An Introduction to the Therapeutic Relationship in Counselling and Psychotherapy

Stephen Paul, Divine Charura

• Publisher: SAGE Publications Ltd
• Year: 2014
• ISBN:
  9781473908703
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

The therapeutic relationship is considered to be the most significant factor in achieving positive therapeutic change. As such, it is essential that trainee and practising therapists are able to facilitate a strong working alliance with each of their clients. This book will help them do just that, by offering a practical and evidence-based guide to all aspects of the therapeutic relationship in counselling and psychotherapy. Cross-modal in its approach, this book examines the issues impacting on the therapeutic relationship true to all models of practice.

Content covered includes: - The history of the therapeutic relationship
- The place of the therapeutic relationship in a range of therapy settings, including IAPT
- Concepts and practical skills essential for establishing and maintaining a successful working alliance
- The application of the therapeutic relationship to a variety of professional roles in health and social care
- Practice issues including potential challenges to the therapeutic relationship, working with diversity and personal and professional development
- Research and new developments

Using examples, points for reflection and chapter aims and summaries to help consolidate learning, the authors break down the complex and often daunting topic of the therapeutic relationship, making this essential reading for trainee and practising therapists, as well as those working in a wider range of health, social care and helping relationships.

Part I Introducing the Therapeutic Relationship

This part sets out for the reader the history and development of the relationship in therapy and the different models of practice.

1 Introducing the therapeutic relationship

The aims of this chapter are for the reader to develop an understanding of:

• The development of psychiatry, psychology and the talking therapies.
• The development of modalities and differing perspectives.
• The importance of the therapeutic relationship in counselling and psychotherapy.

In this chapter the development of counselling and psychotherapy are explained. We give an overview of how the different modalities of therapy evolved in their historical and socio-cultural contexts. We introduce the basic elements of the therapeutic relationship (TR) and their place in the philosophy, psychology, practice and evaluation of therapy. This is done from the perspective of both modality and practice, introducing the reader to a multi-dimensional picture of the therapeutic encounter. The reader is brought up to date with recent developments and research in practice.

Psychiatric and psychological foundations

Psychiatry

From ancient times mental health problems were often thought to have supernatural or spiritual causes and mentally ill people were considered to be in some way possessed by bad spirits. Treatments were often made using magic or sorcery and exorcism was a commonly considered ‘cure’.

Hospitals for those with mental health problems are thought to have been established in medieval Islamic society in Baghdad. In 1247 the first mental institution was opened in Europe – the Bethlehem Royal Hospital, later shortened to ‘Bedlam’. There were no real treatments for people who were admitted to these institutions.

The word ‘psychiatry’ has its roots in the Greek words psyche, meaning soul or mind, and iatros, meaning physician. It was not until 1808 that the term was coined by the physician Johann Christian Reil. Mental health institutions developed more humane treatment methods in the nineteenth century (for example, William Tuke, a Quaker who founded the York Retreat in 1796) and psychiatry was then considered to be a recognized, specialized discipline.

As psychiatry continued to evolve, in the 1930s specialized drugs were developed. Electroconvulsive therapy (ECT) started being widely used from 1938. Drugs such as lithium, which was used for treating mania, were developed in 1948 and antipsychotic drugs were introduced from 1951.

In the 1960s leading writers such as Laing, Szasz, Lacan and Michael Foucault offered critiques of psychiatry. This led to the anti-psychiatry movement which, in essence, was a criticism of certain practices rather than opposing all that psychiatry did. In the UK, the 1959 Mental Health Act encouraged a change towards community care. In the 1970s the development of selective serotonin reuptake inhibitors (SSRIs), typically used in the treatment of depression and anxiety disorders, further facilitated possibilities of community care. Drugs with lesser side-effects, such as Prozac, were developed in the late 1980s.

In the UK in the late 1980s and the 1990s legislation for community care set out the basis for psychiatric support in the community. The large psychiatric asylums closed down and more patients started to live in less institutionalized settings.

The twentieth century brought with it further understanding of the biology behind many mental disorders and the development of new drugs for the treatment of many psychiatric conditions. In current psychiatry, the focus is on a medicalized approach, with referral for psychological treatments or talking therapies where government guidelines recommend.

In this section we detail the development of the talking therapies from medical practice, psychiatry and psychology. The field of counselling and psychotherapy mushroomed in growth in the twentieth century. With roots going back through hundreds of years in philosophy and religion, it was in the twentieth century that the professions were founded. Counselling and psychotherapy are therefore very new professions

Practitioner Clip 1.1 Bars on the windows of the mind

I (Steve) was told by the Senior Nursing Officer of a mental hospital in the north of England in 1975 that with the advent of drug treatments ‘We have taken the bars off the windows of the mental hospitals and put them in the minds of the patients’.

Psychology

Psychology also has its roots in the great civilizations of Egypt, Greece, China and India. The first psychological therapy was performed by Islamic physicians on those with mental illness in a psychiatric hospital built in Fez, Morocco, in the eighth century CE.

Ahmed ibn Sahl al-Balkhi (850–934) proposed that ‘if the nafs (psyche) gets sick, the body may also find no joy in life and may eventually develop a physical illness’. He stated that the body and the soul can be healthy or sick, or ‘balanced or imbalanced’, and that imbalance of the body can result in fever, headaches and bodily illnesses, while imbalance of the soul can result in anger, anxiety and sadness, which could be treated psychologically (Deuraseh and Talib, 2005).

Psychology was considered a branch of philosophy until the mid-nineteenth century when it was developed as a scientific discipline in Germany and then, in the USA, with the focus on the structure of mind. Wundt (1896) wrote the first textbook on the subject and his perspective was from empirical experimentation. The development of psychology as a natural science was in some way counterbalanced by the work of Freud, who has remained influential into the twenty-first century. In the twentieth century, the development of behaviourism and cognitivism were central to mainstream psychology and its empirical focus. Psychology as a new human science flourished.

Freud is regarded as the founder of psychoanalysis, the precursor to psychotherapy. Freud’s original work was with the ‘unconscious’ and working with ‘hysterical’ patients. Traditionally, the therapist analysed the client and there was little emphasis on the interpersonal relationship.

His ideas greatly influenced the work of Jung, Adler, Assagioli, Rank and a host of others who went on to form diverse schools of therapy. Parsons (1909) coined the term ‘counselling’ in relation to vocational guidance, but it was Carl Rogers who developed counselling as a disciplined therapeutic practice, as distinct from psychotherapy. This was primarily because the practice of psychotherapy was restricted to physicians.

Table 1.1 outlines a brief history of psychiatry, psychology and counselling and psychotherapy. The information here can be followed up with further reading.

The talking therapies are historically a relatively new phenomenon. Until the Freudian era, working with mental health had been the domain of doctors, who applied a medical approach. The development of psychology in the nineteenth century led to an objective approach to understanding the structure and functions of the human mind. From the early work of Freud, four forces or traditions which aim to work psychotherapeutically with human distress have developed.

The four forces of psychology

The psychodynamic/psychoanalytic modality focuses on the dynamics between the conscious and the unconscious parts of the self and relations with the outer/social world. A Freudian therapist typically analysed the patient and functioned in an expert role. Adler, Ferenczi, Abraham, Rank, Jung, Fairbairn, Guntrip, Klein and others were all influenced by Freud’s work and were instrumental in different ways in developing analytic approaches to therapy. In recent years, there has been an increasing emphasis on interpersonal relations in the therapeutic process.

Behaviourism developed out of social learning theory influenced by the work of Skinner, Watson and others. The focus here was on changing behaviour. Beck, Ellis and others have developed a range of approaches in this area. In the last 30 years there has been an emphasis on cognition and its effect on behaviour. Specific approaches, such as cognitive therapy and cognitive behavioural therapy, were developed. The therapist here is seen more as a trainer and their role is more of an educator.

The existential-humanistic modality has developed from divergent roots, focusing on individual responsibility and self-determination. Fromm, Laing, Maslow, Rogers, Perls and others contributed to the development of widely differing approaches. Bugental, Laing and others were key in the development of existential therapy, as distinct from a newer area of humanistic psychology which included client-centred therapy, Gestalt and other approaches. The existential-humanistic therapist is typically engaged in helping the client take responsibility for their situation and acts as a facilitator for growth.

Transpersonal therapy, the most recently developed modality, focuses specifically on the...

Table of contents

• Cover
• Half Title
• Publisher Note
• Title Page
• Copyright Page
• Acknowledgements
• Contents
• About the Authors
• Acknowledgments
• Acronyms
• Introduction The therapeutic relationship in counselling and psychotherapy
• Part I Introducing the Therapeutic Relationship
• 1 Introducing the therapeutic relationship
• 2 What the research tells us
• 3 The relationship in different modalities
• 4 A relational approach to therapy
• 5 Developmental factors in a relational approach
• Part II Establishing and Maintaining the Relationship
• 6 Establishing the relationship
• 7 Developing the relationship
• 8 Challenges to the relationship: When things get tricky
• 9 Ending the relationship
• Part III The Relationship in Context
• 10 The therapist’s self in relationship
• 11 Working with difference within the therapeutic relationship: A relational perspective
• 12 Developing your practice: A relational perspective
• Glossary
• Appendix: Conclusions and Recommendations of the Interdivisional (APA Divisions 12 & 29) Task Force on Evidence-Based Therapy Relationships (John C. Norcross, PhD, Chair, 2 January 2011)
• References
• Index