VII' The Therapeutic Relationship

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VII. The Therapeutic Relationship

• The meeting of two personalities is like the
  contact of two chemical substances if there is
  any reaction, both are transformed.
• Carl Jung

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VII. The Therapeutic Relationship

• The nature of any relationship, even a clinical
  relationship, is reciprocal.
• As one person in the relationship, I have to put
  myself into the same life space as the client.
• I must remain totally open to receive whatever
  the client has to offer, without judging the
  adequacy, effectiveness, or emotionality of the
  message.

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VII. The Therapeutic Relationship

• I need to be fully aware of what I am, who I am,
  and what I am feeling in the presence of others.
• I have to be willing to listen to what is taking
  place within me.
• I have to relinquish my own personal attitudes
  and ideas so I can attend fully to the other
  person.

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VII. The Therapeutic Relationship

• I have to open myself to my clients, so they will
  be less afraid to share the thoughts, ideas, and
  feelings that trouble them.
• I have to be free to offer myself, uncontaminated
  by egoistic or absolute professional edicts.
• I have to be authentic.
• I have to have, as Carl Rogers would say,
  unconditional regard for each client.

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A. Education

• The term education comes from the Latin educare,
  to bring up, rear, or train, and from educere,
  to lead, draw, bring.
• It is a process by which knowledge is gained by
  the sharing of experiences.
• Therapy is a dynamic form of teaching.
• A clients growth and learning take place best in
  a non-threatening atmosphere of warmth and
  acceptance.

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A. Education

• In order to facilitate this growth, the clinician
  needs to be a caring, nonjudgmental, authentic
  person.
• The therapist and client must share the
  responsibility for effecting communicative
  change.
• It does not consist of two people sitting across
  the table from each other, but instead, of two
  people sitting alongside each other attempting to
  solve a common problem.

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A. Education

• Therapy is learning as well, for both the client
  and the therapist.
• It is a sharing of information whereby neither
  person has more than than the other.
• Though the knowledge may differ, we have as much
  to learn about our clients as they do from us.
• So, we are relieved of the burden of having to
  come up with all the answers.

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A. Education

• Going through the learning process may result in
  clients experiencing confusion.
• Confusion is a normal, healthy part of the
  learning process.
• We may be confused in the process of acquiring
  new information that we do not have the
  experience to evaluate, and to understand a new
  vocabulary that was previously unfamiliar to us.
• In the resolution of confusion we learn, provided
  we are given time and repetition.

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A. Education

• Unfortunately, clients and their families,
  especially in the early stages of diagnosis, are
  given much more information than they can use.
• Information overload can be harmful because
  increased confusion can lead to feelings of
  inadequacy and anxiety, both of which tend to
  reduce client self-esteem.

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A. Education

• The best rule of thumb is to ask the client,
  What do you need to know?
• If you receive a response, such as I dont even
  know enough to ask a question, which is fairly
  typical in the early stages, you might respond,
  It sounds to me like youre pretty confused.
• This is an invitation to talk about the feelings
  the client has and is experiencing.

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A. Education

• In terms of working with clients with voice
  disorders, some of the areas in which the SLP
  educatesshares informationmay apply
  specifically to our area of expertise, including
• 1. A description of the A P of the vocal tract
  geared to the intellectual level of family
  members, and using a simple visual aid, if
  appropriate
• 2. An explanation of the actual organic
  condition, if present

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A. Education

• 3. A simple explanation of how abuse/misuse
  contributes to aberrant vocal quality and how
  organic conditions develop
• 4. A description of various forms of vocal
  misuse
• 5. An explanation of the various environmental
  circumstances that may contribute to such misuse
• 6. A description of basic principles of vocal
  hygiene and
• 7. An explanation of the overall means and goals
  of voice therapy.

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A. Education Summary

• It is important not to overwhelm the client
  and/or family with all of the significant dos and
  donts.
• If the client does not ask the question, then she
  is not ready to hear the answer and the
  information provided is seldom digested.
• People only learn what they are ready to learn
  and absorb.
• The best indication of readiness is the question.
• Gratuitous information only serves to increase
  confusion and is rarely helpful.

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B. Counseling

• There is a tendency in training programs that
  emphasize the medical model to view counseling as
  something one does after obtaining a careful case
  history and administering the diagnostic tests.
• This approach to counseling is information based
  and involves an explanation of the testing
  results, interpretation, and recommendations.
• By staying with content, we are professionally
  safe from having to deal with client feelings.

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B. Counseling

• With content, students, especially, feel they can
  control the interaction.
• Since emotions are unpredictable and therefore
  potentially disruptive, information-based
  counseling allows us to adopt an attitude of
  detached concern and to control the interaction
  by delivering set speeches.
• Professionals contribute to client confusion by
  providing information-based counseling when the
  client is unprepared psychologically to receive
  it.

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B. Counseling

• Another approach to counseling used by many
  professionals in our field is counseling by
  persuasiona very seductive model of counseling.
• The underlying assumption to this approach is
  that I as the professional have all the
  information and experience. You as the clients
  are ignorant of so many things you need to know,
  so I can make a better decision for you then you
  can yourself.
• This approach often confirms the clients
  perceptions of her own limitations.

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B. Counseling

• The client who feels inadequate and overwhelmed
  by the problem at hand will acquiesce to our
  arguments and recommendations and let the
  doctor decide.
• Counseling by persuasion is almost always a poor
  approach because the client never owns the
  behavior.
• She does not take responsibility for having made
  the decision.
• The responsibility remains with the professional.

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B. Counseling

• Counseling by persuasion also reinforces the
  clients own feelings of inadequacy.
• It confirms her own felt inability to make a good
  decision, so instead she decides to trust the
  professional.
• This creates a dependent clientone who is less
  apt to take any initiatives or responsibility for
  solving the problem.
• The work is all left to the SLP who knows
  better.

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B. Counseling

• Counseling by persuasion does not promote clients
  who think reflectively--they just believe.
• This is neither good education nor good
  counseling.
• True change comes from inside the person who has
  made a decision and is willing to commit to it.

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B. Counseling

• A third approach to counseling is counseling by
  listening and valuing.
• It is virtually impossible for one person to
  damage another person by listening to her, by
  trying to understand what the world looks like to
  her, by permitting her to express what is in her,
  and by honestly giving her the information she
  needs.
• This kind of counseling is a mutually educative
  process which allows for the exchange of both
  information and affect.

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B. Counseling

• Most people have their own particular style of
  internal organization.
• Some people are high in intellect and short on
  affect (cognitive orientation), and others are
  inclined to approach the world and personal
  problems from a feeling orientation with little
  recourse to information (affective orientation).
• The stress of a crisis, which often occurs around
  a communication disorders, tends to push people
  farther into their cognitive or affective
  orientation.

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B. Counseling

• Cognitively oriented persons will want just the
  facts.
• Affectively orientated persons will not be able
  to deal with facts as they are so full of
  emotion.
• To be effective at counseling, we must allow the
  affective oriented person to vent her feelings
  first and then process needed information second.
• For the cognitive oriented person, we must help
  him gain access to feelings.

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B. Counseling

• Feelings are neither good nor badthey just
  areand should be acknowledged and accepted, not
  judged.
• The client is seen as possessing the wisdom to
  ultimately make good decisions for herself, and
  the professional is seen as possessing the
  specialized knowledge to help illuminate the
  possibilities for her.
• The professional, by listening and valuing the
  client, bolsters the clients confidence so that
  good decisions are ultimately made.

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B. Counseling

• It is always a mistake in any relationship to
  tell someone, no matter how nicely we do it, that
  she shouldnt feel a particular way.
• When we do this, we help the person feel guilty
  about her feelings, as though she shouldnt have
  them.
• Probably the least helpful thing to say to a
  client is dont worry about it, because then
  she starts worrying about her worrying.

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B. Counseling

• What we really mean by dont worry or dont
  feel that way is that your expression of
  feeling is distressing to me, so please stop.
• There may be deep pain in having a communication
  disorder, and in many cases we cannot do or say
  anything that will take the pain away.
• Feelings need to be acknowledged for what they
  area very normal reaction to a terrible
  situation.

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B. Counseling

• The goal of counseling is not to make people feel
  better, but to separate feelings from
  nonproductive behavior.
• People and their family members affected by
  communication disorders generally have strong
  feelings.
• Often the display of feelings is very distressing
  to the SLP who thinks this is a sign that the
  client is emotionally fragile and any mistake on
  her part might send her over the edge.

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B. Counseling

• By not knowing how to react properly, we may
  forestall a clients emotional display because we
  are embarrassed.
• We may feel vaguely guilty for having caused the
  painfor being the bearer of bad news.
• We may use humor to try to make people feel
  better, but this is only a distraction to keep
  people in the cognitive realm and away from
  feelings.

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B. Counseling

• Several different feelings may be encountered and
  uncovered in therapy.
• Grief is a common reaction to lossloss of a
  dream, loss of an expectation, loss of stability.
• Grief is not a single reaction but a complex
  progression involving many emotions and attempts
  to cope with loss.
• Behaviorally, the bereaved can get stuck in her
  loss and not see what is there for her because
  she is too busy mourning what is not there.

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B. Counseling

• Anger is another feeling that is frequently
  uncovered in therapy.
• Anger has many sources, the predominant one
  arising when there has been a violation of
  expectationwhen somehow one feels cheated.
• Dealing with or having a communication disorder
  causes a loss of some personal freedom, which
  becomes another source of anger.
• When disability is present, our life options are
  narrowed and we get very angry at these
  restrictions.

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B. Counseling

• Another source of anger, which is more like rage,
  is a family members frustration over having a
  loved one hurting in some way and not being able
  to make it better for her.
• This feeling of impotence or powerlessness can be
  devastating.
• In men, feelings of powerlessness lead to
  frustration and anger for having somehow failed.
• In women, feelings of powerlessness lead to anger
  turned inward, depression, and guilt.

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B. Counseling

• Most people do not have good strategies for
  dealing with anger other than to suppress it.
• When anger is subverted and not allowed to
  emerge, it poisons relationships.
• It is an unwillingness to be direct about anger
  that defeats relationships.
• Anger can be a very healthy emotion in a
  relationship.

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B. Counseling

• Anger reflects a great deal of caring and energy,
  and can be the fuel that leads to change.
• Anger can not emerge unless there is a high
  degree of trust and intimacy in a relationship.
• Only secure people can afford to risk the loss of
  relationship by showing anger.
• Relationships are almost always strengthened
  after anger emerges if there is acceptance of the
  feeling and a mutual willingness to explore the
  sources of anger.

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B. Counseling

• Guilt is the single most pervasive feeling
  experienced by the families of clients with
  communicative disorders.
• In general, guilt is more prevalent in the female
  population as a reflection of powerlessness.
• Guilt is always a negative power statement that I
  have influenced or caused the bad result.
• If I worry about the bad result, then I might be
  able to control it.

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B. Counseling

• A trusting, intimate relationship between the
  parent and professional must be established so
  that the parent or client feels free to discuss
  the awful thing that he or she feels
  contributed to the disorder or the disability.
• Nonjudgmental unconditional regard for the client
  can establish a healing environment in which the
  client feels safe to reveal the guilty secret.
• We can bestow no greater gift than to relieve a
  parent or client of unfounded guilt.

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B. Counseling

• Feelings of vulnerability are also uncovered in
  therapy when the myth of invulnerabilitythat
  nothing bad will happen to us, only to other
  peopleis shattered.
• The anxiety generated by awareness of
  vulnerability can be a positive force.
• When we recognize our vulnerability, we can, and
  very often do, reorder our priorities.
• Feelings of inadequacy, however, may result when
  we feel overwhelmed to deal with new challenges.

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B. Counseling

• The desire to be rescued often accompanies
  feelings of inadequacy/vulnerability.
• When professionals call the plays, the client (or
  family members) become the spectator(s) and
  assume no responsibility for the outcome.
• Spectators seldom grow or learn very much.
• They may praise or blame the coach, but they are
  not involved in handling the challenge.
• To be truly helpful, the professional must
  enhance the self-esteem of the client and help
  her see the possibilities in the challenge.

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B. Counseling Summary

• We cant make clients feel better.
• We can, by our calm acceptance of their feelings
  and our willingness to allow affect to be part of
  the client-professional relationship, prevent the
  development of secondary negative feelings.
• We can help to prevent clients from feeling
  guilty about their guilt feelings and enable
  their guilt to become commitment to making
  something good out of disappointment.

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B. Counseling Summary

• With our sensitive appreciation of the grief
  process, grief can become a sadness that enables
  the client to appreciate what they have not lost.
• Anger can become the energy to make change.
• The recognition of vulnerability can become the
  means by which the client reorders priorities
  and
• The resolution of confusion can become the
  motivation for learning.

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C. Healing

• Healing involves reconciliation.
• Sometimes it involves acceptance other times it
  involves recovery.
• Healing suggests the re-establishment of balance.
• In pursuit of improving defective communication,
  we have to consider our values, motives,
  therapeutic orientation, professional
  responsibilities, and conscious and unconscious
  choices.

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C. Healing

• What roles might we consciously or unconscious
  choose if there is a conflict of power between
  the therapist and the client?
• At one extreme is the benign dictator, the
  therapist who legislates every step the client
  must take in order to communicate more
  effectively.
• This therapist charismatically intimidates the
  client into accepting what the therapist believes
  is best.
• The therapist justifies this approach by reason
  of education, ability, and previous successes.

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C. Healing

• Not only is the therapist the expert, but the
  judge and jury as well, who will insist that the
  client conform to the therapeutic regimen
  established.
• The more the client conforms to the therapists
  prescription, the more impressed the therapist
  becomes with a personal image of healer, and the
  less likely to recognize personal underlying
  motives.

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C. Healing

• If the client questions or resists certain
  intervention strategies, the therapist may view
  this behavior as childlike and assert power as a
  parent.
• In either case, the therapist deprives the client
  of responsibility for the problem and may destroy
  the very process that would ensure communicative
  successthe development of self-empowerment to
  take charge and cope when the therapist is no
  longer present.

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C. Healing

• What is of chief importance to the benign
  dictator is improvement of the communication
  disorder.
• Nothing else is relevant as far as speech-therapy
  is concerned.
• If that is so, then perhaps we are only
  technicians who should limit ourselves to the
  surface aspect of communication and refrain from
  involvement in meaningful interpersonal
  relationships in therapy.

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C. Healing

• At the other end of the continuum is the
  therapist who feels qualified to cope with all of
  the clients conflicts and problems, that are
  associated directly, indirectly, or not at all
  with the speech-language problem.
• This person is the benign supertherapist who,
  being in the power position as helper, attempts
  to intrude into the clients unconscious world
  and take responsibility for facilitating not only
  effective use of speech and/or language, but also
  all aspects of the clients life.

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C. Healing

• For this therapist, it is not enough to deal only
  with the symptomatic features of, let us say, a
  hyperfunctional voice disorder, but also with
  other dysfunctional aspects of the persons life.
• In this therapeutic relationship, the clients
  conscious intention to correct my voice problem
  is given secondary importance by the clinician
  who believes that permanent vocal change can come
  about only through analysis of the clients
  personality and emotional attitudes.

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C. Healing

• Another typical helper is the benevolent
  therapist.
• This therapist exercises power in a more subtle
  manner, but is still manipulative.
• When therapy starts out successfullycongruentlyb
  ut then begins to take a turn, the therapist may
  feel frustrated, angry, or helpless.

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C. Healing

• If the therapist feels overwhelmed by the
  clients ambivalent attitudes, she may be unable
  to separate her own feelings of powerlessness and
  struggle with the client.
• She may project her feelings onto the client and
  attempt to control or coerce her (much like the
  benign dictator) or
• She may continue to go along with the client,
  denying her growing anger and frustration and
  feeling damned if a do, and damned if I dont.

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C. Healing

• Either way, power is used negatively.
• The client is no longer the subject of real
  concern because the therapist has become bound up
  in personal psychic struggles.
• As therapists, we must vary our roles according
  to the clients with whom we work.
• We must also vary our clinical behavior with any
  one client.

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C. Healing

• The therapist who guides and yet is flexible to
  the clients needs will provide a therapeutic
  environment where the client can grow and change
  within her potential.
• This therapist does not take on personally every
  negative response by the client, but uses the
  response constructively to help the client.
• This therapist separates personal ego concerns
  from those of the client, and does not
  self-project or become contaminated by the
  clients projection of feelings.

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C. Healing Summary

• Healing is empowerment to take the good with the
  bad, to change those things which can be changed,
  to accept those things which cannot be changed.