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An Analysis of the Potential Detrimental Effects of Interference with the Therapeutic Relationship
Virtually any type of treatment setting requires an effective therapeutic relationship to succeed. Therefore, this research paper will examine the potential detrimental effects on the client and the therapeutic relationship when an outside person interferes with the therapy in general, and the following two scenarios in particular: 1) the patient's family, friend, or significant other(s) do not refrain from intervening in the therapeutic relationship once it has begun; and, 2) once the patient develops an affectionate relationship with the therapist, the family member, friend, or significant other develops jealousy and attempts to destroy or undermine the therapeutic relationship. To this end, a discussion of what steps practitioners can take when these events interfere with the therapeutic relationship is followed by a summary of the research and recommendations for clinicians in the conclusion.
Review and Discussion
Background and Overview.
According to Carroll, Connors, Dermen, Diclemente, Frone and Kadden (2000), "It has long been recognized that establishment of a working relationship between the client and therapist is an important component of the behavior change process. This relationship has consistently predicted client response to psychotherapeutic interventions in a variety of clinical domains" (p. 139). Furthermore, the importance of interpersonal connections in clinical settings today cannot be understated. For example, it is widely recognized that a healthy therapeutic relationship facilitates positive change (Hubble, Duncan, & Miller, 1999), that the number of friendships is correlated with positive affectivity and health (Moore & Isen, 1990), and that disconnection can result in despair and despondency (Lopez & Snyder, 2002). In both clinical settings as well as in life, though, these interpersonal connections require boundaries that serve to define personal space (Rand, 2002).
In psychotherapeutic settings, this personal space is known as the intersubjective field, which represents the space wherein the majority of verbal and nonverbal boundary negotiations occur; further, boundaries can be characterized according to three general categories:
Boundaries of propriety and space,
Verbal and energetic (Rand, 2002).
Further, within these categories, there are a number of different types of boundary styles; these are comprised of "strong, healthy boundaries, rigid, inflexible or distant boundaries and boundaries which are lacking in definition or are fused. Spatial, behavioral and verbal boundaries are the most commonly considered characteristics of boundaries" (Rand, p. 32). Because every treatment setting is unique, these different boundaries will always be further defined by each therapist and individual patient; nevertheless, all of these limits will come into play to some degree in terms of helping identify when "lines in the treatment sand" have been crossed and can serve to alert the practitioner to the need for some type of intervention to avoid unintended or even harmful outcomes (Holmes, 1998).
On the one hand, an effective therapeutic relationship absolutely demands some level of rapport and intimacy between therapist and patient; on the other hand, it is vitally important that the therapist maintain the aforesaid boundaries as these relationships evolve. In this regard, Andolphi and Angelo (1988) point out that, "The therapist is continually positioning himself at one pole of various triangles" (p. 241). These triangles are generally comprised of the relationships that are most influential in the patient's life at a given point in time, usually other family members and intimate partners; however, one of the unfortunate concomitants of the therapeutic relationship itself is a tendency for the patient to become inappropriately attracted to the clinician. In fact, there would seem to be a natural tendency for some patients to become overly involved and infatuated with their therapists (e.g., "I wish more of my relationships were like the one with my therapist") (Charman, 2004, p. 296).
Potential Third-Party Disruptors to an Effective Therapeutic Relationship.
Clearly, when outsiders interfere with the treatment process for whatever reason, the already fragile therapeutic relationship is jeopardized even further; however, anything that detracts from the effectiveness of therapeutic relationship must be viewed by the practitioner as an opportunity for identifying needed refinements or changes in treatment approach (Charman, 2004). Interferences in the therapeutic relationship can be caused by other family members who, although perhaps reluctant for the patient to initiate such treatment, subsequently desire to intervene in the treatment process after it has begun, particularly if the significant other has serious control issues at stake (Luepnitz, 1988).
In this regard, Sigmund Freud recognized early on that in some cases, some family members will resent the patient seeking outside assistance and will try to interfere with the treatment process:
No one who has any experience of the rifts which so often divide a family will, if he is an analyst, be surprised to find that the patient's relatives sometimes betray less interest in his recovery than in his remaining as he is. When, as so often, neurosis is related to conflicts between members of a family, the healthy party will not hesitate long in choosing between his own interest and the sick party's recovery (Freud, 1940/1964, pp. 172-73).
This is especially the case encountered by therapists treating recovering alcoholics (Carroll et al., 2000).
While interfering family members represent one sort of challenge for therapists, the significant other in a patient's life, particularly young ones, will frequently be even more difficult to prevent from disrupting the therapeutic relationship. For example, in his book, Adolescent Romantic Relations and Sexual Behavior: Theory, Research, and Practical Implications, Florsheim (2003) reports on the case of a 16-year-old girl who was referred to therapy due to fatigue and breathing problems. "We learned that the girl's 18-year-old boyfriend was about to join the army," he notes, "and the girl felt she could not continue living without him. Their relationship had lasted for more than 2 years. The boy was described as a caring person ready to help the girl in every aspect of her life" (p. 130). The patient's boyfriend was the major focus of her life and she reported not caring whether she had any other close friends; however, cases such as this where one partner uses coercive strategies to cause the other to submit are not easy to detect, because the couple may show a facade of a very close relationship (Florsheim, 2003).
Although these cases may be difficult to identify, particularly among adolescents, the author indicates that this is an important part of the treatment process because close partners, particularly young ones, are less willing to listen to an outsider's opinion because of their basic inability to separate from one another (Florsheim, 2003). Because of the shorter duration of adolescent romantic relationships, there is also the likelihood that one only will be referred for therapy rather than as a couple. "More commonly," Florsheim says, "one partner will be in therapy and the nature of her or his romantic relationship will emerge in the therapeutic sessions" (p. 130). If the partner who is not in treatment becomes jealous of this perceived increasingly close relationship and attempts to interfere with the therapeutic relationship, there will naturally be problems for all concerned (Florsheim, 2003). The therapeutic relationship with older adult patients may likewise be threatened by partners who do not expect any positive results from such therapy because of misinformation or past failed personal experiences of their own (Adam, Egeland, Korfmacher & Ogawa, 1997).
Steps to Take When the Therapeutic Relationship is Disrupted
Clinicians who are faced with the aforementioned types of disruptions to the therapeutic relationship have several alternatives available, but the focus should remain on improving the nature of the therapist-patient relationship in the process. The solution to such interruptions may be fairly straightforward and only involve a simple request to the offending party to cease such behaviors. For instance, "Difficulties in the therapeutic relationship are in some ways no different from the difficulties people experience in their 'ordinary' relationships," Flaskas and Perlesz (1996) report. If these disruptions are approached in a positive and forthright fashion, they can actually serve to improve the therapeutic relationship: "If engagement is understood as a process in therapy, not as an event," Flaskas and Perlesz advise, "it may be helpful in a number of ways" (p. 45). In other cases, though, resolution of the disruptive influence may not be so easy since family members or significant others may deeply resent the help-seeking behavior (Carroll et al., 2000). Therefore, depending on the nature of the disruption and the relationship of the disruptor to the patient, then, the therapist could elect to counsel the patient and/or the disrupting significant other individually or collectively that a successful treatment process depends on the ability of the therapist to conduct the patient's therapy unobstructed by outside influences except as they are specifically requested by the affected parties.
At any rate, whatever form they assume, Coale (1998) recommends thoroughly documenting all such disruptions with a complete explanation of the rationale used for any remedial course of action. This is an important consideration because the therapeutic relationship is, by its very nature, one in which both the therapist and…[continue]
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