Relationship building in therapy:

helpful and unhelpful experiences of

female survivors of interpersonal trauma

Researcher: Maria Leahy, Doctorate in Counselling Psychologyleahym2@tcd.ie

Research Supervisors:Ms. Felicity Kennedy, The Women’s Therapy

CentreDr. Mary Creaner, Trinity College Dublin

Overview

1. Introduction

2. Current Study

3. Methodology

4. Findings

5. Key Findings and Implications for Practice

Introduction/Brief Literature Review

Research over the past 50 years has consistently shown that ‘it is the relationship that counts’

(e.g. Smith & Glass, 1977; Wampold et al., 1997; Wampold, 2001)

The therapeutic relationship has been found to predict outcome, whilst the differences due to treatment type are modest

(Hovarth & Bedi, 2002)

While the influence of the therapeutic alliance is well established, “little is known about the alliances true function in a therapeutic setting or about how it develops”

(De Roten, et al., 2004, p. 324).

Clients evaluation of the quality of the alliance that predicts outcome

(Horvath et al., 2010)

Significant events studies: what is helpful and unhelpful in therapy

No studies on relationship-building in therapy: helpful and unhelpful experiences

Literature consistently points towards relational needs of survivors of IPT

(Herman, 1997; Sanderson, 2010)

Need for relationally-oriented therapies (Banks, 2006)

Few studies conducted on helpful and unhelpful aspects of therapy

No studies on relationship-development: helpful and unhelpful experiences

Female survivors of IPT- more likely to be exposed to IPT forms of

trauma, than men (Lilly & Valdez, 2010)

- higher rates of PTSD than men, and increased risk of PTSD when trauma is interpersonal in nature

(Lilly & Valdez, 2010)

Survivors have so often been denied a voice – this study aims to give voice to these women’s experiences

The Current Study: Research Questions

1. What is experienced as helpful in building the therapeutic relationship?

2. What is experienced as unhelpful in building the therapeutic relationship?

- as experienced by female survivors of interpersonal trauma -

Interpersonal Trauma (IPT)

“the prolonged and repeated exposure to chronic, multiple, and repeated abuse within relationships, which give rise to complex PTS

symptoms. Such abuse is commonly committed by someone who is in a position of trust, or to

whom the individual is attached, or upon whom the individual is dependent. Ubiquitous to IPT is the abuse of power, use of coercion and control, the distortion of reality, and the

dehumanisation of the victim”

(Sanderson, 2010, p. 23)

Ethical Considerations Inclusion and Exclusion criteria

Ensure Informed Consent

Anonymity

Confidentiality and limits to confidentiality

Focus on relationship-building and not trauma

Ongoing support/continuity

Research Design

Qualitative, exploratory research design

Method of Data Collection: Semi-structured interviews

(60 mins approx)

Method of Data Analysis:Interpretative Phenomenological Analysis (IPA)

Data Collection Nomination of two helpful and two unhelpful experiences prior to

interview

1. Q. 1: What have you experienced as the most helpful in building a relationship with your therapist?. (Please identify two of the most helpful experiences)

2. Q. 2: What have you experienced as the most unhelpful in building a relationship with your therapist?. (Please identify two of the most unhelpful experiences)

Interview (60 minutes approx) Audio recorded and transcribed verbatim

Demographics Sheet

Debrief

 

Motivation for participating in the research

Understanding of the therapeutic ‘relationship’

Helpful and Unhelpful experiences of therapy (with current and/or previous therapists)

Guiding questions for each of the helpful and unhelpful experiences (IPR – Kagan, 1980)

o Could you tell me how did this come about? o What was it about this that was significant for you?o What impact did this have on your relationship with your therapist?o What impact did this moment have on you?o Were there any thoughts going through your mind at the time?o Were you aware of any feelings you had at this time?o Does any image or metaphor come to mind, that expresses the

significance of this experience for you?

How important is the therapeutic relationship

Development of relationship with therapist

Other

Experience of the interview

Interview Schedule Themes:

Participants9 participants

Age Range: 26 – 64

Length of time in current therapy: 1 week – 17 months

Length of time in previous therapy: 0 – 18 months (7participants), and on/off for 8 - 32 years approx (2 participants)

Nature of IPT:physical, emotional, and sexual abuse within relationship(s)

across avariety of occurrences

Relationship Status: Single (x 5); Unmarried (x 1); Married (x 1); Separated (x

2)

Findings

Client nominated helpful relationship-building experiences

Vera: The room where therapy takes place is bright and

comfortable – there is colour in the room and I can see the sky from the window

The therapist is completely non-threatening both in the spoken word and body language. I feel comfortable in her presence

I feel the therapist is very experienced in dealing with survivors of domestic abuse. She does not force issues, and I feel she is very at ease with herself – there is no ego evident, which I found was a problem with therapists in the past .. I am easily brought back to fear through loud voices or threatening body language. My therapist has a soft voice and emanates a peacefulness that immediately puts me at ease

Client nominated unhelpful relationship-building experiences

Nuala: When a therapist pushes too far, too fast, and wants to make you

talk about something you don’t want/aren’t ready to talk about. Especially when you get the impression they’re excited by it. Traumatic difficult events, as opposed to mundane, everyday anxiety OR when they prompt/put words in your mouth to hurry you along

First impressions – young therapists – hard to get going with them

Jackie: I found at the start of my therapy that my therapist introduced

the role play too soon. I wasn’t fully ready to confront that kind of situation and it made me feel quite uncomfortable for the rest of that session. I didn’t bring up anymore for that one session because I did not want her to suggest role play again

Superordinate themes Subordinate themes

1. The Fearful

Protector: Seeking

Safety

 

Feeling safe enough to be seen

Feeling trust enough to disclose

2. The Vulnerability of

Engaging in the

Unequal Therapeutic

Relationship: “it can

go one of two ways”

Needing to be seen, heard, and understood

Needing to be believed, and not blamed, shamed

or judged

Feeling safe enough to be seen 

“I had to keep thinking ahead to try and second guess what was going to happen when he’d get

home. So I lived like that for years and years and years and em even though the home was nice, I

created it, it felt like a prison all the time” (Vera)

“I was only there, only in the door two minutes .. and she said .. did you ever feel like you were the most

important person in somebody’s life and I was like .. that was a bit much .. I didn’t .. that’s why I’m here

and that’s why I’m crying now but it’s too, she was a complete stranger .. I mean there was no, this was

the very first hour, there was no relationship building, there was no trust established, and to come

out with a question like that” (Nuala)

Feeling trusting enough to disclose

“I would put forward say the smaller things first .. for the first six or seven weeks that’s what I did

present [therapists name] with .. and then when I knew that she understood me because she had

helped me so much to deal with the smaller things then I knew ok she understands I can trust her, ya

know, tell her more” (Cora)

“I think in her attempt .. to come across as experienced, she actually came across as quite

amateur, so I left maybe thinking to myself I don’t know how she’s going to be able to help .. I don’t

know if she’ll be able to speak to me about something that would help me in my life and

where I am right now .. that was what has kind of caused that, that eh that rupture” (Melissa)

The unequal therapeutic relationship

“I see therapy as .. you’re taking particular events from your life and putting them under a microscope, and you and the

therapist look together at something, or you’re down there holding up what event has happened in your life and presenting

it and the therapist is looking down at you, so .. ya know, it can go one of two

ways” (Melissa)

Needing to be seen, heard, and understood

“it’s just all about someone not just sitting there and being completely flat and monotone and not reacting .. just being this therapist who listens or asks you things but never shows

any kind of reaction” (Martha)

“like I’d be talking about certain things and she’d explain them to me as to why they happened and I’d be kind of

sitting there going oh my god, ya know, like I never thought of that, I never understood that but .. for her to be able to

turn around and give me an explanation for it was a massive thing .. I was kinda shocked I remember sitting there ya know going oh my god she’s right and then I knew in my

heart that she understands” (Jackie)

“I needed her to just listen, just to listen .. and not be comparing me to others .. cos I hadn’t spoken about it ..

there was nowhere I could talk about it .. I couldn’t tell my own family .. I couldn’t tell them what my [ex-partner’s

name] done to me .. I couldn’t tell my children so there was nobody .. it’s a very alone feeling” (Cora)

“that point in time kind of slowed down the dynamic maybe more than anything else

but I haven’t had long term effects” (Sarah)

“to believe that they have your best interests at heart .. that .. they’re not just

prodding you like a lab rat .. [and] that they haven’t forgotten that you’re a

person” (Nuala)

“you could say to your therapist .. that you were having suicidal ideation or intrusive thoughts .. you can tell your deepest fears or whatever, whereas if you said that to

your own mother .. she’d be in an absolute panic .. because .. you’re too

close to them .. you often need someone who doesn’t care that much .. who’s a professional .. they won’t feel like all

those spikes of emotion that you would if .. it was somebody very close to you, like your own sister or mother or your

child” (Nuala)

Needing to be believed, and not blamed, shamed or

judged “it was one of many experiences that I came across over the course of those 14 years [in therapy] .. of men and women .. I’m not just talking about therapists now, would blame me now, blame me for the whole thing .. I always thought [that

this was] because I didn’t have an arm hanging off or an eye .. that I still managed to look [good]” (Vera)

“I felt dismissed .. I felt god .. you’ve earned your hours money .. I felt she was clocking up the hours of all the

patients and I was just the next one. . I was the 5 o clock and now it was 6 so out .. I felt insignificant, I felt like I didn’t

matter.. even though it was huge to me, and I just walked out feeling very small and very insignificant and quite sad and

lonely and unimportant and unlistened to .. I felt like an orphan actually (laughs) .. (eyes welled up)” (Jade)

“she probably just wanted to be able to get me to say it again, to talk about it again .. probably she just wanted me to talk

about it again but it just kinda wasn’t clear” (Martha)

“I couldn’t say no, I learned that it was ok to say no, I didn’t have to say yes to

everything and be exhausted all of the time and that people will actually take it and accept it and that sometimes it was ok to stand up for myself even if people

didn’t like what they heard, if I felt I was right, and I didn’t have to backtrack and apologise constantly, apologising for my

existence in life .. I got a lot of confidence to do that, even with small things” (Jade)

Key Findings The importance of emotional safety/emotional regulation

Trust in therapist’s intentions as well as competency

Client deference, lack of verbalisation of discontent, and abdication of power

Needing to be seen, heard, and understood

Needing to be believed, and not blamed, shamed or judged

The unequal therapeutic relationship: some pro’s and con’s

A variety of types of unhelpful relationship-building experiences

The Truly Caring Relationship sustains unhelpful relationship-building experiences

Implications for Practice

Be aware of clients context (IPT and client)

Clients self-protective strategies - respect, encourage, and validate

Therapists role in increasing emotional safety (prioritising emotional regulation)

Variety of types of unhelpful relationship-building experiences

Remain hopeful and committed to repairing ruptures when they occur

Watch for signs of rupture (covert communication)

Encourage client to verbalise ruptures, validate when they do, and respond professionally

Clarify misunderstandings, acknowledge errors, and commit to learning from them with the clients guidance

Rupture and repair training

Use of the word ‘uncomfortable’ or ‘irritating’ rather than unhelpful

Caution: addressing rupture may further the rupture

Offer a truly caring therapeutic relationship

Behave, relate and intervene in ways which increase

the clients emotional safety the clients trust in the therapists intentions the clients trust in the therapists competency

the clients feeling of being seen, heard, and understood the clients feeling of being believed, and not blamed,

shamed or judged

the clients positive feelings towards self the clients feeling of being truly cared about the clients sense of empowerment within the

therapeutic relationship

Individual for each client

Tailor the therapeutic relationship to the individual client

• Trust in therapists intentions: congruence and transparency (as the norm, and especially when therapists behaviour is inconsistent)

• Trust in therapists competence: when the client experiences positive change as a result of therapy

• Be conscious of and monitor for negative transference (e.g. age, gender, physical size, tone, quality of voice, therapists behaviours that remind client of abusive other in their lives)

• Seek supervision when feeling blaming, judging, or feeling negatively towards the client

Be aware of power imbalances in the therapeutic relationship Negative: be aware of potential for re-

enactments and repetitions of abusive others in the clients lives

Positive: clients expectations of professional role (increase trust in therapists competency)

Offer an empowering therapeutic relationship that is experienced as helpful rather than unhelpful Continuum of empowerment within the

therapeutic relationship

Offer a truly caring relationship (can sustain unhelpful relationship building experiences, and prevent premature termination)

See, hear, and show understanding to the client

Don’t blame, judge, or disbelieve the client

Treat the client ‘as a person’ rather than a service user

Need for specialist services for survivors of IPT

Whereby practitioners are:

knowledgeable and informed about the dynamics of IPT

can informed about and cautious of the potential for repetition and re-enactments of negative others in the clients lives

provide information to clients to help them to understand their experiences as well as feel validated and understood

This leads to positive changes in the survivors relationship with self as well as relationship with

others