Therapeutic Alliance, Feedback, Empathy, Resistance, and Relational Interpretation, Term Paper Example

A client will sit in a session and pour out a piece of their life to the counselor, but it is the social worker who lives in the middle of that client’s experience each and every session. Multi-dimensional understanding incorporates the fundamental spirit of social work and many dimensions of alternative, or paradigm thinking. It integrates mindset and power of personal stories and experiences as avenues; combining them to understand human behavior and bringing about social change. A multidimensional clinician unites personal and public through focus on consciousness; the results of patient exploration of personal stories or the stories of others involving troubling circumstances.

The facility where I perform these services is located in the South Bronx. The primary client composition, according to the South Bronx Mental Health Residence includes two-thirds Hispanic male and female population and one-third African American; 24 women, 24 men, of which four were gay and lesbian. (SBMH, 2010, Composition). It took 10 individuals to staff this facility with two directors, six staff members, a cook and a secretary.

An interview as conducted on a client and the information is used for the purpose of defining and explaining five concepts relevant to client treatment. The main purpose is to demonstrate how these concepts are employed in working with the client. A process recording provides summary information necessary to understand the concept and the application during the therapeutic session with the client.  Many obstacles and challenges occurred with this client within the social work environment; including issues of diversity culture, race ethnicity, sexual orientation, age, spirituality, ability and gender. Progress notes and summary will discuss the impact of personal feelings towards the client-social worker relationship and each personal and professional value system.

The client, K.O. is a 44 year old single male of African descent living within the treatment center. K.O. has a psychiatric history dating back to age six. At an early age he began to have difficulty in school and developed behavioral problems, lasting symptoms and problems. His behavioral problems intensified at approximately age 13.  K.O. demonstrated psychotic behavior, including often hearing voices. He was treated with neuroleptics including Thorazine and Haldol. Medications have lead to improvement in his behavioral symptomatology. His mother describes occasional depressive episodes, such as during a hospitalization in 1983.

The client suffers with intellectual problems and was involved in special education classes.  In 1985 K.O.’s IQ measured in the 70’s. K.O. did not complete high school and is interested in completing his GED. He is estranged from his family. He has been in communication with his brother. His traveling is limited unless done with staff support. K.O. has spent the majority of time watching television and reading sports. He desires to make life more meaningful and believes leaving the residential facility will enable him to become independent and move on with life.

With just a dozen sessions our client-social worker relationship became very meaningful, educational, and productive. On a personal level the ability to impart a worthwhile and meaningful addition to his life was very rewarding. It strengthened my resolve beyond anything I could imagine. He was trusting and seemed to voluntarily surrender his life to my judgment. The time spent with K.O. enabled me to solidify an understanding of concepts which benefited our interactions and relationship.

Concepts

Five concepts, therapeutic alliance, feedback, empathy, resistance, and relational interpretation are fundamental to the efforts of a client-social worker relationship. Developing these concepts and working them into the relationship and discussions are beneficial to the patient and the overall relationship. The culture, class, ethnicity, spirituality and race are distinctive to each individual. Developing skills to work with all diversity and learning to treat each person based upon their specific struggles and needs is distinctive to the social worker’s talents and skill sets. Defining and understanding the concepts is vital to the relationship and developing trust and a commonality between the team. Each social worker must evaluate the importance of these concepts and enmesh them into their clinical practice.

Therapeutic Alliance

John Norcross (2002) indicates therapeutic alliance serves as a common ground spanning across all professions and is also called the helping alliance or the working alliance. Therapeutic alliance refers to the quality and stability of the relationship formed between client and social worker. The quality of the alliance is an indicator to successful and effective therapy and speaks to the ability of the therapist and the client to form a personal bond. The client must bond with and belief in the therapist. Only this will produce a nurturing relationship. A person must have faith in another person to be able to trust and communicate intimate life details. According to Norcross (2002) therapeutic alliance has three components, agreement on the therapeutic goal, consensus on tasks in therapy and a bond between the client and therapist, which is based on mutual trust, respect and caring. Individuals who suffer from mistrust due to previous relationships will find it difficult to form such a close bond or connection with a therapist. The social worker should look for this during interviews and determine the clients who are willing to form a bond and those who are not in order to properly understand the usefulness of therapeutic intervention.

A working alliance between therapist and client must have positive contributions to the relationship building and bonding. The three categories include interpersonal, intrapersonal and interactive skill components. These are the necessary building concepts for a working alliance to be beneficial and time worthy. Interpersonal skill component includes the ability to demonstrate sympathy and empathy to the client and their circumstances. Intrapersonal skill component is specific to the therapist’s ability to respond appropriately to the client, thereby engaging the client in therapy. The fit and feel between client and therapist depends on the interactive skills of the therapist. “Some issues that can become obstacles in the alliance are if the therapist has hostility towards himself or towards the client and if there are disaffiliated responses between therapist and client” (Norcross, 2002, p. 38).

Feedback

Unfortunately, it is not enough for a social worker to want the best for a client. A social worker has to give the proper feedback by mentally placing themselves in the position of the client; attempting to determine what the client is trying to change or adjust.  A social workers feedback has to be geared toward the worker having the same mindset of their client to be able to guide clients to make the right choices regarding their life situations and circumstances. Feedback as it relates to psychology is providing information from an external source to a person. This information is specific to that individual and behavior. “Feedback signifies verbal and nonverbal responses from others to a unit of behavior provided as close in time to the behavior as possible, and capable of being perceived and utilized by the individual initiating the behavior [that is, the receiver of the feedback]” (J. Norcross, 2002, p. 217).

There are four general types of feedback content, all of which are common in psychotherapy.  The observation of and emotional reaction to a client’s particular behavior are the first two types of feedback. Next the therapist could make an inference regarding a trait of the client. Finally mirroring is an effective form of feedback. It is quite effective to present the client with a form of an example of their behavior.

Personal communications can sometimes be difficult depending on the topic of discussion and the skill set of the communicators. The first individual, the sender, begins the communication via an idea translated into words, phrases, or body language to the receiver. The receiver must translate the meaning of the message.  “The recipient must then acknowledge the message through some form of feedback to the sender, thus completing the cyclical process.”(L. Shulman, 2006, p.55)

Empathy

Empathy is the art of feeling what another person is feeling. This concept is not always easy.  If the therapist has been in the same situation at some point in their lifetime, empathy is easy to emulate.  If the client feels a sense of understanding by the therapist it is easier to engage the client into a trusting relationship; open and honest. Being able to open oneself and truly feel the other’s emotions is engaging in an empathetic relationship. The client will feel         the social worker’s caring attitude and be able to communicate on an intimate level. There are various ways for a therapist to use empathy with a client. The therapist can respond emotionally, cognitively or respond on a moment-to-moment basis depending on the situation (Norcross, 2002). Empathetic interactions can lead the therapy into a deeper level and allow the client to reveal more in the interview and facilitate a greater understanding of the problem.

There are several methods to show empathy towards another. Demonstrating compassion is considered empathetic rapport.  Using this concept the therapist must be careful to remain professional at all times. Allowing ones empathetic feelings to flow can create a situation of self-disclosure which is not healthy for the therapist and undermines the process for the client.  Communicative attunement is an approach the therapist may find useful and beneficial by attempting to align with the feelings and emotions of the client in order to foster communication based on the moment. This manner is useful in allowing the client to process feelings and emotions on the spot; often revealing a wealth of information.

Person empathy occurs when the therapist allows themselves to identify with the client. This is through going over a person’s history and experiences, particularly the ones which may have led to the problem. “Empathy strengthens the alliance and can be a corrective and emotional experience as well as a cognitive-affective processing condition” (Norcross, 2002, p. 90). Self-expression by the client with total involvement in the process assists a client to begin the process of emotional reprocessing.

Resistant Traits

Resistant traits signify the ability of a client to resist demands made by external sources. High trait like resistance may or may not lead to broader psychopathology, but easy arousal of resistance behaviors is likely to be disruptive to relationships and social activities” (J. Norcross, 2002, p. 130). The ability to resist anything is a strong trait. In therapy it can be the behavior which limits the client’s ability to move forward in therapy. Shulman defines resistance in the therapeutic relationship occurring when a client exhibits behavior that seems to oppose the worker’s efforts to assist the client (Shulman, 2006). Although this is a normal process, it is still important for the social worker to understand and recognize this behavior.

Resistance may be a part of the personality of the client, whether it is situational or functional.  No matter what the cause, it is vital that the therapist identify the trait and work accordingly for the mental health of the client. Resistance may stem from a past experience and can hinder or halt the recovery process.

Resistance can manifest in four distinct ways; cognitive dissonance, emotional exacerbation, manifestation and withdrawal. If a client attempts to explain situations and their behavior is cognitive dissonance. The client is attempting to place logical reasons to their behaviors; however inappropriate or appropriate.  Emotional exacerbation is a client’s attempt to convey the intensity or exaggeration of how they feel. Manifestation of impulsivity occurs when a client does not consider the outcome of their actions. They do not believe that anything will happen and they are free to act without thinking. One of the hardest resistance tactics to deal with for a therapist is the helpful withdrawal or the passive-aggressive behaviors of a client.

It is important for the therapist to acknowledge that resistant clients often have difficulty committing to the therapeutic relationship and may terminate therapy early, affecting the type of intervention that the therapist will choose for this client (Norcross, 2002). Determining the level and type of resistance in a client is helpful in diagnosing the client accurately. Trait resistant clients should be watched closely and evaluated with care; most are distrustful and may believe the therapist is not truthful. They feel they are not responsible or accountable for their behavior. They feel the need to be in control, particularly of themselves and will respond to the therapist ideally when allowed a feeling of participation in their care.

Paradoxical intervention, referred to as reverse psychology, can be useful when working with trait resistant clients because it de-emphasizes the therapist’s authority. This promotes tasks that lifts and promotes self-direction by the client.  Trait resistant clients are not able to see beyond their own thoughts and feelings. They believe they are not at fault and their problems resist with others and outside circumstances.  Trait resistant clients often exhibit their resistance by expressing anger at the therapist or by refusing to acknowledge what the therapist says (Norcross, 2002). Careful acknowledge of the fears and anger of the client will allow the therapist the avenues to engage client into a relationship.

Relational Interpretation

Sigmund Freud discovered the concept of interpretation.  While listening to patient flow of association, Freud noticed that there were gaps in memory.  Freud’s initial treatment approach emphasized the uncovering of early memories and the reconstruction of the past. However, when Freud directly asked has patients to fill in apparent gaps in their discourses, he found that they often deflected his efforts in various ways. Freud hypothesized that forgetting certain memories resulted from an active force, repression, which was activated by the patient’s efforts to avoid anxiety and other emotions that arise from unacceptable impulses. To the extent that ideas entered conscious awareness, they were distorted or disguised by the power of repression. The goal of interpretation in early psychoanalysis was to distill the underlying repressed thought or feeling from the overt, disguised free association material. In order to achieve this goal, analysts interpreted not only free associations, but also slips of the tongue, dreams and symptoms. Interpretations were the main vehicle through which patients gain insight, and such insight resulted in therapeutic change.

Freud emphasized the importance of interpretations that address aspects of the patient-therapist relationship. Such interpretations are generally referred to as ‘transference interpretations’ – an expression that should be defined carefully. The term transference refers to desires, thoughts, feelings, and associated behaviors originating from an early (for example, parental) relationship that are projected or ‘transferred’ onto a current interpersonal relationship. It is used in clinical writings, however, as shorthand for these issues as they arise in the patient-therapist relationship in particular.  Thus, ‘transference interpretation’ is used to describe interpretations that address the patient-therapist relationship. We use the term “relational interpretation” to refer to interpretations that address relationships in general. Transference interpretations are therefore a subset of relational interpretations.

Illustration and intervention

To being the process with K.O., specific issues will need to be addressed. Working with K.O. and using the concepts through illustration and intervention will enable him to deal with his problems and make healthy choices.  First on his mind, K.O. is struggling with the desire to move out of the residence center.  As we worked together, I detailed for him the various options for relocating and the process involved. As we worked together with planning and referral applications we began to bond and form a relationship. He began to see me as a potential source of help provided through a nurturing relationship. As he learned to trust me I was able to learn more about his family and social support network systems. He shared with me some of his past and problems with housing. In one particular location he has some negative memories of things which happened between him and his family. I took on a role of support as I counseled him regarding the community settings. I began to be able to discern the dynamics of our relationship and gain insight to his specific individual and group strengths and weaknesses.

Therapeutic Alliance

Ms. Brown of Life Spire worked with K.O. and myself within a therapeutic alliance as we investigated residence housing within a framework that could also provide mental stability for K.O.  As a bond had already formed between K.O. and me, the relationship opened to Ms. Brown to be another support for this client. Patience was the dynamic being the most beneficial in this situation. Although the choices may not have been what K.O. had envisioned or hoped for, the trust we had formed made him realize he needed to look at what was the best for him and his specific circumstances. He was able to do this and demonstrated his respect for this alliance which was build between us. Also showing sensitivity to the client and allowing him the freedom to express his feelings about the situation was also a method I employed and K.O. responded nicely.

Feedback

During the process of bonding with K.O., I had to keep in mind the challenges he would face as he dealt with relocation and how his disability affected this action. His thought processes, emotions and behaviors will not echo that of a person without his mental limitations. Therefore, as I engaged with K.O., I would continually pull him into the discussions and attempt to understand his feelings as he was faced with difficulty in life.  I also gave him regular feedback on his attitude and behaviors when he was frustrated, anger, upset or unhappy with events.

Empathy

Ms. Brown did in fact have an available apartment in the Queens area that K.O. would share with another resident. Since K.O. was looking to live on his own, I had to be careful to explain to him how this might work with a roommate.  Using an empathetic demeanor I communicated with K.O. the pro’s and con’s of having a roommate.  However, I made sure to give him the facts and answer all of his questions; allowing him to make the final decision.

Interestingly as we were initially walking away from the encounter with Ms. Brown, I noticed K.O. was speaking in a harsh and angry manner. He shared that he hated the day program because he felt the women in the program were mean to him. His trust in our relationship was demonstrated as I realized he was able to show anger and frustration with a situation but never forced those attitudes towards me or our relationship. He shared his feelings with me rather than threw them at me.  I have become a support to K.O. and he depends on that support.  When K.O. is having a rough day, I sense it and can usually change the mood by changing venues to avoid any unnecessary feelings of discomfort for K.O.

Resistance

K.O. was treated harshly by police officers around the time of his brother’s death. This situation causes him a lot of unhappiness and repressed emotions. I gave him feedback that he was attempting to hide his feelings towards his brother’s death. This honest dialogue helped breakthrough to K.O. and he spoke of his difficulties and anxieties surrounding his own health. His brother suffered from a heart attack and K.O. is concerned he will follow in his footsteps. The fact that he did not know about the heart attack for approximately six months after the funeral further creates anxiety for K.O. and what could happen to him.

K.O. was not able to attend his brother’s wake due to health problems which he feels started with the death of his brother.  While apparently the brother did not die from the heart attack, it weakened his health. My goal at that moment was to listen to K.O.’s reasoning surrounding this issue and respond by giving him positive suggestions to think about, thus allowing his thoughts to focus on what exactly it was that troubled him concerning the confusion between his health and his brother’s death. Often a client will begin a session with some unconscious ambivalence, or a form of resistance, surrounding discussing a difficult or painful topic.

It is important for the therapist to watch for signs and symptoms from the client for becoming resistant by internalizing and not sharing or communicating to anyone. As we continued our communications it was obvious he was showing resistance to his brother’s death and having a difficult time understanding how it related to his new and bothersome concern for his own health.  Constant silence was the method that K.O. used to avoid dealing with this issue. Silence is thought to be a form of resistance, but occasional silences or pauses in conversation are a part of the therapeutic process, which can provide the opportunity to reflect with the client. I do not feel K.O. was resisting me or our bond but rather the pain of having to deal with the issues. As I attempted to engage him in conversation I received short and repetitive answers. He would sit quietly for a few moments and then suddenly would decide to break the silence with a thought. He would speak inconsistently which may have been due to the time lapse of the incidence and the trauma it caused. This is an issue which needs further attention. This affects his daily life.

Relational Interpretation

Relational interpretation could be seen in K.O.’s inability to carefully verbalize his understanding of the incident as this aided to my interpretation of the situation. Through this I was able to more carefully and closely evaluate the depth of K.O.’s mental anguish.  I did not interject any comments during his silence. My intervention most certainly would have interfered with K.O. and his ability to speak openly and when he was fully ready to do so.  This did create a sense of discomfort for me as the therapist.  I found it difficult to be silent and have to carefully pick the right questions.  This limited my choices in the conversation. Whether this was instinct or limiting my right to speak freely, I felt that K.O. should take the lead in the conversation.  He demonstrated interpretation impairment in the way he attempted to engage me in conversation. This demonstrated that he was clearly still concerned with his brother’s death. He chose to interpret his brother’s death as though he was still alive and internalizing the last fond memories they shared together.

As the conversation progressed it became apparent through body language and behavior that K.O. was uncomfortable by my attempts to teach him to accept and deal with reality. This may have contributed to his silence at certain times. It was a way for him to hide emotionally and not have to cope with his feelings of discomfort.  Although we were able to deal with several challenges during the process. He still suffers with his disability and this creates a difficult situation at times for meaningful conversation and informative results.  He has a delay I comprehension creating the need for repetitiveness and a standstill for progress. I had to be patient and sensitive to his situation when working with him.

Conclusion

Working as an intern allowed me the opportunity to experience real life situations with adults suffering from developmental disabilities. I learned to apply concepts and theories learned in school to a real situation. In this population the individual disability in and of itself is a challenge. As a growing professional and practitioner in training, I will always try to keep in mind that taking theories from the classroom to practice is as important as learning the actual theories. Learning and applying concepts allows each of us to bring our own personal style, artistry, background, feelings, values, and beliefs to our professional practice. Rather than denying or suppressing these tools, we need to learn more about them and ourselves in the context of our practice.  By doing so it enables one to assist not only ourselves, but others as well in pursuit of professional development and career goals.