Impact of the Therapist’s “Use of Self”

Andrew M. Sleater*a, Julie Scheinerb

Abstract

The aim of this research was to explore the therapist’s “use of self” to gain an understanding of this phenomenon through the participants’ lived experience. A literature review yielded a number of common themes associated with “use of self”: self-disclosure, personality, intersubjectivity, relationality, attachment, belief systems, and embodiment. The study comprised of semi-structured interviews conducted with six experienced and accredited clinicians. Interpretative Phenomenological Analysis was used, as it facilitated the objectives of the research, which were to capture the lived experience of the clinicians, identify common themes, and observe for any new insights. The authors found three superordinate themes in relation to the therapist’s “use of self”, all of which are intertwined: connection, awareness and wellness. The research supports the fact that the therapist’s “use of self” has an impact on therapy. While connection and awareness feature strongly in the literature, the importance of wellness is not highlighted. The authors propose that an obligate symbiosis exists between awareness and wellness.

Keywords: use of self, relationships, awareness, wellness, conflict

The European Journal of Counselling Psychology, 2019, Vol. 8(1), https://doi.org/10.5964/ejcop.v8i1.160

Received: 2017-11-25. Accepted: 2019-07-02. Published (VoR): 2020-01-13.

Handling Editor: Akis Giovazolias, Department of Psychology, University of Crete, Rethymno, Greece

*Corresponding author at: Friarstown, Knockmore, Ballina, County Mayo, Ireland, F26 D1W0. E-mail: andrew.m.sleater@gmail.com

This is an open access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

While it is widely known that the therapeutic relationship is important in the outcome of therapy, and much has been researched on the client’s side of the relationship (Easterbrook & Meehan, 2017; Kastrani, Deliyanni-Kouimtzis, & Athanasiades, 2017; Kuutmann & Hilsenroth, 2012; Sexton & Whiston, 1994), less has been explored on the therapist’s side.

Understanding the impact of the therapist’s “use of self" in more depth could be useful in highlighting the benefits that longer-term relational models offer and could also help to inform professional training programmes. The authors’ aim for this study is to explore “use of self” in the therapeutic relationship, in order to gain an understanding of the phenomenon through the lived experience of the participants.

Literature Review [TOP]

Although the therapist’s “use of self” has been the subject of minimal qualitative and quantitative research, nevertheless “use of self” has been found to be an important factor in the therapeutic relationship (Jennings & Skovholt, 1999; Jones, 2012; Kivlighan, 2007).

Jennings and Skovholt (1999) qualitatively researched 10 peer-nominated master therapists using phenomenology and highlighted the importance of their cognitive, emotional and relational characteristics in the therapeutic relationship. The participants came from diverse therapeutic modalities. Kivlighan (2007) used a quantitative approach to study both the patient and the therapist’s contribution to the therapeutic relationship, to bring into focus the bidirectional effect in the therapeutic relationship. Using Latent Group Analysis (LGA) and Actor-Partner Interdependence Analysis (APIM), he found that the therapist and client working alliance ratings had both a shared dyad-level aspect and mutual influence. The participants came from diverse therapeutic modalities. Jones (2012) used auto-ethnography as a qualitative research method to study “use of self” as an important factor in successfully working with borderline personality disorder and found that this narrative approach was a useful tool in linking the researcher’s personal self to the empirical knowledge.

Well-known therapists and their clinical experience also support the therapist’s “use of self” as an important aspect of the therapeutic relationship. Satir, Banmen, Gerber, and Gomori (1991), Andolfi, Ellenwood, and Wendt (1993) and Lum (2002) consider “use of self” as the single most important factor in building the therapeutic relationship. Edwards and Bess (1998) argue that the therapist needs to be aware of their real self and use it in the therapeutic relationship. Wosket (1999/2006) promotes the value of the therapist researching their own clinical practice to improve effectiveness and proposes that training programmes pay little attention to the “use of self”. Rowan and Jacobs (2002/2008) examine what they claim to be the central questions in therapy: who is the therapist? And, how does that play out in the therapeutic relationship? Dewane (2006) explores “use of self” through five aspects: personality, relational dynamics, belief systems, anxiety, and self-disclosure, and proposes that “use of self” is the hallmark of skilled practice. MacLaren (2008) discusses “use of self” in the context of Cognitive Behavioural Therapy (CBT), and finds that the integration of the professional and the personal is what allows full engagement in the therapeutic alliance. Baldwin (2013) looks at “use of self” as failing to gain the attention it deserves and maintains that who the therapist is, and what is shared, is as important as the therapeutic method used. Adams (2014) discusses the myth of the untroubled therapist and how the therapist’s own process can be a valuable compass in the therapeutic relationship.

In the existing literature on the therapist’s “use of self”, a number of core themes prevail, including: self-disclosure, personality, intersubjectivity, relationality, attachment, belief systems, and embodiment.

Therapist Self-Disclosure [TOP]

Self-disclosure is perhaps the most discussed form of “use of self”, and often the first to come to mind when we talk about the therapist’s “use of self”. Self-disclosure not only gives insight into the therapist’s life but also has an impact on the client’s feelings. If the client has a positive feeling towards the therapist in general, then the latter’s self-disclosure is likely to enhance that positive feeling. Likewise, if the opposite is true, then self-disclosure is likely to reinforce the negative. We also inadvertently self-disclose – often unconsciously – through such channels as the clothes we wear, the layout of our room, and body language.

Different therapeutic schools of thought approach self-disclosure from different perspectives. The cognitive behavioural approach traditionally does not hold the therapeutic relationship to the forefront and consequently fails to focus on self-disclosure. The psychoanalytical approach traditionally values the “blank screen” of the therapist and views therapist self-disclosure as a countertransference issue that needs to be resolved. The humanistic and existential approaches tend to apply more clinical flexibility, acknowledging the value of considered self-disclosure when delivered in the right circumstances, and by experienced clinicians.

The self-disclosure of the therapist can be valuable in the form of impact messages. These are internal emotional reactions experienced by the therapist as a direct result of the client’s interpersonal communication (often non-verbal) with them. The therapist needs a heightened sense of self-awareness to appreciate how much of the disclosure is about themselves and how much is about the client. Self-disclosure should always be given exceptional and careful consideration, as it can interfere with the boundaries of a good therapeutic relationship. The disclosure should be in the here and now. It should be spontaneous, against a backdrop of being prepared, and mindful of what is going on in the room, immediately bringing the focus back to the client. Furthermore, the therapist must ensure that they do not take the therapeutic space that belongs to the client (Dewane, 2006; Henretty & Levitt, 2010; Kiesler, 1996; Kivlighan, 2014; Paul & Charura, 2015; Raines, 1996; Weiner, 1978).

Hanson (2005) qualitatively researched 18 clients using grounded theory and found self-disclosure to have both a positive and a negative effect. Audet and Everall (2010) used a phenomenological methodology to qualitatively study nine participants and found that self-disclosure had both facilitative and hindering effects. Audet (2011) warns that self-disclosure can blur the therapeutic boundaries. However, when it is used skilfully it can enhance the relationship. Bottrill, Pistrang, Barker, and Worrell (2010) used phenomenology to qualitatively study 14 trainee clinical psychologists and determined that working out one’s approach to self-disclosure is a challenge for trainee therapists and that support is often required to master the skill.

Levitt et al. (2016), using a naturalistic methodology, qualitatively examined therapist self-disclosure within 52 two-therapy dyads and found both positive and negative results. Self-disclosure that humanised the therapist seemed to have a more positive affect than disclosure that expressed encouragement. Self-disclosure that highlighted similarity with the therapist seemed to have a more positive impact than disclosure that failed to convey either similarity or dissimilarity.

Knox, Hess, Petersen, and Hill (1997) qualitatively studied 13 adult clients in therapy, through phenomenology, and found self-disclosure to have a positive effect on discussing their important personal issues. This was in the context of the therapists being perceived by the clients as intending to normalise or reassure them and consisted of their provision of non-current information.

Burkard, Knox, Groen, Perez, and Hess (2006) qualitatively researched 11 European American psychotherapists’ self-disclosure in cross-cultural settings phenomenologically. The results were positive when the therapists shared their own views on racist and oppressive attitudes, with the intention of enhancing the relationship.

In summary, self-disclosure can have both a positive and negative effect in the therapeutic relationship. However, it is an area where skill and experience is essential, and the therapist’s self-awareness is of great significance.

The Personality of the Therapist [TOP]

The traditional psychoanalytical approach tended more towards restraint of self in the therapeutic relationship, with the “blank screen” of the psychotherapist being the ultimate restraint of self. Since those early days, there has been a move towards encouraging the active “use of self” in the therapeutic alliance. The humanistic and existential approaches recognise that the whole personality and identity of the therapist, when engaged with the patient, has the best therapeutic value. Presence is important and being truly present can have a healing effect. In order for “use of self” to be effective, it is important for the therapist to practise their professional knowledge against a backdrop of their awareness of their own personality traits, belief systems, and world view. The cognitive behavioural approach is now paying more attention to the value of the relationship that it did in the past (Baldwin, 1987; Brown, 2015; Edwards & Bess, 1998; Jung, 1963/1995; May, 1958/2004; Mearns & Cooper, 2018; Mearns, Thorne, & McLeod, 2013; Paul & Charura, 2015; Rogers, 1951/2015, 1961/2016; Searles, 1966-67/1979, 1958-1965/2005).

Kastrani et al. (2017), through their qualitative research study, using Interpretative Phenomenological Analysis (IPA) with 27 female psychotherapy and counselling clients, found that women attempted to define their relationship with their counsellor by comparing it to other interpersonal relationships – mostly to friendship or family relationships. Easterbrook and Meehan (2017), through a qualitative research study using a case-study approach, found that the therapeutic relationship can have an important role within the CBT approach. Kuutmann and Hilsenroth (2012), using a multi-method assessment technique, researched 76 outpatients receiving psychodynamic psychotherapy. They found, in session, that a focus on the patient-therapist relationship was effective in working with patients who exhibited relational problems.

In summary, the person of the therapist is an important factor in the therapeutic connection, and this involves expanding their awareness to become more effective clinicians.

Between the Therapist and the Client [TOP]

The humanistic and integrative approaches view the therapeutic relationship as co-created, rather than one in which the therapist sets the scene for therapy and uses techniques. All elements of the relationship are important, including the real relationship, together with the transference relationship. The therapeutic process is mutual, co-constructed, and intersubjective, where the therapist refrains from imposing their meaning on the client’s frame of reference. We are all unique and furthermore the therapeutic relationship is unique to the two individuals – the therapist and the client – at a particular point in time and space, whereby both continually impact each other consciously and otherwise. Existential phenomenological thinking defines existence as relational and refers to us as having been “thrown” into this world. We spend our lives in a state of “being with others” – in a relational field, in a state of intersubjectivity. We have a great temptation to run from this relatedness into isolation, in order to avert our anxiety of “being with others” (Cohn, 1997/2008; Heidegger, 1927/1977; Paul & Charura, 2015).

The traditional psychoanalytical approach uses terms such as “transference” and “countertransference” when referring to the intersubjective aspect of the therapeutic relationship and promotes a “blank screen” approach by the therapist. However, over the years a more relational approach has emerged from the psychoanalytical community, which views the therapeutic relationship as a mutual relationship. Both patient and therapist continually contribute to, and are affected by, the interpersonal and intrapsychic realities of the therapy. Here, the patient’s unconscious, fantasies and conflicts come into the room in the interaction between the experience of the therapist and the patient. Therefore, in the therapeutic relationship it is important for the therapist to be open to being emotionally vulnerable with their client and to accept the risk to self, through experiencing previously unconscious aspects of self. This will help to facilitate the growth and expansion of the therapist’s awareness and will ultimately enable the patient to reaching their inner self. Relational psychoanalytical thinking refers to the therapy as a two-way process and maintains that, unless both the doctor and patient become a problem to each other, no solution is found. The therapist’s interpretations are of less importance than their non-verbal participation in the therapeutic relationship. In summary, the therapeutic relationship is not separated from the outside world, but embedded within it, emergent from it, and meaningful because of the understandings, values, beliefs and culture of the community. The analytic space is a co-constructed space, where both the therapist and patient engage in a relationship that is much more than the sum of the individuals. This can be referred to as the “relational unconscious”, which describes the concept of the “within”, the “outside”, and the “in-between” shades of experience of both the therapist and the patient (Aron, 1996/2009; Edwards & Bess, 1998; Jung, 1963/1995; Mitchell, 1988; Searles, 1948-1949/2017; Searles, 1958-1965/2005; Searles, 1978/1986; Zeddies, 2000).

Luca and Filipoppoulos (2014) qualitatively researched eight participants using constructivist grounded theory, examined problems the participants encountered with subjective versus objective reality, and through a phenomenological relational style found that migrants and returnees faced intense dilemmas following relocation. Haugvik and Mossige’s (2017) research on intersubjectively-oriented, time-limited psychotherapy studied three 6-11-year-old children, each receiving 12 therapy sessions. Among five main themes, they found that the importance of the therapist’s awareness of their own thoughts, feelings and reactions during the therapy session was in line with an intersubjective approach.

In summary, much goes on outside our awareness, in the space between the therapist and the client, and in this context, the therapist has a duty to continually expand their own awareness and, as appropriate, that of the client.

Different Levels of Consciousness/Awareness [TOP]

Humanistic and existential schools of thought maintain that there are three ways for a therapist to use self: as the instrumental self, the authentic self, and the transpersonal self. An instrumental approach, such as CBT, uses techniques and sees the client as someone with problems to resolve. It holds the position that “what the therapist does is more relevant than who the therapist is”. An authentic approach, such as humanistic or integrative, seeks to be more personal, with the personality of the therapist being involved in the client’s healing through meeting, being in the world, and using a real authentic relationship with boundaries. The transpersonal approach maintains that there are five broad levels of consciousness: persona, ego, total organism, transpersonal and unity consciousness. The matching of different therapeutic approaches to different levels of awareness is important, as each approach has evolved to speak to a different level of consciousness. These altered states, also referred to as “deeper potentials”, reach beyond the personal, whereby the therapist and the client have the opportunity to integrate. Presence and embodied empathy play a key role in the therapy, with the therapist momentarily living the client’s experience, but with conscious awareness that it belongs to the other. An “I-Thou” way of relating that operates in this transpersonal realm is a deeply intimate experience in which the participant surrenders to that special moment in which individual identity is experienced and at the same time transcended. The “I-Thou” experience refers to that unique quality of presence: being fully available and in tune with the client without boundary or limit. These deeper operating potentials cannot be learned through technique, but instead through time and experience. A strong trusting therapeutic relationship needs to develop, in order for this relational depth to materialise. It can be described as a deep connection that facilitates the therapist in confirming the deepest thing within the client, in the form of accepting their whole potentiality, a state of profound interaction between the therapist and the client. Transpersonal models do not seek to replace other models but instead, aim to expand the view of human nature to stages that go beyond that of the ego (Baldwin, 2013; Buber, 1923/2013; Buber, Rogers, Anderson, & Cissna, 1997; Kasprow & Scotton, 1999; Mahrer, 1996; Mearns & Cooper, 2018; Rogers, 1980/1995; Rowan & Jacobs, 2002/2008; Wilber, 1977/1993, 1979/2001).

Giovazolias and Davis’ (2005) quantitative research study with 95 participants, using commitment to change algorithm (CCA), found that matching the appropriate therapeutic intervention with the client’s stage of readiness was an important factor in working with addictive clients.

In summary it is important to match the appropriate therapeutic approach with the relevant level of awareness. Different levels of consciousness exist for both the therapist and the client and it is therefore an essential realm for the therapist’s development.

Attachment [TOP]

The psychoanalytic tradition, and in particular Bowlby, places emphasis on the intimate attachments to others in one’s life. Early attachment experiences will play out in other relationships in the patient’s life, and especially in the therapeutic relationship, where the therapist mimics the process that characterises the behaviour of the mother-child relationship.

This provides a unique opportunity to expand the quality of the intersubjectivity between the patient and the therapist, resulting in the patient having a different attachment experience from that afforded to them in their earlier life (Bowlby, 1969/1997, 1973/1998, 1980; Mitchell 2000/2010; Winnicott, 1965/2001).

Grigoriadou and Kleftaras’ (2017) quantitative research study with 207 participants, using a Questionnaire of Self Evaluated Depressive Symptomatology (QD2), identified a link between depressive symptomology and attachment. Furthermore, they highlighted that through the intimate experience of the therapeutic relationship, it is possible to facilitate a change in the way the client interacts with others.

Darroch and Dempsey (2016) found that interpreters who work in the therapy room experience transferential dynamics. The results indicate that interpreters are affected by the transference and are susceptible to vicarious traumatisation.

In summary, the psychoanalytic/psychodynamic tradition believes that we all have a tendency to mimic our way of relating to what we have experienced in our early childhood relationship with our primary caregiver. The therapist needs to hold this within their awareness and, at the same time, scan for the client’s interaction, as the latter will also have a tendency to operate from that place.

Embodied and Anxious [TOP]

The existential phenomenological approach views human existence as embodied: being in the world and being in the body are both viewed as one. Therefore, the body is not a mere physical object, but instead an embodiment of consciousness. We use our physical abilities to interpret our world by receiving information in bodily form. Consequently, there is a need to view the body in the light of how it will react with the outside world, through the lens of our unique experience or worldview. In psychotherapy, the physical health of the therapist can be impacted through their body, resonating with that of the client’s, in the intersubjective space that exists between them. Psychotherapy works best when we have an optimum level of anxiety. Thus, it is important that the therapist regulates this level of anxiety and keeps it within a safe window of tolerance. This has been referred to as a “safe emergency” within the therapy, where we can relive and rework old maladaptive experiences (Cohn, 1997/2008; Cozolino, 2013; Merleau-Ponty, 1962/1978; Ogden, Minton, & Pain, 2006; Perls, Hefferline, & Goodman, 1951/1994; Shaw, 2003; Spinelli, 2007; Sussman, 1995; Turner, 2008).

Rossouw, Smythe, and Greener (2011), using a hermeneutic-phenomenological methodology, qualitatively studied the experience of therapists working with suicidal clients. They found that the work had a significant impact on the therapist, confronting them with professional, institutional, and personal issues and often triggering a crisis of existence. The study highlights that the world as understood by the laws of natural science is very different from the life-world of being human. The authors propose that the profession needs to pay more attention to taking care of the therapist, so that they in turn can take care of the client.

In summary, being in the world and being in our body are one and the same. Each of us has our own worldview, which is very different from the natural scientific paradigm of one world. Through tuning our awareness to our bodies, and those of the client’s, we can gain valuable information about what might be happening in the moment with the client, or with ourselves. We can then utilise this information to enhance the therapy and/or develop and expand our own awareness.

In conclusion the existing literature has clearly identified the importance of the personality of the therapist in establishing a solid therapeutic connection with the client. This is facilitated by the expansion of the therapist’s awareness, through engagement with their own process, including paying attention to their own and their client’s embodied existence, and how the body communicates. This form of communication generally happens on the edge, or even outside, of awareness.

In the empirical studies in this literature review, the participants were selected from diverse therapeutic approaches, including humanistic, experiential, psychodynamic, and CBT. They included therapists ranging from those in training to highly experienced practitioners. The empirical research to date has focused primarily on the area of self-disclosure with the other aspects of “use of self” (personality, intersubjectivity, relationality, attachment, belief systems and embodiment) not being so widely researched, but nonetheless clearly described in the literature. The present research will help to close the gap we have identified, by contributing to empirical knowledge on the wider aspects of therapeutic “use of self”. The participants in this research study practised a humanistic and integrative approach and ranged from relatively newly qualified, five years in practice, to highly experienced practitioners. The aim of this study is to explore “use of self” in the therapeutic relationship, in order to gain an understanding of the phenomenon through the participants’ lived experience.

Relevance to Counselling Psychology [TOP]

This research is an interpretative phenomenological study, firmly positioned in clinical practice, with a particular focus on counselling psychology. It provides an evidence-based insight into the lived experience of the therapist’s “use of self” in a European clinical setting. The findings support the acquisition and maintenance of core competencies in line with the standards for accreditation of doctoral programmes in counselling psychology, especially in the area of “personal and professional skills and values”. The findings clearly bring the mutuality of the therapeutic relationship into focus, highlighting the important role of intersubjective experience and the need to expand the therapist’s awareness in conjunction with their wellness. The authors propose a model for the therapist’s “use of self” and suggest that an obligate symbiosis exists between awareness and wellness. This research can both assist in informing future training programmes in counselling psychology and serve to strengthen the practitioner model. Furthermore, the findings can help to advance counselling psychology in a European context, as the focus on intersubjective experience is relevant to the multicultural dynamics encountered with the crossing of national borders.

Method [TOP]

The primary focus was to study the lived experience of the participants and for the researcher to “use self” to interpret the meaning participants were making of their lived experience of “use of self”, and not the opposite. This is known as the double hermeneutic (Smith, Flowers, & Larkin, 2009). The goal, therefore, was to recruit participants with different levels of experience, to gain a broad insight into therapeutic “use of self”. IPA was used, as it facilitated the provision of a rich and deep descriptive of “use of self”.

Historical Elements of Interpretive Phenomenology Analysis [TOP]

IPA is deeply rooted in philosophy and is underpinned by three important concepts: phenomenology, hermeneutics and idiographic approach (Smith et al., 2009).

Phenomenology [TOP]

Phenomenology is concerned with studying experience and was first put forward by Husserl (1927/1997) and later built on by Heidegger (1927/1977). Heidegger (1927/1977) in Being and time, talks about both the person “in context” and the concept of intersubjectivity, and stresses the importance of comprehending that our interaction with the world is shared, overlapping and relational. Merleau-Ponty (1962/1978) refers to us never being able to fully share another person’s experience, as their experience is fundamental to their embodied position in the world. Sartre (1943/2003) claims that our world is not our own: rather, our perception of our world is greatly influenced by the presence or absence of others. Phenomenological observation endeavours to take into account all aspects of consciousness by “bracketing” our existing knowledge and keeping an open mind. This process has the objective of putting aside any bias or prejudice on behalf of the researcher. It is also known as the epoché or suspension of previously held assumptions. This is a search for true observation by holding an open mind, while also being mindful that truth is very complex and can be viewed from different angles. It is important to realise that phenomenological observation seeks to understand but cannot make any claims to absolute truth (van Deurzen, 2015).

Hermeneutics [TOP]

Hermeneutics is the science of interpretation. Heidegger (1927/1977) regarded phenomenology as an interpretative activity and IPA is rooted in this concept. It is an iterative process of moving back and forth through our thought processes, rather than completing each step in sequence (Smith et al., 2009). The “hermeneutic circle” highlights the importance of looking at the whole to understand the parts and looking at the parts to understand the whole. This is a non-linear, dynamic style of investigation or thinking and was deployed in the present research.

Idiographic Approach [TOP]

IPA is considered an idiographic approach, as it involves a rich and deep analysis of the lived experience of the individual and seeks to interpret that unique embodied experience. This is in contrast to most research in psychology, which is nomothetic in nature, is, concerned with making claims at a population in general, and seeks to establish general laws (Smith et al., 2009). Therefore, in qualitative research, sample sizes tend to be small in order to facilitate the collection of extensive detail about each individual studied (Creswell & Poth, 2018; Willig & Stainton Rogers, 2017).

Participants [TOP]

Author 1 started the process by emailing accredited psychotherapists in clinical practice. The inclusion criteria for respondents were: (a) accreditation to a recognised professional body; (b) > 5 years’ clinical experience; (c) Humanistic and Integrative Approach (d); providing one-to-one/individual counselling. The exclusion criteria for respondents were: (a) failure to meet the above inclusion criteria; (b) maintaining a broad representation across gender (male > 25%): last in first out; (c) maintaining a broad representation across years of experience: last in first out. Four clinicians responded and all were selected, as collectively they had a representative gender balance (male > 25%) and a broad range of experience, 5 to 29 years. When the four were interviewed, it was decided to extend the sample further, in order to ensure that saturation was achieved. The sample was then extended by 50% to a total of six participants. After interviewing these additional participants, and analysing the data, the author(s) felt that saturation had been reached, as the same themes were found to consistently reoccur with no new themes presenting (Willig & Stainton Rogers, 2017). The final sample selected, consisting of rich individual cases, provided the opportunity to collect sufficient data to develop meaningful points of similarity and difference (Smith et al., 2009; Willig & Stainton Rogers, 2017).

The cumulative experience of the participants, women (N = 4) and men (N = 2), interviewed extended to 86 years (M = 14.33 years, SD = 8.98 years). The sample comprised the following: two psychotherapists at master’s level involved in leadership and training, as well as clinical practice (M = 26 years, SD = 3 years); two senior psychotherapists (M = 12 years, SD = 2 years); and two early-career psychotherapists (M = 5 years, SD = 0 years). All held licences to practice psychotherapy in Ireland and some held more than one licence. Four were practicing clinical supervisors. Their theoretical orientation was primarily humanistic and integrative. The masters-level and senior psychotherapists (N = 4), were in the age group 55 to 65 years while the early career psychotherapists (N = 2), were in the age group 30 to 40 years.

Semi-Structured Interview Construction [TOP]

It was decided to use one-to-one semi-structured interviews. These consisted of open-ended questions designed to give the therapist as much freedom and space as possible to recount their unique lived experience, while at the same time keeping a structure to the interview. Author 1 drafted five questions, which were then independently reviewed by Author 2. Through a process of discussion and review, the original questions were reduced to three:

1. What do you feel “use of self” is, when we refer to the “therapist’s use of self”?

2. In what way do you bring yourself into the therapeutic relationship?

3. What do you do in terms of your own self-care as a therapist?

Semi-Structured Interview Procedure [TOP]

The semi-structured interview approach had the effect of the participant relaxing when they realised that the researcher was just interested in their unique lived experience. It was important that the researcher left the research world and came around to the other side of the hermeneutic circle to join the participant in their frame of reference. In their world, the participant is the expert in their lived experience (Smith et al., 2009). The interviews afforded the participant the opportunity to reflect on their “use of self” in clinical practice and consequently enhancing their awareness of how they practice (McLeod, 2003/2011). A number of participants were pleasantly surprised by the enriching experience and expressed gratitude for the opportunity afforded to them. On average, the interviews lasted 45 minutes and were recorded with a digital recorder. This facilitated ease of transcription afterwards and enabled the researcher to pay full attention, while maintaining eye contact during the interview (Breakwell, Smith, & Wright, 2012).

Data Analysis [TOP]

Author 1 transcribed the interviews verbatim for ease of analysis (Breakwell et al., 2012). The transcripts were designed with two blank columns on each page to facilitate the analysis. The first column was used to draft initial comments, being mindful of those that were descriptive, linguistic and conceptual. The second column was then used to document emergent themes. After that, a process of inductive reasoning was followed, in order to identify patterns between emergent themes, with a view to formulating superordinate themes. A process of polarisation was followed to draw out differences in the emergent themes. This approach has the effect of breaking down the interviews into parts and then reassembling those parts into a new whole at the end of the analysis. This is one aspect of the hermeneutic circle where we look at the whole to understand the parts and look at the parts to understand the whole (Smith et al., 2009). Author 1 separated each transcript into small units of data, a paragraph or less, and wrote one or two exploratory comments that represented that piece of data. Emergent themes were then identified, reviewed and grouped into superordinate themes. This process of analysis involved painstakingly working through 1,726 pieces of data to generate 471 comments, which facilitated the identification of 12 subthemes. The final distillation yielded three superordinate themes.

Findings [TOP]

The findings are distilled down to three main themes: connection, awareness and wellness. These superordinate themes best capture the essence of therapist’s “use of self” (See Table 1).

Table 1

Illustration of the Findings From the Participant Interviews

Main Theme/Superordinate Theme Sub Theme
Personality/Connection (C)
Self-disclosure
Personality
Worldview
Relationality/Awareness (A)
Self-disclosure
Intersubjectivity
Mutuality
Attachment
Worldview
Embodied & Anxious
Health & Wellbeing/Wellness (W)
Self-awareness
Embodied & Anxious
Self-care

Connection (C) [TOP]

Self-Disclosure [TOP]

Three distinct forms of self-disclosure emerged during the research: overt self-disclosure, inadvertent self-disclosure, and unconscious self-disclosure. When initially asked about self-disclosure, the participants tended to think of overtly disclosing something about themselves that might benefit the client’s process. Most responses were hesitant in this area and were generally leaning towards non-disclosure. Everyone agreed that it must always be for the benefit of the client. However, on deeper reflection, the participants also spoke about the existence of inadvertent and unconscious self-disclosure. The following extract clearly acknowledges the presence of other forms of self-disclosure than overt self-disclosure. The participant does not attach much importance to overt self-disclosure against a backdrop of inadvertent and unconscious self- disclosure, both of which can be quite disclosing, and maintains that, in any case, the client will interpret any disclosure through their own lens.

Participant: um, [pause], I think in some ways for me it is a false topic, for me, because I think, it’s quite disclosing to be, just to land in the room, you know … another degree of disclosure is neither here nor there, um, I think there is a lot of talk about this. We witness clients in a very impersonal way, even though it seems personal, they are not that interested often in taking up, on what clothing of oneself [reference to the therapist’s clothing], apart from what they see through their own lens, this is the transference for them, so I don’t attach much importance to it. So overt self-disclosure of some unusual piece of information, it doesn’t really relate that strongly with me.

Personality [TOP]

The uniqueness of each therapeutic relationship was very much a theme throughout the research and from listening to the participants recounting their lived experience it was evident that they use their personality to facilitate the therapeutic connection. The following extracts highlight the role contributed by the therapist’s unique personality to establishing the therapeutic connection. The therapist tailors their interaction to the client as appropriate, and this contributes to the uniqueness of the connection for that particular client.

Participant: that is it, bringing yourself in in all aspects of one’s knowledge skills, and personality and [pause] just I suppose aware of your own self-awareness.

Participant: You need to try to tailor things to an individual’s experience, you know, in the same way that you would hope that would happen for you.

Participant: I am a person sitting here, but I am also a therapist sitting here, so I think as soon as they come in, I think my natural personality, will come out. I don’t, um, I don’t welcome people from a therapist point of view, I work, I welcome people from a human point of view.

Participant: Exactly, and that’s, that’s good too, so I think I would be, would be warm you know I think, and I think open and encouraging and, you know I think “use of self” bringing my, who I am, into it elsewhere, who I am at so many levels.

It was evident that intersubjectivity comes into play during the unique interaction of that therapist with that client, at that particular point in time and space. This can trigger the therapist’s process. Through self-awareness and continuous commitment to one’s own process, the therapist can intercept that which they must own and take it to the safety of supervision and/or personal therapy for introspection and processing. The following participant extract clearly points to the important role played by the person of the therapist in the therapy, and the constant need to expand awareness, in order to become more effective clinicians.

Participant: Ideally in coming from a place of self-awareness, you know, and so when the therapist…“use of self”… in that we are contributing that to the client’s personal development we are also having to monitor, as well what’s goes on for us.

The more experienced therapists talked about presence to a greater extent than the less experienced ones, and how we embody our own self-development and self-awareness as we gain more experience. This embodiment facilitates an automatic transfer to the client through “use of self” in a positive way, just as the negative can flow, if allowed to go unchecked. Each of the participant extracts below refers to the personal self-development and expansion of awareness of the therapist, to the extent that the new learning is embodied and naturally flows through the therapist’s personality and presence.

Participant: a response in the moment which I can only regard as a, as a, as a therapeutic “use of self”, as my response is myself …it’s very, it’s very definite that this is what most people respond to best, is when the therapist is being there as a self, rather than a bag of techniques.

Participant: and when you come to a place where you can forgive yourself and be compassionate towards all those, those parts of yourself, that when somebody sits with you, you’re, you are sitting with that growth and compassion and love of yourself so that when somebody is sitting with you talking [pause] about their stuff [long pause] you, you hope that they are experiencing that you are not judging them in any way, because you are not judging yourself in any way, you stop judging yourself, so they automatically know that.

Participant: you have embodied it through your demeanour and through you’re … and that’s “use of self”.

The instrumental, authentic and transpersonal “use of self” was evident. The more experienced participants seemed to work more in the authentic/transpersonal realm, with the less experienced participants tending to work more on the instrumental/authentic end of the spectrum. Most of the therapy seemed to happen in the authentic realm, with the transpersonal experience being less common. It seemed difficult for the participants to put the transpersonal experience into words, which concurs with it being an experience that tends to transcend the ordinary. The two participants’ reflections on the transpersonal experience below refer to the deepest levels of relationality and to Buber’s “I Thou” experience. These are special moments in the therapeutic relationship.

Participant: I thou experience [very reflective] and you don’t get it all the time, here and there, glimpses I think [pause].

Participant: Yeah, imagine what that does to a client totally connected and such an acceptance of you as you are, in your warts and all [slow and reflective]

In summary, the findings support the personality of the therapist as being the key factor in the therapeutic “use of self”. The “blank screen” of the therapist is a myth, as we cannot be “blank screens”, no matter how hard we try. The more experienced therapists were much more comfortable with the use of their personality than those who were in the earlier stages of their careers. These therapists were skilled at navigating the boundaries, which inevitably become more complex as one moves away from the “blank screen”. As well as having the extended clinical experience, they were much further along in their personal process.

Worldview [TOP]

The participants talked about their worldview and how their unique way of being forms part of the dynamic in the therapeutic relationship. They shared the following insights from their clinical experience, which highlight the need for the therapist to bring into their awareness where they have come from, and how that may contribute to the dynamics between the therapist and the client in the therapeutic relationship.

Participant: Yeah, and I felt then after, was I with her, was I with her at all, because I went into my own belief system … but if I was where she was [pause] I’m not sure I would have been any better than her, that was on reflection afterwards, so what I am saying is, even though with experience and with all of that we are still human in certain areas of the work.

Participant: it’s just one experience that is so profoundly different from the rest and it’s kind of, we all use a variation of the same theoretical models but there is a large component of our own internal world and our own self, I believe being brought in there as well.

Participant: so like, so “use of self”, even though you use it and you use it to the benefit of the client as much as possible, that can get blurred a little sometimes in your own strong belief system.

Participant: so if I am the sum total of my encounters, well then I plead guilty.

Awareness (A) [TOP]

Relationality and Intersubjectivity [TOP]

The uniqueness of each therapeutic relationship was a common theme. The participants talked about how particular clients resonated with them, which usually linked in some way to the therapists’ own experience. The following participant extract highlights the uniqueness of each therapeutic relationship, shaped by the being of the unique client and the being of the unique therapist, at a particular point in space and time.

Participant: I have had many different therapists and of course I have related differently to them … we are all unique, the therapist is and the, and the, and the client is, and you know there is none of us are blank sheets, like you know, we are all coming with some of our history, our culture, our experiences, our genetics, our everything and so too is the client. So [pause] yeah.

All participants spoke about the dynamics of the therapeutic relationship and what goes on in the room, often outside awareness. Some described it as transference and countertransference, while others referred to the inner world of the therapist interacting with the inner world of the client. The following participant extract supports that which goes on in the space between the therapist and the client. It highlights the importance of the therapist’s duty and need to expand their awareness.

Participant: and I recognise that now, I never thought of that, but I also never thought about all the client’s judgements that they will have made on me before they come in and sit down, never thought of that.

Participant: and that the client is aware of in you and you’re not aware in yourself, let alone the other way about.

The less-experienced therapists held the impact of the client work on their psychic more to the fore than the more experienced ones. However, the latter were much further along in their own personal process.

There was general agreement that no matter how much awareness we have in the therapeutic relationship, sometimes information reaches our unconscious mind before it reaches our conscious mind. This can inadvertently cause some of our own history to trigger and enter into the therapeutic space. The following participant extract alludes to the fact that expanding awareness is a constant process in the realm of lifelong learning and a journey that never ends

Participant: and even as aware as we are, sometimes things reach our unconscious before they reach our conscious mind … now I look back and I realised that there was an awful lot going on in the unconscious before it moved into my conscious mind and what was happening for me in terms of what he was touching, that would have been triggers in me you know, that took me a while.

Mutuality and Vulnerability [TOP]

All participants talked about how the therapeutic relationship could be a space for personal growth, if we engage in a non-defensive way. In fact, it is essential, in order to work effectively, with the knock-on effect being the therapist’s personal growth. It involves having to constantly tune into what is going on in the space between the therapist and the client. The following participant extracts highlight the complicated nature of human experience. In the interaction between the imperfect therapist and the imperfect client, it can be a challenge to decipher that which belongs to the client and that which the therapist must own. However, this is the reality of our existence.

Participant: We are messy creatures you know, so the messy self in contact with the messy self, seems to be closer to what reality is.

Participant: having to continually revisit what that use of, of, self is, what that self is, sort of speak and how it is evolving.

Participants recounted that as they gain more experience, they become less defended and emotionally vulnerable with their clients. This facilitates greater self-awareness through experiencing previously unconscious aspects of self. However, it is important that this new experience is processed in appropriate supervision and personal therapy. The following participant extracts clearly point to mutuality in the relationship and the importance of the therapist paying particular attention to their own process, and seeking supervision and personal therapy, as appropriate, to expand their awareness.

Participant: So, you become less defended, and that’s a good word, as you go along, and I think you relax into it a bit more and you become, um, more confident about, you know, as the client is … is there and they are engaged with their process, you are checking in, what is going on with you, I would be looking at my physical response, you know, my emotional response, as well as applying the theoretical.

Participant: I think that, that is really, really, crucial and that I suppose the boundaries of that may not be so black and white, if I haven’t done my work in that area, then the danger of that getting up mixed up with the client and maybe even use the client for my own work, yeah.

Participant: and in the moment, even as I was sitting in your chair, I will have to be doing a little bit of work on myself, that doesn’t take away from the present to them, but is part of the work.

Attachment [TOP]

A number of participants referred to different attachment styles and how they tend to manifest in the therapeutic space. They talked about tuning into the attachment style of the client, through “use of self”. This involves checking in with the therapist’s own reactions to the client and using this knowledge to work with the client, to seek to establish a healthier relationship in the therapeutic space. The following participant extract captures the essence of how the therapist can attune to the attachment style of the client to understand their history and how it manifests in the present moment. The therapist achieves this by paying attention to the transference and countertransference, against a backdrop of expanded awareness of their own history and way of relating.

Participant: if I find myself feeling,… fatherly towards somebody or parental towards somebody and I don’t actually act on it, but I share it, and they go, yes I recognise that, I have entered their world in a particular way, is [has] come from me, is [has] come from something that has been going on in me, about them, they didn’t come in and say I want you to be parental.

Embodied and Anxious [TOP]

There was evidence that being embodied is an important aspect in the therapeutic “use of self”. If we tune into our bodies, we can find valuable information that can provide us with an insight into what might be going on – not only for the therapist but also for the client. This facilitates the expansion of our self-awareness and contributes to our wellness. The following participant extract highlights the value and importance of embodied experience.

Participant: always [slight surprise] yeah, yeah, I think the more you pay attention to body experiences the more information and general, deepening of experience you have, it’s not always comfortable … this is why we shut it off, because it’s often uncomfortable, it is a very valuable place to, um, to attend to … the body is the seat of honesty because the body doesn’t lie but everything else does or potentially does.

Participants talked about bodily sensations, including a wide range of feelings, for example anxious feelings that emerged for them in the room, or often after the session. They spoke about how this was a valuable source of information, but not necessarily an easy thing to do. The following participant extracts concur with the importance of paying attention to the body and the valuable source of information that can be obtained through part of our being.

Participant: so the bigger “use of self” that I had when I heard of “use of self” would be more what am I picking up here in, you know, that kind of, I am finding in my body, I suppose, and I am really feeling sad and the client isn’t sad, I am feeling angry and the client isn’t talking, saying words, but there are not really in touch with it, so I suppose I’m curious about that point. Is it me or my stuff or is it something that they have disowned and they are not in touch with? Yes so it could be the client … to be able to sit back, to sit back and just let what needs to emerge in that space, and yeah, I can sit sometimes, and I noticed myself there, minutes ago, sitting a little bit forward and sitting back, anxious or what is going on in me.

Participant: it manifests itself in my body and I try, don’t always succeed, not to work out of that place [pause] but to be more, um, present but not working out my own feeling place, but I have it held somewhere, I have it compartmentalised … so that, “use of self” is having all of that knowledge, before the client has it, but only using it, when the client is ready for it. So that’s the “use of self”, of me as therapist, so you use a lot of it as therapist information, of theories, of life’s experience.

Participants described how their bodies could automatically be in tune with that of the client, enabling them to access a deeper understanding of what is going on in the moment. Through this connection, they can enhance their awareness. This skill involves being able to identify that which belongs to the therapist, as opposed to that which belongs to the client. The following participant extracts point to the automatic aspect of body experience and how it manifests in the therapeutic connection.

Participant: I am using my body and that happens automatically, I don’t say I use my body in this, it just happens, so when somebody isn’t embodied then that’s how I know immediately we are not connected.

Participant: yeah, but there will always be a degree, and I don’t mind that,… there is, that it’s me, it makes me, it makes me alive, but there might have been, in the past, too much of a degree in that, am I enough? … You will feel … if somebody comes in, and I feel pressure, I will actually feel it, in my body.

Wellness (W) [TOP]

Expanding Awareness [TOP]

The participants referred to the importance of the “observer” or “internal supervisor” in facilitating expansion of awareness, when they reflected upon improving clinically and personally. Developing a strong internal supervisor that objectively looks at what goes on in the room and reflects on what is happening for both the client and the therapist, is key to the linkage from the room to the supervisor and ultimately to the expansion of the therapist’s self-awareness. The research found that it is important for the therapist to hold a “not-knowing” stance, an open mind if you like, and a compassionate disposition to oneself and one’s therapeutic work. The following participant extract alludes to the “internal supervisor”.

Participant: you are, as you do your work you become that, yeah, so that reflective piece goes on always in yourself, not critically, so if you do not critically, you do not critically to everybody else so, I would have developed through my own therapy and through my own supervision, a huge amount of compassion for my mistakes, my, … not getting it right, for not getting it right for me would have been difficult.

Self-Care [TOP]

All participants talked about the importance of taking time for self-care. The more recently qualified therapists talked a lot about the importance of their own process, facilitated by personal therapy, supervision and peer support. They discussed being aware that the work can have an impact on them and how it can trigger their process. It was noticeably greater for them than for the more experienced therapists, who were much further advanced with their clinical work and personal process. The following participant extracts highlight the important role played by self-care in the clinical work of the therapist.

Participant at early stage of career: I think the more we practise the more we realise how important that is, because again when we first finish our training it’s all about the client and it needs to be largely about the client to a certain degree, but we can’t ignore the impact that it has on us, it is one of the most challenging professions, in terms of the impact on the individual.

More experienced practitioner: That’s the essential issue of self-care, are you suitable are you ready for this? Is this you? Because, if it is you, you will, you will survive, you will be fine and if it’s not, you won’t.

Two distinct levels of self-care emerged – “fundamental self-care” and “supportive self-care” – both of which are essential for enhancing the therapist’s awareness and wellness. “Fundamental self-care” is supervision and personal therapy, where necessary. Consultation with a supervisor is an essential requirement throughout the therapist’s career. However, personal therapy needs can vary, depending on the stage of the therapist’s career and their development. Personal therapy may be required from time to time, as the therapist navigates through their own life experiences and face new challenges. The following participant extracts highlight that it is often difficult to identify that which belongs to the client versus that which the therapist must own. Either way, the self-care of the therapist is relevant and important for maintaining effective therapy and facilitating the expansion of the therapist’s awareness.

Participant: Again, the boundaries, are kind of like, it was a hard day I saw four or five clients and its normal to be tired or it also might be something else I have picked up in sitting with a client and what I do with that is self-care.

Participant: it [strong feeling] mightn’t be mine even afterwards, do you know, probably don’t but anyway it’s inside my skin now, what do I, do with it?

Participant: Oh it’s very important in this work. I know when I am a bit stressed, I know it in my body. I often get pains in my hands you know yeah, if I am feeling a bit stressed.

The second level of self-care is “supportive self-care”. This is where we do the things we like doing, enabling us to recharge and stay healthy. It includes taking care of the physical domain, requiring good nutrition, sound sleep and physical exercise. Relaxation and other activities, which enable us to switch off and recharge, can be unique to each individual therapist. However, the important element is that it is an activity that the therapist enjoys, and it facilitates their ability to temporarily leave aside the role of the therapist. One participant personified supportive self-care in the following reflection:

Participant: Too much reality isn’t always very good for us, not always good for us, so I think we need other spaces we can be in, in order to find meaning in a world that is increasingly commodified, meaningless.

Discussion [TOP]

The findings of the present research support the theory that the therapist’s “use of self” has an impact on therapy. Three superordinate themes were identified: connection (C), awareness (A) and wellness (W). While the importance of connection and awareness are well supported in the existing literature, the importance of wellness is not highlighted. Our findings appear to fill a gap in the existing literature by bringing attention to the importance of the therapist’s wellness in the therapeutic “use of self”.

Connection (C) [TOP]

The findings supported the view that it is not possible to be a blank screen, with the participants recounting how they bring their personality into the therapeutic relationship. They highlight the value of deepening the therapeutic relationship and how this unique connection is the fulcrum of the work. The connection strengthens over time, as awareness expands for both the therapist and the client (Brown, 2015; May, 1958/2004; Mearns & Cooper, 2018; Mearns et al., 2013; Rogers, 1951/2015, 1961/2016).

Awareness (A) [TOP]

It is clear from the findings that the therapeutic relationship is co-constructed and unique to that therapist and the client, with each contributing from both within and outside their awareness. Thus, the importance of the therapist developing and expanding their awareness is highlighted, as well as the need to be emotionally vulnerable with their clients. This involves an acceptance of risk to self in the form of experiencing previously unconscious aspects of self. Consequently, this accentuates the need for appropriate self-care and the nurturing of wellness. Thus, the mutuality of the relationship is of particular significance. The therapist is afforded the opportunity, as well as having an obligation, to personally grow through the experience of that unique therapeutic relationship. This involves paying particular attention to developing their emotional and relational domains, in addition to their cognitive domain (Aron, 1996/2009; Bowlby, 1969/1997, 1973/1998, 1980; Darroch & Dempsey, 2016; Edwards & Bess, 1998; Grigoriadou & Kleftaras, 2017; Jennings & Skovholt, 1999; Jung, 1963/1995; Mitchell, 1988; Searles, 1958/2005). It is important that the therapist is attuned to the changing spectrum of consciousness and takes into account the importance of matching the correct therapeutic intervention to the relevant level of awareness (Edwards & Bess, 1998; Giovazolias & Davis, 2005; Jung, 1963/1995; Kiesler, 1996; Kivlighan, 2014; Searles, 1966-67/1979, 1958-1965/2005; Wilber, 1977/1993, 1979/2001).

Wellness (W) [TOP]

Two levels of self-care were identified, both essential to enhancing the therapist’s wellness: “fundamental self-care” and “supportive self-care”. These featured strongly in the research, with the recently qualified clinicians holding them more acutely in their awareness than the more experienced ones. The research has clearly brought to the fore the role of supervision and personal therapy. Personal therapy is an essential requirement not only for the training therapist but also for the more experienced therapists, as the need arises. Supervision is an essential requirement for all therapists, throughout the whole of their career. Shaw (2003) has found that the physical health of the therapist can be impacted by the fact that we are embodied, and our body resonates with the client’s body in the intersubjective space between therapist and client. Therefore, it is important that we understand what belongs to the client and what it is that the therapist must own and engages in self-care, as appropriate. Rossouw et al. (2011) found that therapists working with suicidal clients were not only faced with professional issues but were often triggered to experience their own crisis of existence. Furthermore, while acknowledging that therapists must attend and contain radical shifts in the consciousness of the client, they ask the question: who attends to the same in the therapist? They maintain that clinical supervision is challenged to go beyond its scope of competent application of technical skills and professional development, to bring more focus on the relationship and the dynamics that come into play in the therapy room.

In conclusion, this research with humanistic and integrative therapists in clinical practice has found that, in addition to providing the necessary professional framework and skills, it is of the utmost importance that the wellness and awareness of the therapist is provided for, through the provision of appropriate self-care.

Critical Analysis [TOP]

Through detailed critical analyses, the authors have identified interlinkages between the themes of connection (C), awareness (A), and wellness (W), each having its own role in a proposed wider therapeutic model, as illustrated in Figure 1.

Figure 1

Model of “Therapeutic Use of Self”

The therapist’s awareness (A) is located at the top of the model, as we consider it of paramount importance in the therapeutic process. Therapists expand their awareness through training, supervision and personal development. It is essential that they work on their own process, through personal or group therapy, as they progress through their careers. Awareness (A) involves expanding the therapist’s awareness of both the unique therapist’s way of being, illustrated at X, and the unique client’s way of being, illustrated at Y. The therapist continually aspires to bringing the intersubjective experience that exists between the client and the therapist into their awareness. This is illustrated at Z and is generally located below the radar. The therapist’s state of wellness (W) is a key supporting factor in this therapeutic model and is also of paramount importance. Thus, we have located it at the same level as awareness. Furthermore, we believe that wellness and awareness are in an obligate symbiosis. In other words, one cannot function properly without the other: if wellness is impaired, so too is awareness. Consequently, the therapeutic “use of self” becomes sub-optimal. In order for the therapist to fine-tune their awareness, they must also fine-tune their wellness. This involves being aware of how the work is impacting on them, in order for them to engage in appropriate self-care – a major contributor to wellness. Through a high state of wellness, the therapist is in a better position to fine-tune their awareness. In our model, this symbiosis is reflected by the reciprocal arrows between wellness (W) and awareness (A).

In summary, the therapist’s objective is to bring the unique therapist’s way of being (X), the unique client’s way of being (Y), and the intersubjective experience (Z) into their awareness (A) and to use that psychological information to enhance the connection (C), thus strengthening the therapeutic relationship. This will serve both the therapist and the client in a mutualism whereby both will benefit from the interaction. Searles (1973/1979) highlights this symbiosis, as does Mitchell (1988, 2000/2010), who refers to it as mutuality in the relationship. In order to maximise the mutuality of the relationship, the therapist must pay particular attention to their own wellness, as it is in an obligate symbiosis with their awareness. This can be facilitated through working on their own process and by engaging with appropriate, fundamental and supportive self-care.

Limitations [TOP]

The results of this research should be interpreted in the context of several limitations. Firstly, this research is an interpretative phenomenology analysis of the individual therapist’s lived experience of “use of self” and seeks to interpret that unique embodied experience. It is considered an idiographic approach – in contrast to most research in psychology, which is nomothetic in nature, concerned with making claims at a population in general and seeking to establish general laws (Smith et al., 2009). Therefore, it does not claim to be representative of the population as a whole. Secondly, phenomenology seeks to understand, but does not make any claims to absolute truth. Rather, it endeavours to put to one side any bias or prejudice on behalf of the researcher through epoché; the suspension of previously held assumptions. It is a search for true observation by holding an open mind, while also being mindful that truth is very complex and can be viewed from different angles (van Deurzen, 2015). Lastly, this research could be further enhanced by adopting a more diverse sampling process, interviewing a larger number of participants, and by utilising a team approach to the collection and analysis of the data.

Further Research [TOP]

The findings propose that an obligate symbiosis exists between wellness and awareness. Psychotherapy could benefit from further research in this area, especially since the literature fails to highlight the importance of the therapist’s wellness. Therapy reflects the outside world and the therapeutic relationship reflects all outside relationships to a certain degree. Consequently, the findings that are reflected in the model of “use of self” could be utilised outside the therapy room to improve relationships in general.

Public Significance Statement

This research increases awareness of important issues linked to “use of self” by therapists in their practice and helps to prevent the negative impact that burnout could have on care-receivers/clients.

Funding [TOP]

The authors have declared no funding exist.

Competing Interests [TOP]

The authors have declared that no competing interests exist.

Acknowledgments [TOP]

The authors are grateful to all the participants who generously volunteered their time and confided in the researcher and the process. Without their contribution this research would not have been possible. Thank you sincerely.

The authors are grateful to all who read previous versions of the manuscript and contributed their thoughts and experience. Thank you sincerely.

The authors would like to thank the New School of Psychotherapy & Counselling together with the Department of Psychology, Middlesex University for their support in the process and enabling this research to come to fruition.

References [TOP]

  • Adams, M. (2014). The myth of the untroubled therapist: Private life, professional practice. London, United Kingdom: Routledge.

  • Andolfi, M., Ellenwood, A. E., & Wendt, R. N. (1993). The creation of the fourth planet: Beginning therapists and supervisors inducing change in families. The American Journal of Family Therapy, 21(4), 301-312. https://doi.org/10.1080/01926189308251001

  • Aron, L. (2009). A Meeting of minds: Mutuality in psychoanalysis. New York, NY, USA: Routledge. (Original work published 1996)

  • Audet, C. T. (2011). Client perspectives of therapist self-disclosure: Violating boundaries or removing barriers? Counselling Psychology Quarterly, 24(2), 85-100. https://doi.org/10.1080/09515070.2011.589602

  • Audet, C. T., & Everall, R. D. (2010). Therapist self-disclosure and the therapeutic relationship: A phenomenological study from the client perspective. British Journal of Guidance & Counselling, 38(3), 327-342. https://doi.org/10.1080/03069885.2010.482450

  • Baldwin, M. (1987). Interview with Carl Rogers on the use of the self in therapy. Journal of Psychotherapy & The Family, 3(1), 45-52. https://doi.org/10.1300/J287v03n01_06

  • Baldwin, M. (Ed.). (2013). The use of self in therapy (3rd ed.). New York, NY, USA: Routledge.

  • Bottrill, S., Pistrang, N., Barker, C., & Worrell, M. (2010). The use of therapist self-disclosure: Clinical psychology trainees’ experiences. Psychotherapy Research, 20(2), 165-180. https://doi.org/10.1080/10503300903170947

  • Bowlby, J. (1997). Attachment and loss, Vol.1. Attachment. London, United Kingdom: Pimlico. (Original work published 1969)

  • Bowlby, J. (1998). Attachment and loss, Vol. 2. Separation, anger and anxiety. London, United Kingdom: Pimlico. (Original work published 1973)

  • Bowlby, J. (1980). Attachment and loss, Vol. 3. Loss, sadness and depression. New York, NY, USA: Basic Books.

  • Breakwell, G. M., Smith, J. A., & Wright, D. B. (Eds.). (2012). Research methods in psychology (4th ed.). London, United Kingdom: Sage.

  • Brown, C. (2015). Understanding person-centred counselling: A personal journey. London, United Kingdom: Sage.

  • Buber, M., Rogers, C. R., Anderson, R., & Cissna, K. N. (1997). The Martin Buber-Carl Rogers’s dialogue: A new transcript with commentary. Albany, NY, USA: State University of New York Press.

  • Buber, M. (2013). I and thou (R. G. Smith, Trans.). London, United Kingdom: Bloomsbury. (Original work published 1923).

  • Burkard, A. W., Knox, S., Groen, M., Perez, M., & Hess, S. (2006). European American therapist self-disclosure in cross-cultural counseling. Journal of Counseling Psychology, 53(1), 15-25. https://doi.org/10.1037/0022-0167.53.1.15

  • Cohn, H. W. (2008). Existential thought and therapeutic practice: An introduction to existential psychotherapy. London, United Kingdom: Sage. (Original work published 1997).

  • Cozolino, L. (2013). This month’s expert the neuroscience of psychotherapy by Louis Cozolino, PhD. Psych Central. Retrieved from http://pro.psychcentral.com/this-months-expert-the-neuroscience-of-psychotherapy-by-louis-cozolino-phd/004308.html

  • Creswell, J. W., & Poth, C. N. (2018). Qualitative inquiry and research design: Choosing among five approaches (4th ed.). London, United Kingdom: Sage.

  • Darroch, E., & Dempsey, R. (2016). Interpreters’ experiences of transferential dynamics, vicarious traumatisation, and their need for support and supervision: A systematic literature review. The European Journal of Counselling Psychology, 4(2), 166-190. https://doi.org/10.5964/ejcop.v4i2.76

  • Dewane, C. J. (2006). Use of self: A primer revisited. Clinical Social Work Journal, 34(4), 543-558. https://doi.org/10.1007/s10615-005-0021-5

  • Easterbrook, C. J., & Meehan, T. (2017). The therapeutic relationship and cognitive behavioural therapy: A case study of an adolescent girl with depression. The European Journal of Counselling Psychology, 6(1), 1-24. https://doi.org/10.5964/ejcop.v6i1.85

  • Edwards, J. K., & Bess, J. M. (1998). Developing effectiveness in the therapeutic use of self. Clinical Social Work Journal, 26(1), 89-105. https://doi.org/10.1023/A:1022801713242

  • Giovazolias, T., & Davis, P. (2005). Matching therapeutic interventions to drug and alcohol abusers’ stage of motivation: The clients’ perspective. Counselling Psychology Quarterly, 18(3), 171-182. https://doi.org/10.1080/09515070500290186

  • Grigoriadou, M., & Kleftaras, G. (2017). Depressive symptomatology, attachment style, job insecurity and burnout of civil servants in the Greek economic crisis. The European Journal of Counselling Psychology, 6(1), 96-112. https://doi.org/10.5964/ejcop.v6i1.126

  • Hanson, J. (2005). Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients. Counselling & Psychotherapy Research, 5(2), 96-104. https://doi.org/10.1080/17441690500226658

  • Haugvik, M., & Mossige, S. (2017). Inter-subjectively oriented, time-limited psychotherapy with children: How does the therapist evaluate the therapeutic process and what are the therapist’s tasks? Journal of Child Psychotherapy, 43(3), 353-368. https://doi.org/10.1080/0075417X.2017.1369554

  • Heidegger, M. (1977). Being and time (M. Niemeyer Verlag, Trans.). San Francisco, CA, USA: Harper San Francisco. (Original work published 1927).

  • Henretty, J. R., & Levitt, H. M. (2010). The role of therapist self-disclosure in psychotherapy: A qualitative review. Clinical Psychology Review, 30(1), 63-77. https://doi.org/10.1016/j.cpr.2009.09.004

  • Husserl, E. (1997). Psychological and transcendental phenomenology and the confrontation with Heidegger (T. Sheehan & R. E. Palmer, Trans.). Dordrecht, Netherlands: Springer. (Original work published 1927-1931)

  • Jennings, L., & Skovholt, T. M. (1999). The cognitive, emotional, and relational characteristics of master therapists. Journal of Counseling Psychology, 46(1), 3-11. https://doi.org/10.1037/0022-0167.46.1.3

  • Jones, K. A. (2012). Developing the therapeutic use of self in the health care professional through autoethnography: Working with the borderline personality disorder population. International Journal of Qualitative Methods, 11(5), 573-584. https://doi.org/10.1177/160940691201100504

  • Jung, C. G. (1995). Memories, dreams, reflections. London, United Kingdom: Fontana Press. (Original work published 1963)

  • Kasprow, M. C., & Scotton, B. W. (1999). A review of transpersonal theory and its application to the aractice of psychotherapy. The Journal of Psychotherapy Practice and Research, 8(1), 12-23.

  • Kastrani, T., Deliyanni-Kouimtzis, V., & Athanasiades, C. (2017). Women as counselling and psychotherapy clients: Researching the therapeutic relationship. The European Journal of Counselling Psychology, 6(1), 138-161. https://doi.org/10.5964/ejcop.v6i1.130

  • Kiesler, D. J. (1996). Contemporary interpersonal theory research. New York, NY, USA: Wiley.

  • Kivlighan, D. M. (2007). Where is the relationship in research on the alliance? Two methods for analyzing dyadic data. Journal of Counseling Psychology, 54(4), 423-433. https://doi.org/10.1037/0022-0167.54.4.423

  • Kivlighan, D. M. (2014). Three important clinical processes in individual and group interpersonal psychotherapy sessions. Psychotherapy (Chicago, Ill.), 51(1), 20-24. https://doi.org/10.1037/a0032162

  • Knox, S., Hess, S. A., Petersen, D. A., & Hill, C. E. (1997). A qualitative analysis of client perceptions of the effects of helpful therapist self-disclosure in long-term therapy. Journal of Counseling Psychology, 44(3), 274-283. https://doi.org/10.1037/0022-0167.44.3.274

  • Kuutmann, K., & Hilsenroth, M. J. (2012). Exploring in-session focus on the patient-therapist relationship: Patient characteristics, process and outcome. Clinical Psychology & Psychotherapy, 19(3), 187-202. https://doi.org/10.1002/cpp.743

  • Levitt, H. M., Minami, T., Greenspan, S. B., Puckett, J. A., Henretty, J. R., Reich, C. M., & Berman, J. S. (2016). How therapist self-disclosure relates to alliance and outcomes: A naturalistic study. Counselling Psychology Quarterly, 29(1), 7-28. https://doi.org/10.1080/09515070.2015.1090396

  • Luca, M., & Filipoppoulos, P. (2014). Motivational and adaptation experiences of returnees and migrants to Cyprus: A grounded theory study with counselling psychology application and practice implications in Europe. The European Journal of Counselling Psychology, 3(1), 20-41. https://doi.org/10.5964/ejcop.v3i1.18

  • Lum, W. (2002). The use of self of the therapist. Contemporary Family Therapy, 24(1), 181-197. https://doi.org/10.1023/A:1014385908625

  • MacLaren, C. (2008). Use of self in cognitive behavioral therapy. Clinical Social Work Journal, 36(3), 245-253. https://doi.org/10.1007/s10615-008-0156-2

  • Mahrer, A. R. (1996). The complete guide to experiential psychotherapy. New York, NY, USA: John Wiley & Sons, Inc.

  • May, R. (2004). Contributions of existential psychotherapy. In R. May, E. Angel, & H. F. Ellenberger (Eds.), Existence (pp. 37-91). New York, NY, USA: Rowan & Littlefield Publishers. (Original work published 1958)

  • McLeod, J. (2011). Doing Counselling Research (2nd ed.). London, United Kingdom: Sage. (Original work published 2003)

  • Mearns, D., & Cooper, M. (2018). Working at relational depth in counselling & psychotherapy (2nd ed.). London, United Kingdom: Sage.

  • Mearns, D., Thorne, B., & McLeod, J. (2013). Person-centred counselling in action (4th ed.). London, United Kingdom: Sage.

  • Merleau-Ponty, M. (1978). The phenomenology of perception (F. Williams, Trans.). London, United Kingdom: Routledge & Kegan Paul. (Original work published 1962)

  • Mitchell, S. A. (1988). The intrapsychic and the interpersonal: Different theories, different domains, or historical artefacts? Psychoanalytic Inquiry: A Topical Journal for Mental Health Professionals, 8(4), 472-496. https://doi.org/10.1080/07351698809533738

  • Mitchell, S. A. (2010). Relationality: From attachment to intersubjectivity. New York, NY, USA: Routledge. (Original work published 2000)

  • Ogden, P., Minton, K., & Pain, C. (2006). Norton series on interpersonal neurobiology. Trauma and the body: A sensorimotor approach to psychotherapy. New York, NY, USA: W. W. Norton & Company.

  • Paul, S., & Charura, D. (2015). An introduction to the therapeutic relationship in counselling & psychotherapy. London, United Kingdom: Sage.

  • Perls, F., Hefferline, G., & Goodman, P. (1994). Gestalt therapy: Excitement and growth in the human personality. Gouldsboro, ME, USA: The Gestalt Journal Press Inc. (Original work published 1951)

  • Raines, J. (1996). Self-disclosure in clinical social work. Clinical Social Work Journal, 24, 357-375. https://doi.org/10.1007/BF02190743

  • Rogers, C. R. (2015). Client-centered therapy. London, United Kingdom: Robinson. (Original work published 1951)

  • Rogers, C. R. (2016). On becoming a person. London, United Kingdom: Robinson. (Original work published 1961)

  • Rogers, C. R. (1995). A way of being. New York, NY, USA: Houghton Mifflin Company. (Original work published 1980)

  • Rossouw, G., Smythe, E., & Greener, P. (2011). Therapists’ experience of working with suicidal clients. The Indo-Pacific Journal of Phenomenology, 11(1), 1-12. https://doi.org/10.2989/IPJP.2011.11.1.4.1103

  • Rowan, J., & Jacobs, M. (2008). The therapist’s use of self. Glasgow, United Kingdom: Open University Press. (Original work published 2002)

  • Satir, V., Banmen, J., Gerber, J., & Gomori, M. (1991). The Satir model. Palo Alto, CA, USA: Science and Behavior Books.

  • Sartre, J. P. (2003). Being and nothingness (Metheun & Co Ltd, London, Trans.). London, United Kingdom: Routledge. (Original work published 1943)

  • Searles, H. F. (1979). Countertransference and related subjects: Selected papers. New York, NY, USA: International Universities Press. (Original work published 1966/1967/1973)

  • Searles, H. F. (1986). My work with borderline patients. Lanham, MD, USA: Jason Aronson Inc. (Original work published 1978)

  • Searles, H. F. (2005). Collected papers on schizophrenia and related subjects. London, United Kingdom: Karnac. (Original work published 1958/1965)

  • Searles, H. F. (2017). Concerning transference and countertransference. Psychoanalytic Dialogues, 27(2), 192-210. https://doi.org/10.1080/10481885.2017.1285167

  • Sexton, T. L., & Whiston, S. C. (1994). The status of the counseling relationship: An empirical review, theoretical implications, and research directions. The Counseling Psychologist, 22(1), 6-78. https://doi.org/10.1177/0011000094221002

  • Shaw, R. (2003). The Embodied psychotherapist: The therapist’s body story. London, United Kingdom: Routledge.

  • Smith, J. A., Flowers, P., & Larkin, M. (2009). Interpretative phenomenological analysis: Theory, method and research. London, United Kingdom: Sage.

  • Spinelli, E. (2007). Practicing existential psychotherapy: The relational world. London, United Kingdom: Sage.

  • Sussman, M. B. (1995). A perilous calling: The hazards of psychotherapy practice. New York, NY, USA: Wiley.

  • Turner, B. S. (2008). The body and society (3rd ed.). London, United Kingdom: Sage.

  • van Deurzen, E. (2015). Structural existential analysis (SEA): A phenomenological research method for counselling psychology. Journal of Contemporary Psychotherapy, 45(1), 59-68. https://doi.org/10.1007/s10879-014-9282-z

  • Weiner, M. F. (1978). Therapist Disclosure: The Use of Self in Psychotherapy. Boston, MA, USA: Butterworths.

  • Wilber, K. (1993). The spectrum of consciousness. Wheaton, IL, USA: Quest Books. (Original work published 1977)

  • Wilber, K. (2001). No boundary: Eastern and western approaches to personal growth. Boston, MA, USA: Shambhala. (Original work published 1979)

  • Willig, C., & Stainton Rogers, W. (Eds.). (2017). The SAGE handbook of qualitative research in psychology. London, United Kingdom: SAGE Publications Ltd.

  • Winnicott, D. W. (2001). The family and individual development. London, United Kingdom: Brunner- Routledge. (Original work published 1965)

  • Wosket, V. (2006). The therapeutic use of self: Counselling practice, research and supervision. London, United Kingdom: Routledge. (Original work published 1999)

  • Zeddies, T. J. (2000). Within, outside, and in between: The relational unconscious. Psychoanalytic Psychology, 17(3), 467-487. https://doi.org/10.1037/0736-9735.17.3.467