How Do Therapists Make Sense Of Their Reactions Towards .
How Do Therapists Make Sense of TheirReactions Towards Clients: AnInterpretative Phenomenological AnalysisJacob MaundersA thesis submitted in partial fulfilment of the requirements of the School ofPsychology, University of East London for the Professional Doctorate inCounselling PsychologySeptember 2010Word count: 31646 (excl. references and appendices)
AbstractThis study attempts to contribute to our understanding of therapists‟ personal reactions(cognitive, affective, sensory or behavioural) towards their clients by adopting an indepth qualitative analysis. This study consists of semi structured interviews with sixtherapists who work mainly from a psychodynamic orientation. The transcribedinterviews were analysed according to the principles of Interpretative PhenomenologicalAnalysis (IPA). Three analytic themes were derived from the analysis: (1) self as a“measuring instrument”, (2) managing reactions, and (3) therapist self care. Thefindings highlight the different ways that therapists understand and manage theirreactions. The analysis of the interviews also reveals support for the theoretical trend inpsychodynamic approaches towards a relational/intersubjective understanding of thetherapeutic relationship. It is argued that therapists are embedded within the client‟srelational pattern, and furthermore, this is inevitable and to be welcomed.ii
Table of ContentsTable of abbreviationsVAcknowledgementsVIChapter 1: Introduction.11.1 Overview.11.2 Relevance to counselling psychology.21.3 Perspectives on therapists‟ reactions .31.3.1Therapists’ reactions as own conflicts or vulnerabilities.41.3.2Therapists’ reactions as response to client’s style.61.3.3The relational perspective.81.3.4Management of therapists’ reactions.101.3.5Limitations of existing research.151.4 Summary.16Chapter 2: Methodology.172.1 Principles of Interpretative Phenomenological m.182.1.4Hermeneutics.192.2 Epistemological position.192.3 Reflexivity and quality.212.3.1Reflexive note.222.3.2The independent audit.232.4 Conducting Interpretative Phenomenological Analysis.232.4.1Participants.232.4.2Interview schedule.242.4.3Ethical considerations.252.4.4Data analysis.262.5 Summary.26iii
Chapter 3: Analysis.283.1 Personal arina.293.1.4Simon.303.1.4Sarah.303.1.5Carol.313.2 Themes.313.2.1Master theme: self as a “measuring instrument”.343.2.2Master theme: managing reactions.443.2.3Master theme: therapist self care.62Chapter 4: Discussion.694.1 Summary of findings.694.2 Making sense of therapists‟ reactions.704.2.1Self as a “measuring instrument”.704.2.2Managing reactions.734.2.3Therapist self care.794.3 Limitations.804.4 Contribution to counselling psychology.824.5 Implications for practice.834.6 Future research.834.7 Concluding remarks.84References.85List of Appendices.91iv
Table of abbreviationsCATCognitive Analytical TherapyCBTCognitive Behavioural TherapyDADiscourse AnalysisFDAFoucauldian Discourse AnalysisIAPTImproving Access to PsychologicalTherapiesIPAInterpretative PhenomenologicalAnalysisNHSNational Health ServiceTATransactional Analysisv
AcknowledgementsThis study would not have been possible without those who were interviewed. I wouldlike to express my gratitude for their willingness to share their personal experiences. Iam grateful for their time and the interest they showed in my research and I hope thatparticipation was beneficial for them in some way.A number of different people have assisted me with my project. I would like to thankmy colleagues for their help and support throughout the duration of the course. Theopportunity to discuss my research with others has been invaluable. Barbara Norbaldeserves special thanks for her encouragement, patience and love. You have been therefor me throughout the last four years and you have helped to keep me going.Finally, I would like to thank my supervisors, Rachel Tribe and Jane Lawrence. Fortheir commitment and guidance I will always be grateful.I confirm that the work contained in this thesis is original except where other sourcesare cited.vi
Chapter 1: IntroductionThis chapter begins with an overview of the research project. It presents the researchquestion, the rationale for the research, the relevance to counselling psychology and areview of the literature.1.1 OverviewThe aim of this thesis is to contribute towards our understanding of the therapeuticrelationship from a phenomenological perspective. In particular, it explores theimportance of the reactions evoked in therapists to the therapeutic process. The interestin therapists‟ reactions is partly the result of developments in phenomenology whichhave been applied to the therapeutic relationship, moving clinical theory in anintersubjective direction (Diamond and Marrone, 2003; Fonagy and Target, 2003).From a developmental perspective, intersubjectivity asserts that the self always exists inrelation to another. There has been a growing interest in self identity as constructed inrelationship to others (Bretherton and Munholland, 1999; Strawbridge and Woolfe,2003). According to these writers a sense of self is formed by the relationships oneexperiences in childhood and further developed throughout one‟s life. Whilst the selfmay be shaped by early experiences these writers emphasise that the self-concept doesnot necessarily remain fixed but is always being adapted and refined throughexperience.From the psychotherapeutic perspective intersubjectivity means that the therapist cannotbe a detached and objective observer. Instead, client and therapist are viewed as themeeting of two subjectivities who mutually shape the experience of each other. Recentdevelopments in psychodynamic therapy often described under the heading ofintersubjective approaches, place a greater emphasis on both client and therapist beingopen about interpersonal issues that are taking place between them (Mearns and Cooper,2005; Safran and Muran, 2000). This has led to an interest not only in the clients‟thoughts and feelings towards the therapist, but also the meaning of the therapist‟sreactions towards the client. Whilst it is generally agreed that therapists need to makesense of their reactions, Fauth (2006) has criticised much of the existing research for1
placing the therapist in a passive and reactive position. For example, he argues that thecountertransference research mostly assumes that the client‟s material connects withsomething in the therapist triggering a countertransference reaction. The present studypoints to the limitations of such a static and linear approach to understanding therapists‟reactions. It attempts to highlight the complexity of the subject with an emphasis onexploring personal meaning and lived experience. Although there are a number ofdifferent perspectives on therapists‟ reactions, it is generally accepted that therapistsneed to understand and manage their responses (Fauth 2006; Hayes and Gelso, 2001;Peabody and Gelso, 1982; Robbins and Jolkovski, 1987; Van Wagoner, Gelso, Hayesand Diemer, 1991). In view of the importance of understanding therapists‟ reactions,the aim of the present study is to explore the experiences of therapists using an in depthqualitative analysis. The method used is Interpretive Phenomenological Analysis (IPA),which aims to explore participants‟ experience and how they make sense of thatexperience (Smith, Jarman, Osborn, 1999). In keeping with the inductive andexploratory nature of IPA, the research question has been formulated as the following:how do therapists make sense of their personal reactions towards clients?1.2 Relevance to counselling psychologyIt is widely accepted that the main principle of effective clinical practice is the ability tomaintain an effective therapeutic relationship (Horvath and Symonds, 1991; Martin,Garske and Davis, 2000; Woskett, 1999). Developments in the field of counselling,psychotherapy and counselling psychology have led to an interest in discerning anddefining the ingredients of successful therapeutic outcomes. It has also led to anincreased scrutiny of the counselling process, which has led to attempts to formulatecounselling psychology in terms of identifiable skills and practices (Burton and Davey,2003). Particular interest has developed in the area of relational issues and processes.In psychodynamic theories the relationship is central and is considered to be the engineof change. Therefore, as Laughton-Brown (2010) argues, knowledge of psychodynamictheory is necessary for helping the counselling psychologist understand what ishappening between therapist and client.Counselling psychology has origins in phenomenological, existential and humanisticthinking that argued for the need to consider human beings in a holistic manner,2
emphasising a search for meaning and understanding (Strawbridge and Woolfe 2003).It challenged behaviourism and psychoanalysis which were seen as overly deterministic(McLeod, 2003). It emphasises a view of reflective human beings with the capacity forchoice as opposed to being determined by a range of internal (as in psychoanalysis) orexternal forces (as in behaviourism). As Fairfax (2008) points out, one of thedistinguishing features of counselling psychology is the amount of attention paid totherapeutic process and phenomenological understanding rather than diagnostic criteria.The emphasis on self-reflection underlines the importance of a commitment to personaldevelopment and that is why personal therapy and supervision are such important partsof the training. Counselling psychologists are encouraged to be reflective and pay closeattention to meaning and processes in therapy thus supporting a stronger therapeuticrelationship. Therefore, it is hoped that the present study will contribute towards ourunderstanding of process issues, which is directly relevant to the practice of counsellingpsychologists.The historical origins of counselling psychology identifies it with the basic assumptionsof qualitative research. It emphasises meaning, subjective experience and mutuallyconstructed realities (Strawbridge and Woolfe, 2003). More generally, philosophicaldevelopments in psychology have seen a paradigm shift away from a reliance onquantitative research methods to a more balanced reliance on a mixture of quantitativeand qualitative methods (Ponterotto, 2005). Qualitative research is concerned withunderstanding people‟s experience and how they make sense of their experience. Theseapproaches are intended to allow new aspects of meaning and experience to emerge.Qualitative researchers are particularly interested in the individual‟s subjective world,thus facilitating a more in depth understanding of their experience. The objective isusually to explore, describe and interpret the experience of participants. This involvestrying to understand the experiences of a comparatively small sample of participantsfrom their own frames of reference (Reid, Flowers and Larkin, 2005).1.3 Perspectives on therapists’ reactionsTherapists may experience a range of thoughts, images, emotions and sensations at anyone time, regardless of theoretical orientation. This section reviews the differentperspectives on therapists‟ reactions.3
1.3.1 Therapists’ reactions as own conflicts or vulnerabilitiesThere is a large body of psychoanalytic literature on therapists‟ personal reactions calledcountertransference. The classical Freudian approach understands the relationshipbetween therapist and client in terms of transference (Lemma, 2003). Transference isthe largely unconscious process through which thoughts, feelings and behaviouroriginally experienced in childhood are transferred onto others. Psychopathology isunderstood to be the result of conflict between the instinctive urges and the defencesagainst those urges. Since there will be an increase in pressure for the gratification ofinstinctual drives in the transference, this allows the therapist to examine the client‟sdefences against the impulses and the compromises reached by the ego between id,superego and external reality. Therefore, the Freudian approach understands theclient‟s behaviour towards the therapist as a misreading of the present based on the past.In the Freudian conceptualisation, countertransference is seen as the therapist‟stransferential response to the client‟s transference which reflects the therapist‟sunconscious conflicts that need to be resolved (Lemma, 2003). Unresolved conflictswhich originate in the therapist‟s childhood may become triggered by the client‟stransference, which may result in the therapist behaving in any number of ways. Thetherapist may distort the client‟s experience, thus clouding their judgement or it mayresult in them pursuing their own needs in the therapeutic relationship. From theclassical perspective, countertransference is a hindrance that needs to be overcome andworked on to resolve the vulnerabilities that cause it. However, more recently it hasbeen argued that it is also possible to consider the potential benefits of this sort ofcountertransference (Gelso and Hayes, 2007). An example could be those conflicts withwhich the therapist has reached a sufficient level of resolution resulting in them beingmore empathic. Gelso and Hayes (2007) would also argue that it is useful to considerdifficult or unpleasant reactions that are not simply the therapist‟s transference withinthis definition because they also have the potential to impact the therapy. It couldinclude conflictual reactions that emanate from difficulties that have occurred morerecently in the therapist‟s life.The understanding of countertransference as the therapists own conflicts has beendescribed in cognitive behavioural terms as originating from the therapist‟s own beliefs4
and automatic thoughts (Gelso and Hayes, 2007). Cognition refers to a number ofmental processes such as attention, memory, thinking, decision making and problemsolving. A key idea in cognitive theory is that people have schemas about the self andothers which have often developed from early experiences. These schemas enable us toorganise information and make sense of the world. In the same way that transferencebecomes a relationship template that is transposed onto others, therapists also havecertain beliefs and ways of perceiving the world that may lead to selective attention andbiases in interpreting information. Cognitive behavioural therapists inevitably havetheir own conflicts and vulnerabilities and there will be occasions when clients evokeconflictual reactions from their therapists. Furthermore, the way in which therapistsunderstand and respond to their clients will to some extent be subjective and influencedby their own conflicts. Therefore the understanding and management of their reactionsmay be just as important as in psychodynamic approaches.In contrast to psychodynamic writings, countertransference is discussed much less in thehumanistic and experiential literature. Nevertheless, as Gelso and Hayes (2007) pointout, the therapist‟s internal experience is still an important part of the therapeuticprocess. The difference is that the language of countertransference is replaced withlanguage that is experiential in nature. However, there is another reason whycountertransference is not referred to a great deal in the humanistic literature. There is abasic assumption in the humanistic approach that human beings are inherently good.Rogers (1961) talked about the core conditions necessary to facilitate the kind ofpersonal connection needed to create the good enough relationship that enables clientsto redefine themselves. Whilst these conditions have been described in different waysthe common theme is the significance and worth ascribed to clients and level ofengagement with them. The nature of human beings is towards growth anddevelopment and therefore the therapist‟s inner experience is something that is positiveand realistic (Rogers, 1961). This contrasts with the often negative attributes ofcountertransference in psychodynamic thinking. Furthermore, when the therapeuticrelationship is characterised by the core conditions, countertransference becomes less ofan issue. However, it could also be argued that the emphasis on the „here and now‟ andconscious awareness, risks becoming susceptible to the influence of unconsciousinfluences on behaviour (Gelso and Hayes, 2007).5
1.3.2 Therapists’ reactions as response to client’s styleAn alternative view of countertransference as the therapists‟ conflicts is the view that itis a response to the clien
Barbara Norbal deserves special thanks for her encouragement, patience and love. You have been there for me throughout the last four years and you have helped to keep me going. Finally, I would like to thank my supervisors, Rachel Tribe and Jane Lawrence. For their commitment and guidance I will always be grateful. I confirm that the work contained in this thesis is original except where other .
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