The 'therapeutic relationship' explained

...or rather, how it comes about that often the relationships between mental health workers and their clients aren’t beneficial to either party.

We become clients of mental health services because we find it impossible to maintain happy social relationships - we may never have experienced them, or experienced trauma when they breakdown, or had difficulties in making new ones.

We then enter a system of care which doesn’t offer us ordinary relationships, or training in how to conduct and maintain them, but instead involves a form of social interaction based on the worker playing out two roles; that of bureaucrat on the one hand, and counsellor on the other.

Firstly, there is always the aspect of a ‘paid friendship’, so you can never be sure of the genuineness of the worker, their feelings about you are always hidden to a greater or lesser extent. They are not choosing to be with us. What are we to conclude when we see a mismatch between what they say and what they display non-verbally? They are of course observing the same in us, but usually concluding it’s an aspect of our character, rather than a reflection of their behaviour!

If the relationship should turn out to be a good one it is quickly terminated by the worker; if it is less successful it may persist for decades.

We usually meet them at a time and place of their choosing, often in a specially designated building isolated from normal social life. This is presented as an aspect of confidentiality and freedom to disclose. However, whilst the location often feels familiar and safe to the worker, for us it may be quite the opposite.

Given the isolating nature of mental distress, and the fact that the worker has many other clients, they are almost always (for good or bad) more important in our lives than we are in their's.

They assess us, and even if they accept our conception of our problems, even if we are able to assert our rights and entitlements, they remain the gatekeepers to care. We are promised confidentiality, but also told that when they deem it necessary they will consult others.

We are told the encounter is our space, ours to control or direct. Yet because they do not self-disclose - we are expected to talk about the most intimate, and therefore most difficult to articulate, aspects of our lives to someone who always remains a stranger.

Since the assumption is that we are the ones who bring our problems to the encounter, what is actually happening in the room is either ignored or grossly misinterpreted because of an unconsidered factor - what years of meeting everyday with a variety of people in mental distress has done to the health and perceptions of the worker! (Remember, they get their supervision from even more experienced workers).

Normal, healthy encounters are as follows. We meet as strangers, often have strong first impressions of like or dislike, intuitions of threat or safety (which we ought to follow, leaving immediately if necessary). It is only after some time that we reveal confidences, when some trust has been established based on both parties willingness to mirror and match the other with minor disclosures about themselves. Equality and reciprocity are built-in to normal social encounters. We are attracted by points of similarity between ourselves and the other person. Friendship may or may not follow. If it does, then it becomes appropriate to give advice or instruct. You earn the right to say - ‘don’t do that, I know what happened last time, even if you have forgotten’. When on the receiving end, you may not like what is being said, but by now you have undeniable evidence that the person cares about your wellbeing. And of course, all this time you have been meeting at a time and place negotiated between yourselves.

So how can these abnormal encounters with workers actually improve practical opportunities for more and better social interaction in the real world? You walk away from a meeting with a mental health professional and within a few hours, like all encounters, you remember little of what was said rather the atmosphere that was created. We leave with a feeling of whether it was a good or bad experience. But we should go further and ask ourselves, have I learnt something practical today which will make it easier to get up tomorrow?