The research is clear. The client’s experience of the therapeutic alliance is the greatest predictor of client success and change (Duncan, B. & Miller, S., 2000). It is crucial to the health of their clients and to their practice that student-therapists train to develop the necessary skills to create this vital link. This paper will illustrate how through adapting, acknowledging and participating in the clients’ process facilitates the process of establishing the therapeutic alliance and the specific methods the student-therapist uses to begin to establish this working relationship.
According to Minuchin and Fishman, creating this alliance is “more an attitude than a technique” (1981, p. 31). I discovered when I took a college-level modern dance class that the word attitude is used in reference to position. How a dancer holds his hands, his head or feet (position) relative to the body influences the fluidity (flow or progression) of the dance. For the therapist, alliance is also about position or how a therapist views and “holds” the problem in the beginning and through-out the process of working with their client(s). Central to the process is the therapists’ personal work to understand and adapt to the clients’ experience of their lives. Therapists must challenge their own assumptions, expand their lens of compassion and heightened their understanding of the problem by being curious about their client’s own perception of the problem.
Acknowledging that “The family is the natural context for both growth and healing” (Minuchin & Fishman, 1981, p. 11) and then utilizing this context, allows the therapist to join the family’s process of growth and healing. Adapting to the family perception of the problem and the family process of healing allows the therapist to rely less on the therapist’s expertise to solve the family problems and more on the family’s experience. Although the therapist participates in the process, the process is dependent on the clients’ readiness, willingness and ability; qualities that influence the client(s) active participation and autonomy towards change. The research as noted in Duncan, B. & Miller, S., Sparks, J. (2000) The heroic client, that “the quality of the patient’s participation in therapy stands out as the most important determinant of outcome” (Orlinsky, Grawe, & Parks, 1994, p. 361) reinforces the importance of the client’s initial investment in the solution.
The therapist must not resign him/herself to a passive role however, he/she “must be comfortable with different levels of involvement” (Minuchin & Fishman, 1981, p.31) and remain fluid (flexible) during the therapy process by adapting the process as the clients vacillate between change and the “status quo.” The therapist adapts his/her participation to create a complementary exchange (Nichols & Schwartz, 2008) which challenges and encourages the client to continue involvement in the process towards change. Minuchin reported that ‘whenever a therapist can be helpful to a patient, he also likes that patient (1981, p.41). This mutual admiration further encourages the client/therapist complementary exchange and allows for the therapist to “join” (Minuchin & Fishman, 1981, p. 31) the process. Minuchin and Fishman’s definition of joining; “letting the family know that the therapist understands them and is working with and for them” (1981, p. 31-32) through the process of “listening, understanding, validating and empathizing” (Nelson, 2008) reinforces successful interaction between the client and the therapist by communicating to the client the therapist’s mutual investment in their process.
The methods of creating a safe environment, regulating my anxiety and eliciting the client’s story are used to begin to establish a working relationship that supports the therapeutic alliance. The work to create a warm, accepting and supportive (safe, non-threatening) environment includes creating a visually and physically welcoming (safe) environment and regulating my anxiety. Initial questions in the process of therapy orientate the therapist to the clients’ context and illustrates the importance of the process of “listening, understanding, validating and empathizing” (Nelson, 2008) to the continued work of building the alliance.
To create a visually and physically welcoming (safe) environment to begin to establish my working relationship, I first scan the room and consider the visual first impression of the room. Are there items present that might create a visual distraction such as trash, inappropriate signage, or items intended for storage stacked haphazardly around the room? If so, I safely and immediately remove, organize or properly store those items. Next, I step back and look at the organization of the furniture in the room and ask, “Will the room comfortably accommodate the client(s)?” Once I have determined that the room size and furniture will comfortably accommodate the client(s), I look for hazards. “Are there broken fixtures, furniture, etc., that might create a physically unsafe environment?” I also look for items that will provide for client comfort. “Are their tissues, adequate supplies for activities, etc?” “Is the lighting adequate?” Is it too glaring?” Once I am confident that I have created a visually and physically welcoming (safe) environment, I can consider the next step: regulating my anxiety.
To create and maintain a calm demeanor (and continue the establishment of a safe environment) is to evaluate and regulate my personal internal process which includes the regulation of my anxiety. A new client will stir a level of anxiety that a returning client does not stir. As indicated during a class lecture by Dr. Jennifer Nelson (2008), as student-therapists, “we have to train ourselves to know what we are feeling and to regulate those feelings.” My awareness of my anxiety response to new situations allows for me to prepare in advance for the first meeting through acknowledging my fear of the unknown (new) and regulating my anxiety. This is particularly important because fear will “influence our emotions, behaviors, or perception directly” (Class Lecture 2008, Siegel, 2001). This refers back to taking an position (attitude) of joining when treating our clients. If I am anxious it is because I perceive a threat (Nelson, J. 2008) and left unchecked, I will respond to my client(s) as though they are presenting a threat. In the same manner that I must clear the room of any hazardous items; I must clear the emotional atmosphere from positions (attitudes) that could result in harm to my client’s state of mind by unintentionally communicating rejection or disgust. Once the client feels an initial sense of safety and acceptance there are specific questions I ask to continue to build this working relationship.
Initiating questions in the process of therapy orientate the therapist to the clients’ context and conveys a sense of acceptance which strengthens the work of building the alliance. “Listening, understanding, validating and empathizing” (Nelson, 2008) provides opportunity for the therapist to connect and re-connect with the client as their story unfolds. Minuchin supports this notion by suggesting that the “therapist joins and joins again many times during a session and during the course of therapy” (Minuchin & Fishman, 1981, p.49) and it is this “joining” (1981, p.49) that “changes things (1981, p.49).”
One such question I use to engage the client in the process is to ask the client to “tell me something important” about him/herself. This question allows for an informal assessment of what the client(s) think of their individual importance or the importance of their individual concerns. My experience is that the client, who is highly anxious about the client/therapist relationship, will immediately begin with the definition of the problem. This response will provide me with a sense of where to meet the client in the process of therapy and help to assuage any initial concerns or questions. Specific things I do to handle these initial concerns, are to assess the client(s) immediate need and take a variety of “joining positions” (Minuchin & Fishman, 1981, p. 33). If I observe (assess) that the client(s) feels threatened and becomes defensive I work to take a “close” (Minuchin & Fishman, 1981, p.33) though provisional, position. This may be done in the form of short-lived “coalition” or “confirmation” (Minuchin & Fishman, 1981, p. 33) where I validate the individual’s reality. If the client(s) complaint is that they do not feel heard, I choose a “median” (Minuchin & Fishman, 1981, p. 34) position and join “as an active listener” (Minuchin & Fishman, 1981, p. 34) and help the individual to “tell their story” (Minuchin & Fishman, 1981, p. 34) by asking them to “tell me more.” My hope is that in reducing the remaining fear or doubt in the process will clear the path for establishing an alliance.
Client(s) less anxious about the relationship can invest in the process of change and will respond on a more personal level with information about their family history, occupation, hobbies, talents, passions, etc.. This response indicates their readiness, willingness and ability to integrate and interact in the therapeutic process. This allows the construction of personalized metaphors through-out the session which forms a connection to the client’s sense of self, thus deepening the quality of the joining.
This question of “importance” is posed to each individual present at the session. It is crucial that everyone involved and available contribute to the community identity in light of Minuchin’s assertion that “the identified patient is only the symptom bearer” (Minuchin, 1981, p.28). This assertion implies that there exists a context of the family that has generated the presenting symptoms. To ask a family member to reveal something “important’ allows for an opportunity for individual to communicate information that might not have been known or acknowledged in previous conversations. This allows the therapist to join the family through facilitating the process of communication thus facilitating the interactions and relationships. Dysfunctional family transactions (Minuchin & Fishman, 1981) often involve a surface level communication. This specific question provides opportunity for “healing” (Minuchin & Fishman, 1981, p.28) by “changing those dysfunctional family transactions (Minuchin & Fishman, 1981, p. 28) by facilitating “deeper” more meaningful communication (transactions).
Often, if there are minor siblings, I will ask the youngest individual in the family to define “the problem” because it has been my experience that they are less inhibited to being direct. This also provides the simplest definition of the presenting problem and informs the student-therapist of generational boundary breaches. If it is necessary for the presenting problem to be articulated in more detail because the youngest is unable to define “the problem” I will ask the oldest individual. Often a conversation between the two siblings is initiated and I work to encourage the process of interaction. Because “family therapist tend to underutilize sibling contexts and overuse therapeutic designs” (Minuchin & Fishman, 1981, p. 19) it is important to engage the sibling interaction to assess “the problem” and identify the emerging patterns of family interaction.
Two specific factors that I attend to in my initial sessions that begin to establish a working relationship and support the therapeutic alliance through the process of “listening, understanding, validating and empathizing” (Nelson, 2008) and impact subsequent work, is the client’s body language and the client’s perspective within the therapeutic context.
The first factor of body language is significant to the dialogue between the client and the therapist. Body language creates a picture and is a form of expression when words are not adequate. For adults and adolescents there are limits on the use of expressive language. Whether those limits are imposed by the relationship or individual development, they exist. Therapist can glean valuable information from the client’s body language. For instance, if an individual has expectations that are neither expressed nor met, they may express their experience as one of boredom which can be “a mask for frustration and anger” (Nelson, J. 2008). This awareness impacts and slows the “pace” of therapy by providing an opportunity for the therapist to “pause” (Nelson, J. 2008) the session and be curious around the emerging emotion. In order to understand the individual’s expression through body language requires this “pausing” of the process. This pause also allows the client space to become aware and then identify their individual experience and process of expression. This allows both the client and the therapist an opportunity to understand one another in a more meaningful way, thus strengthening the “joining” process.
The second factor I attend to in the initial sessions is the client’s perspective within the therapeutic context or their attitude about therapy. Their attitude directly affects their level of participation and openness. Is the therapist considered “the expert” or “the enemy?” My experience is that the client, who is highly anxious about the client/therapist relationship, will feel “threatened.” Understanding the client’s attitude provides me with a sense of where to meet the client in the process of therapy. Specifically, I “join” (Minuchin & Fishman, 1981) the client. As stated previously if I observe that the client(s) feels threatened and becomes defensive I work to take a “close” (Minuchin & Fishman, 1981, p.33) though provisional, position. This may be done in the form of short-lived “coalition” or “confirmation” (Minuchin & Fishman, 1981, p. 33) where I validate the individual’s reality. If the client(s) complaint is that they do not feel heard, I choose a “median” (Minuchin & Fishman, 1981, p. 34) position and join “as an active listener” (Minuchin & Fishman, 1981, p. 34) and help the individual to “tell their story” (Minuchin & Fishman, 1981, p. 34) by asking them to “tell me more.” Again, my hope is that in reducing the remaining fear or doubt in the process will clear the path for establishing an alliance.
In summary, I begin to establish a working relationship that supports the therapeutic alliance through the process of “listening, understanding, validating and empathizing” (Nelson, 2008) and through the methods of creating a safe environment which includes regulating my anxiety and eliciting the client’s story which then reinforces and communicates acceptance and joining.
References
Duncan, B. & Miller, S., Sparks, J. (2000). The heroic client. San Francisco: Jossey-Bass
Miller, W.R. & Rollnick, S. (2002). Motivational interviewing. New York: Guilford Press.
Minuchin, S. (1974). Families and family therapy. Cambridge: Harvard University Press.
Minuchin, S., & Fishman, H. C. (1981). Family therapy techniques. Cambridge: Harvard University Press.
Nelson, T. (Fall 2008). Clinical Foundations I. Class Lecture. Lenexa KS.
Nichols, M.P., Schwartz, R.C. (2008). Family Therapy: Concepts and Methods (8th Ed.). Boston: Allyn & Bacon.
