In psychoanalysis the therapeutic relationship has been theorized to consist of three parts: the working alliance, transference/ countertransference, and the real relationship. [1] [2] [3] Evidence on each component's unique contribution to the outcome has been gathered, as well as evidence on the interaction between components. [4] In contrast to a social relationship, the focus of the therapeutic relationship is on the client's needs and goals. [5] Therapeutic Alliance / Working Alliance [ edit ] De Groef, J. (1999) Mental Handicaps: A Dark Continent. In De Groef, J. and Heinemann, E. (Eds), Psychoanalysis and Mental Handicap. Free Association Books. The working alliance forms the basis of the client–therapist (or therapist–supervisor) relationship, and includes the contract. It focuses on building a shared understanding and foundation, so that if the relationship falters, both parties can return to this stage and try to repair it.

Barrett-Lennard, G. T. (1962). Dimensions of therapist response as causal factors in therapeutic change. Psychological Monographs: General and Applied, 76, 1-33. The transferential/countertransferential relationship refers to the idea that we may remind a client of someone from their past, or vice versa, and the related feelings from the past may be transferred to the present, so affecting the therapeutic relationship. If this happens, it is important to explore the issue in supervision.

In all the complete CAT therapies which I undertook with people with learning disability there was an issue around the patient not making themselves heard, e.g. through the placation trap or through bottling up of feelings. In therapy, as exits from these procedures were found, the patient’s voice gradually became stronger. In listening to the patient’s new found voice, valuing it and bearing witness to the story that was told, (whilst at the same time remaining faithful to my own truth), I found that a more authentic connectedness based in real, lived experience developed between us. This seemed to be powerfully therapeutic. Humour also had a role in promoting the person-to-person relationship. With Michael we used buttons in each session to help him express his feelings and experience. Each time at the beginning of the session when he opened the tin of buttons he would comment “what no biscuits then.” It was a moment we both enjoyed.

Countertransference is described by Clarkson as what the therapist feels towards the patient. It is now generally understood to be a valuable therapeutic tool, which can give insight into the experience and responses of the patient. (Clarkson 1995) Different types of countertransference have been described by Ryle and Kerr (2002 p104) as personal countertransference (what the therapist brings to the encounter) and elicited countertransference (the reaction induced in the therapist by the patient) the latter being either identifying or reciprocating. In my work with people who have learning disability I found that in recognising, facing, accepting and appropriately communicating our limitations, woundedness and vulnerability, in person-to-person relationship, we were brought to a part of ourselves where we could meet together, as adults of equal value, at a deeply significant level and experience a creativity which was bigger and beyond ourselves. With it there came a sense of freeing bonds that had tied us both, allowing for spontaneity, movement and change. Often this was expressed in the diagrammatic representation of the work as the patient brought this alive with their use of colour and drawings. (For examples see King 2002). I understand this to be the transpersonal aspect of relationship. Consultant in Psychiatry of Learning Disability (retired). Currently clinical assistant with Salisbury Alcohol and Drug Advisory Service and CAT Therapist”.Psaila, C.L. and Crowley, V., 2006. Cognitive Analytic Therapy in People with Learning Disabilities: an Investigation into the Common Reciprocal Roles Found Within this Client Group. Reformulation, Winter, pp.5-11. Therapist empathic understanding: The therapist experiences an empathic understanding of the client's internal frame of reference. Accurate empathy on the part of the therapist helps the client believe the therapist's unconditional regard for them. This means that in therapy, you are bringing yourself in to the therapy room fully, you are the product that the client is paying for. Remember you are dealing in a real relationship, albeit a professional one. The Transpersonal Relationship

I found this aspect of the therapeutic relationship to be particularly important in work with people with learning disability. What was needed varied from patient to patient and also with different stages in therapy with the same patient. Early on in therapy I was often aware that I took a very explicit encouraging, accepting and nurturing role, taking responsibility for keeping harmony between us and allowing a degree of dependency. Reassurance was often a strong need at this point. I allowed Barbara to hold my hand when she talked about the time when she had been swamped by feelings of anger and hopelessness when she was first told as a child that she had a learning disability and that nothing could be done to help her. As well as reassurance she needed responsiveness from me to allow her to re-live that terrible moment in a different emotional climate. She needed patient encouragement and support whilst she found her own strength. As therapy progressed it was important to give her more space to try out her new-found strength and to become more emotionally independent. In relationship psychology, The Five Relationships states that to achieve an “Intersubjective Relationship”in counselling requires all three components to be met; The Intersubjective Relationship

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Symington, N. (1981) The Psychotherapy of a Subnormal Patient. British Journal of Medical Psychology, 54, 187-199 Therapist congruence, or genuineness: The therapist is congruent within the therapeutic relationship. The therapist is deeply involved, they are not 'acting' and they can draw on their own experiences (self-disclosure) to facilitate the relationship. In counselling we call this empathy and this is mirrored across many approaches such as person-centred and psychoanalytic theory. Carl Rodgers first said this was one of the necessary conditions required for successful therapy to take place, along with genuineness and unconditional positive regard, those were referred to as the core conditions.

Clarkson (1995) emphasises that these are aspects rather than stages in the relationship. However she describes a gradual development through the different aspects as therapy progresses. This was echoed in my work in which the development of the relationship seemed to evolve naturally, though at times I was aware of guiding or encouraging the process. The working alliance was established at the start and deepened as the therapy progressed. Sometimes it was threatened by transference and countertransference issues, which needed attention. Provision of the developmentally-needed relationship was required from early on. Working with these three aspects of the relationship seemed to allow for a stronger development of the person-to-person relationship in which could be found the transpersonal with all its creative energy. It was my experience that all of these aspects of relationship were grounded in the very ordinary stuff of being human. Clarkson (1995 p181) describes the transpersonal relationship as “the timeless facet of the psychotherapeutic relationship, which is impossible to describe, but refers to the spiritual dimension of the healing relationship.” She suggests a relationship “analagous to that of the marital pair” with its potential for space and fruitfulness, writing about the “sacred space.”

Moss, A., 2007. The Application of CAT to Working with People with Learning Disabilities. Reformulation, Summer, pp.20-27. Other Articles in the Same Issue Gelso, C.J. & Samstag, L.W. (2008). A Tripartite Model of the Therapeutic Relationship. Handbook of Counseling Psychology (4th ed.). (pp. 267-280). Rogers describes the core conditions of Empathy, Congruence and Unconditional positive regard, as the foundations of building an interpersonal alliance between two people. In terms of “The 5 relationship model,’ the therapist would use these conditions to facilitate the ongoing encounter with the client.