The Therapeutic Relationship. Arlene Vetere

Transcription

1 The Therapeutic Relationship Arlene Vetere

2 Psychotherapy and Culture Cultural and ideological diversity of clients and professionals The multi-layered spirit of practice in modern healthcare systems Engagement and communication: common factors in healing Collaborative practices The complexity of change processes The link between entrenched social disadvantage and physical and mental health EU Green paper on Mental Health

3 Bruce Wampold, 2011 Lest we forget, it is the therapist who makes psychotherapy, and other helping professions, effective. Accumulating research demonstrates that in practice, as well as in clinical trials, much of the variability in outcomes is attributable to the therapist, regardless of the treatment being delivered.

4 A SECURE BASE For not only young children, it is now clear, but human beings of all ages are found to be at their happiest and to be able to deploy their talents to best advantage when they are confident that, standing behind them are one or more trusted persons who will come to their aid should difficulties arise. The person trusted provides a secure base from which his (or her) companion can operate. Bowlby, 1973

5 Diana Fosha The roots of resilience.are to be found in the sense of being understood by and existing in the mind and heart of a loving, attuned, and self-possessed other.

6 What Does the Research Tell Us? The therapeutic relationship is the key predictor of client outcome (Elliott et al, 2011) The therapeutic relationship accounts for 30% of the variance in client outcome (Lambert and Barley, 2001) The therapeutic relationship is accepted as necessary for change in all major psychotherapies Empathy is the evidence based component of the therapeutic relationship (Norcross and Wampold, (2011)

7 What Does the Research Tell Us? Empathy: A conscious perspective-taking process (affective and cognitive), whereas sympathy is an emotional response to another s affective state Rogers accurate empathy : understanding the other and communicating this through reflective listening Empathy linked to positive engagement: 10% variance in client outcome Alcohol use problems: higher empathic engagement, less drinking..

8 What Does the Research Tell Us? Empathic responding helps clients identify and modify their own affect Empathy: acceptance and warmth Trust: listening, being present, focused, caring emotional risk taking If we believe out therapist can help us stronger commitment to therapy and therapist s hope in usefulness of therapy linked to client engagement

9 What Does the Research Tell Us? Therapist empathy and interpersonal skills highly linked Empathy trust Principal healing components of the therapeutic relationship (empathy, genuineness, positive regard and validation) form the basis of compassion (a higher order process?)(kirschenbaum and Jourdan, 2005) Empathy and curiosity = self-reflexivity Attributes and/or learned skills??

10 Active Listening Focus attention on the child without interrupting with own thoughts and comments Acknowledge you are listening, both verbally and non-verbally speaker can both see and sense they are being listened to Pick up the non-verbal cues what is not being said. Don t be distracted by thinking of your reply while child is speaking Offer an appropriate response

11 Listening, Speaking and Hearing Stress responses get in the way of hearing Anger, fear and panic produce fight or flight or dissociation responses cognitive functioning and memory are impaired Repeat what has been said and check it has been understood Give opportunities to repeat and develop understanding Rehearsal helps

12 Attunement, Empathy & Reflective Function Empathic and well attuned bonds emotional security greater Understand child s feelings, respond in a way that effectively communicates that understanding, and contains distress with sensitivity Fonagy: a reflective caregiver increases likelihood of child s secure attachment which in turn, facilitates development of mentalisation

13 Attunement: Reading the Rhythms of the Child This is why the core of good teaching is attunement. Attunement is being aware of, and responsive to, another. How does this child feel? Is she interested, engaged, capable of listening to what I want to say? What is the best way to communicate this idea, fact, concept, or principle to her in this moment? What will engage, encourage and excite her about this subject? What will be heard, perceived, felt and learned in short, what the teacher will communicate depends upon how receptive the child is. And how well a teacher reads a child s receptivity depends upon an understanding of how humans communicate without words. Bruce Perry

14 Internal Working Models Beliefs and expectations about One s own and other people s behaviour Views of the SELF How loveable, worthy and acceptable am I? How available and interested are others in me, and in caring for and looking after me?

15 ATTACHMENT STRATEGIES AS A CONTINUUM: styles of protective & defensive processes DISMISSING/DE-ACTIVATING PRE-OCCUPIED Learn that expressing emotions cannot reliably elicit comfort or caring, defensive strategy develops of distancing or excluding emotions. Cognition is relied on and can be employed to help omit or distort emotional information: inhibit affect, falsify, deny physiological discomfort and pain: - idealise, care for others - deny need for others compulsive reliance on self Learn that cannot rely on words and cognition, inability and failure to predict. Increasingly rely on affective information. Split feelings of anger and vulnerability so display one and suppress the other. Cognitive defences involves passive thinking, reducing complexity by blaming of others and avoiding considering own contributions, rationalising/justifying own actions: - anger towards others - anxiety and vulnerability

16 ATTACHMENT ALWAYS TWO SIDED Attachment always has TWO sides. Responses to nonavailability of the attachment figures: PROTEST - anger of hope and of despair and VULNERABILITY sadness/fear/shame One may be shown more than the other, or shown in rapid alternation. Internal conversation potential Strange Loops

17 Systemic Intervention Identify unhelpful patterns with the couple the pattern is the problem, not the person unresolved hurt (NB violence needs a different response see Cooper & Vetere, 2005) Validate each person s experience deep listening - expand and process - help to soften a blaming position intention vs effect! Encourage integration of representational systems and reflection coherent narrative Support listening and curiosity about the other s experience compassion, trust, soothing and affect regulation Support re-bonding enactment in/outside the session Assisting with other difficulties and worries Repair, consolidation and new narratives

18 Implications for Therapy Naming and regulating emotions Standing in the emotional shoes of the other Comforting and self soothing Information processing Transformations in representational systems

19 Secure Attachment what sustains our relationship is, I m extremely happy with her, and part of it has to do with the fact that she is at once completely familiar to me, so that I can be myself and she knows me very well and I trust her completely, but at the same time she is also a mystery to me in some ways. And there are times when we are lying in bed and I look over and sort of have a start. Because I realise here is this other person who is separate and different and has different memories and backgrounds and thoughts and feelings. It s that tension between familiarity and mystery that makes for something strong, because, even as you build a life of trust and comfort and mutual support, you retain some sense of surprise or wonder about the other person. Barack Obama. The New Yorker, January 19, 2009, P50

20 For Better or Worse. Physiological and psychological implications Attachment and Repressive Coping Style Cancer and the immune system Hostile conflict and wound healing (Kiecolt- Glaser and Glaser) Pain and comfort Social support networks London Depression Intervention Trial John Gottman: divorce prediction? Criticism, contempt, stonewalling, defensiveness

21 Our Wish for Connection: Research on Bonding 1. Emotional connection: turns on positive emotion (oxytocin) & mediates threat perception 2. Effective dependency and resilience: open systems, curiosity, & the ability to learn and play.. 3. Responsiveness and accessibility: are you there for me? 4. Emotional separation: cues panic and protest 5. Safety and emotional risk-taking: demand anger of hope (protest); dismiss anger of despair (shut others out): cues negative cycles, maintains felt insecurity, distorts attachment signals (John Gottman, Mario Mikulincer, Pat Crittenden, Susan Johnson)

22 John Gottman: The Science of Trust 2011 Enhance your love map Nurture fondness and admiration Turn towards each other Let your partner influence you Solve your solvable problems: a) softened start up ; b) make and receive repair attempts; c) soothe self and each other as conflict can lead to flooding ; d) compromise Overcome gridlock existential base of unexpressed dreams Create shared meanings stories we tell about our relationships

23 Felt security in a relationship Affect regulation (less reactivity, hyperarousal & under-arousal) Support seeking Information processing (curiosity, open, more toleration of uncertainty) Communication (meta-communication, disclosing, collaborative, assertive, empathic) Sense of self (elaborated, articulated, positive) (Mikulincer and Goodman)

24 INTERNALISED OTHER INTERVIEWING Three people : if you can get into pairs (A & B) where you know each other reasonably well. Person A: Gets into role of becoming Person B Person B: listens Interviewer C: interviews person A as if they were B. Now B, can you tell me how you are feeling today, etc..! For about 5 minutes, then Reverse: Interview B as A A, B and interviewer C discuss the conversations: What did this feel like? How accurate were they? What surprised each of them about what the other said?

25 Couples Therapy & Attachment Theory Focus on attachment needs & forms of engagement/disengagement (Minuchin, 1974) Privileges emotion the music of the attachment dance (Johnson, 2002) Therapy as a secure base (Byng-Hall, 1995) Supports different bonding responses & events: integration and reflection Addresses impasses & attachment injuries

26 Working with Dynamic Systems Focus on attachment theory guides interventions (Dallos & Vetere; Flaskas; Johnson) The couple relationship can either support or undermine the sense of emotional safety: for both partners and their relationship mutual influences Couple distress is understood in the context of recent research (eg John Gottman; Mikulincer and Goodman; Crittended; Hazan and Shaver) Attend to key emotional responses that maintain distress therapy alliance as secure base Pursuer-distancer circularities are especially relevant to an understanding of couples attachment relationships

27 Working with Dynamic Systems Support for altering emotional responses and dispositional representations in ways that enhance and develop secure connections reprocessing, integrating, reflecting and doing Transition points in families provide a particular challenge for the couple system, as partners seek either to re-establish familiar reaction patterns ie falling back on old solutions, or take the risk to develop new patterns ie corrective scripts There is mutual influence between the couple unit and other subsystems of the family (life cycle theory and inter-generational family therapy)

28 Focusing on Emotions: Johnson, 2008 Focus on most poignant or vivid aspect of experience: non-verbal expression of emotions and non-conscious relational responding Focus on emotions that are most significant for attachment needs and fears eg of rejection Sadness and grief related to a sense of loss and helplessness Anger is often a reaction to perceived or actual nonresponsiveness (or threat of abandonment or rejection) in an attachment figure Support & help develop differences & interaction

29 Focusing on Emotions: Johnson, 2008 Shame may indicate a partner s lack of entitlement to share their needs and longing for closeness, and fear that such sharing will lead to rejection Fear and vulnerability are core aspects of human attachment and evoke a partner s longing for closeness and secure connection Focus on emotions that play a part in organising negative cycles of interaction: therapist explores and expands emotions that are present in couple s problematic patterns (Johnson, 2008)

30 Working with Emotions: EFT Expressing and expanding emotional experience is central to change in interactional patterns Accessing primary emotions (eg sadness, fear of loss, shame) enables new meaning to be brought to understanding family members behaviour Processing the experience and the underlying emotions that may have been on the edge of awareness And to challenge long held perceptions of family members

31 Exploring Patterns of Comforting When you were upset or frightened as a child what happened? How did you get to feel better? Who helped you to feel better? How did they do this? What do you think your parent/s learned from their parents? What have you learnt from this for your own family? What do you want to do the same? What do you want to do differently? How do people comfort each other in your own family/relationship? How do you comfort your children? How do they comfort you? What do you want your children to learn about comforting, for now, for the future, and for the future of any children they might care for? Can be held as a family or couple interview or as a one-to-one conversation.

32 Empathy & the Therapeutic Alliance Reaffirming and clarifying clients experiences Modelling acceptance of both partners experiences Slowing down the session, enabling partners to process their experiences Helping to organise different aspects of clients experiences (action, feeling, thought and intention) into a more integrated whole a coherent narrative Comforting in response to a difficult emotional experience Exploring the meaning of important and powerful human experiences

33 THERAPY AS SCAFFOLDING: Emotional and cognitive Developmental perspective: (Vygotsky) Learning occurs though internalising conversations Zone of Proximal Development staying within the zone of not too familiar and not too different What we can do with the assistance of another person/therapist Therapy and scaffolding: Emotional base safety, security reduce negative arousal Assisting in identifying and regulating feelings Encouraging reflexivity standing in the emotional shoes of the other Exploring comforting and self-soothing Assisting integration of feelings and events Assisting coherence: helping families/couples develop a narrative of how they healed their relationship

34 Attachment Narrative Therapy with Families/Couples Creating a secure base

35 Attachment Narrative Therapy with Creating a secure base Families/Couples Mapping the context & talk about talk Engaging warmly with each member of the family Reflecting on our relationships in the room modeling open communication Use of self therapist reflecting on his/her own experiences Adopting a non-blaming approach - working together vs fixing families, purpose is not to find fault in the past or present Externalizing Framework Exploring the problem - beliefs, feelings, explanations A conservative (paradoxical) framework - not pushing for change Access, illuminate, expand, reprocess emotional experience De-escalating unhelpful patterns

36 Creating a secure base Reflection, containment and emotional safety Supporting, building the therapeutic relationship Validation and support- acknowledging emotional risks, demands of therapy, temptation to withdraw Clarifying, context how we will communicate Establishing sense of safety, pacing: Identifying, exploring and de-escalating unhelpful patterns of interaction

37 Exploration - Narratives and Attachments within a Systemic Framework Identifying attachment dilemmas Identifying attachment needs and wishes eg for reassurance, underlying core patterns of feeling, thinking and behaviour Discrepancies: thoughts and feelings, head and heart Divided loyalties ambivalences in relationships Reflections on the therapeutic relationship: empathy and listening Exploring problems, emotions and competencies: Access, illuminate, expand and re-process emotional experiences

38 Considering Alternatives emotional risks and change Loosening Attachment Dilemmas Considering alternatives unique outcomes Acknowledging risks of change, Threats to perceptions of self and others Relational and emotional risk taking, in therapy and outside conflict resolution Re-bonding consolidating more satisfying interactions

39 The Future: Maintaining the Therapeutic Base Shared narratives of healing Acknowledging possibility of relapse temptation to retreat to patterns of thinking and feeling Holding each other in mind how we will think about each other in the future What support will be able to draw on in future consolidating change Creating opportunities for future reflection

40 EMOTIONAL SCULPTING Sculpting with family members themselves, or sculpting with objects (coins, buttons, stones, figures etc ) PROMPTS (can use direct or circular questions ) Map the current attachment patterns, relationships who looks after whom, etc. How does it feel to be, for example, at the centre, on the edge, between your parents, and so on? Now that you and your brother are closer, how does that make you feel? If you were to get closer to your mother what would that be like? How do you think your sister feels being that distant from your father? And so on...

41 Corrective and Replicative Scripts This utilises ideas from John Byng-Hall that families make comparisons across the generations in terms of similarities and differences between how our own parents were with each other and us (the children) and how this is repeated or altered in the next generation. Importantly it allows us to work in a positive frame with the family in that we may construe the intentions of the parents positively, i.e. they have tried to repeat what was good or correct what they felt was bad about their own experiences. This can then lead to a discussion of whether these attempts have been successful or not, and possibly how they might be altered, strengthened, elaborated etc. What are your thoughts about how similar or different your relationship with each other and your children is to your parent s (grandparents ) relationships? What have you tried to make similar or different to either of these relationships? What do you value vs feel critical about in either of your parent s relationships? Does what you have tried to repeat/change work? Is there anything that you want to alter, strengthen, abandon about what you have been trying to repeat or change?

42 Suggested Reading: Dallos R and Vetere A (2009) Systemic therapy and Attachment Narratives; Applications in a range of clinical settings. London: Routledge Dallos, R. and Vetere, A. (2014) Systemic therapy and attachment narratives: Attachment Narrative Therapy. Clinical Child Psychology and Psychiatry, 19, Johnson S (2002) Emotionally Focused Couple Therapy with Trauma Survivors. New York: Guilford Vetere A and Dallos R (2008) Systemic therapy and attachment narratives. Journal of Family Therapy, 30,