Therapeutic Relating in Expressive Therapies: Reflections On Being With Young Clients

Mark:
Mark has been conducting training courses in Expressive Therapies and Sandplay Therapy around Australia since 1989. He has completed further studies in Transpersonal Psychotherapy with Dr Stanislav Grof, and holds a Masters in Education, majoring in behaviour management, and a PhD, researching multiple intelligence theory in counselling.
Mark has over 28 years of experience as a counsellor and counselling supervisor, and has been a Lecturer and Senior Lecturer in counselling at three Australian universities, and for the Australian College of Applied Professions. He is the Co-Director – with Helen Wilson - of Expressive Therapies Australia.

Helen:
Helen is co-founder of Expressive Therapies Australia, and is a senior trainer in Expressive Therapies and Sandplay Therapy, around Australia and internationally.
Helen has conducted a counselling and supervision practice for over 34 years. She has completed advanced studies in Transpersonal Psychotherapy with the Grof Transpersonal Training, has a degree in Human Resource Management, a Master of Counselling, and a PhD, researching self-compassion. Helen has completed all three levels of training in Emotional Release Counselling and Transpersonal Studies and holds a Post-Graduate Diploma. She has a Certificate in ERC with Children, a Certificate in Sandplay Therapy, as well as several qualifications in clinical supervision. Helen has completed advanced Sandplay Therapy. She has been a Lecturer and Senior Lecturer in counselling with a number of Australia universities. She is a Level 4 member of ACA.

This article shares reflections on building rapport with young clients within an activity-based approach to counselling – expressive therapies. Current research confirms that creative arts-based approaches can increase positive therapeutic outcomes. Certainly, they engage a client in ways that can dramatically support self-understanding and growth. However, as the research also indicates, the client’s relationship with the counsellor is one of the key ingredients in therapeutic success. Effective therapeutic relating involves more than attentive listening, curiosity, being comfortable with uncertainty, using invitations and offering choice. In practice, effective relating also requires activities that support the young client to gather their thoughts, identify their feelings and feel safe enough to discuss their behaviour. We address here some ways expressive therapists endeavour to both ‘be with’ a young client and engage them in activities to enhance therapeutic relating.

Growth, change and capacity for self-reliance have been found to be directly related to what a client engages with in a session (Cook-Cottone, Anderson & Kane, 2019; Swift & Greenberg, 2015). The question then is whether the theories that underly our methods offer us the key to effective therapeutic relating with this client group. In fact, unsurprisingly, the strongest predictor of positive outcomes is a capacity and willingness to relate with our clients as individuals. Importantly, establishing trust has to be primary (de Greef et al., 2017) alongside our ability to instil hope of change (Swift et al., 2012) and to engage the young person in the process (Swift & Greenberg, 2015).

One of the many joys of supporting clients with expressive therapies (ET) is that the activities include multiple catalysts for trust to flourish and allow young clients to reflect on their situation, prioritise what they want to focus on and find starting points for communication. Ideally, they also enable the swift development of rapport. ET provides creative arts-based activities that focus on resolving emotional difficulties, exploring beliefs, growing somatic awareness and regulating behaviour. Over the last 35 years, ET has been developed in Australia as counselling support for children, adolescents and adults, with the goal of resolving challenges, in addition to expanding personal development that leads to wellbeing.

ET approaches include a flexible, interactive range of experiential activities that explore, process and support resolution of sources of emotional distress. Rather than sessions being problem resolution saturated and focusing on cognitive dialogue, ET is person-focused and action-based. We are interested in who the client is rather than what they have done. At its heart, ET is process-oriented, and the invitation to self-discovery is the most effective avenue to foster a client’s capacity for emotional regulation, hope, optimism and self-reliance. We seek to offer ways to engage without clients necessarily experiencing what feels like interrogation. With its activity-based creative arts counselling and psychotherapy approach, ET privileges self-discovery through emotional and somatic knowing. ET practitioners work in the present, while the scaffolding of activities open psychological space, allowing – but not forcing – anything from the past to emerge. ET also seeks to identify and optimise, in positive ways, a young client’s individual strengths and their self/other awareness.

ET integrates the strengths of a range of approaches and offers pluralistic, creative arts-based activities that include somatic and emotion focus using art, music, metaphor, movement, writing, drama, miniatures, relaxation, visualisation and mindfulness. Activities such as completing sentence starters, expression through arranging a group of miniatures and showing feelings with colours and lines all stimulate clients’ self-reflection, and provide them with reflection time and a safe way to recognise what they feel ready to share or ask.

Significantly, our way of being with clients, our willingness to hold them in their ‘not knowing’ space, and being comfortable with our own momentary not knowing, is critical to client–therapist attunement. In addition, our understanding of and expertise with the methods contributes to forming and maintaining positive therapeutic alliances. Therapeutic alliance has long been shown to be closely correlated with positive therapy outcomes (e.g., Botella, et al., 2008; Lambert & Ogles, 2004; Luborsky & Luborsky, 2006). The manner in which activities are employed, as well as their appropriateness can, however, influence the alliance. Both over-structuring and under-structuring therapeutic interventions predicts a negative alliance (Muran & Barber, 2010).

Research suggests that, overall, there are 3 clinically relevant features of a therapeutic alliance: bond, goals and tasks, as originally identified by Bordin in 1979 (Faw et al., 2005). Younger clients may focus more on the bond, whereas adult clients may be more focused on goals, strategies and tasks. Baylis et al. (2011) identified further behaviours on which the alliance – according to their young clients – was dependent. Of course, these were ‘being nice’, doing activities, active listening and expressions of caring. The concept of alliance developed from feedback from young clients (Campbell & Simmonds, 2011) included the therapist’s ability to understand the child’s view of the world, and the expressions about the bond included warmth, trust, respect and empathy, with trust being identified in this research most often.

With its activity focus, ET readily engages young clients who often prefer to ‘do’ something rather than talk about difficult events or feelings. If you are an experienced counsellor, none of this will be new information. However, ET privileges taking time to develop a connection prior to offering activities that may focus on emotion – or indeed any intervention. A priority in offering activities that support a workable therapeutic connection is the ability to ‘sense the most appropriate moment’ (Ceberio, as cited in Soares et al., 2010, p. 177). By evaluating ‘which one best suits that particular client’ it is, in that moment, possible to offer the most useful intervention (Ceberio, as cited in Soares et al., 2010).

We evaluate whether our client’s natural strengths reside in visual/spatial expression, in somatic awareness and movement, in music and rhythm, or perhaps in silent reflection and written expression (Gardner, 2006). Counsellors ideally pay particular attention to their relationship with the young client and find ways to enhance what that person contributes to the therapy. This can be achieved by including awareness of the multiple intelligences theory and practice (O’Brien & Burnett, 2000; Pearson & O’Brien, 2012).

In terms of ‘what to do’, expressive therapists are blessed with an abundance of activities. Having a collection of miniatures in the consulting room, for use with symbol work or sandplay therapy, means the client can identify, and then perhaps communicate about, internal states via their attraction to specific miniatures. Miniatures can be arranged in a way that graphically communicate relationships (for example, showing family dynamics), and can be rearranged to indicate transformations in the therapeutic process (Pearson & Wilson, 2001). Additionally, because it does not require clients to be explicit, arranging miniatures is a safe way to provide metaphors for implicit reflection on and communication about disturbing experiences.

Having a range of visual arts equipment to choose from may mean a client can gravitate to ways of non-verbal thinking (Lowenfeld, n.d.), emotional processing and abstract expression of internal states – for example, through use of abstract combinations of colours, lines and shapes – that may be difficult to identify and process if verbalisation alone were to be used. Or perhaps a more kinaesthetically inclined young client may be drawn to shaping clay, creating representational or abstract shapes that express their fears, hopes or dreams.

Simple as it sounds, meeting a client ‘where they are’, ‘joining with’ them in whatever mood or state they may present in can support a feeling of safety and may be a prerequisite for rapport and engaging their interest in self-exploration. First and foremost is working through any need for the client to fit, or validate, our framework. For example, can an expressive therapist, with their vast array of creative, artistic, experiential activities, be equally comfortable supporting a young person who is highly articulate, as well as those who use only one or 2-word responses when asked a question? Can we be equally at home if a client wants problem-solving support or eagerly immerses themselves in playful, silent use of miniatures or artistic expression with crayons, paints and sculptures? And can we understand the life challenges faced by young people with diverse lives, and how do we maintain ongoing awareness of and work with those challenges?

Self-reflection and self-awareness become possible, and start to solidify, once feelings of safety within the relationship can be tested by the client. For the client to feel safe enough to relax any defensiveness, initial apprehension or experiential avoidance, the next step involves an invitation to respectfully encounter their internal world. To connect with their emotion, follow their thoughts, depth their somatic awareness and identify their wants and needs requires a counsellor to begin to understand what might be personally and culturally appropriate. We need to be listening actively for what might be problematic for them, as well as their strengths, hopes and dreams. Ideally, we will have explored similar steps in our own personal development, as our personal experience provides an ideal grounding for pursuit of flexible and compassionate relating.

A person-centred way of relating can quickly develop a sense of safety for the client. In one of his earlier works, Rogers (1951) asked questions to determine if therapists’ attitudes were truly client centred. Over 70 years later, these questions still provide useful reflection points for therapists intending to value clients’ internal resources. For example, Rogers asked if our valuing of person-centredness was simply a concept or if we carried it into therapy in a practical way. He asked if we really respected our clients and if we could let go of a need to control. Rogers points out that our own personal development may determine our ability to be person centred.

Trust is not automatic. We cannot assume the young person in front of us can feel safe to trust us or themselves. In reality, if they are in our counselling room, chances are they’ve experienced an unsafe or unhelpful world. How do we be and relate in ways that are likely to develop trust and safety? Outer trust, with the therapeutic environment and the counsellor, is a prerequisite for moving forward. Research from neuroscience and psychotherapy (e.g., Cozolino, 2006; Porges, 1995) provides supportive evidence that a counsellor needs, ideally, to be in a regulated and ‘present’ state to allow clients to risk dropping experiential avoidance, to explore difficult emotions and to understand and make a choice to change behaviours. Outer trust can emerge reasonably quickly with some clients, but can also be fragile and require constant ‘reworking’ for a client who carries a legacy of shame, traumatic experience and/or attachment disruption, and ultimately experiences self as incapable.

A client’s inner trust with themselves is a significant requirement in counselling. Inner trust refers to a client’s capacity to experience themselves as safe, successful and able to hear and tolerate their own distress, as well as engage with the therapeutic ‘tools’ offered. For example, an adolescent client who has never before used miniatures as symbols to explore an issue of loss or grief might at first wonder how their distress could be eased by simply picking some small objects off a shelf and arranging them on a table. Gradually they come to see these spontaneous actions begin to open windows to their thoughts, feelings and needs, and start to trust spontaneity within therapy and the activities we offer.

Undoubtedly, counsellors want to know if there is a way our relating with a client can enhance their openness to vulnerability and self-awareness. It’s a perennial question. When feelings of trust and safety are established, we can offer questions or activities that focus awareness on their body, mood, energy, self-image, and thoughts and beliefs of the moment. What fosters that feeling of inner and outer safety? Is it our room? Our voice? Our questions? Our presence? Our calm and focused state? Of course, it is all of the above, with creative activities offered at the right moment.

We have found that young clients may have limited notions of what counselling is and what will be ‘expected’ of them. Finding simple ways to communicate this is likely to reduce apprehension and support a more open, honest exchange. Within this framework, of course, is explaining confidentiality. Other boundary setting is also required; for example, in an approach that encourages role-play, movement, noise and emotional expression, boundaries between the consulting room and the outside world need to be clear.

Ideally, we want to relate with a young person in a way that assists them to have the agility to re-establish connection with their own resourcefulness and self-efficacy. A therapeutic alliance that assumes clients have the capacities and internal resources to solve their problems, even if these seem distant or unknowable when the client first enters therapy, can support this reconnection. After emotional and cognitive challenges are initially addressed and a client feels support for growth in their sense of self, they can more readily reconnect with their resilience and creative potential. Sensing this support, clients are more likely to pursue productive choices and formulate positive action steps.

Having established rapport with the young client, we think about what activities can be offered. Whenever possible, offer an approach that integrates self-awareness, self-reflection and self-expression opportunities. These opportunities may be times of quiet sharing using drawing or choosing miniatures; they might involve accessing and expressing difficult emotions through emotion-focused processes. Activities that provide an outlet for reactivity might be appropriate, in addition to activities that enhance integration as well as future planning.

Encouraging a client to connect internally and discern their motivations, wants and wishes and anxieties means allowing time during the session for them to reflect, time for them to ‘hear’ what they discover about themselves. Hence, the process of therapy moves to a holding space of ‘allowing’ rather than a space of continual ‘doing’. We would not want our young clients to merely be submissive responders to our directions. We want them to develop the knowing that within therapy they are able to query, retain privacy, enact some control and have their preferences respected. This means asking something like ‘When you tune in to your body and feelings, what do you think needs to happen next?’ This is more respectful than guessing what is happening and giving an instruction or telling them to do something. Invitations encourage the client to reflect on their needs and choices and to increase their commitment and motivation to participate in the session.

A common perception in novice therapists is that efforts to establish empathy mean they need to use clever questioning and have the skill to assess what a client is feeling or thinking. The result is that what sounds like a question can mask a statement. Rather than ‘It sounds like you may be stuck/sad/angry/lost, etc.’, we could we simply ask ‘Would you be able to share what’s happening for you right now?’ The task is to question our assumptions and to take a step back from being the director and from controlling the process, while at the same time guiding the conversation, providing options and offering choices.

Step 1 of the ET 5-step Session Model (Pearson & Wilson, 2009) focuses on building rapport and trust with the client and all stakeholders, a first step in growing a strong therapeutic alliance. This stage aims to break the ice, establish feelings of acceptance and safety and allow the counsellor to begin learning about the client’s experiences. We know that to develop rapport we need to allow silence and give the client time to think and feel before launching forward with more questions. And rapport can develop quickly, even within the first 10 minutes of the first session, and will commonly strengthen over time (Pearson & Bulsara, 2016). An essential cognitive component of trust and rapport-building is providing some framework or rationale for counselling and for the myriad creative arts activities that can be offered within ET.

Steps 2, 3 and 4 are the areas that involve skilled facilitation and understanding of the appropriate choice of experiential activities that can be safely explored in a field of mutual empathy between counsellor and client. The final step in an ET session aims to provide opportunities for a young client to formulate their own strategies, action steps and ways of seeking support to achieve productive, positive outcomes from their interactions with the world. While the counsellor refrains from making overt suggestions, they discuss the appropriateness of the client’s self-generated strategies with the client in detail. The counsellor can provide the client feedback about the overall suitability of the strategies and their contribution to getting the client’s life on track in a way that has positive results for them.

Therapeutic Relating in Expressive Therapies: Reflections On Being with Young Clients