‘Therapeutic use of self’

Therapeutic use of self can be defined as: A therapist’s thoughtful, deliberate effort to use their self as a tool, one which embodies a self-aware therapeutic way of being in the service of clients and the client-therapist relationship.

It is the self-aware intertwining of both our professional self (the one that uses knowledge, skills, and techniques) and our personal self (which arises from our history, beliefs/values, personality, and embodied lived experience). It involves our therapeutic practices that we’ve learned and our particular way of maintaining a caring, attuned, holding presence. In other words, therapeutic use of self involves the totality of our being and doing; it is present in our every intervention.

Virginia Satir (1967) was perhaps the first to fully articulate its relevance to psychotherapy. In different writings throughout the 1980s, she challenged practitioners to shift from being merely skilled ‘technicians’ (whose primary focus is on skills and techniques) or ‘clinicians’ (who combine skills with practice-acquired wisdom) to become ‘magicians’ who use skills, practice wisdom and the use of self.  In other words, she was urging therapists to move beyond just ‘doing’ to embrace ‘being’ by becoming more self-aware and attending to the therapeutic use of self:

“I have learned that when I am fully present with the patient or family, I can move therapeutically with much greater ease. I can simultaneously reach the depths to which I need to go, and at the same time honor the fragility, the power, and the sacredness of life in the other. When I am in touch with myself, my feelings, my thoughts, with what I see and hear, I am growing toward becoming a more integrated self. I am more congruent, I am more “whole,” and I am able to make greater contact with the other person.” (1987/2013, p.25).

Adapting and adjusting therapeutic responses

Research consistently emphasises the importance of adapting therapy to the individual. “The clinical reality is that no single psychotherapy is effective for all patients and situations no matter how good it is for some” (Norcross & Wampold, 2018, p.1893).

As therapists, we make deliberate choices about how and when to intervene.  We continuously adapt and pace the levels of care, formality, spontaneity, emotionality, challenge, support, self-disclosure, intimacy, control and directiveness we offer. 

Early in the therapeutic relationship, we might listen in a reserved, empathic way as part of engaging a client in therapy. Then, as therapy develops, we might raise the element of challenge by adopting a more muscular, directive approach.  In an introductory contracting session, we may be quite formal and boundaried, to show we are a trustworthy ‘professional’. Later, we might reveal more of ourselves as a ‘person’ as trust and intimacy grows. Sometimes, we find ourselves being lively and activating; at other times, our pacing may be slower, in order to offer clients a space of stillness.

There’s no magic formula here. It’s about exercising our professional judgment, minute-by-minute, in response to what we responsively assess is needed. 

The therapeutic alliance can be understood as the mutual partnership that, while emerging over time, is also infused with each moment of therapy. It expresses itself as a warm emotional bond where the therapist is responsive and encourages collaboration. Enacted in different ways, it reveals itself in the form of mutual respect and trust. As therapy unfolds, the client feels seen and supported; they sense that the therapist is on their side. 

In the dialogue below, the therapist initially contains his (potentially destructive) responses, holding himself back in order to enable the client to be more present. Recognising that something delicate is emerging, he doesn’t want to inhibit Jenny’s process by inserting his own reactions too strongly or quickly.  Then, the therapist becomes more present himself when disclosing that he is open to her anger. He carefully reflects back Jenny’s words, all the time becoming more directive as he coaches her to express herself.               

Jenny (client): When I woke up this morning, I didn’t really want to come to therapy.

Therapist: [Initially, the therapist feels some irritation and wants to say, “If you don’t want to be here, you don’t need to come.” But he has enough self-awareness to contain this reaction (which he recognises as coming from a rejected child place) to stay with Jenny’s experience.] What was happening for you in that moment?

Jenny: Often I wake up feeling angry, I want to say “no”, I just want to stay in bed and do what I want to do. But then my grown-up responsible part of me gives me a shake and reminds me what I ‘should’ be doing. I knew I needed to be here.

Therapist: [He notes that she sees that responsible part as ‘adult’ whereas he believes its Jenny’s ‘good girl’ part. He doesn’t correct her or share his different interpretation. He stays with her experience and just reflects back.]  I’m hearing that part of you didn’t want to be here; but another part, got you moving and told you to be responsible and go to therapy.

Jenny: Of course I want to be here. I really value you and our work together.

Therapist: And what about that angry part?  Are you open to working with that part a bit more?  [Jenny nods hesitantly so the therapist proceeds gently not wishing to overwhelm or scare her further.]  I noticed that when you initially described your waking angry part you had your fists closed. Can you do that for me now and really try to exaggerate that moment?  [Both therapist and client hold their fists up tightly like boxers. The therapist does it with her to normalise it and ‘be-with’ her in that place.  Initially her arms are still a bit lose and floppy and she looks feeble. He encourages her to put some ‘muscle’ and force into them. He provocatively – but gently – pushes against her arm until she holds her fists strongly.] If those fists could be talking what would they say? [Conscious of the risk that Jenny might be experiencing him as being too aggressive like her father, he keeps his tone curious and gentle. Later he will recognise that he occasionally comes across too forcefully which elicits her compliance, and he wonders if at those points, he is inadvertently replaying her history. He takes his initial irritated response to supervision.]

Jenny: [hesitantly] Go away?  I’ll fight you if you try to make me? 

Therapist: Can you say that again with more conviction? “Go away. I’ll fight you if you try to make me!”  [Therapist mirrors Jenny’s behaviour and words but takes out the questioning tone and invites her to say it again more loudly.]

Jenny: Go away! I’ll fight you if you try to make me! 

Therapist: What’s happening for you right now? You’re looking thoughtful.

Jenny: I’m feeling strong. And I’m remembering my childhood. My father and brother used to fight like this all the time. I couldn’t stand up to them. I never did this. When I tried, I was punished and told “girls don’t fight”. I’d end up hiding in my wardrobe.

Therapist: [Now the therapist is feeling compassion for the ‘good’, scared little girl who was never allowed to express herself.]  Like you told yourself not to be angry this morning?  [Jenny nods slowly with this new insight.]  But what if I said that I’m okay about you expressing your anger here and that I like to see it? 

Jenny:  It’s alright for me to be angry?  [Therapist smiles softly and nods encouragingly.]  Now there’s a new concept!

Critical reflections

Expertise is less about mastering the therapy method and more about the relationship, responsiveness, and commitment to improvement. (Norcross & Karpiak, 2017, p.73)

The ‘science’ and ‘art’ of therapy are expressed in the clinical judgements we make regarding when and how to intervene as we fluidly engage varying levels of: support/challenge; separation/distance; connection/intimacy; self-containment/self-disclosure; non-directiveness/directiveness, and more. 

As I reflect on the complexity of this process, I am awed by the artful way we continually negotiate subtle experiential and relational layers.  I am reminded about Storr’s words that “psychotherapy will always remain more of an art than a science” (1990, p.69).

When we ‘go with the relational flow’ and trust the therapeutic process, client and therapist, find themselves immersed in a duet of co-created music. Yet, while moments of connection can feel magical, our craft skills and strategic techniques can be reflected upon, observed, and learned, as the micro-communications identified in the case study above.

Ultimately, its about being a human being in relation with another human being.  Use of self is less about applying therapy techniques and more about finding a way to be-with our clients, in patience, curiosity, compassion, caring and challenge, while they go exploring in search of a different path. It involves going beyond knowledge, protocol, and skill, to a place of Being not Doing.

Working relationally with a focus on the therapeutic relationship means privileging the emergent, here-and-now relationship between therapist and client and flexibly attuning and responding to each client’s relational needs (DeYoung, 2003; Spinelli, 2015; Erskine, 2020). It is about opening to the other while being willing to give of self and as it is in the service of the client, it remains an ethical undertaking. It also means opening to wider social-cultural factors and influences imbedded in our embodied intersubjective relationships.

The therapist needs to have the courage to stay in ‘the process’: to be emotionally present to intra-psychic and interpersonal dynamics while being prepared to take some risks towards the co-creation of the therapy. The challenge is to embody ways of ‘being-with’ naturally and effortlessly, rather than be led by theory or technique (Finlay, 2016).  Then, we need to take up opportunities to reflect and grow. On the basis of their extensive critical review, Hill et al (2017) conclude that growth through therapy, supervision, reflection, and feedback is crucial to the development of expertise.

Thinking about your own practice, it’s worth taking time to reflect on how you use your self. Hint: think about your being and doing. You may find the following self-inventory questions helpful (adapted from: Edwards & Bess, 1998; Dewane, 2006):

  • Why do I like being a therapist? What personal needs are met?
  • What special qualities or abilities do I offer clients?
  • How do my beliefs affect the way I work?
  • What traumas or life challenges have shaped my worldview and might be triggered in work with clients?
  • How easy is it for me to just ‘be with’ clients and not rush into ‘doing’ or ‘performing’?
  • How does my theoretical model of practice influence my work?
  • How do I adjust my levels of intimacy, disclosure, spontaneity, support, and challenge with different clients?
  • How do I react if a client resists, or is critical of, their work with me?

References

Dewane CJ (2006) Use of self: A primer revisited. Clinical Social Work Journal 34(4), 543- 558.

DeYoung PA (2003) Relational Psychotherapy: A Primer. New York: Brunner‐Routledge.

Edwards JK and Bess JM (1998) Developing effectiveness in the therapeutic use of self. Clinical Social Work Journal, 26(1), 89–105. https://doi.org/10.1023/A:1022801713242

Erskine RG (2020) Compassion, Hope and Forgiveness in the Therapeutic Dialogue, International Journal of Integrative Psychotherapy, 11, 1-13.

Finlay L (2016) Relational Integrative Psychotherapy: Engaging Process and Theory in Practice. Chichester, West Sussex: Wiley. 

Hill CE, Spiegel SB, Hoffman MA, Kivlighan DM Jr and Gelso CJ (2017) Therapist expertise in psychotherapy revisited. The Counseling Psychologist 45: 7-53. DOI: 10.1177/0011000016641192

Norcross JC and Karpiak CP (2017) Our best selves: Defining and actualizing expertise in psychotherapy. The Counseling Psychologist 45(1): 48-60. DOI: 10.1177/0011000016655603

Norcross JC and Wampold BE (2018) A new therapy for each patient: Evidence-based relationships and responsiveness. Journal of Clinical Psychology 74(11): 1889-1906. DOI: 10.1002/jclp.22678

Spinelli E (2015) Practising Existential Therapy: The Relational World (2nd Edition). London: Sage Publications.

Storr A (1990) The art of psychotherapy (2nd ed.). Oxford: Butterworth-Heinemann.