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Nov 24, 2024

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1 Client Case Study Institutional Affiliation Student’s Name Instructor’s Name Course Name Date

2 Client Case Study Introduction An integrated approach to counseling and psychotherapy draws interventions from several modalities. This approach creates a strategy to meet the client's needs by fusing pertinent theories and interventions. Many therapists have shifted to utilizing these approaches because they can provide a customized method of working with clients. As a result, it enables the counselor to practice in a way that is consistent with their theoretical and philosophical stance. A therapist decides to integrate different modalities by applying relevant techniques in a complementary way and viewing the client's process through various lenses. One of the models of integration is Petruska Clarkson's 5 Relationship Model. The Five Relationship Model was Clarkson’s lasting memory in her thesis on human relationships based on the philosophical idea of intersubjectivity (Clarkson Overview). She identified five therapeutic relationships in her work: the working alliance, the transpersonal relationship, the reparative relationship, the transference/counter-transference relationship, and the real relationship (Clarkson, 1990). The counseling relationship might contain all five therapeutic partnerships at once. However, more frequently, there is one dominant relationship, or two or three, and the dominant therapeutic relationship tends to vary during therapy. Clarkson’s model of integration also compares with other approaches. One of these competing models is Paul Wachtel's model of cyclical psychodynamics. Like Clarkson's approach, this model also emphasizes the importance of the therapist-client relationship in a client's well-being. However, according to Wachtel’s model, connections the client has outside of treatment can be very important in determining whether or not their problematic behavior

3 patterns persist or change; the therapist-client relationship is not the only factor in ensuring the client's well-being (Wachtel, 2017). The purpose of this method is to enable the client's continuous life experiences to serve as important therapeutic agents while also fostering new ways of connecting with others outside of therapy. In other words, the relationships a client creates inside, and outside treatment make a difference in their overall outcome. For instance, when a change is desired, a therapist can evaluate the client's personality dynamics to determine people who maintain vicious and virtuous cycles and behavior patterns. Another model is Anthony Ryle's cognitive analytic therapy (CAT) model. Like the first two models, CAT also emphasizes the importance of the client-therapist relationship in influencing the desired outcomes. According to Taylor et al. (2019), CAT is a systematic psychological therapy typically provided as individual therapy but can also be carried out in a couple or group setting. CAT is a therapy with a limited time and sessions of offering. It is a relational therapy model that focuses on the collaboration between the therapist and the client. The therapist and the client examine the patient's life experiences to identify the primary relationship issues. These issues may lead to halted or postponed decision-making or futile efforts to address them. Even though Anthony Ryle's model and that of Paul Wachtel compare significantly with Clarkson's approach, this paper will utilize Clarkson's integration model on a client, MW. With the use of the five therapeutic relationships offered by Clarkson, this paper will build a positive client-therapist relationship between NW and the therapist to help prevent her from stopping to come to sessions and achieve the desired outcomes. The desired outcomes include having a better mood, addressing anxiety and overwhelming feelings, mending the rocky relationship with her mother, and taking care of her two children with the help of her husband.

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4 Body of the Case Study Client’s History and Presenting Issues The client considered in this case study is MW. NW is married and thirty-four years old. She has two children, and both are below five years. For seven sessions now, MW has been coming to therapy because she is dealing with three issues: low mood, anxiety, and overwhelming feelings. Additionally, NW also reports that she has self-harmed in the past. While her husband has always been supportive in helping deal with her issues, NW and her mother have a rocky relationship; they do not seem to get along. Recently, after the seven sessions, NW stopped coming to therapy, claiming that the sessions are not helping her feel better, and she thinks counseling is not helpful. Without counseling, these issues might overwhelm NW and affect how she relates to people around her, like her children, husband, and mother. As a therapist, I would like to incorporate Clarkson's integration model in her next therapy session as I believe it will help her attain the desired outcomes. Since childhood, I have always believed that a person can solve their problem when they share with others they trust. Therefore, when MW gains trust with the therapist, it is most likely that she will share all her issues to help them find a better solution. Clarkson’s Model of Integration Clarkson's integration model is based on the importance of the relationship between a client and a therapist. According to her, an effective relationship between these two individuals often leads to successful therapy. Many studies agree with Clarkson's idea in the model. For instance, the American Psychological Association affirms, “ a number of relationship factors— such as agreeing on therapy goals, getting client feedback throughout treatment and repairing

5 ruptures—are at least as vital to a positive outcome as using the right treatment method" (DeAngelis, 2019). Therefore, a solid therapeutic alliance is necessary for a client to connect with, stay in, and benefit from treatment. Since the relationship is the center of this model, every time a therapist is working with a client, Clarkson notes that it is important to understand all the five aspects of the client-therapist relationship: the working alliance, the transpersonal relationship, the reparative relationship, the transference/counter-transference relationship and the real relationship (Clarkson, 1990). These five elements of a therapeutic relationship serve as an organizing framework that enables therapists to integrate various ideologies into a unified whole. Therapists know that every connection is distinct and that various aspects of the therapeutic alliance will be more or less present with various people throughout the work. The Working Alliance The working alliance is the first relationship that Clarkson notes. According to her, this is the foundation of the client-therapist connection, which enables both parties to collaborate (Clarkson, 1990). It may include a contract, a presentation of the issue that has brought the client, and the realization of the relationship between the two. The goal of the initial stage is to establish a shared understanding and a solid foundation so that, if things go south, both parties can refer back to the agreement and work to mend the therapeutic alliance. This is the so-called reparative phase (Clarkson Overview). The transference/counter-transference relationship This second stage of the therapeutic relationship depends on the first one; the working alliance. Transference refers to the idea that someone reminds the therapist of another person in

6 the past, and the therapist transfers to the client (Transference (1)). However, Clarkson notes that the therapist must ensure vigilance at this stage if they experience negative emotions such as [ CITATION Cla90 \l 1033 ]. If they react to their patients as they would an individual they remember from their experience, a process known as "counter-transference," it may be unfair and emotionally destructive for the client (Transference and Countertransference). They need to investigate where this comes from under supervision. The Reparative Many clients view therapists as perfect and tend to emotionally adapt to them as s a "parent figure" to assist them throughout the presumably future personal improvement during therapy. According to Clarkson, this reparative relationship involves corrective or replenishing actions where the previous parenting was insufficient (Clarkson, 1990). This stage helps the client begin to trust their judgment and reduces the need to utilize the therapist for emotional support; this brings therapy to an end. The Real Relationship At this stage, Clarkson focuses on the relationship between the client and the therapist, which does not include working. Studies note that building a personal connection with clients and establishing trust are key components of counseling and psychotherapy. This is true regardless of the method (DeAngelis, 2019). This is the core of the real emotional connection between the two. The Transpersonal Relationship This last relationship involves a client's feeling when they feel satisfied with the counseling. Clarkson describes this relationship as a spiritual connection[ CITATION Cla90 \l

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7 1033 ]. Clarkson’s model of integration also includes some theories: Attachment theory by John Bowlby, Donald Winnicott's theory, and Self-psychology by Heinz Kohut. Attachment theory by John Bowlby The attachment theory suggests that humans naturally need to form ties with their caregivers while young. These early connections can still impact attachments later in life (Wilson-Ali et al., 2019). In relation to Clarkson’s approach, his theory helps clients move from relating insecurely to relating more positively by their therapist; reparative. Self-Psychology by Heinz Kohut Self-psychology theory strongly emphasizes the discovery of the essential building blocks of effective development and growth and the development of empathy for the patient. Therapists may use self-psychology theory to guide patients in thinking about how their early experiences may have shaped who they are today (Baker, 2021). In relation to Clarkson’s transference relationship, by imitating, praising, applauding, appreciating, and respecting clients' sentiments of pride in their accomplishments, the therapist aids the client in working through this transference (Kohut, 2022). If a therapist is empathetic, the client starts viewing them as a "self- object," which reawakens their met needs, and the client opens up. Application of Clarkson's Approach to MW MW stopped coming to counseling after seven sessions claiming that it was not helpful because she did not get any better. To improve things and help her overcome the issues she is experiencing, the therapist will apply the Clarkson approach to MW. Firstly, MW’s dissatisfaction can be blamed on the failure of the first and second therapeutic relationships in Clarkson’s model. While the therapist and the client had been together for seven sessions, there

8 seems to be a lack of a strong bond between the two, and that is why MW claimed that she feels like the process was not helpful to her. Therefore, the therapist must utilize Clarkson's model's first, second, and third therapeutic relationship aspects to amend this. In the second aspect of the therapeutic relationship in Clarkson's model, the therapist in charge of MW will avoid transference and positively utilize countertransference. However, after the seven sessions failed and MW felt dissatisfied, they did not build a shared understanding and foundation; hence, they needed to repair their alliance again (Clarkson, 1990). Therefore, the two have to begin by recreating their working alliance, ensuring they meet during all the set session times, and making the client feel safe again. As Donald Winnicott would have it in his theory, the therapist and client should have “a practical aspect of holding” (Winnicott Presentation). Once the alliance is rebuilt, there is a high possibility of maladaptive transference in the second relationship aspect, which might affect the therapeutic relationship. However, as Clarkson notes, the therapist must be much more vigilant and avoid being unjust to the client because something they have or have said relates to their past. Therefore, based on Kohut's theory, to help the MW through the transference, the therapist will try to empathize with her by imitating, praising, applauding, appreciating, and respecting clients' sentiments of pride in their accomplishments. The therapist will also avoid maladaptive transference by being interested in MW’s issues, asking about her past, how she feels talking about it, and how she feels about sharing it with the therapist. For instance, the therapist can ask, “Have you always felt this way?” Alternatively, the therapist can also interpret MW’s past by trying to connect them with the present together. The two should try to work with resistance rather than against it (Transference (1)).

9 They will also utilize the reparative relationship with MW to ensure her satisfaction in counseling and achievement of the desired outcomes. At this stage, the therapist will try to gain the trust of MW and ensure she is confident enough to speak their mind and even challenge the therapist. This stage includes encouraging the MW to do more of what she is supposed to improve her state. The counselor should try to listen to what the MW is saying and feel their sadness; reactive CT. For instance, while the therapist has not had a rocky relationship with their mother, they can relate to the MW by feeling sad. MW should view the therapist as part of her emotional support. After this stage, the rest would not be challenging to adopt, provided MW is seeing some impacts in her condition. Alternative Approach: Cognitive Behavioral Therapy (CBT) For a long time, therapists have often utilized CBT to address many issues, including alcohol and drug abuse, anxiety, depression, eating disorder, marital issues, and severe mental health issues. While working with clients, CBT therapists often emphasize helping their clients learn to be their counselors. This is achieved through helping clients develop skills to solve problems they encounter and giving them exercise. They tend to emphasize what is happening in the client's life than what led to the issue (David et al., 2018). When incorporated into MW's intervention, CBT will help her develop the relevant skills for coping with low mood, anxiety, and extreme emotions. Impact of Long-term or Short-term Working with Clarkson’s model Long-term working with Clarkson’s model would offer the client enough time to trust the therapist and begin to get necessary interventions. On the other hand, short-term working with

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10 this model might not give MW enough time to bond with the therapist and make her dissatisfied again. Hypothesis 1: Short-term rather than long-term CBT will offer better outcomes Hypothesis 2: Long-term rather than short-term Clarkson's approach would have offered better outcomes for MW.

11 References Baker, A. (2021). A defense of Kohut’s “self. Psychoanalysis, Self and Context, 16 (1), 85-93. Clarkson, P. (1990). A multiplicity of psychotherapeutic relationships. British Journal of Psychotherapy, 7 (2), 148-163. David, D., Cristea, I., & Hofmann, a. S. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, , 4. Retrieved from Posttraumatic stress disorder . DeAngelis, T. (2019, November 1). Better relationships with patients lead to better outcomes . Retrieved from American Psychological Association : https://www.apa.org/monitor/2019/11/ce-corner-relationships Taylor, P. J., Perry, A., Hutton, P., Tan, R., Fisher, N., Focone, C., . . . Seddon, a. C. (2019). Cognitive analytic therapy for psychosis: A case series. Psychology and Psychotherapy: Theory, Research and Practice, 92 (3), 359-378. Wachtel, P. L. (2017). Attachment theory and clinical practice: A cyclical psychodynamic vantage point. Psychoanalytic Inquiry, 37 (5), 332-342. Wilson-Ali, N., Barratt-Pugh, C., & Knaus, a. M. (2019). Multiple perspectives on attachment theory: Investigating educators’ knowledge and understanding. Australasian Journal of Early Childhood, 44 (3), 215-229.

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