Compare and contrast the models of therapeutic relationship

The importance of an effective therapeutic relationship in successful psychotherapy is without question and can be traced back to the most fundamental aspects of a ‘relationship’ in society. Indeed, one of the great determinants of social well-being and happiness stems from the ability to form close relationships with others, illustrated by the concept of ‘support networks’ as a therapeutic structure. The patient-physician relationship is a part of this therapeutic support network, perhaps even a compensatory mechanism for the perceived decline in religious and moral relationships entered into in the modern age. Upon exploration of the interaction between physician/therapist and patient it would appear that several different methodological approaches are practiced, varying according to the intended aim of the therapeutic relationship and the intrinsic vicissitudes evident in the ‘presenting complaint’. Two well known and utilised views of the therapeutic relationship include the transference/countertransference model and the reparative model, both of which adopt different methods in order to analyse and explore the pertinent issues of the therapeutic requirement. This paper will provide an overview of the therapeutic relationship in modern practice, particularly through comparison and contrast of these models, providing examples of effective therapeutic application. The similarities and differences between the models will be discussed and appropriately summarised.

The Therapeutic Relationship

When considering the essential components to a successful therapeutic partnership, deconstruction of the motivations of the therapist is required in order to define the dynamics which may emerge, as inevitably the patient has a clear role in the partnership, ‘…to use the analyst not only to resolve them, but as a receptacle for his pent-up feelings’ [1] . One of the key aspects of the role of the therapist should be that they enter into the relationship on a voluntary basis and strive to effect a working relationship, by whatever means or model they feel most appropriate. Indeed, it has been suggested that the particular choice in model does not influence the outcome of therapy significantly, but rather the relationship formed is a more important determinant of success [2] . In spite of this a number of different techniques are utilised to various degrees by psychotherapists, adapted to suit particular problems. Clarkson (1990) provides an overview of these models, identifying five major examples: the working alliance; the transference/ countertransference relationship; the reparative/ developmentally needed relationship; the I-You relationship; and, the transpersonal relationship [3] . In this paper the transference/countertransference and the reparative will be discussed in detail.

Overview of Models

The transference/countertransference model is based on the concept of transference, which is an important idea in psychodynamic theory, as relevant today as it was a century ago. Essentially, transference is when feelings present from childhood re-emerge and become a means of interpreting current situations. These feelings are often representative of experiences with parental figures from childhood [4] . In the therapeutic domain, projection of these wishes and/or fears onto the therapeutic relationship can take two different forms: proactive and reactive. Proactive transference refers to the past experiences which the patient brings to the relationship, where as reactive transference is the reaction of the patient to ideas introduced by the therapist. This leads to the definition of countertransference, which is essentially the elements of the relationship introduced by the therapist (and can also be proactive or reactive) [5] . Both elements must be addressed for the relationship to work.

A commonly cited example of transference is the imposition of a parental figure onto the therapist. Something may have triggered this phenomenon, such as habits or appearance of the therapist, resulting in emotional and psychological need transference to the present situation [6] . This concept was initially identified by Freud, but was not greatly elaborated upon: he considered that it may be a barrier to psychotherapeutic success initially. However, countertransference enables the therapist to better understand the relationship and enables greater control over their own feelings. Of course, the therapist is a human being with past experiences and emotional perspectives and therefore brings a certain degree of those exposures to the relationship. Establishing how the patient may be attempting to elicit responses from the therapist, is one of the key features of countertransference understanding [7] .

The goal of this intervention is to establish the underlying reasons for the transference and to abut those inappropriate responses with a reaction that is appropriate to the proposed therapeutic dynamic i.e. the actual situation. It is important to note that although it is an important process, and underlies a large degree of psychoanalytical theory, it is not an essential step in ‘curing’ the patient [8] . It should certainly not be forcibly introduced into a relationship. Rather transference should be invited as part of the analytical process and then gradually disassembled through interpretation [9] .

The second model is the reparative relationship, which adopts a contrasting approach to the resolution of patient issues and concerns. The basis of this approach is that the therapist intentionally aims to correct or repair a parental relationship or action when there is evidence for abuse, deficiencies or over-protection in the initial parenting. Those elements which were absent in that initial parental relationship are supplied by the psychotherapist in an attempt to compensate for the previous actions. Another term for this model is the developmentally needed relationship, which is an accurate description in a lot of cases, as there is a perceived need in the present that was lacking in childhood [10] . Typically, it can be observed that the adult (patient) regresses i.e. reverts to a form of thinking more suited to earlier stages of their development, when such a need arises, defining the role of the therapist as the mediator of the regression through reparation [11] .

A variety of well known psychoanalysts have adopted this approach in response to adults who were mistreated or under-loved as children. Sechehaye and Ferenczi both extended the parameters of this relationship to the point that they would take the patient on outings, or let them live at home with them for extended periods of time [12] . Certainly, a dynamic approach is adopted by many psychotherapists who utilise this model, though perhaps not to the same extremes.

Comparison of models

Having explored the intricacies of the two models, there are some noticeable differences which are immediately identifiable. Firstly, the approach to the patient is quite different: where as in the transference/ countertransference model there is a general consensus that the therapist should remain impartial in their responses, quite the opposite is true in the reparative model. A good example of this is illustrated by Clarkson, who uses the therapist response to the patient-posed question ‘How are you?’, often the first notable interaction in a therapeutic session, as a means of contrasting these models. For instance, the therapist would either react silently or by querying the underlying reasons for wishing to know why the patient is concerned with the therapists well being in the transference model. In the reparative model, the therapist will base their response on the perceived developmental need of the patient: if they were encouraged not to demonstrate their care towards their parent as a child, the therapist might respond and thank them for their interest in their well-being [13] .

The answer to this simple question is a microcosm for subsequent interactions in the session, or sessions, with the general notion that in the reparative process an intentionally structured set of responses are offered to satisfy the developmental need, while in the transference method an opposing view is offered which does not conform to the child-parent interaction that may be desired by the patient. Therefore it can be said that the role of the therapist is in contrast: one method sees the therapist as a parental figure (or substitute in extreme examples), and the other sees the therapist acting as an ‘adult’ rather than a ‘parent’ [14] . Or put another way, that the therapist does not indulge in the child-parent interaction desired by the patient. Indeed, this would seem to reflect an elevated level of dynamism on behalf of the therapist in the reparative model.

The approach adopted by the therapist is very different in these models, which perhaps implies that there is a difference in intended therapeutic outcome or ‘end-point’. Of course, as mentioned earlier, there is evidence to suggest that it is the therapeutic relationship itself which determines the effectiveness of intervention, rather than the model used, however it is clear that the ‘means to an end’ are quite different in these examples. Firstly, in the transference model there is an emphasis on the analytical power of the process, rather than any notion of perceived ‘cure’. If performed correctly, exposure of the transferences and their underlying causes lead to analysis and remedy. However, when one considers the methods utilised in the reparative model it would seem that the purpose of intervention is to elicit change directly. Therefore, it can be said, that the reparative model, rather than acting as an analytical tool per se, acts as a pivot for change by addressing the inadequacies/deficiencies in the patient’s past. Interestingly, this raises another distinction, where it is suggested that the transference relationship is ‘past-focused’ and the developmentally needed relationship ‘future-focused’ [15] . Clearly, this is an over-simplification, but essentially when a patient undergoes reparation there is an emphasis on future change which compensates for past occurrences.

Despite these differences, there are distinct features present in both models. For example, the nature of transference is a core component of the reparative model as there is a re-living of the past in the present. In the reparative model the repetition of the past is altered in such a way so that traumatic incidents are not constantly revisited, rather by modifying an aspect of the past (i.e. the therapist adopting a parental role) the experience acts as a platform for healing. However, it can be argued that the reparative approach represents nothing but an idealised version of the transference relationship, hence a lack of recognition of the model in some important psychotherapy works [16] . Therefore the degree of similarity can transform the reparative approach into an extension of transference. Contemporary thought still maintains a distinction between the models however, based on the marked differences as discussed previously.

Conclusion

In summary, the therapeutic relationship is a vital part of the therapeutic process. A number of different approaches are available to the therapist, which facilitate contrasting interactions with the patient, unique to their issues. In transference/countertransference the client imposes aspects of their childhood onto the therapeutic relationship, forcing the therapist to adapt their responses in order to challenge this behaviour. Once the behaviour has been identified then further analysis will enable resolution. This contrasts to the reparative relationship model, in which the therapist seeks to correct parental inadequacies or overprotectiveness by altering their responses accordingly. The client will project certain behaviours and feelings onto the therapeutic relationship and the therapist must guide this regression, in order to facilitate future behavioural change. In spite of these differences, it is clear that whichever model is utilised, provided it is done effectively, the outcomes should not differ greatly. The increased responsibility and effort on behalf of the therapist in the reparative model, may however limit its use in practice.