The elements of a therapeutic professional relationship

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The 'facilitating environment' and 'potential space'

Winnicott (1971) and Bion (1959) developed an in-depth understanding of the conditions necessary to develop a therapeutic encounter. Both developed their ideas from an understanding of the mother/infant relationship and applied it to the therapeutic encounter. Winnicott used the terms 'facilitating environment and good-enough mother'; Bion used 'the container and the contained' to refer to a particular quality and nature of the mother/infant relationship. In the last chapter the importance of the relationship between the mother and infant was discussed in the development of the secure base in the professional encounter. All these terms are used to describe the same qualities and as they are all used it is important for the counsellor to be familiar with their meaning. Winnicott's explorations of the mother and infant identified the 'good-enough' mother as having particular qualities - an attitude of being emotionally available, supportive, aware and understanding of the infant's vulnerability. Winnicott (1988) used the term 'holding' to refer to the actual physical holding of the infant by the mother and also the emotional holding of attunement in the mother's mind. That relationship could then become 'facilitating' for emotional growth and development. These ideas can be transferred to a professional consultation and the empathic understanding of a patient's anxiety. Winnicott emphasised that constructive relaxation could take place in the confidence of a living relationship. Further a well-timed interpretation of correct understanding 'gives a sense of being held, that is more real than if a real holding had taken place'. However, he points out how this can be interfered with if there is anxiety in the caregiver.

The term 'potential space' is related to the 'facilitating environment' and is the interactional space created within the relationship. It is a shared space where the conversation takes place and an understanding of each other can be achieved. It refers to the potential for exploration, thought and creativity to develop when there is a degree of confidence, trust, interest and reliability in the relationship. Winnicott quotes the importance of the capacity of 'if I were in your shoes ...' and in so doing is pointing out that the essential ingredient in establishing a 'facilitating environment' with 'potential space' is empathy.

In a similar way, Bion (1959) also explored the mother/infant relationship and applied it to the professional relationship. There are however some additional ideas which relate to what happens as a result of the mother being attuned to the infant's vulnerable, anxious self. Bion used the terms 'contained' by the 'container' to describe the process of anxiety being understood (contained), by the container (the mother). More importantly, the mother is capable of transforming the anxious or angry negative emotions of the infant and giving them back in a positive form. In everyday life this happens when a mother is heard lovingly saying to her screaming infant, 'Oh, dear you are so upset, you are tired .' In the professional relationship the terms refer to the ability of the counsellor to tolerate negative emotions, to be able to internally process them and transform them into positive feelings of empathy, concern and compassion. In practice, the counsellor is not disturbed by the patient's high anxiety, but understands the fear, is able to tolerate it and gently and compassionately conveys that sentiment. In a more contractual language the counsellor and patient have to set up a working alliance.

The working alliance

This term refers to the necessity for the counsellor and patient to work together to complete the agreed tasks. The ease or difficulty of forming an alliance is related to the attachment pattern of the patient. The counsellor recognises the different attachment patterns by listening to the patient's language, tracking the content and meaning, and assessing the patient's style of handling their story and emotions. These factors help the counsellor determine what adjustments need to be made to create an effective professional relationship. The counsellor's sensitivity to the individual's style is a determining factor in development of a working alliance. Bordin (1982) considers that there are three components to the working alliance: a consensus between the counsellor and patient on the goals of the encounter; an agreement on the topics and number of meetings to address how the goal is achieved; and, most importantly, the development of a strong affective bond between the professional and patient.

The co-construction of purpose of an interview with the definition of roles

A natural corollary to the working alliance is the idea of the co-construction of the purpose of the interview where the counsellor and patient jointly agree on the purpose of the interview. This usually happens at the beginning of an interview with the counsellor exploring who is asking what question. The following two examples demonstrate different styles of clarifying the purpose of the consultation.

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