Posted on November 12, 2018 by Origins Behavioral HealthCare
Open your favorite academic search engine and query “intimacy in counseling” or some variation on that theme. The vast majority of articles, chapters and books you will find referenced address how counselors help patients deal with intimacy in their relationships. This is certainly how it should be given the importance of the topic in our field. However, there is another aspect of intimacy in counseling that is also highly relevant yet less frequently discussed: intimacy in counseling and supervisory relationships.
Perhaps one reason for this paucity in literature is that the term “intimacy” is often associated with romantic or sexual relationships that would be inappropriate in a counseling or supervising relationship. A more comfortable and commonly used frame of reference is the concept of therapeutic rapport. This is a broadly understood paradigm for the level of connection and openness in a counseling relationship that facilitates healing and growth in patients. Similarly, in supervisory relationships with students or other new counselors, healthy rapport serves to facilitate learning and skill development.
Having spent many years as a therapist and clinical supervisor, I have found that the concept of therapeutic rapport is one that is conceptualized in many different ways and that my own understanding has changed over time. My experience is that newer counselors having a difficult time setting boundaries with patients will often tell me that they don’t want to “hurt their therapeutic rapport”. Another pitfall is overuse of self-disclosure in an effort to “develop therapeutic rapport”.
It is sometimes difficult to quantify how to best develop healthy and ethical therapeutic rapport but I have come to believe that in order to understand it, we must examine the very real aspect of intimacy that is a part of it. Sullivan (1993) suggests that intimacy involves four qualities: proximity, mutuality, trust and self-disclosure. A seasoned counselor will read those qualities and either see four areas of potential danger or four areas of immense opportunity, depending on their mindset at that moment. Let us consider each, examining some threats and opportunities in both counseling and supervision.
Whether through physical closeness in an office or through telemedicine, the practice of counseling and clinical supervision alike will involve regular times in close proximity.
Prior to the last decade or so, proximity has been a relatively static term. It simply meant the degree of physical closeness one person or object had to another. Today, the proliferation of social media into our national and global psyche has complicated that term. Particularly when working with individuals who have grown up with social media as a norm, counselors and supervisors must consider how both physical and virtual proximity impact the dynamics of the professional relationship.
Awareness of how proximity effects patients or supervisees comes as the result of the professional counselor assuming nothing and asking regular questions. At the onset of the professional relationship a counselor is well advised to initiate a discussion about proximity and how the patient or student sees their own needs in this area. Throughout the process, especially when there seems to be an unexplained strain in the professional relationship, having these conversations are also well advised.
Also, given the dynamics of virtual proximity in today’s culture great care should be taken in considering to “follow” or “friend” a patient. This act is construed by many as equal to any other “face to face” friendship and one may unwittingly enter into an inappropriate dual relationship.
Webster defines mutuality as “a sharing of sentiments”. In non-professional relationships this is often an apt descriptor of an important quality of intimacy. Though intimate relationships never require persons to feel the same about everything, a general sharing of sentiments about significant issues is important.
In clinical and supervisory relationships, mutuality is much more about having a shared direction and end-goal for the relationship. As counselors, our end goal is to facilitate health and well being in out patients even if their values are contrary to our own. We need not share sentiments; we need to share goals. Also as supervisors, our goal is not to make counselors who will think like us. Our goal is to protect patients and enhance the science and art of counseling through a reflective, tutorial process.
In professional relationships it is the counselor’s responsibility to clarify this difference in mutuality and to clearly establish the process. This can be uncomfortable when patients or supervisees are primarily seeking validation for the professional relationship. Though it can be tempting to take the easy route of simply providing warm feelings for patients and supervisees, our job is to help facilitate movement towards goals and this must not be lost.
In any relationship, trust involves two important principles: fidelity and veracity. Fidelity is about keeping promises and veracity is about telling the truth. When one asks, “do you trust me?” they are asking, “Do you believe that I will do what I say and that I will say what I mean?”
In counseling and supervisory relationships, the question of trust is key to establishing an environment of safety. It is this safety that allows for and cultivates vulnerability, which is necessary for any genuine growth to occur. The great difficulty with trust is establishing and nourishing it and the potential pitfall of trust is overdependence on this trust.
I have often been asked by supervisees, “How do I get patients to trust me?” This answer is: be trustworthy. In fact, I believe the question “Do you trust me?” is generally the wrong question to ask in any relationship. The better question is: “Am I being trustworthy?” When we ask ourselves, our patients and our supervisees this question, we potentially gain important and actionable information. This is only insofar as we are genuine in this question and we seek to be open to growth and change at ourselves at all times.
The potential pitfall with trust is that it can cause overreliance with anyone involved. Patients may believe that their counselor has all of the answers for them and develop unhealthy dependence. Students and supervisees may experience this as well. In clinical supervision supervisors may have so much trust in a supervisee’s natural abilities that the supervisor may provide less oversight than is needed. It is important to remember to keep trust in its professional realm. When we set clear boundaries and expectations, we can simply ask, “Am I doing what I say and saying what I mean?”
As an educator, I have often told students that they should never use self-disclosure as a therapeutic tool for at least their first five years as a credentialed counselor. Now this is meant to be a bit tongue-in-cheek but it has an element of seriousness to it.
When I was a little boy, I remember a teacher once told me that “intimacy” meant “into-me-you-see”. Many decades later I see intimacy differently but I still believe that this teacher’s idea has some merit to at least part of the equation. There is a power to self-disclosure and it tends to draw people to each other. Appropriate use of self-disclosure can sometimes be a catalyst to help a patient or student begin to consider moving into trust.
However, there are many potential pitfalls to self-disclosure (too many, in fact, for this article). The most significant problem with utilizing self-disclosure is that it has the potential of turning the focus from the patient or student to the professional counselor, effectively losing the point of the entire process. Counselors at all levels should use self-disclosure like hot pepper. It should be used sparingly, with forethought, and everyone should know about it. The question “Am I sharing this for my patient or am I doing this for me?” should be at the forefront of any self-disclosure.
Proximity, mutuality, trust and self-disclosure: four complicated elements of intimacy but worth a close and ongoing examination if we are going to develop healthy, effective rapport with patients and supervisees. As a counselor looking to be effective and ethical in these areas I try to remember the idea that “no one can see the spinach in their own teeth.” The development of intimacy in a context of clinical excellence will always require both intention of action, openness to invite colleagues to help us to see what we cannot see ourselves and a willingness at all times to make course corrections in the best interest of our patients.
Originally posted in Counselor Magazine. You can visit their publication here.