Over the last 15 years or so, relational perspectives have had a significant impact across the field of psychotherapy. However, the wider its increasing influence has spread, the less clear it has become what we actually mean by ‘relational’. The default common denominator would be the recognition that in therapy it's the relationship between client and therapist that matters, and that the quality of that relationship is a significant indicator of outcome.
The skin-deep apparent consensus around relationality
However, whilst there is quite a lot of agreement that the therapeutic relationship matters, this apparent consensus breaks down at the first hurdle: there is no such level of agreement as to what actually constitutes quality of relationship. On the contrary: there is a tendency for the traditional approaches to define and interpret ‘quality of relationship’ either within their own frame of reference only, or within a very limited range of options. Because of this tendency of the traditional approaches to take their own paradigm of relating for granted and to absolutise and privilege it, it is not generally accepted that 100 years of psychotherapy have given us a diversity of distinct notions what kind of relating is to be considered ‘therapeutic’.
As Petruska Clarkson - in her seminal contribution in the early 1990's - has asserted: there are now in existence different - and quite contradictory - kinds of therapeutic relatedness, or to say it more simply: we find different - and quite divergent - relational spaces across the therapeutic traditions and approaches. Unless we take into account these different notions of relatedness - or in Clarkson’s terms: the different relational modalities championed by the various traditions and perspectives - what we mean by ‘relational’ will remain confused and confusing. It clearly means very different things to different therapists, without - however - these differences being acknowledged or investigated.
Relational as defined by its supposed opposite: what do we mean by 'non-relational'?
As a byproduct of these developments and unacknowledged divergences, and partly due to its own success, the term ‘relational’ has largely lost its meaning. It now only retains some substance in contrast to its supposed opposite: the current consensus for what we might mean by ‘non-relational’ would be some quasi-medical treatment - in the current situation in the UK we would be thinking of CBT and associated approaches. However, most CBT therapists would feel sorely misunderstood in being categorised like that, as they tend to emphasise the collaborative nature of the relationship with their clients, which - in their frame of reference - is being relational (and there is now, of course, a new subcategory of CBT being developed, i.e. ‘relational CBT’). This is just one illustration that we do not have a cross-modality shared understanding of the term ‘relational’. Unless we take into account the underlying paradigms and preconceptions and what each of the traditional approaches means by ‘therapeutic relating’, we are talking at cross purposes.
And many medical professionals are rightly riled by being categorised as the supposed antithesis of relationality and by the idea that they are being 'non-relational'. We only have to think of a traditional family doctor and their very strong relatedness to their patients and their families (within an implicitly assumed bio-psycho-social framework and in an unbroken relational attachment often over decades), to notice that to categorise and construct medical practitioners in opposition to relationality is oversimplifying, misleading and unhelpful.
So we can't even afford to define what is 'relational' by its supposed 'non-relational' medical model opposite. To exclude medical model relating from the field of psychology - as Clarkson herself was doing by default (as she did not include it in her list of relational modalities) - and thus invalidating it as form of psychotherapeutic relatedness, perpetuates the traditional dichotomies and adds to the confusion.
‘One-person psychology’ versus ‘two-person psychology’
A well-established notion that is supposed to bring some clarity to the situation is Stark’s distinction between ‘one-person psychology’ and ‘two-person psychology’ (with a third, somewhat tongue-in-cheek transitional option of ‘one-and-a-half-person psychology’ in between). Whether these distinctions do indeed help to clarify matters depends largely on our underlying attitude in using them:
- when we are using these terms in an antagonistic, polarising way (typically to establish the supposed superiority of the all-new two-person over the ‘old-hat’ classical one-person perspective), they don’t seem to mean much more than ‘relational = modern = good’ versus ‘non-relational = classical = out of fashion’.
- there is a way of using these terms (and Stark occasionally supports this usage) where all three kinds of therapeutic relatedness (‘one-person’, ‘one-and-a-half-person, and ‘two-person psychology’) can be seen as a valid aspects of what actually happens in the therapeutic relationship. When we can appreciate these notions in such an integrative and embracing way as mutually complementary, we can use them very productively to enquire into and investigate the relational process
(I have described Stark's ambiguity between these two positions in a detailed critique of her introductory chapter to her seminal 1999 book 'Modes of Therapeutic Action').
Expanding Clarkson's model of 'relational modalities' into Michael's 'diamond model'
As I have tried to suggest in that critique, we can develop a more therapeutically useful and detailed idea of relationality by combining Clarkson’s model with Gomez's 'alongside' and 'opposite' positions and Stark’s three kinds of therapeutic relatedness - giving us six relational modalities all operating in the contested force field of the therapeutic relationship. This way of using relational perspectives (summarised in what I call my ‘diamond model’) can become quite fine-grained and helpful in supervision and in reflecting on the therapeutic process generally. It is based upon not only validating a diversity of relational modalities as existing, but upon recognising that each modality can have therapeutic as well as counter-therapeutic effects, depending on context. All therapeutic theories, tools, techniques, ideas as well as relational modalities can become vehicles for enactment - none of them are immune against that possibility.
Defining relationality through the notion of 'enactment'
The diamond model conceives of Clarkson's modalities not as sequential treatment options, but as all simultaneously present in the intersubjective forcefield of the therapeutic relationship. This forcefield is structured primarily around the rupture-and-repair cycles occurring in the attachment bond between client and therapist, within a fundamental tension between working alliance on the one hand and transference-countertransference enactment on the other (this is based on my suggestion that we can think of the development of the field in terms of 3 relational revolutions, the first being Freud's re-formulation of the transference from an obstacle to the royal road into the wounding; the second being the countertransference revolution which generated a similar re-frame of what was previously considered the therapist's stuff as an obstacle into another royal road; and I am suggesting that the notion of enactment constitutes another quantum leap which re-frames what was previously considered the central danger and obstacle, i.e. countertransference enactment, into a two-person psychology notion of therapeutic action via the transformation of enactment (I have been suggesting this for many years now, but other people are beginning to say more or less the same thing, see Michael Varga: Analysis of Transference as Transformation of Enactment).
Enactment (and its possible transformation) is the key notion capable of capturing the essence of relationality and lending it substance. By recognising enactment as the paradoxical heart of the therapeutic process (when it comes to the transformation of unconsciously engrained characterological patterns), a differentiated and sophisticated appreciation of the diversity of relational modalities - always already present in the relational space - becomes possible. Rather than comparing and contrasting ideas about relationality as attitudes, strategies or stances chosen by the therapist intentionally (and then used to play different therapeutic approaches off against each other as better or superior to others), we can use our experience of the relational modalities present in the ‘here and now’ as a perceptive and interpretive tool, as a map of the forces operating within the field, as a meta-process of reflection, giving us access to the unconscious forces influencing the therapeutic relationship.
I did a 5-hour teaching session on the 'diamond model' last week in Pakistan and a video recording of that session should become available soon ... stay tuned ...
Also, a free 3-hour talk on the same topic will take place on Sunday morning, 23 Oct. 2016 in West Oxford - see below for details:
Free Sunday morning workshop: What do we mean by ‘relational’?
23 Oct. 2016 - 10.00 - 13.00 - West Oxford Community Centre - Mary Town Room, Botley Road, Oxford OX2 0BT
This 3-hour CPD workshop will offer a whistle-stop tour through the three most established and mutually complementary formulations regarding relational stances, those by Gomez, Stark and Clarkson, with a brief overview outlining my ‘diamond model’, which is an attempt to integrate all three of them. It is in the nature of the topic that the talk will be quite abstract - to help you prepare for it, I will offer some reading materials prior to the event.