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Relationship building in therapy: helpful and unhelpful experiences of female survivors of interpersonal trauma Researcher: Maria Leahy, Doctorate in Counselling.

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Presentation on theme: "Relationship building in therapy: helpful and unhelpful experiences of female survivors of interpersonal trauma Researcher: Maria Leahy, Doctorate in Counselling."— Presentation transcript:

1 Relationship building in therapy: helpful and unhelpful experiences of female survivors of interpersonal trauma Researcher: Maria Leahy, Doctorate in Counselling Psychology Research Supervisors: Ms. Felicity Kennedy, The Women’s Therapy Centre Dr. Mary Creaner, Trinity College Dublin

2 Overview 1.Introduction 2.Current Study 3.Methodology 4.Findings 5.Key Findings and Implications for Practice

3 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).

4  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

5  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

6  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

7 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 -

8 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)

9 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

10 Research Design Qualitative, exploratory research design Method of Data Collection: Semi-structured interviews (60 mins approx) Method of Data Analysis: Interpretative Phenomenological Analysis (IPA)

11 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

12  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:

13 Participants 9 participants Age Range: 26 – 64 Length of time in current therapy: 1 week – 17 months Length of time in previous therapy: 0 – 18 months (7 participants), and on/off for years approx (2 participants) Nature of IPT: physical, emotional, and sexual abuse within relationship(s) across a variety of occurrences Relationship Status: Single (x 5); Unmarried (x 1); Married (x 1); Separated (x 2)

14 Findings

15 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

16 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

17 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

18 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)

19 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)

20 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)

21 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)

22 “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)

23 “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)

24 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)

25 “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)

26 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

27 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)

28  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

29  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

30 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

31  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

32  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

33 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

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