Mutuality in the therapeutic relationship: A meeting of hearts

by Marie Tierney

Introduction
Mutuality in personal relationships is a goal for many people and its absence a common reason for seeing a psychotherapist (Jordan, 1986). Being connected and attached to others through relational mutuality is a deeply satisfying experience, while disconnection can cause suffering and impact self-esteem. Mearns and Thorne (1999) state that trust is a two-way process in psychotherapy – the therapist needs to develop trust in the client and the client’s process, as the client grows to trust the therapist and the therapeutic relationship. As a trainee therapist, this concept of mutual trust in the therapy relationship intrigued me. This article explores the theory and practice of mutuality in the therapeutic relationship through the lens of different approaches to psychotherapy, with a particular focus on mutuality as both a process and an outcome of relational psychotherapy.

Definition of mutuality
Mutuality in psychotherapy is an elusive concept which I discovered can be confusing, difficult to define and understand. There are many definitions depending on the type of therapy, and even within the same type of therapy. The definitions that I find most helpful are Jordan (1986: 2): “in a mutual exchange one is both affecting the other and being affected by the other” and Murphy and Cramer (2014: 2): “the bi-directional, reciprocal experience of empathy, unconditional positive regard, and congruence of each person within the dyadic relationship”. McLeod (2003: 300) describes mutuality as a relationship, “that emerges out of a boundaried containment rather than being an open collaboration from the start”. Mutuality does not mean sameness, equality, or reciprocity; it is a way of relating in which therapist and client participate as fully as possible (Miller & Stiver, 1997).

Watson (2007) movingly describes Mary Cassatt’s painting The child’s bath, which depicts a woman bathing a child wrapped in a towel on her lap, as a powerful metaphor for psychotherapeutic themes of “holding, vulnerability, closeness, attachment, peace and recognition” (65). He describes how the paired reflection in the water allows both persons to see and be seen together, individually and as a dyad, permitting mutual recognition and self-expression. As I gaze at this painting I experience a felt sense of mutuality. I am moved by the tender presence and engagement between mother and child; in the shared activity both are affected by and affecting the other. There is an obvious inequality in the parent-child relationship as the mother offers holding and containment for the child, and yet both are involved in generating and perceiving the relationship.

History of mutuality
Sandor Ferenczi was a controversial, daring, and innovative Hungarian psychoanalyst described as “the most loved of Freud’s inner circle” (McLeod, 2003: 107), and renowned for working with difficult patients. He defied Freud in his unequivocal belief that many clients had been sexually abused in childhood, and in his emphasis on creating a loving therapeutic relationship to heal past wounds, as a precursor to humanistic psychotherapy. Although forgotten after his death, his ideas have been resurrected and influence contemporary therapists, particularly those interested in developing a more collaborative, active approach to working with clients (McLeod, 2003).

Concepts such as brief therapy, the active involvement of the therapist, flexibility in the use of technique and increased equality between therapist and client were all discussed in a 1924 book Ferenczi published with Otto Rank called The development of psychoanalysis. Ahead of his time, he argued for therapist use of counter-transference and also experimented with the idea of mutual analysis and therapist self-disclosure. His ideas have influenced the development of Rogers’ client-centred therapy, psychoanalytic object relations theory and relational psychoanalysis (McLeod, 2003).

Mutuality of Rogers’ core conditions
Mutuality is a key concept in person-centred psychotherapy. Rogers believed that a therapeutic relationship characterised by congruence on the part of the therapist allows the client to develop congruence by feeling valued and understood by the therapist. The therapist is open to experience and willing to communicate this to the client as appropriate. Tickle and Murphy (2014) describe mutuality as an encounter where unconditional acceptance and empathy are experienced to varying degrees by both client and therapist. In this encounter, client and therapist are perceiving and experiencing Rogers’ therapeutic conditions, both in the other and towards the other. In remaining focused on the client’s moment-to-moment experiencing, the therapist relates to the client in a “Thou-I” stance (Tickle & Murphy, 2014: 2).

Rogers Buber dialogue
Martin Buber’s I and Thou was first published in English in 1937. Buber believed that we live mostly in a world of I-It relations in which we relate to people and things as objects. We can have moments of I-Thou relations characterised by mutual giving of ourselves to one another with no separation between us; without I-Thou relations we are not fully human.

In 1957, Martin Buber and Carl Rogers met in public dialogue in the University of Michigan. Woods summarised the discussion, described as courteous, restrained and humorous, in which they offered different perspectives on the nature of the therapist-client relationship. When the client is able to sense therapeutic attitudes in the therapist, Rogers describes “a real experiential meeting of persons in which each of them is changed” (Woods, 2014: 16). In response, Buber points out that the therapist-client relationship by nature lacks mutuality and equality: “you are not equals and cannot be” (Woods, 2014: 16). The therapeutic relationship is unequal when viewed from the outside. From inside, the same therapeutic relationship is described by Rogers as “something immediate, equal, a meeting of two people on an equal basis – even though in the world of I-It, it could be seen as a very unequal relationship” (Woods, 2014: 16).

Research evidence for the impact of mutuality in the therapeutic relationship
David Murphy, an academic psychologist and psychotherapist in Nottingham, has contributed greatly to the theory of mutuality by researching its process and development in contemporary person-centred psychotherapy (Murphy, 2010). His mutuality hypothesis suggests that clients do better in therapy when there is mutual experience of congruence, unconditional positive regard and empathic understanding; further research is needed to understand how mutuality develops within the therapeutic relationship. Murphy argues for the increasing recognition of a bi-directional and mutually generated therapeutic relationship, challenging “therapist-centric thinking” (Murphy, 2012: 185) and replacing the focus on the therapist as the active agent responsible for changes made by the client. Murphy believes that although mutuality is a core process at the heart of the therapeutic experience, it is consistently under-acknowledged in the relational depth literature.

Relational-cultural therapy
In 1976, Jean Baker Miller published Toward a new psychology of women, and the following year a small group of women psychotherapists, known as the Stone Centre at Wellesley College, began meeting in her living room. Through listening to each other, to their women clients, and to other feminist writers, and by critiquing prevailing psychotherapy theory, largely developed by men, their process gave birth to a new psychotherapy model called Relational- Cultural Therapy (RCT) which recognises our need for “growth-fostering relationships” (Miller & Stiver, 1997: 26). This approach values all relationships and views psychological ill-health as the result of chronic disconnection in relationships within a culture that over-values power and independence. The three core relational processes of RCT are mutual empathy, mutual empowerment and mutual responsiveness. Mutual empathy is present when the therapist is open to being affected by the client and the client in turn is affected by the therapist’s affect. In her essay, The meaning of mutuality, Jordan (1986) explores relationships characterised by mutual inter-subjectivity. The opportunity for mutual growth and change occurs when boundaries become temporarily altered through empathic attunement.

Relational psychoanalysis
The idea of a relationship provided by the therapist for the patient persisted from the early days of psychoanalysis until the emergence of more patient-focused humanistic therapies in the 1960s. The primacy of the relationship has become established in the past twenty years, with the embracing of the relational turn in psychotherapy and counselling by all therapeutic approaches (Mitchell, 2000). More recently the idea of working at relational depth has been a further development from the idea of a relationship provided by the therapist for the client, with the shift from a one-person to a two-person psychology. Mutuality encompasses the science and art of seeing and being seen in relationship (Murphy, 2012).

Relational psychotherapy
Relational psychotherapy is an integrative form of therapy combining self-psychology, relational psychoanalysis and relational-cultural therapy. It shifts the emphasis from inner experience (intrasubjective) to exploration of the impact of relationships on individual experience (intersubjective). A key principle is the development of a strong, collaborative relationship between the therapist and client that acts as a model for other relationships. In order to develop relational awareness, the client learns about their strategies for disconnection and how they push others away, using the therapeutic relationship to develop a new and healthy map of relating to others (Good Therapy.org, 2016). Through struggle and conflict in the therapy relationship, the client learns about relational process in cycles of rupture, disconnection and reconnection (Tickle & Murphy, 2014).

Relational body psychotherapy
With the relational turn in psychotherapy, body psychotherapy is becoming more relevant and nourished by contemporary developments, including mutuality; the relational approach is now central to body psychotherapy (Rolef Ben-Shahar, 2014). Affects are created and shift continuously as therapist and client affect each other (Knoblauch, 2000). Nolan (2014) describes how interactive regulation operates between therapist and client through body sensations, feelings, imagination, thinking and movement.

Love’s deep mutuality
I finally started to grasp the true meaning and intention of mutuality when I read Zen Buddhist master Thich Nhat Hanh’s (2014) slim book How to love, in which he teaches that understanding is another name for love – to love another means to fully understand his or her suffering. In order to do this, our hearts need to expand – otherwise understanding and compassion are limited, resulting in suffering. When our hearts expand, we can accept ourselves and others as they are. This is similar to Carl Rogers’ (1980) belief that if he was to facilitate the personal growth of another person, then he too had to grow; before he could help another person he had to develop a helping relationship with himself, by becoming aware and accepting of his own feelings.

Thich Nhat Hanh states that real love, rather than our fantasy of another person, is based on four elements: loving kindness, compassion, joy and equanimity. Listening is the key to establishing trust and respect. When we know how to love, we can avoid unintentionally wounding others. Loving requires understanding and understanding requires listening.

Neuroscience
Neuroscientific data demonstrate that we are wired to connect, that the brain grows in connection, and that disconnection causes pain. Attachment theory describes the importance of early regulation by a good enough mother for childhood development and empathic connection. By showing that the brain is capable of changing throughout life, neuroplasticity, or brain plasticity, provides hope that every person has the capacity to develop empathy and to experience healthy, connected relationships. Researchers such as Schore (2003) (affect regulation), Porges (2011) (social engagement, polyvagal theory), and Fisher (2014) (neurofeedback), are discovering the scientific evidence that supports the mutual impact of the client’s and therapist’s nervous systems on each other, and how essential mutuality is to our wellbeing.

How I would use mutuality in therapy
My personal therapeutic journey from fear-based disconnection and guarded protection, to healing through the mutuality of therapeutic encounter, has shaped me as a person and as a therapist. I am inspired by Yalom (2002: 26-27) who captures the spirit of mutuality in his advice to “let your patients matter to you, to let them enter your mind, influence you, change you – and not conceal this from them”. This challenges me to be vulnerable, remaining open and allowing myself to be affected by the client, being spontaneous, mutual and authentic, while holding the therapeutic frame. Courage and trust is required to surrender into the intersubjective space, empathically attuning to the client moment to moment.

Mutuality and therapy is about both connection and separation. By seeing our interconnectedness and overlapping interests with others, the relational-cultural therapy model of the primary relatedness of humans heals the split between self and other, between self and society. I can be with others in my vulnerability rather than standing against others in my separateness.

Mutuality is tender presence. The “moment-to-moment encounter of psychotherapy” happens in the immediate present (Rogers, 1980: 2155); “it is involvement in the immediacy of experience of relationship”. This is the existential attitude of presence which Rogers described towards the end of his life, as a self-transcending, slightly altered state of consciousness. This attitude of tenderness may be the fourth core condition (Thorne & Lambers, 1998).

A model for an integrative approach influenced by mutuality is The Toronto Institute for Relational Psychotherapy (2017), which integrates self-psychology, inter-subjectivity theory, relational psychoanalysis, psychodynamic developmental theory, trauma theory and feminist psychotherapy theories. Another model is provided by The Irish Women’s Therapy Centre (Kennedy, 2014).

Mutuality has an important role to play in the mutual impact between trainer and student in psychotherapy training, and supervisor and supervisee in the supervisory relationship, with the potential for mutually rewarding and satisfying experiences for each party (Aron, 1996).

Limitations
Mutuality is an elusive concept which can be interpreted and understood in different ways. There is no standard theory or definition of mutuality. It can be challenging to describe and understand how mutuality develops within the therapeutic relationship. As revealed by the conversation between Buber and Rogers (Woods, 2014), the experience of mutuality as moments of deep connection is more of a felt sense than an intellectual idea, experienced differently by those in the relationship than by outside observers. It is important for a therapist to consider the impact of sharing or not sharing aspects of him- or herself with the client and how this can influence the power dynamics in the relationship. It may be challenging for therapists who adopt a more neutral or expert role to step out of that role and allow themselves to be seen by the client. This may be particularly difficult when a therapist is triggered by a client’s work, highlighting the importance of ongoing personal therapy and supervision for therapists. The general principle of self-disclosure based on therapeutic intent rather than personal need is a useful guideline, as is the idea of mutuality as boundaried containment, rather than open collaboration (McLeod, 2003). Relational cultural theory, built on mutual empathy and mutual empowerment, as a feminist theory, is at risk of being seen as a female rather than a more generally human experience of relationship. A major challenge for mutuality is maintaining the tension between connection and separation, between mutuality and autonomy.

…psychoanalysis requires a dialectical relationship between mutuality on one hand and separateness, difference, and autonomy on the other. Without some concept of autonomy, the meaning of mutuality would degenerate into merger or fusion.

(Aron, 1996: x)

Finally, training in mutuality may be challenging as the approach does not rely on specific techniques that can be taught to students.

Conclusion
The openness to being changed by the other and to have an impact on the other is the core of mutuality. Mutual empathy and mutual empowerment are both a process and an outcome of relational psychotherapy, as therapist and client allow each other to matter. Connection in relationship with others, through growth-enhancing relationship, is key to successful healing and recovery. Healing takes place in the movement from disconnection to reconnection, in the dance between autonomy and separation, and connection and relationship (Baker Miller, 1976). The mutuality of difference facilitates growth, as acknowledging our differences helps us to connect with our common humanity. Moments of deep connection, or mutuality, happen when we remain open, rather than closed to experience, positive and negative, in relationship with others.

Finally, the writing of this article has been a process of putting into words my theoretical and personal experience on the journey of encountering, understanding, and identifying with the concept of mutuality. Personally and professionally, this has been a powerful process for me. I am inspired by the visionary pragmatism of Jean Baker Miller and her colleagues in the Stone Centre who through ‘listening each other into voice’ have allowed so many women and men, including myself, ‘to listen ourselves into voice’, in the company of others on the path of healing.