Collaboration in Experiential Therapy

Abstract

We offer a view of the nature and role of client-therapist collaboration in experiential psychotherapy, focusing on Gestalt and emotion-focused therapy (EFT). We distinguish between the necessary condition of mutual trust (the emotional bond between client and therapist) and effective collaboration (regarding the goals and tasks of therapy). Using a case study of experiential therapy for social anxiety, we illustrate how the development of collaboration can be both complex and pivotal for therapeutic success, and how it can involve client and therapist encountering one another through taking risks by openly and nonjudgementally disclosing difficult experiences in order to enrich and advance the work.

Collaboration in Experiential Therapy

Experiential or humanistic psychotherapies share several features, including a focus on promoting client in-therapy emotional experiencing within the context of an empathic, compassionate, and authentic relationship. Commitment to a phenomenological approach follows from this interest in experiencing. All experiential therapies are also united by the understanding that people are wiser than their rational, cognitive processes and that tacit experiencing is fundamentally adaptive, and potentially available to awareness. A key aspect of these therapies is the offer of a deeply collaborative therapeutic relationship.

In this article, we look at therapeutic collaboration from an overlapping Gestalt and emotion-focused therapy (EFT) perspective. We will look at how client and therapist in experiential therapy find a way to establish effective therapeutic collaboration, sometimes struggling in meantime. We will illustrate our points with a case study in which the struggle to achieve a productive, collaborative relationship appears to be a crucial element of the change process.

Collaboration in Gestalt and EFT

Since Bordin (1979), it has become common to distinguish between bond, task agreement, and goal agreement aspects of the therapeutic alliance. The bond aspect is the emotional connection between client and therapist; while the task and goal agreement aspects are generally put under the general heading of therapeutic collaboration, the working together (co- + laborare) of client and therapist. For us, client-therapist collaboration is a key aspect of alliance: There is no alliance without collaboration. Thus, even in highly relational psychotherapies such as person-centered therapy, Gestalt and EFT, an effective therapeutic relationship is seen as more than an emotional connection. It also entails commitment and involvement on the part of both parties working together toward the global, shared goals of therapy (Bordin's Goal Agreement aspect of the alliance), by making use of specific agreed-to therapeutic activities carried out within the session (Bordin's Task Agreement aspect).

In Gestalt therapy, the relationship is probably the most important aspect. The interaction is based on a dialogical co-construction, in the here and now, of a relational process with the purpose of developing awareness, responsibility, and self-actualization in the client (Yontef, 1995; Hycner & Jacobs, 1995; Spagnuolo Lobb, 2009). To create a collaboration with the client, the therapist needs to be

• presence-centered, meaning fully aware of self and actively expressing self in the here and now,
• inclusive, trying to put themselves as much as possible in the client's experience, and
• committed to staying in connection or contact with the client.

The Gestalt therapist is ideally creatively active, both verbally and nonverbally, through any possible way that therapist and client, by experimenting, can create together (talking, singing, dancing, drawing, etc). These experiments grow out of their immediate interaction; they are spontaneous and relevant to a particular moment and what is emerging through the client's report, for example, of a dream, a need, a fantasy, or a physical sensation. Experiments are done with the full participation and collaboration of clients; rather than achieving a particular outcome, experiments are aimed at developing client awareness and capacity to try out new ways of behaving (Polster & Polster, 1973).

In a recent article on the therapeutic alliance, Quattrini (in press) describes the collaboration between therapist and client as a fragile and precarious process that develops through a series of passages. First through building trust, which occurs only once the client realizes that the therapist is “on his/her side,” so that they don't need to constantly monitor the therapist. The client at that point typically accepts what the therapist may suggest with an open attitude to explore what interesting experience can come out of it, even if the suggestion is not necessarily appealing at first. A metaphor of the therapeutic alliance is the image of the therapist as a guide in the jungle, with whom the client needs to collaborate, rather than oppose, to stay safe in an unknown and dangerous area. Another metaphor is that of seeing therapist and client as a pair of mechanics who work on the same car: they need to collaborate, to avoid situations in which one is unscrewing something on one side while the other is unscrewing it on the other side (Quattrini, in press).

After agreeing in general with the creative and experimental nature of Gestalt therapy, EFT has attempted to specify the work of developing and repairing client-therapist collaboration. In EFT, we assume that, in addition to the therapeutic bond, the client must engage in different kinds of work via various therapeutic tasks. For example, to work on resolving an internal conflict, the client can engage in identifying, separating, expressing, exploring, and specifying different partial aspects of self; the client must also create interaction between the different parts. For the client to engage in this or other kinds of therapeutic work, she or he must (a) have the knowledge, skills, or resources to carry out the various forms of therapeutic activity (“task requirements”) and (b) agree to engage in these activities in the session (“task agreement”). If these conditions do not exist, the client will not be able or willing to work effectively.

The therapeutic bond comes first, enabling the client literally to take his or her eyes off the therapist. This sets the stage for the deepening development of the relationship through the successive stages of agreement on therapeutic focus (general problem areas for therapy), goal agreement, and task agreement. The therapeutic bond goes a long way towards establishing the “safety conditions” (Daldrup, Beutler, Engle, & Greenberg, 1988) needed by clients to attempt novel or unusual therapeutic activities.

However, EFT specifies the following additional relationship principles as necessary for facilitating client change.

Offer a relationship of collaborativeness and mutual involvement

In addition to fostering client involvement through providing information and exploration, it is useful for the therapist to offer a mutual, collaborative relationship of equals. As the case example to follow illustrates, this attitude is communicated by the therapist (a) using both “I” statements and inclusive “we” messages, (b) being willing to consider alternatives, to admit error or misunderstanding, and to negotiate disagreements openly, and (c) avoiding of an overly definitive, expert manner.

Obtain client agreement and commitment on the process goals and activities of therapy

EFT holds three general process goals as important for all clients: (a) helping the client use the optimal way of working with their experiences for a given kind of therapeutic work; (b) autonomy and acceptance of responsibility for own experiences and actions; and (c) completion of important kinds of therapeutic work. In other words, the therapist tries to help clients become more effective in making use of their immediate experiences, exercising greater self-determination and resolving the particular problems they bring to therapy. In addition, as Bordin (1979) noted, different therapies make different demands on clients. As with Gestalt therapy, EFT asks clients to engage in several kinds of activities (e.g., mindful attending of experiences, symbolizing and expressing experiences, opening up; Elliott et al., 2004).

To foster client agreement with these process goals, it is a good idea to present them to the client at the beginning of or even prior therapy. For example, the client “William,” the client described later in this article, was told the following during his initial telephone screening:

The therapy we are offering is person-centred and focused on your experiences. This therapy may be different from others that you are familiar with: In the person-centred/experiential approach, your therapist will not give you behavioural solutions for problems, and will not make interpretations about you. Instead, your therapist will work actively and respectfully with you to help you explore your emotions and other experiences to help you find your own answers.

Foster development of client task abilities

Many clients (especially those new to psychotherapy) have difficulties with expressing and exploring their feelings. As in the case example below, at the beginning of therapy, many clients are distant, uninvolved, or out of touch with their own and others’ emotions (termed “incongruence” in person-centered therapy, Rogers, 1957; or “deflection” in Gestalt therapy, Polster & Polster, 1973). This distancing from self and others manifests itself as intellectualization and emotional and interpersonal isolation.

As a result, it is possible that some clients will be unable to carry out some therapeutic activities. Even though they are willing to do so, they simply lack the understanding or skills to do so. For example, some clients may not know that attending to inner experience can be facilitated by silence, looking at a neutral “focal point,” imagining an internal space, and asking yourself open questions. At such times, it is very useful for the therapist to temporarily take on the role of process teacher, or “teacher of the method” (Mahrer, 1983), explaining the rationale or basis of a particular activity, and patiently coaching or modeling for the client activities that can help them move toward resolution. Thus, in both Gestalt and EFT, the therapist works actively in various ways with the client to help develop a mutual, collaborative relationship.

Case Illustration

Therapist and Researchers

The case presented below is part of an ongoing study of experiential therapy for social anxiety conducted at the University of Strathclyde. The therapist is the first author (LB), an experienced, 45-year-old Italian Gestalt psychotherapist, trained in both person-centred and Gestalt therapies and working within the EFT arm of the study. The principal investigator of the study is the second author (RE) and one of the developers of EFT; he finds that the therapist's practice fits easily within the framework of EFT. The client's assigned researcher is the third author (JS), an MSc student in counselling working within the social anxiety research project.

Client Description and Presenting Problem

The client, “William,” is a 20-year-old European male, presenting with social anxiety focused on social interactions and being criticized by others. He was referred to the social anxiety research study after having been seen for eight sessions by a student counsellor in a related study. Although he fit the diagnostic criteria for Social Anxiety, he did not meet any other the Diagnostic and Statistical Manual of Mental Disorders (DSM) Axis I diagnostic categories. In addition, he met criteria for schizoid and narcissistic personality patterns on Axis II, reflecting his highly rational, intellectual, and interpersonally detached style. He did not present any family psychiatric history or any contributing medical problems.

William scored in the clinical range on all five of the outcome measures used in the research study, including the Personal Questionnaire (PQ; an individualized outcome measure comprising seven problems the client wanted to work on in therapy; Wagner & Elliott, 2001), Social Phobia Inventory (SPIN; Connor, Davidson, Churchill, Sherwood, Foa, & Weisler, 2000), CORE-Outcome Measure (a measure of general psychological distress; Barkham, Mellor-Clark, Connell, & Cahill, 2006), Strathclyde Inventory (a person-centered outcome measure; Freire, 2007), and Inventory of Interpersonal Problems (IIP; Horowitz, Rosenberg, Baer, Ureño, & Villaseñor, 1988). Table 1 summarizes his pretreatment scores.

Table 1. Client Outcome Data

Instruments	Cutoff	RCI Min*	Pre	Session 8	Session 17
Note RCI Min = Reliable change index minimum value for p < .2; CORE-OM = CORE-Outcome Measure Value in bold fall within the clinical range; *p < .2; **p < .05; ↑ = increased score indicates positive change; ↓ = decreased score indicates positive change; (+) = reliable positive change in relation to first available score; (=) = no change in relation to first available score; (–) = reliable negative change in relation to first available score.
Personal Questionnaire	<3.5	1.0 (↓)	5.86	5.14	3.71** (+)
Social Phobia Inventory	<1.12	0.67 (↓)	1.59	–	1.12 (=)
CORE-OM	<1.25	0.5 (↓)	1.50	–	0.97* (+)
Strathclyde Inventory	>2.45	.46 (↑)	1.65	–	2.19* (+)
Inventory of Interpersonal Problems	<1.5	0.57 (↓)	2.04	–	1.73 (=)

William was randomly assigned to receive up to 20 individual sessions in the EFT arm of the study. As of the writing of this article, he remains in therapy, so we are using data from his first 17 sessions. William agreed to use his case for the present article. This case has been selected because the process of establishing collaboration between therapist and client was complex, and the therapist at first found it challenging to create a contact and collaborate with him.

William is a very intelligent and articulate young man with strong opinions and a wide variety of distinctive intellectual and artistic interests, which he loves doing mostly on his own. He wanted to extend his network of social contacts and become more popular with his peers; however, he found it difficult to enjoy the interests and activities engaged in by others (such as going to the pub or dancing). At the beginning of therapy, William was self-conscious in public and social contexts, and tended to avoid them. In general, he tended to develop physical symptoms (e.g., stomachaches) when anxious. He had come to therapy to work on enhancing his social skills and becoming relaxed enough to interact more effectively with other people; he hoped this would enable him to develop a wider network of long-term friendships.

First Session and Case Formulation

In the first session, William presented with many experiences common to clients suffering from social anxiety: social avoidance, anxiety, physical symptoms, self-consciousness when with other people, worry about others seeing these vulnerable aspects, and strong self-criticism. Moreover, apart from his strong self-focus on his “nervousness” and anxiety, he functioned primarily on a cognitive level, even when talking about difficult personal matters; he was not in contact with his emotional experiences and body responses. In experiential therapies, these elements are crucial for developing self-awareness and self-acceptance; during the first session, the therapist suggested to William the possibility of working to help him develop greater and more immediate body and emotional awareness.

The therapist also explained to the client her way of working: first, letting the client lead the sessions, and, then, based on the emerging needs and experiences, working with him to co-construct new and alternative experiences. From the beginning, the client agreed to try this, but at the same time overtly expressed his doubts about the effectiveness of such an approach, given how long he had had some of these difficulties. The therapist's first impression of William was positive in terms of his original, sophisticated capacity for analysing and describing himself and his view of the world. On the other hand, she experienced him as interpersonally distant and carefully observing her responses and her presence.

Course of Psychotherapy

For the first five sessions William arrived well prepared, with written notes about the things he wanted to discuss and resolve, as well as information about his current life, interests, family background, and relationship with each relative. These descriptions were expressed in an emotionless, rational, and logical manner, with great attention to accuracy. In experiential work, the mode of engagement or “how” that clients use to express themselves is at least as relevant as the content: It may function as either a bridge or an interruption of the contact between different parts of the self, as well as between the client and the therapist, and quite often illustrates how the client carries himself or herself in the world. In the formulation of this case, mode of engagement was a key point for the therapist, and had a quite strong affect on the way she decided to work during the sessions. Greater engagement would probably reach a deeper emotional level of communication and contact within the therapeutic relationship, and through that enhancing the client's self-awareness and his emotional contact with himself and with others.

William's detailed and emotionally detached reports during the first stage of therapy made it difficult for the therapist to feel connected with him. This lack of felt connection lasted for several sessions and, at times, made it difficult for her to be fully present, tuned into her client's needs, and creative in the therapeutic work. Whenever she asked him about his emotional awareness in the here and now, he responded that he felt “nothing special,” or asked, “What do you mean?” When, at appropriate markers, the therapist offered typical experiential therapy methods, such as empty chair work for unfinished business or two-chair work for internal conflicts, William tried them briefly, but then explained each time that this sort of thing was of no use for him, although he appreciated that it might be useful for other clients.

In session five, William expressed a clear perplexity about the usefulness of therapy, saying that he felt that he was only providing the therapist with information, but wasn't getting anything useful or insightful for himself. This comment matched the therapist's experience to this point as well as her sense of frustration, which she had not yet disclosed to the client. After this point, she used several different sources of supervision to explore what was getting in the way of her allowing contact. At the same time, she appreciated the client's honesty in communicating his frustration with the therapeutic process, taking it as a demonstration of his willingness to collaborate and engage, and using it to work on opening herself up in her work with William.

In fact, William's observation of how psychotherapy had been going perfectly fit her experience: Therapy so far had been nothing more than a sequence of meetings in which he was reporting facts and providing information and where the therapist, although feeling empathic and warm towards him, had been unable either to “get” him empathically or to interact with him in a constructive way. After session six, in which the client mentioned depression and a low mood, the therapist went to supervision with both her personal supervisor and the second author; she was encouraged to express her difficulties directly to the client, consistent with EFT formulations of relationship work (Elliott et al., 2004).

In session seven, the therapist shared her feelings with William, explicitly validating his sense of a lack of progress in therapy, disclosing her frustration at not being able to help him access his emotions during the sessions, and sharing her difficulty in working effectively if the dialogue remained only at a cognitive level. The client was immediately receptive and expressed his willingness to collaborate more from this point of view. In session eight, indeed, he presented a list of challenges he was encountering at the time, naming for each of them how he was feeling about them.

William's opening up in session five and the therapist's disclosure in session seven shifted something in the relationship, and from this point forward, the collaboration became clearer and more overt. However, William continued to talk about his emotions rather than to express them, and he still reported a diminished capacity to put into practice useful change in his behaviors.

After session eight the therapist had further supervision and, thanks to a comment of her supervisor, she had an insight and suddenly felt able to connect much more with her client's fear of opening up with other people (including, possibly, with herself). Dialoguing about what it was bringing up for her (the therapist), the supervisor used the following metaphor: “It is as if when you open yourself to others, you are at the same time allowing them access to your internal stuff and that they can even extirpate it from you, as you don't necessarily have control of what they will do with it.” This image had a strong emotional affect on the therapist, and she thought that she could use it with her client.

In session nine, then, when the client mentioned his difficulty with taking risks and opening up with other people, the therapist shared this image with him. She used her hands to spontaneously portray the act of taking “stuff” from him—an example of the creative expression in the here and now, rather than “talking about”:

T:

I would like to know the impact that what I am going to tell you has on you. OK. You say that exposing yourself to others would create polarizations [they may like me less or more than before], and this is a way to see it, when you give something of yourself. What I am seeing is that if you give something of yourself, the other “takes it” (the therapist moves suddenly towards the client pretending to grab something from the client's stomach).

C:

Mhm… (He blushes and coughs, then there is silence.) Well, I don't know what do you mean by “taking it.”

T:

Well, they get something from you, and they have something of you. (C: mhm) And then they can decide what to do with it. (C: mhm [nods]) But a step before is that they have taken a piece of yourself, that is very intimate, if you see what I mean. (C: mhm) From the perspective, I am watching it, the thing is that the more you give, the more the other takes. (C: Mhm) Takes of you, of your personal stuff…

C:

But in saying that I would say that it would scare me, (swallows) because I don't know what they are doing with that.

T

Exactly! That's my point!

C:

And that's where my need for security comes from…

T:

… And they may like it or not, but they have taken a piece of me and this is scary!

The therapist's sudden action had a huge affect on William, who reacted by blushing and feeling afraid. At the same time, he seemed to have realized something meaningful to him. It was then possible to work on William's core, social-anxiety-related maladaptive fear: it was in the room, in the here and now, and open to transformation. This work began with acknowledging the fear, allowing space for it, identifying its object (offering other people access to deep and personal aspects of him), and looking after this fear, through body awareness and a warm, acceptant attitude towards it.

Interestingly, on the Helpful Aspects of Therapy Form (HAT; Llewelyn, 1988) for session nine, the client wrote that the most helpful event was:

Others Take a “Piece of You” theory. Outlining how being open and giving away information about oneself resonates in others – both positively and negatively. [What made it Helpful:] Going towards the core of the issues/deal with and putting fear in perspective. (Helpfulness Rating: 7 to 8: Moderately to greatly helpful.)

According to William's PQ weekly outcome scores, this was the turning point of his treatment. His PQ scores started to decrease, from 5.14 at session 9 to 4.86 at session 10 and dropping gradually to 3.71 by session 17, as shown in Figure 1. (William also noted that the approaching end of the academic year might also have affected his PQ scores.)

Figure 1. Client weekly personal questionnaire scores across therapy.

Outcome and Prognosis

In terms of collaboration, the relationship between therapist and client changed dramatically after session nine. The next sessions became much more collaborative and co-constructive in their process. William arrived looking physically more relaxed, more open, and usually without bringing prepared lists of what he wanted to talk about. He was more spontaneously present in the here and now. The therapist also felt much more present and in contact with William, and no longer struggled to work effectively with him.

After session 10, William began to talk about several improvements in his social life, based mainly on a feeling of “legitimation,” a word he used many times in different sessions to refer to an internal process of evaluating possible actions. For example, he stayed by himself if he wanted, or opened up to others only as much as he wanted and in different ways each time. As a 4-month summer break in his psychotherapy approached, after 17 of his scheduled 20 sessions, he appeared to the therapist to be more relaxed and aware of what he needed or wanted. William appeared more accepting and less critical of aspects of self that he previously thought needed to be changed.

These changes were also highlighted by the client himself when the researcher (JS) interviewed him about his experiences of therapy after session 17. William noted that although aspects of his social anxiety still remained, he was also aware of other personally relevant changes that he attributed to the therapy. For him, the most important and unexpected of these was that through an internal “dialogue” (his words) of asking himself “how do I feel?” and “what do I want?” (as the therapist had done with him during the sessions), he had developed a much deeper awareness and consideration of his internal world, which was in turn helping him to feel calmer and more flexible in social situations.

The researcher also assessed William's outcome to date more formally during his break from therapy, as presented in Table 1. Of the five outcome measures, his PQ data show the strongest reliable change over the 17 sessions. His pretherapy score of 5.86 dropped to 3.71 after session 17 (p < .05). In addition, he showed reliable change on CORE Outcome Measure and Strathclyde Inventory, although he remained in the clinical range on four of the five measures (all except for the CORE), pointing to the need for further treatment.

Clinical Practices and Summary

This case shows that the development of a productive collaboration is not necessarily a natural or spontaneous process, but can instead require a series of efforts, with both client and therapist having to take emotional and interpersonal risks by disclosing themselves to each other in an immediate and genuine manner. In Gestalt, this is understood as a process of experimentation to establish contact between therapist and client and, through that, between different parts of the client's self. In EFT, this process is described as a specific kind of therapeutic work (“Relational Dialogue for Alliance Difficulties”), which over the course of several sessions moved from a client complaint (session five) through exploring the difficulty via mutual dialogue about the relationship (session seven) into developing a shared understanding of the difficulty and its relation to core issues of the client (session nine), and finally into deeper engagement in therapy (sessions 10 onward).

There were several pivotal points in the case. First, in sessions five and six, William took the risk of sharing his frustration about therapy and his depression, which set up a therapeutic process in which client and therapist could encounter one another by sharing their respective perceptions. This seemed to have created an opportunity to use therapy actively and creatively to help the client reach a deeper level of emotional awareness, providing a basis for effective therapeutic collaboration.

This case shows also how in experiential therapies the presence and personal process of the therapist can be either hindering or helpful in developing collaboration. Because collaboration is an I-Thou relationship, the co-construction of the process is equally distributed between the two participants, requiring several passages or turning points, before the “dance” can flow fluently without stepping on each other's feet (Quattrini, in press).

We have tried to show how in experiential approaches collaboration is built on initial trust (Bordin's 1979bond aspect of the alliance) and provides a basis for therapist and client to play with the varied possibilities of psychotherapy, giving life to the process by making it their own. Even though common themes such as trust, risk, and collaboration weave through most, if not all, successful psychotherapies, each course of psychotherapy is unique and allows space for creative experimentation, expression, and constant discovery of new paths from psychological pain and stuckness to healing.