1. THE THERAPEUTIC RELATIONSHIP WITHIN CLINICAL SOCIAL WORK PRACTICE SOW6425 Professor Nan Van Den Bergh, PhD, LCSW

2. FEATURES OF THE SOCIAL WORKER’S MANAGEMENT OF THE CLINICAL RELATIONSHIP Attention to: Transference Countertransference Boundaries Sustainment Modeling Balancing support and demand behaviors

3. 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

4. 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

5. 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)

6. 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

7. 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

8. 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)

9. 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

10. 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

11. 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.

12. 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?

13. 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?

14. 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

15. 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.

16. Benefits to The Social Worker of Clear Boundari es 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

17. 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

18. 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

19. 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

20. 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

21. 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%)

22. Curative Factors in Practice (cont.) Carkoff and Truax: Predictors to client retention in treatment: –Empathy –Congruence –Genuineness