Rapport and Dialogue in The Therapeutic Relationship

Rapport is one of the fundamental requirements of effective therapy – whether that is hypnotherapy or psychotherapy. It is impossible to imagine any kind of psychotherapy without rapport of some form and rapport is quite possibly the single most important requirement. The term "dialogue" has been given to an authentic meeting between two people. I believe this is the foundation of rapport.

Mackewn (1997 p. 80) defines dialogue thus: “ dialogic does not refer to speech in the ordinary sense, but to the fact that human beings are inherently relational” The specific features of dialogue in therapy, give a quality which elevate the therapy session to one of depth, richness and therapeutic efficacy. This is one of the factors that distinguishes Gestalt therapy to psychoanalytical therapies (Yontef, p. 133) in which the therapist is a comparatively passive observer, and also in contrast to the cognitive-behavioural therapies in which the therapist adopts a directive attitude. Yontef (1993) speaks of the components of dialogue in Gestalt Psychotherapy being:

· inclusion, "putting oneself as fully as possible into the experience of the other without judging, analysing or interpreting"

· presence, "The Gestalt therapist expresses herself to the patient. Regularly, judiciously, and with discrimination she expresses observations, preferences, feelings, personal experience and thoughts. Thus, the therapist shares her perspective by modelling phenomenological reporting"

· commitment to dialogue "The Gestalt therapist surrenders herself to this interpersonal process. This is allowing contact to happen rather than manipulating, making contact, and controlling the outcome. "

· dialogue is lived. "Dialogue is something done rather than talked about. "Lived" emphasizes the excitement and immediacy of doing"

Buber (1996) speaks of the I-Thou relationship emerging through a dialogic meeting between two people, and points to a spiritual reality which arises and exists in that I-Thou encounter. The "I-Thou" exists between two people who meet openly and authentically, yet does not belong to either person in isolation. Hycner equates dialogue with the interplay of I-Thou and I-it moments. Carl Rogers (of person-centered counselling) speaks of authenticity, acceptance, communication and empathy in the therapeutic relationship as being the essential components of a therapy. Polster and Polster (1971) do not specifically delineate the concept of dialogue, however they do speak at length about contact, immediacy, and therapeutic presence. Perls, the well-known founder and exponent of Gestalt therapy, and other early Gestalt practitioners railed against "Aboutism", i.e. talking about something as distinct from directly experiencing something.

Key Principles

Inclusion

An effective therapist is fully engaged in the subjective world of the client without judgment, whilst maintaining his or her own identity. The therapist judiciously shares her own phenomenological (directly experienced) observations and allows herself to be touched and affected by the content of the session. This sharing is either therapist self-disclosure or phenomenological reporting of what the therapist is experiencing. This approach facilitates deeper trust in the therapeutic relationship, and facilitates deeper awareness by the client of their issues.

Yontef: "Inclusion provides an environment of safety for the patient's phenomenological work and, by communicating an understanding of the patient's experience; helps sharpen the patient's self-awareness."

Rogers (1961, p. 53): "Can I let myself enter fully into the world of his feelings and personal meanings and see these as he does?" and "can I step into his private world so completely that I lose all desire to evaluate or judge it?"

Joyce and Sills (2002 p. 46) "Inclusion is an extension or broader form of empathy. In empathy, the counsellor tries to know the subjective world of the client ... without judgment or opinion. Inclusion also encompasses the counsellors awareness of her own feelings, reactions and experiences"

Presence

Presence means that the therapist is fully present to the moment-by-moment experience in relation to the client. The therapist is fully engaged in the session, and has full attention for the client and the client-therapist relationship. This type of attention is rarely encountered in the outside world; a person who ‘has presence’ has all of their attention available to them, is not role-playing, and is not ‘in their own head’. Under these circumstances, a therapist can model phenomenological reporting, immediacy and realness to their clients, which sets the scene for the client to behave in a similar way. A corollary of this is that if the therapist is trying to be something, they are not present.

Korb et al write " Presence. It is the basic ingredient in the I-Thou relationship" "true progress can only occur throughout the I-Thou interactions" "The therapist and client become unmediated presences to each other" "From the experience of that presence, personal material ...emerges for a client"

Yontef (1985) states " therapist shares her perspective by modelling phenomenological reporting, which aids the patient's learning about trust and use of immediate experience to raise awareness. ...In Gestalt therapy the therapist does not use presence to manipulate the patient to conform to preestablished goals, but rather encourages patients to regulate themselves autonomously. "

Polster and Polster (1974 p. 11) state that the "therapy experience ... is an experience of unhampered living now"

Rogers (1961, p. 53): "Can I own, and if need be, express my own feelings as something belonging to me"

Clarkson (1989 p. 69) states: "emphasis on the manifest presence of the therapist as a person in therapy is one of the most important differences between Gestalt therapy and psychoanalytic approaches".

Joyce and Sills (2002 p. 45) “presence is a quality that emerges when you let go of…all your concerns and strivings and allow yourself to ‘be there’”.

Commitment to dialogue

Given that dialogue comprises presence and inclusion, a commitment to dialogue implies that the therapist is actually real and present to their clients, and is not playing the role of therapist. Yontef notes that the therapist “surrenders herself to the [interpersonal] process”. Additionally, recognition of the fact that contact occurs at the boundary between two people, Yontef (1993 P. 223) states “it specifically means allowing the outcome to be determined by The Between and not controlled by either individual” Hycner states that “To take such an approach seriously means a willingness to set aside one’s ego-oriented needs and intentions” and “The ‘Between’ is that reality which encompasses both therapist and client, and to which both approach, to a greater or lesser degree”

Rogers (1961, p. 51) states: "Can I be expressive enough as a person that what I am will be communicated unambiguously" Rogers maintains that core therapeutic attitudes must be communicated to the client in order for them to be effective in a therapeutic context.

Buber (1996 p. 62) writes: “The relation to the You is unmediated. Nothing conceptual intervenes between I and You”. Clearly, Buber is indicating that any belief or pre-conception on the part of “I” about the “You” interferes with presence. He continues “No purpose intervenes between I and You, … Every means is an obstacle. Only when all means have disintegrated encounters occur”

Joyce and Sills (2002) identify “Willingness for open communication” as a key facet of the dialogic relationship. They explain that this involves some choice on the part of the therapist about therapist self-disclosure; that it should be guided by intent to improve the client’s awareness and work.

Dialogue is lived

Yontef writes that dialogue is something done, not something talked about. Buber posits an entirely spiritual perspective on living dialogue: “Those who experience do not participate in the world, for the experience is ‘in them’ and not between them and the world” (p. 56) he continues “the basic word I-You establishes the world of relation” (my italics). So Buber is telling us that if we are either in the I-It state, or are egocentrically experiencing dialogue as something, we are not authentically in dialogue.

I-Thou and I-It

Buber's existential philosophy of I-Thou is clearly a foundational influence on Gestalt and Gestalt psychotherapists. Buber's text is a deeply spiritual and even mystical work, which points at the existential meeting between two people as a key facet of relational existence per se. "I require a you to become: Becoming I, I say you", "the basic word I-You establishes the world of relation"

Hycner: "Dialogue is the ever-changing interplay of I-Thou and I-It moments"

Contact and Dialogue

Earlier Gestalt writers such as the Polsters, Perls, Hefferline and Goodman elaborate extensively about contact and the contact episode, but do not delineate dialogue as an entity in its own right. Partly I suggest, this is because of the philosophical abhorrence for “aboutism” (talking about something as distinct from living something) and partly that the practice of Gestalt psychotherapy has evolved in the 40 odd years since Perls’ major works.

Hycner writes "...whether dialogue can be equated with contact. The simplest way to to put this is that all dialogue is contact -- not all contact is dialogue"

Therapeutic Relationship

Clarkson (1989 p. 16) speaks of the "central focus [of Gestalt Therapy] is the moment by moment process of the relationship between client and counsellor" - and "a relationship basically characterized by dialogue", what Hycner (1985) has described as a "dialogical relationship". Hycner (1985) quotes Laura Perls as saying "The true essence of Gestalt therapy was the relationship formed between therapist and client"

Similarity and Differences

By far the largest difference that emerged in the various readings, is that the early Gestalt writers : Perls; Perls Hefferline and Goodman; Polster and Polster, did not articulate dialogue as a separate entity, although their work demonstrates dialogue in process. The later Gestalt authors: Clarkson; Mackewn; Joyce&Sills, Hycner, and Jacobs have written about dialogue in depth, and only a few nuances separate their concepts. All agree that Inclusion and Presence are essential to the dialogical relationship, there is a subtle differentiation between Yontef, who separates “Commitment to dialogue” from “Dialogue is Lived”, and Joyce and Sills, who identify “Communicating inclusion” and “Willingness for open communication” as components of the dialogical relationship. Interestingly, early non-Gestalt writers appeared to incorporate more depth about the dialogic therapeutic relationship than early Gestalt authors. Buber’s original work in 1932 and Roger’s works from the 1950’s and 1960’s more clearly articulate the principles of the dialogic relationship than e.g. Perls, Hefferline and Goodman (1951). Hycner notes that Buber’s “dialogical and existential conceptualizations” were an influence on Laura Perls, but Fritz Perls “seemed to focus more on the biological metaphor”

My experience with dialogue

My own experience of being trainee therapist bears out the theory as presented here. I find that when I am present, inclusive and committed to dialogue, my sessions are deeper, more healing and more personally satisfying than when I am unable to bring these features to bear. If for example, I am affected by something that happened in a previous session, and am unable to bracket off the experience, I cannot truly be present, and I find myself working hard and it is then unusual to feel satisfaction about the session. If on the other hand, I am completely present and inclusive, the sessions will flow and without trying, some kind of therapeutic benefit occurs. As an example, once I was working with a client and experiencing a lot of I-Thou moments, being deeply affected by my client’s story (Buber) and sharing my phenomenology. My client said “I think Kath (on of the trainers) is worried about the time” and I had forgotten that there were observers present for the session, so deeply was I present to the “Between” (Hycner) between myself and my client. I responded “I don’t care what Kath thinks, I am here for you”. This was not a reactive response but a phenomenological one. As Buber says (p. 59) “Neighbourless and seamless, he is You and fills the firmament” in other words, the client-therapist relationship is all that is present in an I-Thou encounter.

My experience of being client also bears out the theory. If I feel that my therapist is being inclusive, present and in a dialogical relationship with me, I feel capable of accessing deep parts of my beingness and, for example, performing experiments that would otherwise be too confronting. It is as if my resistances are lowered when I feel in a dialogical relationship, and I am able to express deep, otherwise hidden parts of myself that I would normally keep unspoken. Conversely if I think my therapist is attempting to get some particular outcome, my resistances are fortified, and my willingness to participate decreases. If my therapist is simply chatting, I respond with chatter rather than emotional depth.

Conclusion

There is widespread agreement that therapeutic dialogue is essential to an effective psychotherapy outcome. The core attributes of such a dialogue are : Inclusion; Presence; Commitment to dialogue; and lived dialogue. There are some minor differences in emphasis between later writers on the subject of therapeutic dialogue, and it is clear that some development of the theme of dialogue has occurred. The importance of Buber’s work is that it permeates all of the authors' works that I have reviewed.

References

Buber, M (1996) I and Thou. New York: Touchstone Books

Bugental, J.F.T. (1987) The Art of the Psychotherapist. New York: W. W. Norton and Company

Clarkson, P (1989) Gestalt counselling in action. London: Sage Publications

Hycner, R.A. The I-Thou Relationship and Gestalt Therapy: The Gestalt Journal Vol XIII, no 1

Joyce P. and Sills, S. (2002) Skills in Gestalt Counselling and Psychotherapy. London: Sage Publications

Korb, M.P., Gorrell, J., Van De Riet, V. () Gestalt Therapy Practice and Theory. Boston: Allyn and Bacon

Perls, F, (1969) Gestalt Therapy verbatim. Moab, Utah : Real People Press

Perls, Hefferline and Goodman (1951) Gestalt Therapy – Excitement and growth in the human personality. London: Souvenir Press

Polster, G and Polster E (1974) Gestalt therapy Integrated. New York: Vintage Books

Smith, Edward W. L. (1977) The growing edge of Gestalt therapy. Secaucus,NY: Citadel Press

Yalom, I (1991) Love's Executioner and other tales of psychotherapy. Great Britain: Penguin books

Yontef, G. (1985) Awareness, Dialogue and Process.

Yontef, G (1993) Gestalt therapy: An introduction. Excerpted from Awareness, Dialogue, and Process. New York The Gestalt Journal Press in http://www.gestalt.org/yontef.htm

© Alex Whittle 2005