Relationships play an important role in everyday life. You or I may define a relationship with a person in many different ways depending on the context with whom the relationship is with, whether this be peers, colleagues or loved ones. So is it possible to have a relationship with someone who you don’t know, someone such as a therapist? It may be possible; however this is not the type of relationship that is being described within counselling therapy.
The client-counsellor relationship is unlike these day to day relationships that you may form with peers or loved ones, it is highly specialised; depending on the approach, it is usually informal in a structured manner, with boundaries and rules to dictate where the relationship may or may not go. These boundaries can have a powerful effect on the degree of the relationship; for instance the provision of confidentiality can help the client self-disclose more easily, and this confidentiality in turn creates and provides an atmosphere of trust which has been described as an aspect of an intimate relationship (Monsour, 1992).
This essay will focus on the relationship process in different counselling approaches; namely Existential counselling, Psychodynamic counselling and Person-Centred counselling. It will aim to understand the process and therapeutic approach used in counselling and how the relationship between client-counsellor evolves and what effect this will have on the outcome. Throughout history, support has been seen to be a key aspect of recovery from illness.
Iroquois Indians believed the cause of ill health to be unfulfilled wishes (Wallace, 1958 [cited in McLeod, 2009]); diviners would discover these unfulfilled wishes which were seen to be unconscious, and organise a festival of wishes where by neighbours, loved ones and the community would help to fulfil these wishes. In countries such as India the prevalence of mental health counselling is relatively low; the notion that western counselling theories and can be transported across from individualistic societies to collectivistic society may be seen as inappropriate.
In India family support, even today, is still seen as being used as the first point of contact for illness; culture and religion plays a significant role in the day to day lives. Western society was not so different to this before industrialisation. Religion played an important role in the western societies, where mild emotional and interpersonal problems were dealt with by priests (McNeil, 1951 [cited in McLeod, 2009]), and a shift from “tradition centred” (Riesman, 1950 [cited in McLeod, 2009]) to “inner-direction” approach was seen with the rise of Freudian and Rogerian counselling.
According to Burnard (1992) “the main point of working in the health care field is to communicate”. Communication is broad, and the form of communication that takes place is as varied as those in the relationship. The positioning of people and body language all contribute to revealing the feelings of one person to another (Argyle, 1983); this is because non-verbal communication, unlike verbal communication can not be effectively withheld.
Morrison & Burnard (1997) say that listening and attending are “by far the most important aspects involved in counselling”, and that clients would lose faith in a counsellor who stares out of the window or fiddles with a pen. If a counsellor uses Rogers’ (1957) core conditions, the counsellor will be exhibiting a presence which is inviting and warm, and allows for an effective therapeutic relationship. Rogers is seen as the founder of ‘client-centred approach’ (often referred to as person-centred).
The approach involves the counsellor helping the client find their own solutions to problems, without the counsellor giving direct advice (Morrison & Burnard, 1997). The person-centred approach believes the client is the best authority on themselves and their experiences, however that achieving this potential requires favourable conditions and that poor conditions may disrupt personal development. Rogers (1957) believes the client often comes to a counsellor because of incongruence between the client’s self image and their ideal self, and the role of the counsellor is to facilitate the client to resolve this incongruence.
One reason that incongruence may occur is because individuals often cope by accepting views of others and gradually incorporating these into their own views about themselves. Overtime an individual’s intrinsic sense of their own identity, evaluations of their own experiences and attributions of value may be replaced due to conditional acceptance from others. This is the basis for the first of the three core conditions (1. Unconditional positive regard/acceptance; 2. Empathic understanding; 3. Congruence), maintained by the person-centred approach.
The first condition allows the client to freely explore all thoughts and feelings without danger of rejection, and crucially the client is free to explore these without having to meet any standards of behaviour to earn positive regard. The second, empathic understanding, is so that the counsellor can accurately understand the clients thoughts, feelings and meaning, from the clients perspective. Burnard (1992) cites Kalisch as defining empathy as “the ability to perceive accurately the feelings of another person and to communicate this understanding to him”.
The final condition, congruence, is for the counsellor to be authentic and genuine, and not to present a facade, where the client is free to understand the counsellor as much as the counsellor understands the client. Rogers states that if a counsellor is being congruent then this may lead to the counsellor self-disclosing, however that this is not so that the counsellor can talk about their own feelings, but to ensure that a client is not deceived by a facade (Corey, 1991).
Rogers believed these three conditions were both necessary and sufficient for therapeutic progress to occur, and that there is nothing essentially unique about the relationship, and that a healthy relationship with others may manifest the core conditions in them. However a frequent criticism is that delivering the core conditions is what all good therapists do anyway before applying their individual therapeutic approaches. Bowers and Clum (1988) reviewed studies which compared therapies with a technique focus, therapies with a relationship focus (placebo therapy), and therapies with both.
They found that both contribute to the effectiveness of psychotherapy, and that the therapeutic relationship contributes a unique piece of variance to the effectiveness of therapy. In addition, Bolstad (1992) found that using closed questions or too many questions at all was found to be an inhibitory factor in the relationship, so the use of minimal prompts (such as “umm”, “yes” and even body movements like nodding [as seen in Rogerian person-centred counselling]) should be present in all counselling sessions. The existential approach views humans as continually changing and transforming, living essentially finite lives.
The focus of this approach being on the client’s life and exploring the meaning and value in accordance with one’s own ideals, priorities and values. Psychological disturbance is taken as the outcome of avoiding life’s truths and working in the shadow of other people’s expectations and values. This approach places great emphasis on the therapist’s ability to be aware of, and to question their own biases and prejudices; the facilitation of the client’s beliefs and values are essential to building the therapeutic relationship, and thus the therapists is seen to being naive within the therapy.
To understand the client, the therapist explores the client’s existence on four main dimensions (1. phsyical; 2. social; 3. psychological; 4. spritiual). Van Deurzen (2000) observes there are “obvious existential elements” in the person-centred approach; and in an historical context the philosopher (Soren Kerikegaard) most frequently mentioned by Rogers, also contributed significantly to existential counselling.
Legg (1998) surmised that academic Psychology has advanced over the last 50 years, whereby theories (such as personality theories) have evolved, but the empirical foundations of counselling (both person-centred and existential) are virtually never addressed in current literature. The difference between person-centred and existential being that the existential approach focuses on the relationship a person has with themselves and the world around them, whereas the person-centred approach focuses on the development of the self under more or less welcoming conditions.
Modern psychological therapies can trace some roots back to Freud and his methods of psychoanalysis. He strongly supported the idea of lay analysts without medical training, which was ever increasing difficult as western society moved towards medical, biological and scientific approaches to illness. Psychodynamic therapy focuses on the idea that most of mental disorders lie in the unconscious mind, and therefore the patient is unaware of them. Freud believed that in order to treat the problem, the client’s repressed desires and problems must be uncovered in order for the therapy to proceed.
The psychodynamic therapist uses the here and now to determine possible explanations in everyday life (McLeod, 2009). Although modern psychodynamic therapy is still heavily influenced by Freud’s original ideas from the early 1900’s, it has been highly developed since, taking a more social relationship-oriented approach (McLeod, 2009). The core principals are for the therapist to understand the development of personality, particularly how it was shaped by early family life and environment.
Freud favoured two methods of assessing a client’s unconscious thoughts and feelings; dream analysis, and free association. These were developed after Freud learnt ‘hypnosis’ from French psychologist Charcot & Janet. Freud maintained the idea that a client and therapist must have a good rapport for therapy to work, however his scepticism about hypnosis lead to the development of ‘free association’, which works on the principal that the client is comfortable enough to talk freely.
The relationship within a psychodynamic therapy in modern psychology allows for a more personal relationship; by having the counsellor as a ‘blank screen’ onto which the client can project their thoughts and feeling about themselves, allows for the therapist to understand how the client is feeling, this hopefully leads to the same relationship and rapport that the client is trying to overcome; this is the most commonly used method in modern psychodynamic therapy (transference).
However a major criticism of psychodynamic therapy, unlike other therapies, is that the counsellor/therapist is offering his or her own opinions on the situation. Both existential and person-centred tries to get the patient to reflect on their own experiences, here in psychodynamic therapy we see that the counsellor may offer an interpretation. Researchers found that in extreme cases, such as sexual abuse in women, psychodynamic therapy may elicit more withdrawals than progressive results (Farber, 2009).
This also occurred in sessions with post traumatic stress disorder patients, who withdrew considerably after a psychodynamic treatment (Markowitz, 2009). Van Denburg & Van Denburg (1992) note premature termination resulted from failures in empathy; they also note that others have suggested that premature termination occurs from too strong negative transference(Mahler, 1952), fears of abandonment by and separation from the therapist, and too strong feelings regarding dependence on the therapist (transference resistance – Freud).
Today psychodynamic therapy is mainly used to treat problems such as personality disorders, anxiety attacks, panic and depressive disorders. Thus far this essay has looked at three approaches in counselling, and identified ways in which the therapists build relationships with the clients. But how effective is the therapeutic relationship in counselling?
Research has consistently reported a positive relationship across studies between the quality of the therapeutic alliance and therapy outcome, although there are some instances where the working alliance fails to predict outcome or where associations are nonsignificant (Gaston, 2004; Hovarth, 1991, 1993, 1994; Krupnick, 1996 [cited in Knaevelsrud & Maercker, 2006]). Blagys and Hilsenroth (2000, 2002) found seven interventions that stood out as distinguishing psychodynamic and interpersonal therapy from cognitive–behavioural treatment, and six techniques and interventions were identified as distinctive activities of CBT.
Lambert and Ogles (2004) indicated that varying types of therapy usually yield similar results, but the possibility of differences should not be excluded. However, different approaches have been exposed to systematic evaluation to various degrees. A comparison was made between psychoanalytical psychotherapy and behaviour therapy, where both sets of therapists were rated equally on display of warmth; however the behaviour therapists were rated as more active and seemed more genuine (Sloane, Staples, Cristol, Yorkston & Whipple, 1975).
Research about therapeutic orientation and attachment styles has shown that having a psychodynamic orientation predicted the quality of the alliance as being less positive, and the psychodynamic therapists reported more problems in therapy, compared with cognitive– behaviour therapists, cognitive–analytic/ integrative or eclectic therapists, and humanistic therapists (Black, Hardy, Turpin, & Parry, 2005).