[Solved] Therapeutic Relationship,Establishing Therapeutic Goals,Understanding and Working with Resistance

An Introduction to the Case of Ruth
Dr. Kory and Ruth now begin the process of therapy.

>> Dr. Kory: Maybe you can say a bit about what actually prompted you to make that call.

>> Ruth: Oh you mean to call you?

>> Dr. Kory: Yeah at this point in your life.

>> Ruth: Well a couple of weeks ago I went to the doctor and I was having some trouble with my neck and my shoulders and my heart was racing; and I went to see him and after the exam he told me that there was nothing physically wrong but that I needed to call a counselor.

>> Dr. Kory: Was that reassuring when he told there was nothing physically wrong?

>> Ruth: Well I was glad to know that there was nothing wrong with my heart so I was really worried about that, but now I don’t really know what it is and.

>> For Dr. Kory, letting Ruth talk about what it’s like to come in for therapy is his first priority.

>> Ruth: It makes me kind of nervous because I don’t know if I change a lot like what it will be like at home then, like maybe with my husband it will be different, living with my kids it would be different and so I just wonder if I change a lot here, how they’ll feel about me changing. I’m not sure if they’re going to like it.

>> Dr. Kory: I suppose that’s a risk of this kind of work that you may change. I hope you would but you decide the changes you want to make, and maybe everybody in your life won’t be comfortable with that. If that’s a concern of yours we could do some work with that too. One thing I wanted to do today among several is to give you an opportunity to kind of find out how we’re going to work together. I’d like to find out a bit more about maybe your own expectations, what you’re hoping for.

>> Eliciting Ruth’s expectations, hopes, fears and ambivalent feelings is essential in this first session.

>> Ruth: I thought maybe that you would just ask me questions and then I would answer them; and then you would just tell me how to change whatever it was that I was worried about. That was the main thing that I wanted you to do.

>> Dr. Kory: Let’s say I had a magic wand and I can wave it and all of a sudden your sleep disorder would be cured, you wouldn’t have a racing heart, you wouldn’t have all the symptoms you just talked about. How do you think your life would be any different?

>> Ruth: Well I’m not sure. I guess I would just feel a little bit more comfortable and I wouldn’t worry so much about what’s wrong with me all the time.

>> Dr. Kory: What are the things that are going wrong in you that you’d like to understand more?

>> Ruth: Well, I kind of about the last couple of years I’ve been– I’m getting close to my 40th birthday and I’ve been feeling…

>> Allowing Ruth the opportunity to tell her story is important. Later in the session, Dr. Kory will explain to her how therapy works.

>> Dr. Kory: What I’m hoping we can do today is talk a little bit about how we’ll be working together, and what we’ll be doing in here because I think the more you can learn about this process, the more you can take initiative and use it; and what I hope you do is talk about something that’s difficult; not easy stuff because I assume my job is to help you with things that are harder to talk about.

>> Ruth: So I should decide what to talk about before I come?

>> Dr. Kory: Well you should at least give it some thought. I see my job as more to kind of support you to challenge you, to certainly be present during the session and listen and let you know what it’s like to hear what you’re saying. But my job isn’t to somehow make decisions for you. This is a learning situation and if you really want to make the best use of it I think you’re going to have to do something at home; and one thing I’d like you to do is keep a journal and write down your thoughts and your feelings, and we’ll talk more about that and that’s in the handout that I’m going to give you.

>> In closing, Dr. Kory and Ruth briefly process their first session together.

>> Dr. Kory: I’d like to know how it’s been to have the first hour together here. How has it been for you?

>> Ruth: Well it was very different than what I expected.

>> Dr. Kory: Ah hah, tell me a little more about that.

>> Ruth: Well I thought that you would just ask me a lot a lot of questions and I would just tell you the answers and so it went differently. It was a little bit more comfortable than I thought it would be.

>> Dr. Kory: I’m very open at any point for you to ask questions about what we do. I don’t want to have any mystery in this. I think the more you know about the process and about what we’re doing, the more you’ll be able to use this.

>> Ruth: Okay.

>> Dr. Kory: If I had to draw from any one particular approach in the beginning, it would be a person centered approach which stresses understanding her world as she’s experiencing it; so as much as possible I didn’t want to have any preconceived notions or ideas about how we would end up, but I did want to give her a chance to talk about her fears, her expectations and what it was like in this moment of being together. So the material I got was largely from her and what she was thinking and feeling and doing in that moment. If I had one main thing I wanted to accomplish, it was setting the stage for what we would be doing later. I’d want her at least to begin to think about what her work would be in this and what my work would be. And so giving her that package of materials to read and take home and the assignment or two, will prep her I think for next session.

> Doctor Corey and Ruth now work together in establishing therapeutic goals.

>> I gave you the autobiography that you asked me to write, and I was just wondering you know, was it okay?

>> Oh I read it. How was it for you though? I’m not trying to be evasive, but I would really like to know what you thought of it.

>> Well it was kind of interesting to write. I hadn’t thought much about writing the story of kind of what’s gone on in my life. It did bring up a lot of different feelings for me as I was writing.

>> Mm-hmm, like you said a lot of different feelings. Can you mention two or three different feelings it brought up.

>> Some disappointment.

>> Mm-hmm.

>> Some anger.

>> Mm-hmm.

>> In therapy, autobiographical and journal writing can help uncover areas of difficulty in a client’s life, and lead to a more specific set of goals.

>> I’d like to spend some time in this session talking about specific goals that we’re gonna be working on as long as we’re together. Now we’ll change that. It’s not that we have to talk about that today and forever we’ll hold you to it. But I think it is important that you think about what do you want, and why are you coming here, and how can we best get it. So what were some of the things you came up with?

>> Well I made a list. One of the things on the list that I haven’t said much about yet is that I’d like to feel better about my appearance, about my looks.

>> Mm-hmm.

>> One of the other girls was, about my relationship with Jennifer, my daughter, very strained right now since she’s become a teenager. And I used to feel really close to her, and now it doesn’t feel that way any more. I’m not sure how to change it, but I’d like to feel like we’re not strangers.

>> Ruth, a lot of these things I want to come back to. What I’m trying to do now is just kind of lay out a tentative agenda. And I think it really helps you as much as me to be thinking about what do you want from these sessions. So there’s the thing about school and about other people’s approval, and about weight, and about a different relationship with Jennifer. Any other goals that came up for you.

>> As specific therapy goals are established, Doctor Corey and Ruth now must prioritize them.

>> Of that whole list you just went through, and it may change between now and next week, but are there any things that are on the top of your head that you feel ready to go with? If we had another hour right now, and we were to continue, what do you most think you’d want to pick up on.

>> Hmm. Perhaps the relationship with my husband.

>> Mm-hmm.

>> Clarifying goals will be an ongoing process throughout the course of therapy.

>> Not that these goals end here, this is really the beginning. I think every week I’ll be asking you to keep thinking and refining, and fine tuning what is it that you want, and that could include what you want with others. So it’s not just what you want selfishly, but what do you want in your life, and how do you want your life to be different? So I don’t see that as ending now, but I think sometimes people think themselves very vague. And so what I’ve been trying to do is get you to kind of think about how you can make these manageable. [ background music ] I think what I’m really attempting to get at is for Ruth to look at the direction that she’s moving toward in her life, and then getting her to make an evaluation of that direction. Is it taking her to the place she wants to go. And if she says no, then we can say okay, what direction would you like to go. So, and I’m really borrowing that largely from reality therapy, that asks clients to make the evaluation of what they want to change. And also from behavior therapy and cognitive behavior therapy, the importance of having very clear goals so that we know where we’re going. But the most important thing is that these goals should not be ones that I dream up for Ruth, that I think are important, but ones that really come from her.
In their next session, Dr. Cory works on establishing a therapeutic relationship.

>> So one thing I’d like to find out too, is did you have any afterthoughts Ruth, about the session last week?

>> It seemed, it seemed so different for me, I wondered whether it was being selfish.

>> Do you have an answer for that? Was it being selfish?

>> It seems that that would be the response of some of the people in my life, my husband maybe. I’m not used to having somebody really ask me so many questions about myself and be so interested. It feels kind of awkward, like I’m the subject of all of this and I’m not used to having somebody pay so close attention to what I’m thinking and what I want.

>> In this session, Dr. Cory and Ruth continue to explore and clarify their roles in establishing a working relationship.

>> I was hoping that you’d be telling me more what to do, and you’d be making more of the decisions.

>> Right. And you know I think, even if I had enough wisdom which I don’t, to tell you what to do, I’ll tell you why I wouldn’t want to do that – because you’d have to keep coming forever then, because anytime you’d get a new problem you’d have to come back and say well, where am I gonna go next? So although I can appreciate you maybe wanting that, it’d be easier in a way. I really don’t want to give in too easily to tell you what you should do. It sounds like that’s what you’ve heard a lot in your life already.

>> I just… besides my husband I really don’t talk that much to other men, and so it’s new to talk to somebody that’s a man and somebody that’s stranger. I really don’t know you and…

>> So I’m a strange man?

>> [ laughing ] No. In a way.

>> The therapeutic relationship is one of the most significant factors in the change process. Developing trust as the foundation, will take some time.

>> It sounds like you’re cautious with me. In some way you’re measuring what you’re gonna say and you’re very aware of what I might be thinking, and how I might be receiving you.

>> Well I suppose it’s… my way of trying to determine whether I should trust you with information or parts of…

>> I don’t expect you immediately to trust. I think this is new and it’s gonna take time, but I think what I hope you can do is at least talk about what you do feel, or what gets in your way of building a trusting relationship.

>> In building this relationship, who the counselor is as a person is just as important as his or her knowledge and counseling skills. As this trust deepens, so does the process of therapy.

>> I’ve had a lot of conflict with my father in particular, around my religious beliefs.

>> Okay.

>> And that’s been very difficult for me.

>> So that’s certainly something we could talk about.

>> Yeah, it’s something that I know I’ve struggled with inside myself, but I’ve never spoken about it to anyone before. I’m nervous about what might come out next, what I might say… maybe that I’ve revealed too much.

>> Let’s go with that for just a moment. What if you do reveal too much?

>> Well I’m afraid I’d be feeling exposed.
As you watch Chapter 3 Session 2, The Therapeutic Relationship; Chapter 4 Session 3, Establishing Therapeutic Goals; Chapter 6 Session 5, Understanding and Working with Resistance; and Chapter 11: Session 10 Working with Transference and Countertransference from the counseling sessions with Ruth, pay attention to the techniques from psychodynamic theory that you see Corey using. Refer to pages 66–71 in the Walsh text.
• List the names of the techniques from ego psychology used by Corey.
• Describe how Corey responds to Ruth’s transference in Session 10.
• From an object relations point of view, what have you observed about Ruth’s sense of self?

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