The Therapeutic Encounter

A Cross-modality Approach

David Bott, Pam Howard

• Publisher: SAGE Publications Ltd
• Year: 2012
• Print ISBN: 9780857022332, 9780857022325
• eBook ISBN: 9781446292570
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

The therapeutic encounter is at the core of counselling and psychotherapy training and practice, regardless of therapeutic modality. This book introduces a cross-modality approach to the client-therapist encounter, drawing from humanistic, psychoanalytic, systemic, and integrative approaches.

Chapters introduce a range of client themes - the refusal to join in, the battle for control, the emotionally unavailable etc - and shows how these are enacted in the relationship. The authors invite you, as therapist, to interact creatively with the client, engaging directly in the drama. In this way, they provide a coherent framework within which to understand both the therapeutic relationship and the principles of their approach.

This book is highly recommended for any counselling and psychotherapy trainee, regardless of modality. It is a must-read, with each chapter directly addressing essential teaching and trainee concerns.

David Bott is the Director of Studies of Counselling and Psychotherapy at the University of Brighton and a UKCP registered Systemic Psychotherapist.

Pam Howard is Course Leader of the MA Psychotherapeutic Counselling at the University of Brighton and a UKCP registered Psychoanalytic Psychotherapist

1	Theorising ‘Process’: Contemporary Perspectives

Put the emphasis upon a single method of treatment, no matter how diverse the problems which enter the office. Patients who won’t behave properly according to the method should be defined as untreatable and abandoned. Once a single method of treatment has proven consistently ineffective, it should never be given up. Those people who attempt variations must be sharply condemned as improperly trained and ignorant of the true nature of the human personality and its disorders.

Jay Haley, ‘The art of being a failure as a therapist’ (1969)

That you have picked up this book suggests that you have at least a passing interest in therapy. You may be an experienced practitioner, feeling the obligation to put aside reading the proper books that tell you about real life (literature) to engage with yet another account of the therapeutic process. Perhaps you are an enthusiastic trainee eager to learn how to do it from people who have been judged sufficiently ‘expert’ to convince a publisher that they are worth the risk of a print run. Equally, it is conceivable that you are a customer of therapeutic services – patient or client according to approach – interested in finding out what informs the sometimes puzzling behaviour of the person in whom you are investing your time and, possibly, money. This book is aimed primarily at trainees on counselling and psychotherapy courses, training in any approach whether humanistic, psychodynamic or integrative. However, it is also relevant to practitioners already engaged in therapeutic activity.

Whatever stage you are at in your career as a therapist, you will have made a commitment to a given approach. You will be discovering or know to your cost that this means hours of blood, sweat, toil and, significantly, tears as you engage with a complex literature, attend lectures, face public humiliation in ‘workshops’ and spent time and money on your own therapy. On the way you will have had to report regularly for supervision where your supervisor has the duty to ensure that you are conducting therapy in the right way (and yours to make sure that you present what you are doing according to the requirements of your modality, disguising or failing to disclose deviations). In short, you have developed or are in the process of developing an epistemology: ‘how a person or a group of persons processes information’ (Auerswald, 1985). All therapists make sense of what is going on by reference to an explicit or implicit epistemology. As Gregory Bateson (1971) puts it:

All descriptions are based on theories of how to make descriptions. You cannot claim to have no epistemology. Those who so claim have nothing but a bad epistemology. (p.142)

What you do with the client in an attempt to be helpful – methodology – follows from your chosen or implicit epistemology; ‘rules one uses in making sense of the world and how we make sense of others’ (Bateson, 1971).

While there are profound philosophical and theoretical differences between counselling and psychotherapy approaches, by their nature they share a common feature. A scene is set within which two or more people meet with a view to achieving a therapeutic outcome. In essence, therapy can be viewed as a series of dramatic events arising from the encounter between client and therapist.

Aristotle provides what is possibly the earliest account of the therapeutic process. In the Poetics he defines tragedy as the enactment of an action which gives rise to the experience of ‘pity’ and ‘fear’ with the purpose of cleansing emotions. Here, of course, he is referring to Catharsis, a notion which has found its way into therapeutic discourse and, though originating with Freud, is most commonly found in the more expressive humanistic approaches. Central to the tragedic experience is the notion of ‘harmatia’, literally missing the mark in archery. An incident in the plot leads the protagonist on to a path of tragic error and, thus, a noble man is caused to fall by a mistake in his actions. In therapy, the client is both the author and protagonist of his or her own tragedy. The solutions found in the face of the challenges of early experience have led to a life walked in ‘tragic error’. That a mistake has been made is hardly surprising since the drama being lived out was written by a six-year-old or even an infant at the age of three.

As therapists, our appreciation of the client’s courage in the face of adversity is not enough in itself. We are required to join the protagonist on stage and take an active part in the drama. In this we take the role of ‘Deus ex Machina’ – literally a ‘god out of the machine’. This refers to a plot device much disapproved of by Aristotle (Poetics) and, later, Horace (Ars Poetica). An inextricable problem in the plot line is resolved by the contrived and unexpected intervention of an outside character or event. Typically a god would be lowered from a crane in order to intervene on behalf of the protagonist. This is taken to be bad form in that it interferes with the unfortunate end that is the proper outcome of tragedy. In the therapeutic encounter it is the therapist who is craned onto the stage in order to interfere with the tragic outcome of the client’s drama. But this is not a pantomime and there is no place for a fairy godmother’s magic wand. The human condition is far too conflicted and complicated for such simplistic intervention: even good endings are seldom happy and rescuers are asking for trouble. The role of the therapist as deus ex machina is not to simplify the plot but to complicate it. Predicted outcomes are confounded and the way opened for a richer narrative to replace a thin and predictable plot.

To join the drama is essential but insufficient. Once the therapist is part of the performance they are in position to introduce some carefully chosen lines of their own. The system, that is, the complex interrelationships which make up the client’s internal and external world, is joined by a polite but unpredictable outsider. The client system has become a therapeutic system and, all being well, nothing will be the same again.

You might want to reflect on this in relation to a client you saw recently. If you are person-centred in orientation, you may have taken the view that the client’s difficulties are a function of unhelpful self-perceptions that are restrictive when it comes to achieving their full potential. The psychodynamic reader would have been inclined to focus upon the tasks of early life and tales of repressed desires replayed in a contemporary context, drawing upon the notions of transference and repetition compulsion.

Each of these positions suggests a particular mode of intervention or method: supportive/expressive or transferential/insight. Interestingly, while there are clear differences between each of the above, they share a common ‘psychological’ position in that: the view is taken that family life shapes personality; the therapeutic goal is changing internal experience; and the vehicle for change is an exclusive relationship with a therapist in a controlled environment.

There is now a convincing body of research into positive outcomes, which privileges the relationship over any particular approach or modality (Wampold, 2001). Importantly, the research also tells us that this is predicated on the practitioner having a coherent framework within which the relationship is understood. As we have seen, there are a number of well-established professional accounts, which have proved their worth in responding to and dealing with human distress. They are to be respected as such. What we are proposing in this book does not require you to give up on your commitment to your approach to therapy and its associated knowledge base.

The position we take is that there are enduring themes in human relatedness arising from human growth and development, family context and social arrangements around which the narratives we live by are constructed. These have relevance across therapeutic differences. Your client brings with them a ‘problem saturated story’. This tells of anger, abandonment, hurt, confusion and other forms of human distress providing the content around which the session takes place. Significantly, as the story is told, it is also enacted with the implicit invitation for you to join the drama. What you do next matters. If you take the allocated role and allow the predictable to be re-enacted, you become part of the problem. Each therapeutic model has its own version of how this might be avoided. However, focusing on phenomena which is common to all approaches – narrative and enactment – opens the way to establishing some general principles. These have the potential to enhance intervention making for creative and effective therapy. An openness to new possibilities permits us to benefit from the contribution of: social constructionism; systems theory; communications theory; and pragmatic models for working with resistance. So armed, we are better placed to respond to the predictable with the surprising – the stuff of therapy.

Postmodernism, social constructionism and the drama of therapy

This is first and foremost a book about practice and it is unreasonable to expect the reader to engage with a complex debate which might appear to be several levels of abstraction away from the therapeutic encounter. If you are impatient to get down to business, you may be inclined to engage with other chapters before returning to the philosophical and theoretical underpinnings of the approach. However, in this instance, Kurt Lewin’s assertion that ‘there is nothing as practical as a good theory’ is applicable (1951). That we set out to write and that you are taking the trouble to read this book can be located in what has been called the ‘postmodern or linguistic turn’. Traditionally, it might be anticipated that each of us would confine ourselves to the literature associated with our own corner of the field. For some, this might have meant grappling with the demands of the dense and extensive body of knowledge, which comes under the broad heading of ‘psychoanalysis’ to the exclusion of other potential lenses which might equally shed light on the human condition. Others would have their time cut out directing their efforts towards the abstruse arguments following the latest ‘paradigm shift’ that the systemic world had inflicted upon itself. Those of a person-centred inclination might find themselves engaged in working out to which ‘tribe’ they belonged. A new position with regard to the status of theory is proposed; one that is sceptical of claims to truth but has a high regard for knowledge. This opens the way for a climate where, despite a clear commitment to our own modalities, we can value the other.

Postmodern ideas are slippery and hard to grasp but cannot be ignored since they have had a profound effect upon the field of counselling and psychotherapy. At the same time, we need to keep in mind Best and Kellner’s warning:

The confusion involved in the discourse of the postmodern results from its usage in different fields and disciplines and the fact that most theorists and commentators on postmodern discourse provide definitions and concepts that are at odds with one another and usually undertheorized. (1991, p. 29)

Postmodernism as it relates to therapeutic activity is informed by a conflation or coming together of two distinct but related developments: American social contructionism on the one hand, and French post-structuralism on the other. While the former has had the most direct impact on the activity of therapy, a brief detour into the European philosophical tradition is not without value since it sheds light on some general contemporary pre-occupations in our field. The origins of poststructuralism lie in a post-1968 attempt to challenge enlightenment principles in general and, specifically, the work of Hegel and Marx. The poststructuralists, in effect, turned their back on the grand but flawed enlightenment programme of humanity, progress and freedom in favour of a number of themes, many of which find their origins within the writing of Nietzsche. These are: the rejection of a programme of cumulative and progressive historical change; the celebration of difference over conformity; the privileging of local and irrational knowledge over the universal and objective; moral relativism; and a fascination with the surfaces of things. The relevance of this position to us remains an open question in that there is much that is at odds here with the beliefs and practices which inform helping others. Traditionally, these have tended to look to a secular version of precisely the enlightenment Judaeo-Christian tradition that Nietzschean poststructuralism rejects. However, a number of ideas have significance in relation to what happens in the consulting room.

The first is to be found in a much quoted line by Jean-Francois Lyotard (1979) in his attempt to define ‘the postmodern condition’. Lytotard draws on Wittgenstein’s notion of ‘language game’, where Wittgenstein argues that, contrary to common-sense, words do not gain their meaning from their capacity to picture reality but through social interchange. In essence, a language game is a conversation we engage in to determine reality. On this basis, Lyotard declares ‘an incredulity towards meta-narratives’. This brings into question the bid by any particular approach to claim supremacy over others. Each modality merely exists within the language by which it is constructed and, as such, there is no basis upon which to privilege one over another. An extension of this is that we are required to give up on the quest to find an over-arching global therapeutic theory, which will finally provide all the answers. Instead, we are required look to the enduring therapeutic narratives which have shown themselves to serve our clients well – a local endeavour. Next, we might take note of Derrida’s (1974) familiar proposition: ‘Il n’ya pas d’hors texte’ – there is nothing outside of text. This questions the adequacy of language in accounting for the objective world. We are left with interpretation, since language can only ever refer to other language. If this is the case, therapy might be viewed as a process where the client’s taken-for-granted linguistic reality is deconstructed, opening the way for new possibilities to be brought into language. Finally, Foucault merits attention. Much of the impetus for the ‘postmodern turn’ in therapy is derived from what has come to be seen as oppressive ‘modernist’ practice. Foucault provides a convincing analysis of the implicit power imbalance in the therapist–client relationship – identifying the subtle forms of domination which follow from restricted access to knowledge (1975).

For some, this brief encounter with poststructuralism may have served to frustrate rather than edify. If you are inclined to engage with these ideas at greater depth than the focus of this text allows, you would be well served by Sarup (1993).

The other strand of postmodern thought, social constructionism, has had a profound and direct impact upon therapeutic practice, most significantly in the field of systemic family therapy. These ideas belong to the other side of the world, an ocean away from European preoccupations. They reflect a North American cultural world-view characterised by optimism, openness and pragmatism. The underpinning principles of social constructionism date back to the work of G.H. Mead (1934), subsequently to be developed in the 1960s and 1970s by social theorists like Becker (1963), Goffman (1956) and, notably, Berger and Luckmann (1967). Recently, there has been a resurgence of interest by contemporary thinkers, pre-eminent amongst these is the academic psychologist Kenneth Gergen. There is now an expanding literature which addresses the implications of social construction for the field of counselling and psychotherapy.

According to Mead’s theory of symbolic interactionism, the human infant is born with a rudimentary capacity to relate to and adjust to others. Initially, the infant responds to ‘gestures’ in the form of vocal sounds, movements and facial expressions. Subsequently, the development of language allows for the assimilation of a shared set of mental symbols which, in turn, creates the conditions whereby it is possible for the individual to take symbolically the place or role of the ‘other’: ‘When I am with you I will see myself through your eyes. Further, I will be able to complete mentally your reactions to my actions.’ Mead accounts for this process by distinguishing between the ‘I’ that is unique to the subject and the ‘Me’, the internalised other. Minded activity, our sense of self, consists of a conversation between the ‘I’ and the ‘Me’. In this way the development of personality can be understood in terms of moving from a ‘significant other’, the primary care-giver, to the incorporation of a ‘generalised other’ – the social world. This deceptively straightforward account has profound implications for the way in which we understand the human condition. It presents a direct challenge to our common-sense view of ourselves as boundaried, psychological entities. From a social constructionist perspective, the self does not arise through our exchanges with others. The self is our exchanges with others. The contemporary literature in counselling and psychotherapy is littered with references to Berger and Luckmann’s classic text The Social Construction of Reality (1967). This takes Mead’s original position forward, arguing that what we perceive as reality is based on taken-for-granted assumptions. Social arrangements arise from repeated actions, which are passed on to the next generation as social facts.

The relevance of this to our endeavour will have become apparent. From this perspective, the therapeutic relationship can be viewed as an engagement between the client and a potential ‘significant other’, the therapist. A problematic socially constructed self is exposed to an unfamiliar context where taken-for-granted assumptions are challenged as new possibilities present themselves. So far, so good, but things are not as straightforward as they might at first appear. To understand why, we need to visit the work of Erving Goffman.

Given the focus of this book, Goffman warrants particular attention since his primary concern is with the place of ‘performance’ in social life. For Goffman (1956), the social world is a stage on which identity is constructed and maintained through a series of dramatic acts. Social life consists of turn-taking, where each of us is actor and audience in turn. We give an ‘impression’ through the presentation of signals which invite the other to confirm us in our identity or sense of self. For example, on entering the lecture hall, we, the authors, must present ourselves as credible academics. There are inevitably those occasions when we have but a flimsy grasp of some aspect of our material. This presents us with the dilemma of how to convince our audience, the students, that our role as lecturer is legitimate. A strategy is called for. We might confuse the issue by drawing on language to which only the academically initiated have access or we might fall back on easy charm to avoid challenge. Whatever we do, there is an implicit request for the students (audience) to take seriously the impression that we actually possess the attributes we appear to possess. In the absence of this our identity becomes unsustainable or is ‘spoiled’. By the same token the students are presenting a complementary performance: taking notes (or doodling), feigning interest and, the brave, asking the odd plausible question. If all goes well and everything goes on as normal, we find ourselves convinced by our reciprocal performances and confirmed in our respective identities.

But things do not always go well. There are contexts where opportunities for constructing a satisfactory identity are severely constrained, and some individuals are disadvantaged when it comes to inviting a satisfactory confirmation of self. We might consider the relevance of this for the therapeutic encounter. In Asylums (1961), Goffman uses the term ‘total institution’ to denote an organisation where sleep, play and work happen in the same place: prisons, psychiatric hospitals, care homes and so on. When faced with the absence of a range of contexts and thus opportunities for establishing a desirable identity, the prisoner/patient/resident must decide whether to enter with enthusiasm into the arrangements by which the organisation functions or to find another way of dealing with an unsatisfactory situation. This is a matter of resourcefulness and subversion, where practices are employed precisely because they are forbidden. The intention is to reserve something of oneself from the clutches of the institution. An accompanying volume, Stigma (Goffman, 1963), addresses the dilemma of the individual who is disqualified from full social acceptance by virtue of a discrediting attribute or negative label. This may arise f...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• Acknowledgements
• Introduction
• 1 Theorising ‘process’: contemporary perspectives
• 2 The refusal to join in
• 3 The battle for control
• 4 Engaging with the emotionally unavailable
• 5 The need to be loved
• 6 An inability to relate
• 7 Encountering oppositionality
• 8 The therapeutic encounter: a safe emergency
• References
• Index