Relationship-Based Treatment; What It Is, What It Isn’t, and How Our Industry Can Do Better
By: Nevin G. Alderman, M.A., LPC – New Haven RTC, Clinical Director
Relationship-based treatment is the use of the client-provider relationship to inspire, motivate and facilitate healthy adaptation in the life of a client. Relationship-based treatment is systemic by nature, and considers and utilizes the relational exchange between the client and their environment, social networks, primary support networks, cultural and societal influencers, etc. in determining and implementing interventions to support adaptive growth. Relationship-based treatment operates under the assumption that all individuals are innately valuable with immense potential, are worthy of respect and love, and will naturally gravitate toward self-actualization as basic needs are adequately satisfied. Therefore, in relationship-based treatment, the client is partnered with in a loving, intentional, authentic and trustworthy relationship with a therapeutic goal of understanding and meeting core needs as opposed to reducing the client to an object to be manipulated, controlled, used, broken-down or fixed. Simply stated, relationship-based therapeutic modality consists of relationally joining with a client to identify and satisfy core issues and needs, resulting in natural movement toward self-actualization.
To further emphasize the importance of a relational approach in satisfying core needs, Maslow postulates:
There are at least five sets of goals, which we may call basic needs. These are briefly physiological, safety, love, esteem, and self-actualization… If both the physiological and the safety needs are fairly well gratified, then there will emerge the love and affection and belongingness needs… In our society the thwarting of these needs is the most commonly found core in cases of maladjustment and more severe psychopathology. Love and affection… are generally looked upon with ambivalence and are customarily hedged about with many restrictions and inhibitions. Practically all theorists of psychopathology have stressed thwarting of the love needs as basic in the picture of maladjustment. Many clinical studies have therefore been made of this need and we know more about it perhaps than any of the other needs except the physiological ones. (1)
Relationship-based treatment joins with this notion that love, affection and belongingness in and of itself is grounding, healing and satisfying, and that the lack thereof is often a significant contributor to pathology and dysfunction. In our caseloads there is ample evidence of the devastating effect of a wanting individual in regard to this need. Self-mutilation, engagement in harmful and abusive relationships, addiction and self-medication, eating-disordered tendencies, depression, and personality disordered traits are among the many self-destructive issues that often emerge.
Among our population of adolescents, this lack of relational fulfillment is also highly correlated with lack of self-esteem; Maslow’s fourth level of hierarchal need. In the following illustration, Maslow speaks to what could be describing traits of a defiant or conduct disordered adolescent with some budding Cluster B tendencies, a realm of presentation with which most can relate in residential treatment:
There are some people in whom, for instance, self-esteem seems to be more important than love. This most common reversal in the hierarchy is usually due to the development of the notion that the person who is most likely to be loved is a strong or powerful person, one who inspires respect or fear, and who is self confident or aggressive. Therefore such people, who lack love and seek it, may try hard to put on a front of aggressive, confident behavior. But essentially they seek high self-esteem and its behavior expressions more as a means-to-an-end than for its own sake; they seek self-assertion for the sake of love rather than for self-esteem itself. (1)
Per Maslows example, the individual’s need for love has become so relentless that maladaptive tendencies (aggressive, overly confident or fear-based relational approach) have been adopted in an attempt to attain the relational need of love, affection and belonging. Certainly, we are all aware of examples where more base physiology and safety needs become inconsequential to our clients in an attempt to meet the relational needs of love, affection and belonging. Or in utilization of William Glasser’s Choice Theory, often the need for Love and Belonging outweighs the need for Freedom, Fun, Power and even one’s own need for Survival. “In practice, the most important need is love and belonging, as closeness and connectedness with the people we care about is a requisite for satisfying all of the needs… Being disconnected is the source of almost all human problems such as what is called mental illness…” (2)
Understanding the fundamental need for relational connection, love, affection and belongingness, and a state of pathology that often ensues when such is wanting, attention then focuses on constructs we might avoid in the pursuit of therapeutic alliance in relationship-based treatment. John Gottman, in his renowned research of relational love, satisfaction and connection, proposed what he terms “four horseman of the apocalypse”, or in other words, four key principles shown in his exhaustive research to be heavily correlated with relational dissatisfaction and disintegration. They are Criticism, Contempt, Defensiveness and Stonewalling. (3)
Criticisms in their simplest form are statements that imply that something is globally wrong with an individual. Being overly critical is a common human folly generally, and becomes increasingly difficult to avoid when in an environment designed to be critical in the assessment for, and the identification and healing of maladaptive functioning. In a treatment setting, criticism will often present itself like, “Get back in there and make your bed. You always forget what you are supposed to be doing. Why can’t you just remember what you are supposed to do and do it?! You never listen!” Dr. Gottman states that a more relationally-focused approach is to complain but don’t blame, or in other words, to recognize with the client the problems at hand, but to be careful not to globalize the problems to the clients identity.
Contempt is described by Gottman as the act of putting oneself above another, and as the most destructive of the four horsemen. Contempt is when we begin as treatment providers to see a client as hostile, malicious, less than and/or broken. We lose the vision of the innate value and worth of an individual, and we begin to take maladaptive behavior personally vs. understanding such as a destructive attempt at survival through satisfying core needs. An example is, when attempting to get an adolescent client to comply with a directive, “What is wrong with you?! Are you stupid?! Hello! Can you hear me? (Eye rolling and sighing). You are so dense!” Dr. Gottman offers that creating a culture of praise and appreciation is a good antidote in this arena; constantly reminding ourselves of the good that is innately a part of the client’s identity.
Defensiveness ensues in an attempt to protect our own ego from the lack of influence and control we feel with a client. Defensiveness also acts to buffer us from what we often and too quickly perceive to be personal and malicious attacks as the client’s maladaptive attempts to meet needs play out. Defensiveness is destructive as it blinds a person from personal and relational awareness, insight, adaptation and growth. Defensiveness on the part of a treatment provider commonly presents itself as, “Don’t blame me, I’m not the one that screwed up my life by choosing to do drugs and run away from home. This is your issue. Don’t put your problems on me!” Dr. Gottman shares that the antidote to defensiveness is looking at self first and taking responsibility for one’s own part. With our clients, this means a willingness to look at our systemic role in the lives of the youth and families we serve, and having insight and ownership into our systems collective contribution to stumbling blocks and stepping stones. In addition, assisting the families we serve in fostering a family culture of systemic approach to needs, conflicts and problem resolution.
Stonewalling occurs in reaction to Negative Sediment Override, wherein a client or a treatment provider “tunes out” the other. The negativity tolerance threshold has been surpassed, and one or both parties in the relationship disengage from the relationship in an attempt to buffer themselves from the negativity. Certainly it is at this point wherein a treatment provider’s ability to influence and effect change diminishes. Dr. Gottman shares the vital skill of self-soothing as an antidote to stonewalling in our relationship with our clients, not just that we teach and instruct our youth and the families we serve regarding the development of their own self-soothing strategies, but that we as treatment providers also develop and engage in self-soothing to remain connected, aware, engaged and intentional in our therapeutic relationship.
If left unattended to, The Four Horsemen become cyclical, reciprocal and perpetual in the provider-client relationship. Relationship-Based Treatment emphasizes the refinement of self and system in the creation of a therapeutic alliance; primary focus being given less to what you do, but rather to who you are as foundational to what you do. By adhering to a relationship-based treatment modality, and avoiding those constructs that threaten our capacity for relational rapport with our clients, the relationship we form with our client can itself be healing and satisfying. In most cases, this relationship-based approach will produce a further reaching effect than the use of any other therapeutic skill or technique in isolation. By so doing, we assist the client in satisfying foundational needs that in-turn allows for attention to be given to the higher order needs of self-esteem and self-actualization.
- Maslow, A. H. A Theory of Human Motivation (1943). Originally Published in Psychological Review, 50, 370-396. Obtained online at: http://psychclassics.yorku.ca/Maslow/motivation.htm
- The William Glasser Institute (2010). Obtained online at: http://www.wglasser.com/the-glasser-approach/choice-theory
- Gottman, J.M., Gottman, J.S. (2010). Level 1&2 Training Manual. The Gottman Institute.