Compassion Strengths

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Article 12

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The Therapeutic Relationship

Part II will focus on the processes of the counseling or therapeutic relationship. It was decided to dedicate a specific section to the therapeutic relationship because of its significant importance to providing effective counseling.

Of all the aspects which pervade the art and science of counseling or psychotherapy, the art of forming, developing and navigating an effective, appropriate therapeutic relationship, seems least understood and at times is the most difficult to utilize. This is generally because examining and effectively utilizing the full potential of the therapeutic relationship requires the counselor to look deeply into his own self.

Counseling, whether as a volunteer or a professional, is probably the most personal endeavor a person can enter. The type and amount of responsibility one takes on when agreeing to enter into a therapeutic relationship cannot be understated. Especially when counseling the chronic mentally ill, the fragility of the client's sense of self and their emotional vulnerability should not be underestimated or taken lightly.

In this next section, the counseling or therapeutic relationship will be examined in some detail. Aspects of this relationship, i.e. the personal relationship, transference, counter-transference, regression, and resistance are possibly the least understood yet most powerful allies or hindrances a counselor can have.

It is all too often we, as counselors, wonder in amazement as to what went wrong in our counseling session, why the client isn't getting any better, or why they have suddenly stopped counseling. Answers to these questions usually have some bearing to what has (or has not) been developing, many times outside the counselor's or the client's conscious understanding.

When the counselor becomes aware of the many times subtle, yet significant shifts and transformations, of what is occurring at that time in the relationship with the client, he can not only avoid the pitfalls of a misaligned therapeutic relationship, but also shed a considerable amount of light on the problems the client may be experiencing outside the counseling session in relationships with others and himself.

To this end, the therapeutic relationship will be examined in some detail. Both the client's and the counselor's contributions will be discussed. With the proper focusing of attention, the counseling process as it is actualized within the relationship between client and counselor can produce significant beneficial growth - for both parties involved.

The Therapeutic Relationship

The therapeutic relationship is the "core" to all treatment approaches regardless of their specific aims or target populations. When the counselor is aware and sensitive to the various issues which arise within the relationship, is able to address and deal with these issues, counseling progresses in the appropriate direction and tempo. If the counselor is unaware and/or does not address these issues in an appropriate and timely fashion, then counseling "stagnates" or terminates.

In many ways, dealing with the therapeutic relationship is the process of counseling. This becomes quite understandable when we consider that so much of the emotional difficulties, which accompany chronic mental illness, have been developed through unclear and misunderstood relationships.

While biochemical and genetically "loaded" illnesses such as schizophrenia and major affective disorders cannot be "cured" through the establishment of an appropriate therapeutic relationship, many of the accompanying emotional problems such as poor self-image and low self-esteem can be significantly improved.

The therapeutic relationship begins with the first contact client and counselor make. In some ways it begins even before their first meeting. This is because the client comes to counseling with many preconceived ideas of who and how the counselor will be based on their previous contacts with doctors, nurses, social workers, teachers, parents and other "authority figures." The relationship will have both personal and professional aspects to it from the beginning, and will undergo changes and transformations to the end of counseling or termination of contact.

The first process to be established will be that of providing a "holding environment." This is a term used to describe a relationship, which is safe, confidential, reliable, and consistent with appropriate and clear boundaries. As this is being established, certain wishes and fears in the client will be activated. These wishes and fears are usually associated with parts of their selves that were left "hungry" from insufficient past relationships that have been reactivated in the therapeutic relationship.

This reactivation of past wishes and fears will soon begin to affect how the client perceives the counselor. The client may suddenly become withdrawn, overly sensitive, avoiding the counselor, or become overly friendly, try to please or be seductive towards the counselor. These reactions can be confusing and unless they are dealt with in an appropriate and timely fashion will lead to a stagnation or early termination of the counseling process.

The Therapeutic Holding Environment and the Personal Relationship

Counseling is an intensely personal as well as professional encounter. This is necessary and obvious when we consider the client is asked to share aspects of him, which are; deeply personal and which may have never been expressed before.

This is a necessary aspect to the therapeutic relationship. In order to facilitate an atmosphere of trust in which a client may relax their defenses and open himself or she to the therapeutic process, it becomes necessary for the counselor to be available emotionally. This availability resembles a friendship in several ways, yet it is not.

It resembles a friendship in that the counselor is available emotionally; the counselor listens to the wishes and fears of the client, is not judgmental, is sensitive and reliable, is able to accept the client, does not retaliate and is there primarily for the client's needs. The counselor conveys to the client a sense of trust and safety through his own basic attitudes, therapeutic stance and deep-seated beliefs regarding his own basic value, his trust and confidence in his ability as a therapist and in the therapeutic process.

The fact that counseling is not a personal friendship is obvious, although the boundaries can have a tendency to blur if the counselor is not aware of his own needs. It is a well-accepted fact that people who tend to get involved as counselors, whether professionally or as volunteers, do so out of the desire and sometimes the need to help others. It is when our need to help becomes more important to us than setting appropriate limits and boundaries, at times to the disappointment or anger of our clients, that the personal relationship blurs into a personal friendship.

Some of the signs of losing professional boundaries are:

  1. The experience of feeling sympathy vs. empathy for the client. While it is professionally correct and useful to "imaginatively enter into another person's feelings," it is not correct or useful when that blurs into "sharing of another's emotions."
  2. Trying to take away the client's pain. This is usually an indication of feeling sympathy. When our boundaries blur to the extent that we share another's emotions, especially if they are painful, the tendency is to try to extinguish that which is painful - even when it may be in the best interest of the client to allow the feeling and expression of those emotions.
  3. Wanting to please or gratify the client. When our need to be a "good counselor" is more important or overshadows the needs of the client, we try to please the client rather than help the client. This often leads to trying to do for the client what the client should learn to do for himself. This can take the form of lending money personally, providing transportation when the client is able to provide their own, giving a home phone number and/or taking calls at home, giving inappropriate compliments, ANY inappropriate touching of the client.
  4. Spending too much personal time involved with clients, either directly or indirectly. This includes using personal time to see clients, doing charts, case writing, thinking, worrying or fantasizing about clients, i.e. carrying them around in your head.

On the other side of over-involvement is a lack of or constricted interaction. As contrary as it may seem, a constricted personal relationship is an indication of the same thing over-involvement is; a lack of professional boundaries. The difference is how the counselor approaches or deals with it. The desire to become personally involved may still be there, however the fear of losing boundaries produces a tightening or constriction of interaction with the client. This restriction of the personal relationship when excessive or inappropriate, will prevent the needed "therapeutic bonding" between client and counselor.

The importance of this personal encounter in the therapeutic process becomes apparent when we consider that all human development occurs in interaction with others. It is through this personal relationship the client has with the counselor, the counselor's accepting and empathic responses to the client that begins to reinstate the halted developmental processes that were stunted by inadequate relationships of the past.

The development of the personal relationship starts with the first contact between client and counselor, or, as mentioned earlier, even before this. As the client begins to express his troubles and the counselor listens carefully and empathically, there begins to form a silent bond of trust. While the counselor does not fall into the dangerous trap of gratifying the client's needs, it is necessary for the counselor to have a presence of "authentic benevolence."

As the client becomes aware of the counselor's genuine interest in understanding and helping him, and comes to trust the counselor and the therapeutic process, he begins, possibly for the first time in his life to get a sense that another person is really listening to him.

This can be both exhilarating and frightening for the client, because the thrill of being seen is mixed with the fear of being rejected. As will be discussed, both of these emotions play a major role in the development of the counseling relationship, as it carries both client and counselor through the various phases of the therapeutic process.

Resistance and Regression

With the establishment of a holding environment through the counselor's empathy, the provision of safe and appropriate boundaries, the client will begin to trust the counselor. While this trust is a positive indication and is even necessary for counseling to unfold, it will usually be accompanied by some degree of emotional dependency.

Emotional dependency, contrary to some schools of counseling, is not considered here as a sign of something the counselor is "doing to" the client. Almost universally, clients enter counseling with some degree of "unfinished business" from their own childhood. One of the consistent symptoms of this unfinished business is emotional dependency. Counseling does not create dependency. It does however; create a context for that dependency to surface.

As emotional dependency begins to emerge in the counseling context, two other forces or dynamics also begin to form; resistance and regression.

For most clients who enter counseling, emotional dependency is a dangerous feeling. This is because it is usually a sign of needing and/or wanting acceptance and praise. Along with this feeling of needing, there is the fear of (in the client's mind, almost assured) rejection.

This intense need for acceptance and the fear of rejection is part and parcel of the unfinished business clients bring with them to counseling. Misunderstanding and misaligned relationships in the family, though usually unintentional, leave an intense "hunger" in the client for the emotional intimacy they missed in their childhood.

This hunger is usually much deeper, stronger and more pervasive than what most of us experience in our own lives. It is usually without clear or strong boundaries. Along with this hunger there is an accompanying hurt or injury. They are two sides of the same coin. The more pervasive and intense the hunger, the more intense and pervasive the hurt or injury.

Resistance in counseling is a client's natural response to their growing, although not necessarily conscious, dependency upon the counselor. Resistance is rarely a conscious, willful reaction. It is usually an automatic expectation of emotional pain in the form of anticipated rejection. In the client's mind a phrase such as "the more I need you, the more it will hurt if (when) you reject me," will eventually form as counseling progresses. Again, the "flip side" of the hunger for acceptance is the assuredness of (eventual) rejection.

Resistance may also appear from the outset of counseling. If the client's need for acceptance is strong and there is difficulty in accepting the need for counseling, resistance may appear from the first contact. Also, as previously mentioned, if there has been previous unsatisfactory contact with a counselor, nurse, doctor or other helping professional, the residual effect of that contact may appear initially as resistance.

Resistance is essentially a defense against the client's own emotional vulnerability and dependency, the need for acceptance and the difficulty in accepting the need for counseling. This defense usually takes one or several forms. These are generally: silence, denial, avoidance, and challenge. Identifying and dealing with these defense mechanisms will be addressed in the section on counseling process.

Regression is a term, which refers to the client returning to an "earlier" emotional or developmental stage. It is the reactivation of early, dormant wishes, their defenses, fears, expectations, corresponding fantasies, and resultant inter - and intrapersonal behavior which are actualized in the counseling process and relationship.

Regression is essentially a retreat from objective reality that is experienced as too stressful or threatening for the client to confront, accept or deal with. It occurs not only in the counseling process, but also in day-to-day living. Regression occurs when the stress of our daily living becomes so great, we wish we could become children again and escape the unpleasant situation, either objectively or in fantasy.

There are three types of regression; emotional, cognitive and behavioral regression. Emotional regression is what most people experience under stress. It is not a sign of mental illness. In fact, some psychologists consider it the wellspring of creativity and the essence of play when directed consciously. When used in therapy, psychoanalysts call it "regression in service of the ego."

Emotional regression is very useful and healthy in an individual whose sense of self is cohesive or intact. It is even necessary in certain kinds of therapy. However, when counseling the chronic mentally ill, emotional regression is usually accompanied by cognitive and behavioral regression.

While emotional regression is a returning to earlier stages of emotional development, cognitive and behavioral regression is a return to earlier forms of thinking and behaving.

Cognitive regression occurs in mentally ill individuals whose sense of self is not cohesive or intact. This means, that under the pressure of emotional stress the basic foundation of "self" which gives an individual a sense of wholeness and continuity in time and space, "cracks," "breaks," or "fragments." It means literally, "falling to pieces" mentally. Another way of framing falling to pieces is having a psychotic episode.

This is believed to occur because the process of forming a stable, cohesive self, which is the hallmark of psychological development, is interrupted or reversed by the development of psychosis - usually schizophrenia. Without a stable, cohesive self, the process of thinking breaks down and becomes disorganized under stress, as described in the section on schizophrenia.

Behavioral regression is observed in those clients under stress who may be diagnosed with a personality disorder as well as those with schizophrenia. As with cognitive regression, behavioral regression is a return to earlier or more "primitive" levels of development.

Behavioral regression may be as minor as an adult with a personality disorder throwing a temper tantrum when not getting what he wants, to a chronic schizophrenic not being able to bathe herself or comb her hair. Behavioral regression is essentially a return to earlier or more child-like ways of behaving. The deeper the regression, the earlier or more primitive the behavior.

As is apparent, when counseling the chronic mentally ill, the counselor does not want to encourage, foster or develop regression. In fact, if the counselor observes a significant or sustained development of regression, it is an indication that the counseling process has become too intrusive.

One of the essential differences between counseling the chronic mentally ill and an essentially intact client with a personal problem, is that the latter can tolerate the internal stress of intense self-examination and emotional regression, without experiencing "self disintegration" or disorganization. Self-disintegration and disorganization is another way of describing cognitive and behavioral regression.

In developing and utilizing the therapeutic process, which occur within the counseling relationship, the counselor "walks a fine line." On the one hand, the counselor creates conditions of safety and trust within the holding environment of the personal relationship. These conditions will allow the client to relax and begin to trust the counselor. As the counselor empathically addresses and deals with the resistances or defenses of the client to the therapeutic process, the client's boundaries will loosen and blur and there will be a tendency to regress.

On the other hand, if the client's sense of self is not cohesive, this regression will not halt at emotional regression, but also develop into a cognitive and/or behavioral regression. While minor or temporary cognitive and behavioral regression is unavoidable, it is usually temporary and reversible. Major regressive shifts can precipitate psychotic decompensation.

Major regressive shifts are usually accompanied by some of the following symptoms:

  1. The occurrence or intensification of hallucinations or delusional ideation.
  2. Increasing loosening of associations, tangential or circumstantial speech.
  3. Increasingly blunted, labile or inappropriate affect.
  4. Increasingly disorganized, reclusive or bizarre behavior.
  5. Increasing difficulty in concentration or attending to simple tasks.
  6. Significant difficulties sleeping, frequent awakening at night, or night terrors.
  7. Repeated and increasing behavioral problems, i.e. physical fights or confrontations, significant problems in relationships with others at home, work or school, suicidal threats, gestures or attempts, overt or covert attempts to manipulate and control others, screaming, continual crying, or inability to control behavior, regressive behavior, e.g. loss of ability to clean one's self, appropriately use the toilet, look after basic needs.

Should one or several of these behaviors appear, either directly or be reported by family, friends or caretaker, the counselor needs to examine recent processes within the therapeutic relationship as well as other objective factors which will be discussed later.

Has there been any change in how the client is presenting? Has the client hinted or directly indicated he wants more distance or closeness. Has the client appeared secretive, manipulative, or seductive? Has the client suddenly become withdrawn, reclusive or secretive? Has the client wished more or less contact? Has the client been calling in between sessions? Have there been recent cancellations, reasons for not coming to counseling? Has the client expressed a wish, either directly or indirectly, to see the counselor outside of work? Has there been a change in the "climate" of the counseling session? Is there a feeling or hint of issues, which need to be expressed but have been "skirted around?"

Conversely, the counselor must also ask himself if there has been any recent shifts or changes in his feelings and behaviors within the therapeutic relationship.

Has there been the development of an attraction or repulsion towards the client, personally, situationally, sexually, which is clouding or hindering the counseling process? Is the counselor feeling for the client instead of with the client? Are there unresolved issues in the counselor's own life which are being brought to light in the therapeutic relationship? Is there a blurring or loosening of boundaries between personal and professional thoughts, feelings and behaviors.

It is inevitable there will be a mix of both personal and professional feelings when counseling with clients. We are either deceiving ourselves if we deny this, or too far removed from our own feelings to be effective as counselors. It is unrealistic and ultimately harmful to the counseling process if we pretend not to experience a wide variety of personal feelings in the therapeutic relationship. The mark of an effective counselor is not whether he does or doesn't experience personal feelings; it's how he chooses to utilize them.

The Emergence of Transference

In 1895 Sigmund Freud coined the term transference as it applied to psychoanalysis. In 1905, in an article he wrote called "Fragment of an Analysis of a Case of Hysteria," he defined transference as "new additions or facsimiles of the impulses and phantasies which are aroused and made conscious during the progress of analysis; but they have this peculiarity, which is characteristic for their species, that they replace some earlier person by the person of the physician" (p.116).

Since then, the word transference has become a household word among counselors and therapists; much used and little understood. The concept of transference itself has gone through a number of transformations in psychoanalytic literature throughout the years adding to the confusion.

In classical psychoanalysis, transference is an alteration in the relationship between the patient and the analyst, which develops over time into what is called a "transference neurosis." This essentially means the major conflicts the neurotic patient is experiencing in his life outside the therapeutic relationship become activated and transferred to the relationship with the analyst. This allows the analyst to directly observe and address those conflicts as they are happening within the therapeutic relationship.

Since, as counselors we are not psychoanalysts, and we are not dealing with neurotic clients whose sense of self is whole and intact, do we need to address the emergence of transference in our counseling?

The answer to this question is yes. The emergence of "transference reactions," (as opposed to transference neurosis) is universal in every therapeutic relationship regardless of the diagnosis of the client or the theoretical orientation of the counselor. The tendency to transfer previously unresolved emotional injuries, "unfinished business" to current life situations, especially interpersonal relationships, is known as "repetition compulsion." We are compelled to perceive, think, feel and behave in specific patterns we learned very young, regardless if those patterns were healthy and productive or not.

The chronic mentally ill are no exception. In fact, it is even more the case with the CMI. In neurotic clients, transference reactions usually take some time to develop. This again, is because they have a whole and cohesive self. They are less likely to allow, or give way to the unconscious conflicts, which will eventually find their way into the therapeutic relationship.

With the chronic mentally ill, whose sense of self is weak or fragmented, unconscious conflicts have an almost direct route to the therapeutic relationship, where the person of the counselor can quickly be lost or mistaken for an earlier figure with whom the client has had intense ambivalent feelings and relations.

Definition of Transference

For our purposes in counseling the chronic mentally ill, transference may be defined as a kind of relationship between client and counselor. The main characteristic of this relationship is the experience of feelings to the person of the counselor, which do not befit the counselor. Essentially the person of the counselor is perceived and reacted to by the client, either in an unrealistically idealized, or positive fashion, or in a negative, devalued way.

Transference reactions are activation within the therapeutic relationship (or any other emotionally "charged" relationship) of certain aspects or "parts" of the client as they relate to interacting with others, which are focused or projected onto the person of the counselor.

Transference reactions are always inappropriate. They may be so in the quality, quantity and duration of the reaction. The client may over-react, under-react, or may have a bizarre reaction to the counselor. The transference reaction is unsuitable in its current context; it is a response from the client, which is not warranted or appropriate.

Transference reactions are essentially unconscious. The client is usually unaware that he is reacting inappropriately. From his point of view, the counselor has suddenly or gradually changed. He is unaware that it is he who has had a shift in his perception. Since the major mental/emotional mechanism involved is projection, which by definition is unconscious, from the client's point of view, it is the counselor who is responsible (or blamed) for the changes the client is now experiencing.

The Development of Transference Reactions

When working with the chronic mentally-ill, transference reactions may be experienced in the client considerably sooner and with greater intensity than with neurotic clients, even though CMI clients may not actively, directly or openly demonstrate their reaction. Dealing with transference with the chronic mentally ill may require more empathy and sensitivity than with other populations.

Transference reactions may develop immediately, upon the first contact between client and counselor, or gradually, after some period of counseling. Generally, the more organized and stable the client's sense of self, the longer it will take for transference reactions to develop. With schizophrenic clients, especially if they are chronic, transference reactions may be immediate and persistent.

There are four major qualities to transference reactions, both positive and negative:

  1. Inappropriateness. Transference reactions are emotional responses, which are out of context. They are not warranted to the person of the counselor or the context of the counseling.
  2. Intensity. Transference reactions are generally intense emotional responses, positive or negative. While the intensity may not be openly expressed, it usually reveals itself in some aspect of the client's behavior towards the counselor and/or counseling.
  3. Ambivalence. Just as there is no up without down, hot without cold, so it is with transference reactions. The counselor can be sure, that just as the client may be idealizing him for what a good counselor he is, at some point the client may become disappointed and angry when the counselor must be firm, or draw limits.
  4. Tenacity. Transference reactions are tenacious. They are resistant to change. Even when they are pointed out to the client they may continue to persist. The counselor many times may have to "ride them out," allowing them to transform during the course of counseling.

The chronic mentally ill client may also exhibit other significant qualities to his transference reactions. The first is that the object of the transference reaction, usually the counselor, may not be experienced emotionally as another, separate person.

With the weakness and/or fragmentation of the self, which is the hallmark of chronic mental illness, the ability to experience another person as whole and separate is also impaired. Other people in the chronic mentally ill person's life are usually perceived and reacted to in a way which is quite different from how we, as whole, cohesive selves, perceive and react to other people.

While there may be the intellectual concept of self and other, emotionally that concept may be blurred. Many times chronic mentally ill clients are frustrated, angered, confused when other significant people in their lives do not behave in a way the CMI feels they should behave from their perspective. When the boundaries between self and other are weak, blurred or fragmented, there is an emotional perception and expectation that significant others are to perceive, feel and behave similarly or in accordance with the views of the chronic mentally ill person.

This lack of or blurring of boundaries between self and other, present significant challenges when transference reactions do arise in the therapeutic relationship. There are generally two types of transference reactions, positive and negative.

The Negative Transference Reaction

The negative transference reaction can arise at any time within the therapeutic process. The term negative transference is used to designate transference feelings based on fear and anger in any of its various forms. Negative transference may be expressed as fear, anger, hostility, mistrust, aversion, resentment, dislike, withdrawal, envy, etc.

Since these are powerful and generally unacceptable feelings, the negative transference is usually hidden, split off, or kept away from conscious awareness. However secretly it may be kept, the counselor needs to expect, that at some point in the counseling process, it may make its presence known; directly or indirectly, in thoughts, fantasies, words, feelings or actions.

Some of the indications of the development of a negative transference reaction may include:

  1. Avoidance. When the client avoids the counselor through late or missed appointments, has become withdrawn or uncommunicative, is overtly or covertly secretive, expresses or displays mistrust for the counselor.
  2. Anger. When the client expresses, directly or indirectly, actively or passively, anger, irritation, or resentment to the counselor or the counseling, which is inappropriate or out of proportion to the situation.
  3. Disorganization. When the client becomes significantly or unusually (for this particular client) confused, withdrawn, forgetful, disorganized in thoughts, feelings or behavior, that has the effect of side tracking or derailing the counseling process.
  4. Devaluation of the counselor and/or the counseling process. When the client minimizes or depreciates the value or the need for counseling and/or is overly critical, harsh or depreciative of the counselor.

When these reactions develop in the therapeutic relationship, there is both danger and opportunity for the counselor.

The danger is in the form of the counselor feeling personally attacked or responsible for the feelings of the client. Negative transference reactions can be difficult to understand and even more difficult to tolerate. They can precipitate intense emotions in the counselor, or what is called counter-transference.

Counter-transference is the arousal of an emotional reaction in the counselor in response to what the client is saying, his emotions and/or behavior. It may be a reaction of anger, pity, indignation, repulsion, or the desire to avoid the client. The emotional reaction is usually intense and is usually a response from a part of the counselor's personality where he experiences personal vulnerability.

The opportunity that is available when transference reactions arise in the therapeutic relationship is for the counselor and the client.

For the counselor, the emergence of transference and especially counter-transference, provides the opportunity to look into and experience aspects of his own personality, both strengths and vulnerabilities, which are otherwise unavailable. It is an opportunity for personal growth which, when handled honestly and responsibly, (and many times with the help of a supervisor) will not only facilitate significant personal development, but also provide effective counseling for the client.

For the client, effective management of transference reactions many times is the process of counseling. As will be discussed shortly, the development of a real or realistic relationship between counselor and client is one of the underlying processes of most therapeutic procedures with the chronic mentally ill.

The Positive Transference Reaction

The positive transference reaction is the counterpart to the negative or devaluing transference reaction. In many situations the positive transference may emerge first in the therapeutic relationship. This is because the client often comes to counseling discouraged with his own attempts to solve his problems and looks to the counselor with high hopes and at times unrealistic expectations of who the counselor is and what he can perform to remove the client's problems.

In the case of chronic schizophrenics however, who have had repeated hospitalizations, or other clients who have sought counseling previously, especially if previous contacts have not met their expectations, hopes may be guarded. In these situations negative transference reactions may be predominant and may surface first.

The positive transference reaction is basically an expression of unrealistic expectations towards the counselor and the counseling process. It is based on feelings of need, desire, attraction, or "love" in various forms. It is generally expressed as the desire or need to "merge" with the therapist, physically, mentally, emotionally, and/or socially. It may also be expressed as the need to be seen, admired, or taken care of by the counselor.

Some indications of the development of a positive transference reaction may include:

  1. Idealization of the counselor. Idealization covers a wide range of possibilities. It can include having regard, respect, praise, or admiration, for the counselor. It can also progress to a sense of awe, adoration and even reverence for the counselor. In the more advanced stages, idealization will attribute special abilities or "powers" to the counselor such as the ability to read minds, foretell the future and change events.
  2. Expectations of entitlement. In a complimentary fashion of how the client perceives the counselor through the process of idealization, the client may expect the counselor to perceive him. The client may expect the counselor to treat him special, as "the favorite," with privileges not due to anyone else. This can progress to the client feeling he "owns" the counselor who must respond immediately and magically to his needs, wishes and expectations, whether they are realistic or not.
  3. Wish to merge with the counselor. Again there is a range of possibilities. It can include the wish to know more about the counselor as a person; is he married, does he have children, etc. It can progress to wanting to be more like the counselor; imitate his speech, manner of behaving, wanting to be a counselor, etc. It can also progress to wishes and fantasies of being intimately connected with the counselor, including sexual longings and fantasies.

While negative transference reactions are usually more identifiable and therefore open to direct intervention, the positive transference reaction presents a different, and at times, more difficult challenge for the counselor. In particular, counter-transference reactions are much more likely to be precipitated in the counselor when he is being idealized than when he is being devalued.

As already mentioned, people who tend to get involved as counselors, professionally or as volunteers, often have a strong need to help. Part and parcel of this need is the desire to be wanted, valued and admired. If the counselor is unaware of this need, he may allow the unrealistic admiration of the client to develop unchecked. The counselor may "feed" off the client's idealization and admiration.

If idealization and admiration from the client is intense enough, and the need of the counselor strong enough, boundaries between client and counselor may become blurred or lost. Should this occur, a number of outcomes are possible.

  1. The first is the counselor's loss of objectivity. As counselors we are confronted with the difficult role of being "participant observers." While one portion of our selves is actively engaged in relating empathically to our client, another part of us must remain objective and impassive. With the loss of appropriate boundaries our objectivity, and therefore ability to accurately observe is lost.
  2. The next is escalation of idealization. This can happen in two parts. The first is allowing (consciously or unconsciously) or encouraging the client's idealization of the counselor to foster and grow.

    With chronic mentally ill clients this can be both risky and irresponsible. In contrast to counseling with neurotic clients whose sense of self is whole and intact, and with whom it is appropriate to allow the idealization process to foster, chronic mentally ill clients do not have the means to contain their idealization.

    Unchecked idealization of the counselor may very well "burst the bubble" of the CMI's sense of self, precipitating a psychotic decompensation, eventual massive disappointment and/or behavioral acting out.
  3. The next consequence to escalation of idealization is the client may expect reciprocation. In other words, he will come to expect the counselor to gratify his needs to be admired, to be treated special, to be granted expectations of entitlement. Consistent with the positive transference reactions, this is the "other half," and almost always a consequence of unchecked idealization of the counselor.
  4. The last and most serious outcome is allowing or encouraging inappropriate interaction, whether social, emotional, physical or sexual. This is an indication of a complete loss of boundaries. This can include seeing a client socially, intense and prolonged emotional feelings and/or fantasies towards the client, i.e. infatuation, preoccupation, crushes or "falling in love," any inappropriate touching, sexual longings or involvement.

If a counselor finds himself in any of these situations, it is an indication that his needs (at least with this particular client) are overpowering and out of his control. It necessitates getting immediate supervision and possibly terminating contact with the client in a responsible fashion.

  The Real Relationship

The "real relationship" is a term used to describe the target goal of the processes, which occur within the therapeutic relationship. It is called the real relationship to reflect the basic (and sometimes ongoing) purpose of the therapeutic relationship is to help bring the client closer or more in alignment with a realistic perception of self and others.

The real relationship is an extension and development of the personal relationship as it is transformed through the processes of resistance, regression, negative and positive transference reactions, to emerge again stronger, more resilient and more in tune with objective reality. Consequently, as the relationship transforms, freer from the distortions of the transference reactions, the client emerges with a stronger more cohesive sense of self, a more realistic self-concept, and greater self-esteem.

The real relationship is a reflection and activation of that part of the client, which has an objective, (relatively) realistic perception of him and others, understands (or tries to understand) his difficulties and/or illness, and makes a genuine effort to deal with it. It is generally characterized by the following traits:

  1. It is reality oriented. This means a portion of the self is focused and able to operate in the external world relatively independent from active psychotic process.
  2. There is some capacity for introspection. The real relationship is an extension of that part of the client, which both desires and is able to participate in self-examination.
  3. There is some capacity for objectivity. A part of the self, the "observing ego," is free enough from the distortions of transference reactions to objectively assess and participate in relating realistically with himself and others.
  4. There is some tolerance and ability to accept and forgive the shortcomings of self and others. There is also some frustration tolerance, or the ability to delay the need for immediate gratification.
  5. There is some ability to empathize with others even though there may not be agreement with their point of view.
  6. There is some resilience, or the capacity to accept, tolerate and "emotionally survive" the disappointments and failures of self and others.

Development of the Real Relationship

The development of the real relationship is the underlying process of counseling. It is the hidden or often unnoticed part of counseling which is responsible for setting the conditions which are necessary, before any particular modality, approach or technique of counseling can work.

The development of the real relationship begins with the personal relationship. In a very real way, the personal relationship is like a seed, which is planted. It has all the potential to grow into a healthy and resilient real relationship depending upon the soil in which it is planted as well as the type and amount of nurturing it receives.

The development of a safe, reliable holding environment, the use of accurate empathy and maintaining appropriate boundaries with the client, ensures the personal relationship is given the opportunity to grow. While the seed is given enough nourishment for optimal growth, the counselor must be sure not to drown or starve it by becoming either over- or under-involved.

It is important to note the personal relationship, like a seed cannot be forced, pushed, or rushed into growing. Every client sets his or her own pace. It is also important to note with some clients, especially those who are suffering from severe and chronic forms of mental illness, the "soil" may not be as fertile as with other clients. No matter how well the personal relationship is cultivated, growth may be limited.

To continue with the analogy, as the seed begins to take root, there are still hindrances to smooth growth. If the soil is particularly hard, it provides resistance. In the same way, clients may not easily engage in the counseling process. They may resist "taking root" to the counselor and counseling process because of their vulnerabilities and possible less-than satisfactory experience with counseling in the past.

This may require the counselor to till or soften the soil. This is done by addressing and dealing with the resistances as they occur. This is where the empathy of the counselor must be sharpened. Too much tilling, or at the wrong place or the wrong time, and rooting will regress. Severe regression is analogous to the seed pulling in its roots and the personal relationship dying or going into hibernation.

Once the personal relationship takes root and begins to grow, the client may still get himself entangled with the counselor. This is the emergence of transference. Whether the entanglement is positive or negative, it is up to the counselor to recognize it and eventually help the client to disentangle.

As the personal relationship becomes increasingly free of the entanglements of transference reactions, it develops into a stronger, more resilient and realistic relationship. The strength and resilience of the real relationship, is a reflection of the strength and resilience the client has gained through the process of dealing with his transference reactions.

In summary, the therapeutic relationship is the core to all modalities of counseling with the chronic mentally ill, whether it is task-oriented, supportive or educational. It begins with the personal relationship in which a therapeutic holding environment is developed through the establishment of safe and reliable boundaries. It undergoes a transformation as positive and negative transference reactions are addressed and dealt with, and finally emerges stronger, more resilient and realistic, reflecting a more stable, cohesive sense of self-gained by the client.

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