Principles and Practices of Relational Psychotherapy

Rolf Holmqvist

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000523058
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

This book provides an overview of the basic principles in relational therapy, which, in combination with the latest research about the significance of the therapeutic relationship, makes it possible to present practical therapeutic tools and techniques to help the therapist make optimal use of the interaction between patient and therapist.

It presents models and concepts in relational psychotherapy that may contribute to the patient's development of relational and emotional competence, and to more authentic and meaningful ways of living with oneself and others. The book specially emphasizes the significance of the mutually constructed emotional interplay as the material for key experiences in the development of the patient – and therapist.

The focus is on the usefulness of relational principles and research findings in psychotherapies of shorter duration, in primary care, psychiatric clinics, and private practice.

Rich in clinical examples, Principles and Practices of Relational Psychotherapy is an extremely useful resource for psychotherapists and clinical psychologists in training and practice.

Part I Principles

1 Invitation

DOI: 10.4324/9781003026914-1

This book takes its starting point in two traditions: the psychoanalytic relational movement and empirical psychotherapy studies. Some persons would consider this an oxymoronic project. The spirits and sensibilities in these theoretical traditions may seem incompatible (Hoffman, 2009a; Lingiardi, Holmqvist, & Safran, 2016). Nonetheless, they both, to a large extent, focus on the therapeutic relationship and how to use it for the improvement and growth of the patient. The knowledge basis in relational therapy is the large number of case studies that describe and reflect on subtleties in the interplay between patient and therapist. Empirical research also focuses on the relationship, but with other methodological tools. Some of them are, to be sure, blunt for subtle observations. But the range of different degrees of fineness in methods should impress even sceptics.

Focus on the therapeutic interplay

Relational therapy uses curiosity on the affective aspects of the therapeutic relationship to achieve its effects. The human ability to actively reflect on the motives and reasons for her own and others’ behaviour in interaction is basic to a constructive and self-fulfilling life. Problems in psychological and relational functioning can be characterized as inhibitions and limitations of this reflecting ability (Fonagy, Luyten, & Allison, 2015).

The human species, homo sapiens, stands out among primates by the size of its neocortex (Kanai et al., 2012; Kochiyama et al., 2018). The size of the neocortex is associated with the capacity to interact in social networks. The Neanderthals had larger visual cortex but smaller neocortex. They needed their sight but could not compete with homo sapiens’ ability to reflect on complex interactions. The meaning of our subspecies name, homo sapiens sapiens, can be understood to mean the “human who knows that she knows”. She can reflect on her own cognitive and relational experiences (Hare & Woods, 2020).

A great potential in human interaction is the ability to talk about others, to gossip, to communicate knowledge about the network. The capacity to build security in relationships and to be curious about the dynamics of social relating is the basis for human life – and for human trouble. This curiosity starts at the beginning of life, stimulated in the primary relationships. Good caregivers encourage the child to attend to affects, to find meaning in relationships, and to ask about the ongoing relationship and about social experiences with others (Allison & Fonagy, 2016; Tronick, 1998).

Freud's curiosity

One of the foundational works of psychoanalysis is Freud’s case description Bruchstücke einer Hysterie-Analyse (“Fragments of an Analysis of a Case of Hysteria”; Freud, 1905). In this paper, Freud tried to figure out why his patient Dora abruptly left their therapy. Freud could have left the matter with excuses about the patient’s lack of motivation or young age. Instead, he grappled with ideas about what had happened between them, what conscious and unconscious thoughts and feelings their relationship had activated. He did what humans are wired to do, he tried to understand the interaction between them.

This was one of the first times Freud used the concept transference, meaning the patient’s transferring previously experienced relational patterns to a new relationship. It was a large step forward in the science of psychotherapy; a new way to understand problematic emotional reactions was opened. However, what Freud did not analyze was the complexities in his own reactions to Dora. There, his curiosity stopped. Decade-long theoretical and clinical thinking has rectified him on this point (Mahoney, 1996, 2005). Curiosity on the countertransference and on the therapeutic interaction has led to Relational psychotherapy.

Relationships are conflictual

Human relational development, as a child or as a patient, does not come off linearly. On the contrary, relationships are fraught with hassles, conflicts, misunderstandings, reparative attempts, and new failures (Bazzano, 2014; Sidnell, 2016; Tronick, 1998). Humans enter relationships with different expectations, different representational perspectives, different value systems, incongruent affects, colliding wishes, and intentions (Pizer, 1998; Slavin & Kriegman, 1998). Our longing to be recognized and understood is continuously thwarted, in fact or in fantasy (Benjamin, 1988). Conflicts are the energy of relational development. Relational therapy is Hegelian in considering conflicts as constructive and creative.

The visible therapist

A primary principle in relational therapy is to focus on the therapeutic relationship as material for understanding and vehicle for change. It is an important task for the therapist to contribute to the creation of a vital relationship with the patient. A person cannot relate to another person who does not relate. The patient needs a therapist who relates as much as the therapist needs a patient who relates. Or who plays, to use Winnicott’s (1971a, p. 54) felicitous word.

The challenge in relational therapy is to be fully in the relationship and at the same time to reflect on it; to be “mindful in action” (Safran & Muran, 2000). The therapist is present and participating while at the same time observing the interaction (Sullivan, 1940). Relational sensibility, the ability to be aware of and sensitively communicate about intricate fluctuations in the therapeutic interplay, is the therapist’s most important tool. Other techniques and methods are optional within a large range.

Uniqueness

Social systems have their unique characteristics, partly determined by preceding factors and partly by the interaction that emerges. Tolstoy’s introductory comment in Anna Karenina that each unhappy family is unhappy in its own way, but all happy families are similar is brilliant but not true. Happy families are happy in their own ways, too.

In relational therapy, the uniqueness is “consequential” in the sense that it has bearing on the treatment, in contrast to unique cases of somatic illnesses like diabetes or ulcerative colitis. For somatic states, the physician’s technical expertise is necessary and usually sufficient. As long as the physician understands the physiological conditions, the contact with the patient as a person is of less importance. She can, in principle, be replaced as long as the expertise on the illness is retained. This perspective is also predominant in psychotherapy methods that focus on treatment of limited problems and syndromes rather than on the patient as a person. In relational treatment, however, the therapist is not replaceable. The interaction with the unique therapist is part of the material that the therapy focuses on.

Relational complexity

Theorists and researchers from various theoretical vantage points have pointed to the need to use complex models for understanding change processes in psychotherapy (Gelo & Salvatore, 2016). Change is often nonlinear, sudden, and discontinuous (Hayes, Laurenceau, & Cardaciotto, 2008). Although psychotherapy has been described as “ultimate low in technology” (Wampold & Imel, 2015), it is also one of the most complex professional activities that exist. Each interactional step requires immediate decisions based on complicated and often subtle signals coming from the patient’s and the therapist’s trait-based patterns and current emotional state. Dynamic non-linear models have been suggested as theoretical and empirical tools by relational therapists and empirical researchers (Atzil-Slonim & Tschacher, 2020; Seligman, 2005). The concepts non-linear and dynamic imply that the therapeutic process is open and unpredictable. The trait characteristics of the participants do not determine the system’s transformations, it has emergent and recursive qualities. Previous interpersonal experiences may leave tracks in the mind as common pathways or interactional templates (Freud, 1912a, 1912b) but their usefulness for predicting the system’s properties and alterations is limited.

Stiles, Honos-Webb, and Surko (1998) gave a metaphorical description of the difficulty to predict psychotherapy processes when they compared therapeutic interaction with ballistics, the science about artillery, about trajectories of bullets and rockets. Psychotherapy is not like the firing of a cannonball. To predict the movement of a projectile through the air, the laws of classical mechanics suffice: knowledge about cannon pipe, projectile, wind, air pressure, and moisture. To predict the movement in therapy is impossible. The large number of factors that interact in complicated patterns continuously change the course of the therapeutic dialogue. The mutual interaction entails ever shifting feelings and fantasies, unexpected formulations, and reactions. If the therapist would follow a manual mechanically, the therapy would become meaningless. “what has happened can be narrated, but what is happening cannot be narrated” (Tronick, 2003, p. 477).

Affective interplay

In relational therapy, the affective interplay between patient and therapist is in focus. Affects have basic significance as change agents (Aafjes-van Doorn & Barber, 2017; Greenberg & Pascual-Leone, 2006). Affects are what make relationships vital and meaningful. Thoughtful reflection is a guide in social situations but affects give them life. In many therapy methods, the therapist focuses on the patient’s feelings. In relational therapy, the therapist asks herself what she feels at the same time as she explores the emotional interaction with the patient.

Two-person perspective

The focus on the mutual affective interaction in relational therapy points to its major defining characteristic: the two-person perspective. Therapy interaction is co-constructed, both participants contribute continuously to the process. This means that the idea of exploring recurrent relational patterns becomes problematic. If material brought by the patient like memories, fantasies, fears, expectations, emotions, is continuously and inexorably remoulded in the shared dialog, mutually understood, co-created, the question of roots in the patient’s previous experiences becomes less meaningful. The therapy is an ongoing dialectic between using recurrent interactional patterns and creating new ways of being together.

Psychoanalysis and psychotherapy

Almost since its inception, psychoanalysts have discussed if the principles in Freud’s psychoanalytic theories and techniques can be used in other treatment formats and modalities. In 1919, Freud argued that the press for shorter treatments “will compel us to alloy the pure gold of analysis … with the copper of suggestion” (pp. 167–168). Freud’s view of a contrast between exploration and suggestion has in our days been superseded by other opposites. One is between longer, open-ended treatments with personal growth as goal versus more active psychodynamic methods with circumscribed, sometimes symptom-focused, objectives. Another is between therapies based on the medical model of therapist-treating-patient and relational two-person models.

Although many authors have argued for a distinction between psychoanalysis and therapies that do not go to the infantile roots of the patient’s experiences, using the couch and therapist neutrality as tools (Gill, 1954; Glover, 1954), Freud already in 1914 argued that any therapy that takes as starting points transference and resistance could be called psychoanalysis. During the past half-century, psychoanalytic theorists have by and large accepted that treatments that diverge from psychoanalytic techniques in their classical form may be valuable ways of working with psychoanalytical principles. A notable example is Gill, for many years, a leading proponent of an orthodox view of psychoanalysis and later one of the forerunners of relational therapy. In a paper (1984), he explicitly rejected his former position and questioned the mandatory use of the couch and several weekly sessions.

Modern definitions of psychoanalytic treatment focus on the therapeutic approach rather than on extrinsic criteria. A common idea is that the principle for analytically based therapies should be the therapist’s intention (Cooper, 2010; Mitchell, 2000; Tublin, 2018). If the intention is to elicit and inspire the patient’s curiosity on his mental world, it is psychoanalysis.

Time-limited and targeted psychodynamic therapies

“Pluralism is the hallmark of 21st century psychoanalytic discourse” (Gabbard, 2007, p. 559). Time-limited and goal-focused psychoanalytic therapies have proliferated in the past half-century (Bateman & Fonagy, 2006; Luborsky, 1984; Malan, 1963; Mann, 1973; Sifneos,1979; Yeomans, Clarkin, & Kernberg, 2014). To different degrees, these therapies focus on specific themes or problems, such as circumscribed interpersonal conflicts, diagnosis categories, or problems with specific psychological competencies.

A manualized method for working with the patient’s relationship themes as they emerge between therapist and patient is Supportive-Expressive (SE) therapy (Luborsky, 1984; Luborsky & Crits-Christoph, 1990). This method uses a standardized method for i...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Foreword
• Part I: Principles
• Part II: Practices
• References
• Index