5 Working with the therapeutic relationship
INTRODUCTION
The relationship between patient and therapist is unique. A therapeutic relationship has in its very existence a commitment to the well-being of one person, the patient. Moursand and Erskine (2003) suggest that the business of establishing and maintaining a therapeutic relationship requires a delicate balance, involved but not demanding, vulnerable but not weak, willing to share self-awareness but not imposing that self-awareness onto the patient. In relationship hypnotherapy, the therapist enters consciously into the relationship with the patient and creates a safe space in which the relationship itself supports and encourages change.
The late Milton H. Erickson is renowned as a master hypnotist and as a therapist without par. Lynn and Hallquist (2004) argue that Eriksson’s clinical proficiency was as attributable to his ability to forge strong therapeutic relationships as to his use of particular hypnotic techniques. Erikson’s utilization approach enabled him to gain the cooperation and trust of many of his clients and to establish a strong therapeutic alliance. This in turn enhanced rapport, which is essential for optimizing hypnotic responsiveness (Lynn & Hallquist 2004). Indeed, Erickson was so successful as a therapist due to many of his creative techniques being effective in establishing a strong working alliance. Nuttall (2002) describes the working alliance as the understanding that patient and therapist have in order to cooperate in the therapeutic process. It is that element of the relationship, established outside all others, that enables two individuals to work together.
COMMON FACTORS
Common factors such as empathy, warmth and the therapeutic relationship have been shown to correlate more highly with patient outcome than specialized treatment interventions. The common factors most frequently studied have been person-centred facilitative conditions (empathy, warmth, congruence) and the therapeutic alliance (Lambert & Barley 2001). Decades of research indicate the provision of therapy, including hypnotherapy, is an interpersonal process in which a main curative component is the nature of the therapeutic relationship (Patterson 1985, Bird 1993, Lambert & Barley 2001). Patients often attribute their positive therapy outcome to the personal attributes of their therapist (Lazarus 1971, Bird 1993, Safran 1993, Howe 1999). Patients who felt their therapy was successful described their therapist as warm, attentive, interested, understanding and respectful (Howe 1999, Lambert & Barley 2001). Similarly, in a large comprehensive review of over 2000 studies since 1950, Orlinsky et al (1994) identified several therapist variables and behaviours which have consistently been shown to have a positive impact on treatment outcome. Key factors such as therapist credibility, skill, empathic understanding and affirmation of the patient’s problems, and directing the patient’s attention to the affective experience, were related to successful treatment.
POSITIVE EXPECTANCY EFFECTS
The importance of positive expectancy (the patient’s beliefs, motivations and attitudes) cannot be emphasized enough. Kirsch (1990), based on clear empirical evidence, suggests that a person’s positive expectancy that he or she is likely to produce a given behaviour (e.g. positive outcomes in hypnotherapy) is the single best predictor of that behaviour. Spanos and Coe (1992) report that the more the patient’s expectations are in agreement with the therapist’s, the more likely it is that they will be good hypnotic subjects. However, if a patient is unwilling to cooperate, he or she cannot be hypnotized; the potential hypnotic patient must be motivated to enter the relationship. The closer the patient’s expectations for their conduct match the requests of the therapist, the more likely they are to be responsive. Spanos and Coe (1992) highlight that coupled with motivational factors are certain abilities that appear to be useful in hypnosis (i.e. concentration and absorbed imagining). In keeping with the concept of expectancy, Barrios (1970) viewed the hypnotic induction as an effective method for establishing confidence and belief in the therapist. In addition, a strong personal relationship should develop wherein the therapists’ words should be more effective in bringing about constructive change.
Horvarth and Symonds (1991: 366), reporting on a meta analysis of 90 independent clinical investigations, conclude that: ‘It is likely that a little over half of the beneficial effects of psychotherapy, for example, accounted for in previous meta-analysis, are linked to the quality of the therapeutic alliance’. Research undertaken by Lambert and Okiishi (1997) estimated that only 15% of change can be attributed to specific techniques (with some exceptions); the other 85% of a client’s improvement can be attributed to factors such as the therapeutic relationship. Horvarth and Bedi’s (2002) review on the literature on the therapeutic alliance concludes that establishing a strong alliance is crucial to its ultimate success. Horvarth and Bedi (2002) go on to discuss a number of therapist variables that appear to be related to an effective therapeutic alliance, included are: communication skills, experience and training, personality and intrapersonal process, and collaboration with the client. There are things identified that can be specified about creating and utilizing a good therapeutic relationship and many of these things can be taught directly.
UTILIZATION APPROACH
Considerable evidence indicates that rapport is also important, especially in optimizing hypnotic responsiveness (Lynn & Hallquist 2004). Erickson’s utilization approach enabled him to gain the cooperation and trust of many of his clients and to establish a rapid and strong therapeutic alliance (Hayley 1973). In this respect, the therapist utilizes the patient’s ongoing behaviour, perceptions, and attitudes in facilitating therapeutic change. Patients are not asked to conform to the therapist’s mode of interaction; rather, their behaviour is accepted and utilized in the treatment process. This utilization process would include direct and indirect suggestions. Erickson et al (1976) noted that indirect suggestion permits the patient’s individuality, previous life experience and unique potential to become manifest. Hammond (1984) noted that Erickson relied heavily on indirect suggestion in the latter part of his career. He observed that indirection allowed him to show respect for his patients by not directly challenging them to do what the conscious mind, for whatever reason, would not do. Lankton and Lankton (1983) indicated that indirection is the basis for the therapeutic use of metaphors, and stories, because they allow patients to make meaning relevant for them and to explore their potential to facilitate new responses.
Erickson created a strong therapeutic alliance in the way he displayed respect for his client’s beliefs. He did not impose his position and perspective on the client; rather he paid close attention to the client’s reality. He was a master of rapport building technique, using what the client said or did as a starting place and built on it to establish and preserve positive treatment expectancies and rapport. Erickson capitalized on the positive expectations of his clients regarding hypnosis. Erickson often defined his work with clients as ‘hypnotic’ in nature, whether or not he used a formal induction, or whether his clients discussed their experiences in terms of trance or ‘hypnosis’. There is substantial research support for the idea that simply labelling procedures as ‘hypnotic’ can enhance treatment outcomes (Kirsch 1997).
A good therapeutic relationship increases the power expectancy of a hypnotic intervention and the client’s willingness to be affected by it, and we agree with Gehrie (1999: 87) that: ‘The relationship is not the treatment but the relationship makes the treatment possible if it is properly managed’.
THE TRAVELLING COMPANION
Ebell (2008) regards the therapeutic alliance as a joint venture, one in which the therapist and patient join in a cooperative search for potential changes. The patient examines his or her resources, as well as relevant obstacles and conflicts. Short et al (2005) reported how Erickson clearly placed ‘hypnotherapy’ as an adjunct to other concepts. His emphasis was on the inner resources of the patient and not the actions of the therapist. He maintained that people have more potential and resources than they realize, and hypnosis has the ability to evoke the hidden potential of the client.
The term ‘travelling companion’ has been voiced by Ebell (2008) as the position that a therapist can take when working with patients who are chronically ill. The patient and therapist embark as travelling companions on a journey together through entirely uncharted territories. The onset of the journey involves paying close attention to the patient’s explanation of his or her subjective experience with suffering. Ebell (2008) goes on to suggest that one of the most potent ways to develop the relationship alliance, is to use the patient’s language and language pattern. In the practice of hypnosis, encouraging patients to re-examine their experiences and explanations can, in itself, prove instrumental in the promotion of change (Ebell 2008).
BUILDING THE THERAPEUTIC ALLIANCE
Establishing a strong therapeutic alliance in the early stages of hypnotherapy is crucial to its ultimate success. Lynn and Hallquist (2004) describe how Erickson, in his initial contact with patients, would acknowledge to them that there were some things that they might not want to share, and he encouraged them to withhold such information. However, as the patients disclosed one thing after another, they would begin to withhold less and less and to ultimately tell Erickson what they had set out not to mention (Hayley 1985). This rapport-building technique illustrates Erickson’s skills in encouraging the client’s narrative and in developing a therapeutic alliance.
Empathy
Key to the building of a therapeutic alliance is empathy. The skill of empathic understanding is the foundation store for the hypnotherapy technique that the therapist may use. The most basic ingredient in the empathic process is attending: listening to what the patient says, noticing what they do, and being fully and actively involved in the process. In our attempt to understand the patient, we must take care not to make the patient some ‘out there’ thing, totally separate and distinct from ourselves (Moursand & Erskine 2003). We too are part of the equation; our understanding of the patient is impacted by our own history and expectations. Tansy and Burke (1989) suggest we listen from within; our own responses are the guide we use to interpret and give meaning to what the patient says and does. As Bascal (1997: 670) puts it, ‘Empathy effectively constitutes a reading of the analyst’s own affects and … when we ‘emphasize’ we are always interpreting the effect of our subjectivity of what the patient feels, believes, or does’.
Empathy in this context underpins Eriksonian approaches, or, synonymously, utilization approaches (Erickson et al 1976). Hypnosis in this view is a result of a focused and meaningful reaction between therapist and patient. The therapist to be successful must be responsive to the needs of the patient and tailor his or her approach to those needs, if the patient is going to be at all responsive to the possibilities of change. A patient’s behaviour and feelings are fed back to him or her verbally/non-verbally, thereby creating a sense in the patient of being understood, which is the essence of rapport (Yapko 2003). Hypnosis is considered a natural outcome of a relationship where each participant is responsive to the sensitive following and leading of the other. Yapko (2003) encourages the therapist to actively refrain from the undesirable approach of imposing their beliefs and values on to their patient. The interactional view emphasizes responsiveness and respect for the patient, which is ideal in the hypnotherapeutic context. Lynn and Hallquist (2004: 64) go as far as to suggest that a skilled practitioner of hypnosis lacking familiarity with Erikson’s approach to hypnosis is akin to a physicist lacking familiarity with quantum mechanics.
When exploring the practice of hypnosis, it is as a tool and as such it should not stand alone. Therapists, therefore, incorporating hypnotherapy into their practice, should not solely rely on their skill and confidence in mastering the techniques, but also on the establishment of a strong therapeutic alliance. This view is supported by others from the field of hypnotherapy. Yapko (1992) suggests that many clinicians today adopt the view that clinical hypnosis is not a therapy in its own right, but merely a vehicle or tool for delivering information, increasing client responsiveness and to facilitate experiential work with clients. More recently, the APA’s Division of Psychological Hypnosis (1999) (Yapko 2001) also stated that hypnosis is not a therapy but a procedure to facilitate therapy. They go on to say that it is not a treatment in itself because the training in hypnosis is not sufficient for the conduct of therapy.
When reflecting on the developing relationship within hypnotherapy, Yapko (2001) urges us to be aware of the following important distinction; suggesting that the practitioner should consider whether they are actually ‘doing hypnosis’ vs ‘being hypnotic.’ He goes on to say that someone who reads a script to a client may be doing hypnosis, whereas he suggests that being hypnotic is:
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