The Space Between

Experience, Context, and Process in the Therapeutic Relationship

Carmel Flaskas, Barry Mason, Amaryll Perlesz, Carmel Flaskas, Barry Mason, Amaryll Perlesz

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9780367328863
• eBook ISBN: 9780429922299
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The papers in this book focus on many different aspects of the therapeutic relationship, including the self of the therapist, working cross-culturally and with language difference, impasse, risk taking, the place of research, and the influence of theory. Clinical examples illustrate successful as well as less succssful outcomes in therapy, and these clinical explorations make the book accessible to both systemic and non-systemic practitioners alike. Part of the Systemic Thinking and Practice Series.Contributors:Rhonda Brown; John Burnham; John Byng-Hall; Alan Carr; Carmel Flaskas; Jo Howard; Alfred Hurst; Ellie Kavner; Sebastian Kraemer; Inga-Britt Krause; Rabia Malik; Maeve Malley; Michael Maltby; Barry Mason; Sue McNab; Amaryll Perlesz; David Pocock; Hitesh Raval; Justin Schlicht; and Lennox K. Thomas.

Chapter One
Relational reflexivity: a tool for socially constructing therapeutic relationships

John Burnham

Introduction

When clients come for therapy, the relationship that develops between therapist and clients is seen as a significant factor in whether there is a therapeutic outcome (Hubble, Duncan, & Miller, 1999). Naming one person in the relationship as “therapist” doesn’t automatically make it a “therapeutic relationship”. It takes hard work as well as imagination to coordinate the resources of client and therapist to create and maintain a relationship that is experienced as therapeutic for the client. One of the questions I regularly ask myself (in the spirit of selfreflexivity) is “How can I practise so as to increase the chances of this relationship becoming therapeutic for the people I work with?” This chapter is an account of some of the ways in which I have enjoined the people I work with in working with me (in the spirit of relational-reflexivity) towards answering that question. I will begin with a practice example, relating to theory, and offer definitions as I go, since this more accurately reflects how the praxis of relational reflexivity developed in my work. The initial development was mainly in my work as a therapist but I have since easily transferred these questions and practices to my work as a supervisor and trainer.

A beginning: socially constructing sensitivity

A particularly significant episode in developing relational reflexivity happened a number of years ago (1991), when I was guest supervisor at a Kensington Consultation Centre venue in Hertfordshire, in the UK. Julia Wigglesworth was then a therapist in training with Susan Lang as supervisor and (all female) team members. Julia requested that I do a “demonstration interview” with a couple with whom she had been working with for five sessions. She was uncertain about how the work was going, and she was very concerned to be particularly sensitive in relation to: race—the couple were mixed race Indian and African-Caribbean and Julia was English-white; and sexuality—the husband had hinted at some sexual difficulties. I eagerly accepted this invitation and, with their agreement, began to interview the couple in the presence of Julia and the team.

After about fifteen minutes of interviewing I was beginning to feel that the interview was not going so well and asked the couple, “How is today’s interview going compared to the ones that you usually have with Julia?” Both agreed that it was similar to what usually happened, and the couple agreed to my request to talk with them about the interviews with Julia. As this progressed I had in mind the concerns that Julia had expressed before the session. The following is an example of an episode in the session in which I asked some “questions about questions”:

“Does Julia tend to ask you more questions that are easy to answer or difficult to answer?”

“Easy to answer.”

“Which questions are most useful to you, the easy ones or the difficult ones?”

“The difficult ones, we know the answers to the easy ones because we’ve thought about them already. The difficult ones make us think about things differently.”

“If Julia asked you questions that were really too difficult for you to answer, for whatever reason, would you be able to tell her?”

“Yes, yes, that would be no problem” (both nodding in agreement).

These “questions about questions” caught my imagination during the rest of the session. They seemed to have the effect of directly involving the couple in decisions about the process and content of interviewing. Sensitivity, as well as being a self-reflexive posture of the therapist, became socially constructed between this therapist and these particular clients, through the practice of relational reflexivity. It became a “made to measure” sensitivity related to, but not restricted by, the therapist’s intentions or training.

My interest in “questions about questions” grew and became a regular part of my interviewing style in therapy, consultation, and supervision. Previously, I, like many others in the field (for example, Hoffman, 1992) had been more concerned with developing selfreflexivity. I think of self-reflexivity as a process in which a therapist makes, takes, or grasps an opportunity to observe, listen to, and question the effects of their practice, then use their responses to their observation/listening to decide “how to go on” in the particular episode or the work in general. Their responses might include: continuing with what they are doing, recalibrating slightly, or repositioning radically in how they act in relation to self and others. The practice of self-reflexivity tends to emphasize the “internal” activity of the therapist, as they search their own resources (similar to Tomm’s (1988) notion of “strategizing”). Self-reflexive activity can be prompted by a therapist’s reading of their own responses (where is this interview going? . . . I need to introduce more structure . . . I must pay more attention to gender and culture . . . what kind of questions can I ask?) and/or their empathic sensing of clients’ experience. With regard to the latter I might be thinking in the followinng ways: “The family seem to be liking these kind of questions . . . I’ll keep going”; “The children seem disconnected from the conversation . . . perhaps I will introduce more play”. In the interview with Julia and her clients, using self-reflexive activity (“this interview isn’t going well . . . what shall I do differently?”) as a prompt (“let me see what the couple think about how it is going”) to initiate questions about the questions, seemed to open a relationally reflexive space for the clients to experience empowerment in co-constructing with the therapist a relationship with therapeutic potential.

The responses of clients, supervisees, and therapists in training to this kind of collaborative conversation encouraged me to include other aspects of a session and components of systemic practice within this frame. In a development of the initial definition (Burnham, 1993) I would now describe relational reflexivity as:

the intention, desire, processes, and practices through which therapists and clients explicitly engage one another in coordinating their resources so as to create a relationship with therapeutic potential. This would involve initiating, responding to, and developing opportunities to consider, explore, experiment with, and elaborate the ways in which they relate.

The rest of this chapter explores a range of ways to transform this ethical aspiration into practical activity. I imagine that many practitioners will recognize aspects of their own practices. Perhaps they may already call it “checking out”, or “talking about talk”. It is my hopeful intention that by giving a name to this process (relational reflexivity), and exploring its usefulness in a range of ways, it will help to make this a more reliably creative tool for making the relationships we form with clients therapeutic. The generation of different forms of questions that follows is situated in, and owes much to, the traditions created by the great “question makers” such as de Shazer, 1994; O’Hanlon and Weiner-Davis, 1989, Madigan, 1993; Selvini Palazolli, Boscolo, Cecchin, and Prata, 1980; Tomm, 1987a,b, 1988; White, 1988; White & Epston 1991. I hope that what I offer is both within this tradition and extending it, by the explicit inclusion of clients in the creation of the therapy they receive. In my attempts to theorize this development of praxis, I feel I am working alongside and variously inspired by such concepts as coherence, coordination, and mystery (Pearce, 1989), knowledge of the third kind (Shotter, 1993), language and action (Cronen & Lang, 1994), and relational responsibiity (McNamee & Gergen, 1999).

Warming the context

Bateson (1972) talks of “warm ideas” as having a greater chance of survival than “cold ideas”. In the same way, if the context for conversation is “warmed”, and made less scary/more inviting, then generally participants may feel more willing/able to join the conversation/relationship more productively, openly, and wholeheartedly.

Warming the context would be all the ways that the therapist can, self-reflexively, help to create a “readiness” in the person(s) they are talking to or an audience that is listening to the conversation. When the therapist explicitly engages the client(s) in this process it becomes relationally reflexive.

Preparing a question to fit (I’m not sure whether to begin with . . .)

There is a preference in certain parts of the field to begin a question about change with the word “When . . . [a desired change] happens”, rather than “If . . . [a desired change] happens” on the grounds that “when” creates a greater emphasis on the inevitability of change. I think this is “unfair” on those people who are at the stage of “If” and could impose the idea that “When” is the best place to be. So I now ask routinely, “I would like to ask a question, and I am not sure whether to begin it with “when” or “if”. The question is “When, or if, the changes that you want to happen do happen . . . what will life be like?” Shall I begin the question with “When” or “if”? My intent is to coordinate my resources (different kinds of questions) with the client’s coherence in relation to being certain (when) or tentative (if). In doing so I am being irreverent (Cecchin, Lane, & Ray, 1991) to the injunction to “follow the field” and insist on “when”. Some people respond immediately with their preferred choice, while others think a while and the question about the question seems to have a reflexive effect. When people respond with “if” then we can talk about how close they are to “when”, and what steps they might take to get to “when”. The broad aim is to create a context which is “warm” or receptive to considering the direction of the question rather than imposing “when” as better than “if”. I find that this time is well spent for a variety of reasons.

1. The eventual question chosen/asked fits more closely with the coherence (personal preferences, family style, cultural values) of the client(s).
2. The client(s) have a sense of being able to make active choices in the session in creating “bespoke” questions as well as having “off the peg” questions.
3. They have the sense that the therapist is receptive (warm) to their answers and therefore they can be more willing to answer.

A fascinating episode happened when I asked a young woman of seventeen, who had a very quiet voice (literally and metaphorically) this question, that is “How should I begin this question . . . with ‘when’ or ‘if.’ “ She thought for a while and then said “When”. I began to continue the conversation and the father interrupted and said that he thought she had answered “when” to please me as she was by now very familiar with what professionals wanted. (I was indeed pleased when she made this choice.) I asked the young woman what she thought about her father’s idea. She said yes, she had thought I might be more pleased if she said “when” because professionals want you to move on. I said what if she knew that I would be pleased if she chose the answer she wanted to give, what would she choose, when or if? She thought and said, “It’s somewhere in between when and if”. I spontaneously suggested the invention of “Whif” (amidst general amusement) as something inbetween “when” and “if” and which was accepted. “Whif” became a catchword during the therapy.

When the therapy was ending we discussed “Whif” as an important part of the therapeutic process. It was a catchword that seemed to have meaning at different levels. It was a word we had made together and became part of our local grammar (Cronen & Lang, 1994) or ways of talking. When a word didn’t fit it could be made to fit or a new one could be invented. The episode in which the word was created and the future episodes in which it was used (in humour, for reflection, to tease) helped to shape the relationship. The relationship became reflexive, and one in which co-creation was a regular and practical event.

As the family members realized and experienced the context as “warm”, that is, receptive to their suggestions, they began to exercise choice and imagination. They also became receptive to ideas from the therapist and so “warming the context” (at different points in the process) contributed towards creating a therapeutic relationship in which all voices were heard, including family members, therapist, and team. The family members came to realize that they could ask for things to be different and that the choices offered could be accepted, rejected, or modified. The girl “played” with her self story of, “I am someone who does things to please other people” and experimented with “I am someone who is saying and doing things for myself”. All relationships have a “local grammar” that creates the shared meanings created within that relationship. The shared meanings are created within and partly define the relationship. Such episodes of creating new language can help to create a relationship as therapeutic.

Warming/preparing an audience to respond (“While we are talking . . .”)

When parents or a member of a couple say something like “Will you talk to him/her?” in a session, I would, previously, decline this invitation for a number of reasons. Now I am inclined to say something like: “I am willing to do that and I wonder if, as I am talking to your son/daughter/partner you would listen to the conversation that I have with him/her and take note of things that we talk about that you have not thought about or would like to know more about. Perhaps you could note which questions I ask that helps your son/daughter/partner to talk about their experiences?” In this way the young person hears (I hope) the intentions I have in accepting the parents’ request to talk with them and thus it is more likely that a warmer context has emerged when I turn to talk with him/her. Similarly, as I am talking with him/her I will be asking things like “Of all the things you have talked about so far, what do you hope your parents/partner have understood . . . and what difference would that make to you if they understood that? (Here I am aware of the parents or partner) as the context of audience to our conversation?” If I talked and then turned to ask them without “warming” the listening audience context, I might just put them on the spot whereas by framing my questions in the way I have the son/daughter/partner has been able to give them clues or coach them about how to respond.

I realize, as I write, that this could sound strategic, but it is not my intention to cause the parents to have a particular response, only to increase the chances of coordinating with their son’s/daughter’s wishes to be heard and understood in a particular way.

Warming the context for praise (How much praise can you take . . .?)

Not all clients can respond easily to glowing compliments and the “Wow” utterances by enthusiastic therapists and/or reflecting teams. One father said “I don’t know who they are talking about, but it certainly isn’t me!” after a reflecting team had been complimenting him during their reflections. Asking clients about their relationship with praise and compliments, for example, “How much praise can you take” or “If I or the team wanted to say something positive or appreciative about what we have heard, how might we say it in ways that you could accept?”, can create a context in which the therapist and team members can offer their appreciation without embarrassing the client into accepting something that doesn’t fit or giving him a feeling of not being heard.

Warning about warming

The term “warming” is not used to imply “cuddly” or “cosy”; it is being used to indicate that a context is being prepared for work so that the participants can go on to face experimenting with difference in a context that feels familiar. It is more than being friendly at the beginning to make people feel comfortable. With people who have come to experience initial friendliness by professionals as something to be suspicious about, then “warming the context” may include the therapist asking the family if they would prefer them to be more distant and professional than they have experienced so far. For example, “I was wondering if I had been challenging enough in the therapy so far?” Just as couples can get into stuck patterns in their relationship to each other, so can therapists with the people with whom they work, and some benefit may be derived from saying, “I thought about how we might change how we do the therapy sessions. What do you think?” For some therapists this would require them to “challenge their own coherence” (Pearce, 1989) if they saw themselves essentially as a warm and friendly person.

Coordinating resources

Between models of therapy (“Are you more of a doer, thinker or feeler?”)

At any particular time in the evolution/story of a model of practice or in the work of an individual practitioner, therapists will be attracted/committed to, or “in love with” a particular form of practice, sometimes (usefully or otherwise) to the exclusion of others. The practitioner may believe that this is the way to do it. What they offer the client is a glowing and committed confidence in the way they work. Other practitioners like to offer a choice from within a range of w...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• SERIES EDITORS’ FOREWORD
• ABOUT THE AUTHORS
• FOREWORD
• INTRODUCTION
• 1 Relational reflexivity: a tool for socially constructing therapeutic relationships
• 2 From system to psyche
• 3 “Alice and Alice not through the looking glass”: therapeutic transparency and the therapeutic and supervisory relationship
• 4 Working with men who use violence and control
• 5 Not getting lost in translation: establishing a working alliance with co-workers and interpreters
• 6 Intercultural: where the systemic meets the psychoanalytic in the therapeutic relationship
• 7 Before and beyond words: embodiment and intercultural therapeutic relationships in family therapy
• 8 Sticky situations, therapy mess: on impasse and the therapist’s position
• 9 Systems of the heart: evoking the feeling self in family therapy
• 10 Shame and the therapeutic relationship
• 11 Relational risk-taking and the therapeutic relationship
• 12 Adopting a research lens in family therapy: a means to therapeutic collaboration
• 13 Research on the therapeutic alliance in family therapy
• REFERENCES
• INDEX