Search
  • Dr Andrew Perry

The surprising ways we come unstuck in therapy

Updated: May 5

This blog will look at how we might come unstuck in psychological therapy. One way is by remaining in reciprocal roles (Ryle, Kellett, Hepple, & Calvert, 2014.) A role is a term used for the way we respond to other people. These roles are reciprocal when they form pairs that reinforce each other. In some situations this pairing creates a useful complementarity. For example if we want to stop change occurring and perpetuate a beneficial status quo. However in therapy adopting reciprocal roles can mean a person remains stuck in the distressing patterns of relating that brought them to therapy in the first place. As such this article will examine how these reciprocal roles occur, provide examples of these roles, link particular roles to common mental health problems and detail practical changes we can use to shift roles in therapy. So reducing the client's distress and increasing their health.


How might reciprocal roles come about?


People develop a range of roles from infancy in relation to others, usually starting with thier parents. In therapy the initial preferences of each person may suggest or imply roles. However our preferences for particular role(s) may be unconscious. Bringing them into our awareness can help us examine their usefulness and if we want to change them. As an introduction some common reciprocal roles are listed below.


Role A Role B

Intellectualising / emotional........................................Unthinking / unfeeling

Helpless / irresponsible.................................................Helping / responsible

Rebellious / bullied / masochistic..............................Controlling / bullying / sadistic

Seducing / manipulating.................................................Seduced / used

Always Sad............................................................................Always Angry

Withholding / reactive / rejecting...............................Disclosing / proactive / defensive

Parent / judging...................................................................Child / judged

Narcissistic / demanding ..............................................Acolyte / placating

Doer / expert / prescribing............................................Done too / novice / recipient



Each role represents a part of reality. Allowing the other person to represent a different aspect. When paired together they may allow the two people to better cope with reality. As with all depictions of human relationships these are necessarily simplified. Caricatures to emphasise a particular part of relating. I hope it is also clear from the examples that when roles fit together (are reciprocal) we get a lock of complementarity. This means they become harder to break out from because the roles reinforce each other. Another way to understand reciprocal roles is to look at how they occur in the context of common mental health problems. These are generalisations from my twenty years experience but they are all ways we can get stuck in distressing patterns of relating.


Relational roles, therapists and clients may adopt, in the context of common mental health problems



Generalised Anxiety - reciprocal roles which either over, or under, value the benefits of worry, focus on the future, and/or the value of therapy.


Social Anxiety - reciprocal roles which differ in their fears of being authentic or causing offence, people pleasing, finishing the session early, arriving late, talking about other things. Acting as if we were Ming vases. Seeing therapy as completely typical rather than a partially different experience of life.


Health Anxiety - reciprocal roles which disagree about how desirable it is to accept uncertainty/mortality/vulnerability, where expertise lies and a realistic speed of change.


Grief - roles which contrast in their views of endings, the period of time which is most salient and/or marking the passing of time.


Depression - roles with a variety of approaches to experiencing sadness/anger. Critical, shaming, demanding or punitive interactions. Comparisons of status, education and/or income.


Anger - roles which disagree about the value of expressing sadness, passive aggression, not saying if we are hurt by the other and/or a denial of other feelings.


Paranoia - roles where there are a suspicion of motives, and/ or unquestioning interactions.


Violence - roles which include submission, masochism, a lack of boundaries, a lack of explanation, abrupt interactions, non verbal communication and/or rupture.


Medically unexplained symptoms - roles which vary in their experiences of uncertainty, lack of control, confusion, anger, exclusion and/or discrimination.


Chronic fatigue - roles which divide about their experience of energy, helplessness, dissociation from other emotions, sensitivity and/or disconnection from others.



How can a therapist help clients come unstuck from unhelpful reciprocal roles?


I think the job of a therapist is to create experiences useful to the client. Engaging in repeated, healthy and conscious interactions with reality. For example making conscious shifts in practise to change unhelpful reciprocal roles. In our favour is any motivation we have to repair the past and change our roles. These shifts are made more difficult by any motivation we have to repeat unhelpful roles and experiences of our past. To illustrate how this can work in practise below are examples of conscious shifts to break unhelpful reciprocal roles from my clinical career.



Persistence. Often it is not clear how I can help someone. Persistence in the face of this uncertainty has been the most effective means to make therapeutic progress. Proving I really mean it when I say you want to help.


Talking more about my experience of the here and now. The difficulties, joys and feelings. Me modelling what it is like to do so in that context has often taken the pressure off the client to talk first.


Changing my approach to treatment. In sum ‘I have sat down and put the pen down’. So turning exercises into an option rather than an agenda. Letting paperwork follow the evolving relationship and using my training and experience as a resource not an instruction manual. Often clients have responded positively to being trusted to create a good enough process together.


Using less strong emotions. For example in my facial expressions and using less eye contact.


Acknowledging my failures. In particular apologising when I seem to have hurt someone's feelings even if unintentionally.


Allowing myself to be cared for as a way of caring for others


Sitting with silence, stopping asking questions.


Not feeling totally responsible for the outcome. I can only do my best. Sharing responsibility for the process


Not placing myself between two significant relationships (e.g.father and son).


Stop trying to get everything right e.g. saying i don't know.


Offering choices about the level of structure, homework, past/present/ future focus, challenge, theory and /or practice.



I have learnt these lessons the hard way. Through my own mistakes. So I know shifting practise, in response to the reality of each relationship, can help prevent harm. Beginning with acknowledgement of our part in difficulties. These shifts also signal to the client that the therapist could feel, and know, as they do. Avoiding a my way or your way struggle. Instead communicating that the opposing experiences, and roles can be both respected and added to.


These changes may be seen as a dilution of effort in therapy. I think this is no coincidence. To work therapy has to feel real but not too real. This difference allows for play instead of just drama. So the interactions in therapy are consequential but without the usual consequences. All aiding the participants to tolerate a wider range of emotional experiences than outside therapy. Dilution for therapeutic effect (Benjamin, 2019.)


Come unstuck in therapy


We have considered how we might come unstuck in therapy. Repeating patterns of relationships which have led to distress and poorer health in the past. These reciprocal roles can be unconscious and pervasive. Bringing these possibilities into our awareness, recognising commons patterns, evaluating their usefulness to us and consciously shifting practise we when we seem stuck, can all help.



References


Benjamin, J. (2019, Apr, 1). Enactment and the theory of the third. Retrieved from: https://www.youtube.com/watch?v=GA0dcQ13rt8&list=LLSr6fHMgXhGzrFJ1qwcKfJA&index=2&t=0s


Ryle, A., Kellett, S., Hepple, J., & Calvert, R. (2014). Cognitive analytic therapy at 30. Advances in Psychiatric Treatment, 20(4), 258-268.


A version of this article is available on my counselling directory page. See https://www.counselling-directory.org.uk/memberarticles/the-surprising-ways-you-can-come-unstuck-in-therapy

0 views
 

07503316840 / 01870 603701

©2020 Dr Andrew Perry, Linlithgow, Scotland