Cultivating the Therapeutic Relationship

Cultivating the Therapeutic Relationship is about the importance of Self- development. It is asking and attempting to answer the question—does who you are make a difference to the outcome of your work as a bodyworker? Like all good questions, this question raises more questions: Who are you? How does who you are affect your clients? And, if who you are matters, can you develop yourself in a way that enhances your capacity to make a positive difference?

Does who you are make a difference?

In 2010, the Journal of Clinical Psychiatry published a meta-analysis of 17 randomised control trials of massage therapy and its effect on people diagnosed with depression. They concluded that “massage therapy is significantly associated with alleviated depressive symptoms” (Hou, Chiang, Hsu, Chiu & Yen, 2010). The authors propose several theories to explain their finding, including one non- physiological theory that implicated the role of the therapeutic relationship.

Psychotherapy considers there to be four factors affecting the success of the outcome common to all therapeutic encounters; the client, the therapeutic relationship, expectation (placebo effect) and a method. Studies show that the therapeutic relationship has 5 to 7 times the impact on the outcome when compared to the method used (Duncan, Miller, Wampold, & Hubble, 2010) and significantly, no one method is more effective than another. This is interesting because in the massage and depression study above, there was a wide variety of massage techniques used which included Swedish massage, myofascial manipulations, Shiatsu and traditional Chinese massage.

The issue here isn’t really about whether massage helps with depression, it is about the implications that follow if we recognise that the relationship has a significant impact. The therapeutic relationship is simply made up of the two people involved and of course everything they bring with them! So, what are you bringing?

Who are you?

As we grow up, we learn a system of values from the culture around us, which we use to evaluate the world and choose actions.

—Shohaku Okumura (2012)

The important thing to understand about Shohaku’s statement is that the evaluation and choosing he refers to are generally not happening at a conscious level, they are implicit beliefs. You are it seems a unique and not so unique mix of personal, familial, cultural, and pan-human influences, many of which are more or less hard-wired into your system.

It is critical to realise that we organise our experience around these implicit beliefs and that these beliefs/values are revealed through the way we express ourselves— our thoughts, actions and speech. The consequence of this for us as therapists is that the unattended expression of these beliefs may be creating a less than optimal therapeutic relationship and subsequently affecting the outcome.

How do you affect the outcome?

There are two ways you can affect the outcome, you can make things worse or you can help (it’s probably impossible to have no impact whatsoever).

In terms of what doesn’t work, it seems a style that is experienced as confrontational is ineffective, as are therapist comments that are perceived to be hostile, disapproving, critical, or blaming. Other issues that get in the way, are overly focusing on the problem, inflexibility and excessively structured treatments (Duncan, Miller, Wampold, & Hubble, 2010), perhaps related to a sense of being controlled or left out of the equation.

At first glance it may seem obvious that we wouldn’t want to be for example, critical, but on reflection we can see that it is built into our methods. Take a simple range of motion test that is accompanied by an exclamation about the restriction— that’s tight! Or some comment during a postural analysis—ah, you have quite a kyphosis! All these can very easily be construed as criticism. It is rare in my observations of body therapists that during a postural assessment they comment on all the things that are working well!

Furthermore, if the therapist has the belief that they are the one responsible for the successful outcome then this belief will be driving the need to figure out what is going wrong so they can fix it.

As you might expect, “clients feel connected to therapists whom they view as empathic, accepting, caring, supportive, and personable” (Bischoff & McBride, 1996 as cited in Duncan, Miller, Wampold, & Hubble, 2010). There is also strong evidence to show that therapists who actively take care of the therapeutic relationship by regularly checking in about it with their clients, significantly enhance its impact.

It also important that therapists “enlist and promote client strengths, resources, and personal agency” (Duncan, Miller, Wampold, & Hubble, 2010 loc. 2670). In other-words we need to explicitly recognise and work with the self-healing capacity of the client.

It is not surprising that therapeutic relationships are optimised by, “simultaneously using what works and studiously avoiding what does not work” (Duncan, Miller, Wampold, & Hubble, 2010 loc. 3534). The devil though is in the detail, sustained doing what works while not doing what doesn’t work requires that the therapist is aware of and responds appropriately to the moment to moment experience of both the client and themselves.

How can you develop your-Self to be of service to the therapeutic relationship?

Being able to monitor the ongoing experience of your clients and showing that you see them is fundamental to meeting them where they need to be met. This is no easy task and requires as a start the capacity to really be present to their experience, in this moment, which in turn means having a sustained grasp on your own moment to moment experience so it does not colour your vision.

For psychologist Carl Rogers (1961) the state required of the therapist to be truly present was one of having unconditional positive regard for the client. In other words not placing expectations or requirements (conditions) on how the person would be. Ron Kurtz developer of the Hakomi Method describes the required state as “loving presence” (Kurtz, Martin & Sparks, 2013, p.2) and provides five steps for achieving it. Here’s my take on them:

  1. Begin by cultivating the habit of self-study. Be mindful of your ongoing experience as you relate to another person. Notice the responses flowing through you—the thoughts and ideas you have—the way your body feels and reacts—the feelings that are emerging? You are looking to discover your reactions, the attitudes that arise, your unspoken agendas. You are looking to discover how you habitually relate.
  2. Once you are noticing your ways of relating, the next step is to let go of the ones that get in the way of truly being with the person. Learning to let go creates space and in that space you can choose to respond rather than react.
  3. The relaxation created by the sustained letting go of the implicit beliefs that limit your view allows you to clearly perceive the person. You can begin to see the person beyond the problem. Bill Moyers (1993, p.10) captures this when he says “the body hurts, and the person suffers”—can you really see who is suffering.
  4. This way of seeing someone reveals their inherent strengths and if you continue to be open you will find yourself deeply touched and nourished by the person. This is non-egocentric nourishment and is beyond concern for your own needs.
  5. When you directly and deeply appreciate someone in this way it is reflected back to them, through you. They are nourished in return by truly being seen and appreciated for who they really are.
    This approach to cultivating the therapeutic relationship will naturally and spontaneously provide the context within which healing can happen and it is within this context that we apply our methods.

In the end it seems that the You of you as a therapist has an enormous part to play in the successful outcome of the work that you do. The influence of your personhood on how your clients respond to treatment is far greater than the methods you use. So to conclude with a question—if who you are is so important to the outcome, how much effort and time are you willing to put into developing your-Self?

References

  • Duncan B. L., Miller S.D., Wampold B.E. & Hubble M. A. (2010). The heart and soul of change, second edition: Delivering what works in therapy. Washington, DC: American Psychological Association. [Kindle book]. Retrieved from http://www.am azon.com
  • Hou W.H., Chiang P.T., Hsu T.Y., Chiu S.Y. & Yen Y.C. (2010). Treatment effects of massage therapy in depressed people: a meta-analysis. Journal of Clinical Psychiatry, 71(7):894-901. doi: 10.4088/JCP.09r05009blu
  • Kurtz R., Martin D., & Sparks F. (2013). Loving presence: a practice for life. [e- book]. Retrieved from http://www.donnamartin.net/books.htm
  • Moyer B. (1993). Healing and the mind. New York, Bantam Doubleday.
  • Okumura S. (2012). Living by vow: A practical introduction to eight essential zen chants and texts. Somerville, MA: Wisdom Publications.
  • Rogers C. R. (1961). On becoming a person: A psychotherapists view of psychotherapy. Houghton Mifflin.