THE THERAPEUTIC RELATIONSHIP WITHIN CLINICAL SOCIAL WORK

PRACTICE

SOW6425

Professor Nan Van Den Bergh, PhD, LCSW

FEATURES OF THE SOCIAL WORKER’S MANAGEMENT OF THE CLINICAL RELATIONSHIP

Attention to:

Transference

Countertransference

Boundaries

Sustainment

Modeling

Balancing support and demand behaviors

SUSTAINMENT

• What the Worker Does

• Listens actively and sympathetically

• Conveys a continuing attitude of good will

• Demonstrates consistency in the relationship

• Directly expresses confidence or esteem

• Non-verbally communicates interest, attentiveness

• Realistically reassures the client about potential for goal

achievement

• Realistically encourages the client to persist

• Possibly offers environmental support

What This Technique Does for the Client

•Promotes a confiding relationship

•Instills a sense of the worker’s competence and caring

•Provides an antidote to alienation

•Enhances morale and the determination to persist

•Inspires and maintains the expectation of help

•Creates a setting where confrontation can effectively take place

SELF-DISCLOSURE

•Defined as sharing with the client opinions, thoughts, feelings, reactions to the client, and personal experiences

•Self-involving disclosure - Commenting on the process of the worker/client interactions

•Personal disclosure - Sharing a personal experience that may be relevant to the work being done (this can be risky)

TRANSFERENCE

• Defined as all client reactions, conscious and unconscious, to the social worker

• These include reactions based on experiences with similar types of people in the client’s past, and on here-and-now characteristics of the social worker

Positive vs. Negative Transference

• Positive - the client is attracted to the practitioner, which can facilitate the engagement process

• Negative - characterized by such feelings as anger, distrust, or fear that impede the client’s participation in the intervention

• Positive transference does not necessarily facilitate the client’s achievement of goals

• Negative transference does not necessarily prevent goal achievement

COUNTERTRANSFERENCE

Specific and generally conscious attitudes and

tendencies that a social worker has about a range of clients

Ex.: being drawn to working with children or having an aversion to older adults)

Common Signs of Countertransference Reactions

• Dreading or eagerly anticipating a client

• Differing promptness in responding to client’s needs

• Thinking excessively about a client during non-work hours

• Having trouble understanding a client’s problems

• Being bored with a client

• Feeling angry with a client for nonspecific reasons

• Being unduly impressed with a client

• Feeling defensive or hurt by a client’s criticisms

• Performing tasks for clients that they are capable of doing for

themselves

• Feeling uncomfortable about discussing certain topics with a

client

Managing Countertransference Reactions

• Be aware of your emotional and physical needs as much as possible– Be wary of obtaining too much personal gratification at the

expense of a client

• Understand the client’s cultural and community standards of behavior, so as to appropriately assess behavior in those contexts– Ex.: Nonverbal communication cues or silence. Is it culturally

syntonic?

• When appropriate, selectively use self-disclosure with the client to process countertransference feelings. – It is important for some clients to learn that negative feelings

can be contained and processed

Boundaries

• Boundaries are the generally unspoken rules that we internalize about the physical and emotional limits of our relationships with other people.

• They protect our privacy and reflect our individuality.

• We differentially construct boundaries to facilitate our desire to be close to, or separate from, others.

• Each person’s boundaries are unique; we covertly communicate them to suit our assumptions and intentions about particular relationships.

Aspects of Boundaries

• Contact time: How much time is appropriate to spend in the company of the client?

• Difference if face to face or via phone?

• Types of information: What is the appropriate range of topics to discuss with the client?

• social topics, politics, religion, sex?

• Physical closeness/proximity: • Seating distance and arrangement of chairs?

• Physical contact allowed?

• Range of non-verbal communications is appropriate?

Aspects of Boundaries (cont.)

• Territory. To which of my environmental spaces does the client have access? – Is he or she restricted from others? – Can we only meet at the agency? – What about her home, community settings, recreational

settings?

• Emotional space. To what extent am I willing to share my feelings about sensitive topics with the client? – About what topics will we be expected to share feelings?

Benefits to Clients of Clear Boundaries

• A relationship in which the client feels affirmed and respected

• A predictable environment in which the client is likely to feel more comfortable sharing personal information

• A basis from which to determine whether and when the social worker can cross certain boundaries.

• Boundary crossing implies a conscious and appropriate effort to “adjust” the therapeutic relationship toward greater intimacy– Ex: Attend a graduation,marriage or award celebration

Benefits to Clients of Clear Boundaries (cont.)

• Boundary violation is an inappropriate entry into a person’s privacy and space.– If it is not pertinent, it is impertinent

• For some clients the external structure produced by clear boundaries helps to maintain a clearer internal ego structure.

Benefits to The Social Worker of Clear Boundaries

• Role clarity regarding the range and limits of clinical activities

• A basis from which to make decisions about how and when to cross physical or psychological boundaries

• A means of preventing burnout by avoiding role overload

• Physical safety, when territorial boundaries are maintained

Warning Signs of Possible Boundary Violations

• Intrusion into the client’s territory (physical or geographic)

• Some types of self-disclosure– Ex.: How will what you share benefit the client?

– What is your motivation for self-disclosure?

• Being overly “social” with clients

• Investigating certain details of clients’ personal lives

• Sharing information about a client with an outside party

• Loaning, trading, or selling items to a client

• Accepting or giving gifts

• Fluid boundaries between home and work environments may

indicate that the social worker is at-risk for job burnout

Factors To Consider When Assessing One’s Own Boundary Conduct

• The functioning level of the client – His or her ability to use good judgment

• The client’s history in relationships– Patterns of behavior and judgment

• The history of this particular client/worker relationship– What patterns of interaction have been established– Will a boundary crossing activity by the social worker be growth-

enhancing or a setback for the client?

• Cultural norms of both the worker and client.

• Legal liabilities

• The NASW Code of Ethics

Managing Boundary Dilemmas

• Set clear boundaries with clients at the beginning of a working alliance

• Clarify boundaries with the client over time, as they will change

• Consider the preservation of the client’s privacy to be a major guiding value.

• Secure the client’s informed consent for all service activities

• Use peer consulation and formal supervision routinely

Curative Factors in All Practice Interventions

• Perception of practitioner, by client, as competent and caring– Therapeutic alliance

• “Special setting” of seeking therapy promotes client’s sense of safety and expectation of help

• Interventions and procedures are based on an rationale which is understandable to the client – They include an optimistic view of human nature.

• Practitioner is “congruent” with client’s perception of problem and world view– Practitioner’s ongoing attention too client’s frame of reference

• Client is given new opportunities for enhancing mastery

Curative Factors in Practice (cont.)

• Miller, Duncan and Hubble (2005):– Client characteristics associated with clinical

outcome (account for 40% of outcome):• Nature of the problem• Motivation• Participation

– Quality of therapeutic alliance (30%)– Guiding theory or model (15%)– Placebo effect (15%)

Curative Factors in Practice (cont.)

• Carkoff and Truax: Predictors to client retention in treatment:

– Empathy– Congruence– Genuineness