Book Review: Therapist and Client: A Relational Approach to Psychotherapy by Patrick Nolan

Published by Wiley Blackwell. ISBN 0470019530, 9780470019535

Reviewed by Rosaleen McElvaney, MPsychSc., PhD, Reg.Clin.Psychol.APsSI.

This book focuses on the therapeutic relationship as core to the process of therapy. As a starting point, Nolan points to findings from psychotherapy outcome research in relation to the role of the therapeutic relationship as a central factor influencing better outcomes for clients. He outlines developmental research with infants and the infant-mother relationship as a basis for understanding the client-therapist relationship to underscore his point regarding the evolutionary adaptive nature of this relationship in meeting the infant’s/client’s needs. The importance of a balance between separateness and attunement in facilitating the developing child’s/client’s relational capacities, the creation of a space that forms the third element to the therapeutic dyad and the importance of creativity and play in development is all beautifully interspersed with theory, research findings and case vignettes. The introductory chapter forms the basis for many of the ideas expressed later in the book and the tools used in therapy that are drawn from infant development research: two-way exchange, turn-taking, matching, reciprocity, rhythmic coupling, affect attunement, and affect regulation, much of this through non-verbal communication.

Three chapters are devoted to a discussion of the interpersonal relationship, intersubjectivity and the ‘potential space’ that exists when therapist and client embark on the journey of therapy and how the therapist can maximise the potential for using this space to allow for creativity and play in the therapeutic work. These chapters form the distinctive contribution in this book, focussing as it does on a relational approach to psychotherapy. Through an enhanced self-awareness and awareness of the other, the therapist can be guided by what is happening in the space between therapist and client, both consciously and unconsciously, implicitly and explicitly. Nolan refers to ‘the realm of potential space’, emphasising the potentialities inherent in using this space as, in his view, much of what happens in therapy lies in this space rather than in the internal processes of the client or the therapist. Nolan emphasises the importance of therapist stance as ‘not knowing’, ‘playing with uncertainty’, and using the space as transition for the development of transitional objects. He explores creativity and play in the therapy setting and how both the therapist and the client can play in the therapeutic space, thus enhancing the relationship and contributing to progress in the therapeutic work.

Nolan draws primarily on a psychoanalytic body of knowledge in presenting his ideas about the therapeutic relationship which is appropriate, given the prominence given to the therapist-client relationship in this tradition. He also draws heavily on his humanistic background acknowledging the limitations of both traditions and strongly advocating an integrative perspective whereby all theoretical traditions are respected, none are considered exclusive and theoretical distinctions are downplayed in favour of experiencing the therapist-client relationship in the moment by moment interaction of the journey of therapy.

Nolan advocates an integrated body-mind perspective in his relational approach. In presenting this perspective, he outlines five modes of experience, function and expression that operate in any human encounter: body sensation, emotions, cognition, imagination and motor activity. He outlines many useful techniques of working non-verbally, offering case examples of this from his practice. I would have preferred if this had not constituted a separate chapter but rather, in true integrative style, had been assimilated throughout the book. Also, he chose to focus on non-touch bodywork in his illustrations. Although this is probably more relevant to a broad readership, there is a sparcity in the literature on the use of contact bodywork integrated with other therapeutic approaches that Nolan, given his extensive clinical experience, is well positioned to address.

In addition to the body-mind chapter, he devotes a chapter to a discussion of working with trauma and what he terms ‘fragile’ clients, that calls for a different way of working; one that supports the ego, helps ground the client, providing a safe place to begin the work that is needed. He offers a list of useful principles for working relationally with this client group that includes practical advice on issues such as minding the boundaries of the therapeutic frame.

Nolan’s final chapter addresses the need for a good assessment of the client, their motivations for engaging in therapy and their therapeutic needs, the importance of healthy scepticism in relation to theory and how useful or limiting theory can be in informing our work, the importance of the therapeutic frame and the contract for holding both the client and the therapist, the importance of self awareness on the part of the therapist, and of staying with the unknown. He distinguishes between different levels of working in therapy: counselling and support, intermediate work, deep work and ego support and strengthening, noting that different levels of working are sometimes required within the same session with a client and with the same client at different stages of therapy. He completes the book by emphasising the importance of developing one’s individual style, sharing with us his own views on five overall ways of working that are essential to allowing full attention to the relationship in therapy: flexibility and openness, experimentation, optimal responsiveness, revisiting and integrating and working in the moment.

The real richness in this book is how Nolan illustrates his ideas through his own reflections on his client work and the presentation throughout the book of case vignettes that explicitly demonstrate how the concepts outlined are manifested in his work with clients. Each chapter begins with a presentation of theoretical ideas, supported by theory and research from diverse disciplines including developmental psychology and neuroscience, followed by a demonstration of how these ideas apply in the therapy setting. We are invited to observe the work of therapy, to share in his reflections, to glance into his consulting room where both client and therapist are exposed in all their vulnerability. This book has something to offer both those in training and experienced practitioners engaged in therapeutic work.