A Relational Approach to Therapy

By Karl Gregory, Judy Hemmons and Sarah Anderton

We are evolutionarily hard-wired to heal and be healed by human connection and social interaction’  Elkins (2016 p51)

We are living through interesting times; the rise in terrorism, interest in mental health and an increasing need for connection in our digital age, creating challenges and new possibilities in the helping professions. This article has come about from some rigorous discussion we had on: what is effective in therapy?

There has been much debate about whether the therapy or the therapist is more significant in predicting the effectiveness of therapy. Research has now confirmed that the quality of the relationship between counsellor and client is central to the effectiveness of the therapy (Norcross 2002 and Elkins 2016).

Meta-analyses of studies examining the linkage between the therapeutic alliance and outcomes in psychotherapy (Martin et al., 2000) have also confirmed these results. Significantly, it was also indicated that the quality of the alliance was more predictive of positive outcome than the type of intervention.

Yet currently, therapy is increasingly defined by what we offer according to medical diagnosis. ‘We need to use a CBT model for medical problems such as depression or anxiety or EMDR to work with PTSD’. We can feel defective if we are not trained in the latest techniques. Yet researches into effective therapy and into neuroscience are showing that it is the relationship not particular modalities or techniques that bring relief from the struggles.

Over that last 10-15 years there has been a quiet revolution in our work with a significant paradigm shift, a relational approach that values the subjective experiences that we have with each other. This paradigm shift is helping us to develop our various ‘objective’ models of therapy and focusing us on the subjective relationship itself.

Within the psychodynamic schools, ‘relational theory’ has already developed (Mitchell 1988, Frawley-O’Dea and Sarnat 2001, DeYoung 2015). Transactional Analysis (Hargaden and Sills 2002, Hargaden 2016) has taken a ‘Relational Turn’ and Person-Centred theory has moved to ‘relational depth’ (Mearns and Cooper 2005). Gestalt therapy has elaborated its principles towards a ‘Relational Gestalt Therapy’ (Hycner and Jacobs 1995). Finally CBT have gone 3rd wave, looking at meaning in Compassion Focused Therapy (Gilbert 2010).

In addition, David Elkins (2016) argues that psychotherapy can best be understood as an expression of ‘social healing’ and offers a non-medical model of emotional healing through developing a relational approach. The various schools of ‘Embodied Relating’ are finding prominence as they articulate their lived experiences (Totton 2018).

These relational developments are not new schools of thought or separate theories but are elaborations, further developments within the traditional and contemporary schools that focus on the contact between therapist and client (Jacobs and Hycner 2009). The real relationship (Gelso 2010) being the focus of our attention as therapists, the sort of work that Carl Rogers (1980) was focusing on in his research that got bypassed for much of the time that has elapsed since his death.

We are at a pivotal time in the development of therapy. At the same time as the relational approach has been developing the neuroscience are also having an impact on our profession. (Porges and Dana 2018). Most commentators on the neuroscience have come to the conclusion that the brain is a social organ (Siegel 2010), we are pack animals and our brain/bodies have developed to help each other adapt and heal each other. One person needs another person to heal. Polyvagal Theory shows us that our brain does not control the body it is not separate to, but an integral part of, our whole biological system that interacts dynamically (Dana 2018). We are even told that the use of compassion can literally help clients create healing chemicals in the body (Gilbert 2010), change neural pathways in the brain and develop hormonal responses that can help heal past abuses. (Badenoch 2008) The implication of this is enormous for therapy!

So what does this mean for therapists? How can we use this knowledge to make ourselves the most effective practitioners we can be? What do we mean when we say we work relationally? (Hemmons and Gregory 2018)

Working Relationally
Most problems in life are relational. That is they were born out of our experiences in relationships with others. So if they arise from interactions in relationship, then they can be healed with interactions in relationships with ‘emotionally regulated’ others; regulated in affect, being trustworthy, safe and ethical.

Relationships need to be connected. In relational theory (DeYoung 2015) human beings are seen as part of a network of relationships, continually motivated, from birth, by the need for relationship that shapes internal perception of external experiences. Disconnections in relationships create psychological difficulties. A relational approach is to establish authentic and mutual connections.

The therapist needs to be in the relationship with all their passion and humanness. In our experience clients do not want someone who is disengaged, holding some idea of the ‘role of the therapist’. What they tell us is they want someone fully engaged and human.

Being subjective and using our subjective experiences in service of the client is crucial to relational work. We wish schools of therapy would get away from teaching ‘not to self-disclosure’ and teach students ‘how and when to disclose’, working with what may be useful to the therapeutic relationship. We rename this ‘self-disclosure as ‘relational disclosure ‘as the disclosure is not focused on myself but on developing our relationship together.

Stark (2000) integrates different schools of thought in therapy describing three modes of how therapists relate: one-, one-and-a-half and two-person. The ‘one-‘relationship is classical therapy. The therapist holds the position of wise expert, interprets the clients’ discourse, trying to keep their own personal experiences out of the relationship. ‘One-and-a-half is where the therapist is more involved with their emotions/observations/disclosures in the moment and a ‘two-person’ relationship is a therapist who will use full disclosure of self in service of the client and their relationship.
All of these modes have value, the psychodynamic ‘one-‘ and the Rogerian and Kohut ‘one-and –a- half’ are all familiar concepts to most therapists, the more contemporary relational ‘two-person’ mode is less commonly taught and the area we are interested in developing.

From the neurosciences (Badenoch 2008), to the basics of any therapeutic approach, we feel the interconnecting relational elements (below) are ways in which we can draw on the experience of the various schools of relational therapy.

The Interconnected Relational Elements

In a two person relationship the interconnecting elements are not as static as this diagram above suggests but are more like emerging molecules in the relationship, as they emerge we acknowledge the importance of our connection with each other in a particular way that is unique to each relational system and embodied language (Totton 2018). Each of us then will gradually re-pattern our nervous system (Dana 2018) and re align our neural pathways through the healing properties of the relationship. (Siegel 2010)

Emerging Molecules of the Relationship

Intention holds all our ethical values and principles, the ethic of doing no harm. Intention within the therapeutic relationship is ‘conscious choice’. The notion of intention in this context comes from the teachings of Craniosacral Therapy (Milne 1995) and Shamanism “How we intend to listen, observe, heal or hold sacred space is a creative power second to none” (ibid p59).
If we have the assumption that we are inherently healthy and self- regulating beings; when we meet ourselves and others with this understanding, and align our intention to find ‘where the health is’. We are creating a very positive space in which to engage, allowing the whole body and brain to integrate and function at its best.

When we are present with others we are receptive to what is going on with the other person and viscerally within ourselves. Our state of being constantly emerging and re-emerging as we connect with others and our inner world.

Presence is a fluid, energetic state created and developed as we exist in each other’s company. Working relationally means we need to have a clear a lens as possible, to have worked on our own issues enough to be regulated in our affect and notice when we get dis – regulated. Being relational is also then helping the client or supervisee to be fully present with us. Exploring any taboo’s and blocks in our relationship that may impede fully being together. Two beings fully present create the possibility of attunement.

Attunement happens when two people are coinciding with each other with respect and compassion. They become ‘attuned’ to their internal emotional states then as we bring empathy and attunement together we get a bodily and viscerally felt empathy that creates connectedness (Finlay 2016).

Thomas Merton defined compassion as being based on a keen awareness of the interdependence of all these living beings, which are all part of one another, and all involved in one another…. attunement.

To resonate is to ‘chime’ together, that mutuality which is so important for therapy to work, as the client feels that they are part of what is going on, that they too have a right to exist making observations and contributions to the ‘wisdom voices’ that emerge from the work.

We can get caught in mutuality if it starts moving towards symbiosis – always agreeing with each other, that is speaking only from one mind, one model, and one approach as the only way of doing therapy; a conditioned response to each other.

In all dynamic relationships there is a dance between intimacy and separateness which we can sometimes get wrong. But we have to do the dance and possibly get it wrong because then we can meet each other’s separateness which leads us then to reciprocity.

Reciprocity is the mutual action and transaction that then is agreed together in the relationship; the give/take interchange that continually builds the bridge between two fully relating beings.
In and between these elements we will pick up echoes of, and experience with, blocks and frustrations, distorted affects and mistrust, hurts and resentments that have left imprints and re- enacted in the working therapeutic relationship, ours and the clients!

For example when shame is triggered, both can hide or get caught in ‘feeling loops’, usually triggered unconsciously. Hence the reason for the therapist to know as much about their own issues as possible, not to make sure they are free from these in the therapy session, but more to notice such ‘ruptures’ and work with the feelings triggered in the unconscious, in service of the relationship with the client. To hold, tolerate and explore; leading to reworking and healing often for both client and therapist.

When two people work in this way they are both transformed by the therapy. Day in, day out in our therapy work we move towards transformation. We cannot help being touched by our client’s movement in therapy that also helps us move in the moment of the real relationship. The ruptures and repairs in the real ‘two person’ relationship along with movement through these elements affect each of us when healing takes place, both client and therapist can be healed.

Judy’s example
Once when a person arriving for supervision, wasn’t the person I expected…

…As I adjusted to the person in front of me, my supervisee clearly saw my perplexed expression, and asked “Are you alright”.  I thought I had a cancellation;  I had not put them clearly in my diary. In that initial moment, although I said I was okay, they struggled to begin.  In this moment we were disconnected, and in order to reconnect, I realised I had to name what had happened…I was not expecting them. 

Taking time to explore what was happening, confirmed my confusion which they intuitively sensed. This unnerved them; their pattern is to assume they are in the wrong. I was attuned to another person in my intention, before they came to my door, we were ‘mis- attuned’ and they were able to sense this. By owning my mis-take, they were confirmed in their intuition. They realised their struggle to begin was because I had not been ready for for them; my problem not their’s. My taking time to attend to our mis-attunement and being honest that I had not been expecting them, though initially difficult has now allowed us to connect more deeply. They were able to express their anger that I had not been ready for them and also learned that I was willing to own my mistakes and engage in the pulls and tussles of a healthy intersubjective relationship.

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