new findings and concepts continues, I think it is interesting to note that many concepts like projection, introjection and internalization still appear to stand up well, and even find support from new work.

Studies from neuroscience, meanwhile, reveal the remarkable extent of the body–mind connection. Schore describes how the structure of the brain is influenced by ‘early socio-emotional experiences’. He summarizes this as ‘experience-dependent maturation’ and quotes Cicchetti and Tucker (1994, p. 538). ‘Nature's potential can be realized only as it is enabled by nurture’ (Schore, cited in Green, 2004, p. 24). Science has begun in particular to show how non-verbal, affective processes are mediated by the right brain. As a result, we need to recognize the significance of the transmission and regulation of affects as threads that stitch and potentially repair the cloth of development.

I have found these key scientific findings helpful in my own work with clients and in guiding my supervisees. In Chapter 5, I explore the body–mind connections that they uncover in more depth, and below introduce some from infant research that can also be readily applied in our practice.

Intersubjectivity

In intersubjectivity, we find one of the vital elements of the therapeutic relationship, one that I take up in more depth as the topic of Chapter 4. Infant studies suggest that ‘Learning how to communicate represents perhaps the most important developmental process to take place in infancy’ (Papousek and Papousek, 1997, cited in Green, 2004, p. 34). Infants have an ability to engage in interpersonal communication from birth (Stern, 2004, p. 85). They develop within a matrix of ‘primary intersubjectivity’ defined as ‘an active and immediately responsive conscious appreciation of the adult's communicative intentions’ and as ‘a deliberately sought sharing of experiences about events and things’ (Trevarthen and Hubley, 1978; Trevarthen, 1979). The infant has an awareness specifically receptive to subjective states in other people (Trevarthen, 1998, pp. 124–136). Winnicott's famous remark that ‘there is no such thing as an infant’ makes us realize this receptivity is crucial when he explains that ‘if you set out to describe a baby, you will find you are describing a baby and someone else. A baby cannot exist alone, but is essentially part of a relationship [italics in original]. (Winnicott, 1965b, p. 39).

Intersubjectivity – ‘minds attuned to other minds’ (Stern, 1985, p. 85; see also Chapter 4 on the Intersubjective Experience) – naturally forms the basis of our work as psychotherapists. Knowledge about its elemental role and form can help to shape a therapist's way of working with the individual needs of each client. Babies engage in empathic and reciprocal communication. Even at just a few days old, an infant can imitate the caregiver's expressions, including opening their mouth, smiling, sticking their tongue out, pursing their lips, expressing surprise and moving their head, hand or fingers (Beebe et al., 2005, p. 37; Meltzoff, 1985; Rochat, 2001, p. 143). From neuroscience, we learn that the capacities which facilitate intersubjectivity, including face recognition (Wilkinson, 2006, p. 5), the ability to tune into the rhythm of the human voice and to self-soothe (p. 19), are linked to the right hemisphere of the brain. ‘Self awareness, empathy, identification with others, and more general intersubjective processes, are also largely dependent upon right hemisphere resources’ (Decety and Chaminade, 2003, p. 557, cited in Wilkinson, 2006, p. 20). Schore examines the right brain connection and points out that ‘preverbal maternal–infant communication’ that occurs before the ability to speak³ represents ‘transactions between the right hemispheres’ of the mother and child (Schore, 2003, p. 26).⁴ He suggests that the essence of development is contained in the concept of ‘reciprocal mutual influence’ where these same forms of non-verbal, pre-rational mother–child communications ‘continue throughout life to be a primary medium of intuitively felt affective communication between persons’ (Orlinsky and Howard, 1986, cited in Schore, 2003, p. 26). This non-verbal, emotional coregulation forms our earliest experience of intersubjectivity and the rudiments of social understanding. Mutual engagement, unavoidable and filled with possibility, plays a central role in our work with clients as it infuses the working alliance and serves as the ground for what occurs within it.

Two-way exchange: Including the other

Therapy involves the kind of interpersonal exchange that Buber (2008) called ‘dialogic’: ‘a relation between persons that is characterized in more or less degree by the element of inclusion’ (p. 97). The ideas around two-way exchange include concepts like empathy, containment, correspondence, mirroring, holding, metabolizing, reflecting, resonance and being in tune with the client. Communication that recognizes and responds to the other without any need to change the other is inherent in infants. It becomes a lifelong resource and one to fall back on if later aspects of development fail (Rochat, 2001).

The infant's readiness to perceive the qualities and features of the other orients them, and helps them establish an intentional relationship with their caregiver. Mutual imitation, empathic social mirroring and proto-conversations⁵ improve the early bonding process and make the infant and caregiver eager to engage. I believe that this form of interacting is similar to the positive rapport that can develop between the therapist and the client.

Reciprocity

Recognizing and communicating with their caregiver at the earliest stages after birth helps the infant not only in bonding, but also in the infant's health and development. Two-month-old babies come to have specific social expectations in face-to-face exchanges around smiling and gazing towards others. They become sensitive to the timing involved in taking turns in social interactions, which enhances the flow of communication and increases the possibility of those around tuning into the affects communicated by the infant (Meltzoff, 1990). The reciprocity of this early ‘dialogue’ feels gratifying to those with the infant and makes them more likely to try to develop this contact.

Developing trust and safety as central to the therapeutic relationship relies partly on reciprocity. But it moves beyond mutual gratification. As therapists, we all know clients who share our interest in engaging in the task of therapy. With them in therapy, we may feel that they are like us in, say, their sense of humour or sharp intellect or kindness. This sense of shared attributes helps in forging a strong therapeutic bond and makes these clients the ones that we look forward to seeing. However, for therapy to progress we must address the negative aspects of the therapeutic relationship. If we enjoy reciprocity with our clients, we risk lapsing into cosy mirroring and an unconscious avoidance of necessary confrontation. Attending to the level and types of reciprocity becomes useful as we assess the effects of interventions, the state of the client and how we are including them in the therapeutic exchanges.

Rhythmic coupling

The infant's ability to imitate and match the other is a fundamental aspect of pre-verbal communication. As described by Trevarthen and Aitken (2001), playful reciprocal interactions between a baby and their caregiver involve matching of form, timing and intensity. For example, as a caregiver's expression builds from a very small smile to a broad one, a baby will mirror and respond excitedly to them step by step. At four months, the child is able to time the starting, stopping and pausing of their vocalizations in rhythm with a partner. Using this ‘rhythmic coupling’, infants can tune into their own and the other's timing in any modality, including body movements, vocal, facial and gazing patterns. Studies suggest that the timing of rhythmic coupling between an infant and an adult corresponds to that of an adult communication process, making it a basic trait underlying verbal interactions (Beebe et al., 1992, p. 72, cited in Stern, 2004). From infancy and beyond, rhythmic coupling enhances both synchronicity and access to the other's experience (Jaffe et al., 2001). This makes it another of the natural and essential ways in which the client and therapist sense each other empathically.

Turn taking

An aspect of timing in all communication revolves around turn taking, where each participant constantly sends or waits for cues indicating whose turn it is to be active or receptive. For verbal communication, Beebe et al. (2005) define ‘the momentary silence that occurs at the point of the turn exchange’ as a ‘switching pause’ (p. 64). The pause establishes how long to wait before taking a turn, thus enabling a smooth changeover. If the switching pause is too short, the person interrupting is experienced as abrupt. If the gap is too long, the sense is of the listener as absent. This pattern of exchange is evident even in four-month-old infants (Beebe et al., 2005). I believe it is a form of regulation that is central to the way we negotiate our ongoing relationship with the client. Keeping an eye on the switching pause in therapy can help us as therapists stay in touch with the interactive dynamic and assist in assessing the type of relating pattern the client may have had as a child (see Case Example 1.1).

Case Example 1.1

Theresa, a professional woman in her late 30s, had been beaten by her father and overly controlled by her mother. She was allowed no voice in her family. She was bullied and at times beaten in her relationships as an adult and was unable to defend herself in these situations. In therapy, she took on an abrasive style of relating that did not allow switching pauses in the exchange. She responded to my interventions by falling silent. The affect attunement at these times involved deflation and a sense of quickly draining away. After a while, she would resume, initially speaking slowly, but gathering in pace and volume until the attunement was around surging and a strong intensity level. I felt as if she had assigned me the role of spectator while she ...

Table of contents

• Cover
• Praise for Therapist and Client
• Title page
• Copyright page
• Dedication page
• Foreword
• Preface
• Acknowledgements
• Introduction
• 1 Applying Findings from Infant Research
• 2 The Interpersonal Relationship
• 3 Potential Space, Creativity and Play
• 4 The Intersubjective Experience
• 5 The Relational Body–Mind
• 6 Working with Trauma and Fragile Clients
• 7 Adapting Therapy to the Client: A Relational Approach
• Index