The Role of Relational-Cultural Theory in Mental Health ... · The implications for conceptualizing...

Journal of Mental Health CounselingVolume 33/Number 3/July 2011/Pages 223-242

PRACTICE

The Role of Relational-Cultural Theory inMental Health Counseling

Thelma DuffeyCatherine Somody

One feature that distinguishes professional counseling ß-om other mental health and illness disciplinesis its developmental, strength-based, contextually-focused. and Wellness perspective. Given the multicul-tural paradigm that the counseling field emphasizes, it is increasingly important to identify models ¡ikerelational-cultural theory (RCT) that support these principles. This article includes an overview of thebasic tenets of RCT and applications to mental health counseling.

There are a number of features that distinguish professional counseling fromother mental heath disciplines. Counseling maintains a perspective that isdevelopmental (Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008); strength-based(Erikson & Kress, 2005a, 2005b; Kress, Erikson, Ray le, & Ford, 2005); con-textually-focused (Comstock et al., 2008; Duffey & Kerl-McClain, 2006/2007);and wellness-centered (Myers, Sweeney, & Witmer, 2001; Neukmg, 2003).Given the multicultural focus emphasized within the field (AmericanCounseling Association, 2005; American Mental Health CounselorsAssociation, 2000; Arredondo et al., 1996), it is highly important to identifymulticulturally supportive theories, such as relational-cultural theory (RCT).

Relational-cultural theory has evolved from the work of Jean Baker Miller(1976) and scholars at the Jean Baker Miller Training Institute (JBMTI),located at the Stone Center at Wellesley College. Unlike many traditional

Thelma Duffey and Catherine Somody are affiliated with The University of Texas at San Antonio.Correspondence concerning this article should be addressed to Dr. Thelma Duffey, Professor andChair Department of Counseling, The University of Texas at San Antonio, 501 West Durango B¡vd,San Antonio, TX 78207-4415. E-mail: [email protected].

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human development theories, which often reflect values of individuation,autonomy, and separation (Fedele, 1994; Jordan, 2000; Miller, 1976), RCTposits that people develop more fully through connections with others.Relationship, rather than autonomy, is the comerstone of growth. According toRCT, people become relationally complex rather than increasingly individuatedand autonomous. Therefore, RCT promotes a contextual and relational lens forunderstanding human development.

The implications for conceptualizing mental health issues from this relationalperspective are far-reaching. Clearly, members of today's society are diversewith respect to gender, culture, race, ethnicity, sexual orientation, religion, anda multitude of other factors. RCT takes into account these sociopolitical andrelational aspects while offering a paradigm to support client growth. AlthoughRCT has been an emerging theory within psychology, it is more recentlybecoming mainstreamed in counseling (Comstock & Qin, 2005; Corey, 2009;Duffey, 2009). In fact, the Association for Creativity in Counseling, the newestdivision of the American Counseling Association, was founded in 2004 on RCTprinciples with a mission of using creativity within counseling to promotediversity and relational development (Duffey, 2006/2007; Duffey, 2009; Duffey& Kerl-McClain, 2006/2007). This article includes an overview of underlyingRCT tenets. We also describe an RCT counseling experience using an illustra-tive case example.

RCT: A DEVELOPMENTAL WELLNESS PERSPECTIVE

Roots of RCTEarly in RCT's evolution, researchers at the JBMTI explored the complexi-

ties and relational experiences of women and members of devalued culturalgroups (Jordan & Hartling, 2002). Their work proposed that connection andcontext, rather than individuation and separation, are the basis on which devel-opment can be measured (Jordan, 2000, 2001; Miller, 1986). While the workinitially focused on the experiences of women, RCT is now being used to bet-ter understand the experiences of all groups, particularly those who are margin-alized due to power and privilege imbalances (Jordan & Hartling, 2002).Current RCT literature recognizes that creating and sustaining growth-fosteringrelationships is as important for males as for females (Bergman, 1991; Dooley& Fedele, 2004; Jordan, 2010). Pollack (1998) discusses two decades ofresearch at the Harvard Medical School and the harmful effects of an outdated"boy code" that continues to impact everyone in society (p. 6). Levant ( 1992)offers compelling evidence that many traditional male role expectations areobsolete and dysftinctional, keeping men out of touch with their emotions anddisconnected from tme intimacy. The RCT model, based on relational develop-ment across the lifespan, provides an altemative to traditional Westem theories

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and cultural expectations of separateness and autonomy for men, women, andchildren,

A Contextual FocusThis shift in focus not only influences how counselors conceptualize client

issues; it also establishes a direction for the counselor-client relationship itself.This point becomes particularly salient when we consider the counseling diag-nostic process (Erikson & Kress, 2005a, 2005b; Kress et al,, 2005; White,2002), Clients who might be otherwise diagnosed with some form of pathologymay, from an RCT perspective, display attitudes and behaviors consistent withtheir life experiences.

For example, consider Diana (pseudonym), a 30-year-old woman who stmg-gles with her weight and relationships. On her first visit, Diana relayed that herweight had fluctuated more than 50 pounds in the past year, Diana describedhow she has struggled with weight since she was a young girl. She alsodiscussed difficulties with an on-line relationship: afraid to post her realpicture, she posted a profile on an Intemet dating service using a picture ofsomeone else,

Diana developed an on-line relationship with a man who lived thousands ofmiles away. They connected on many levels, and he wanted to meet her.However, she described feeling shame and fear because she misrepresentedherself to him. As the possibility of their meeting became more real, under-standably Diana felt even more ashamed, isolated, and alone,

Diana's story illustrates a basic RCT principle: while individuals yeam forconnection, they can also develop strategies that, for a number of reasons, keepthem out of the connections they desire (Comstock, Duffey, & St, George,2002; Duffey, 2005a; Jordan, 2001, 2010; Miller, 1986; Miller & Stiver, 1997),These strategies may include withdrawing from loved ones, being unwilling toexamine their role in conflicts, appearing invulnerable to avoid seeming weak,and hiding authentic feelings (Hartling, Rosen, Walker, & Jordan, 2000),Strategies may involve addictions and other abusive behaviors (Duffey, 2005a),All these strategies, by their very nature, have the potential to impede relation-ships, induce shame, prompt further avoidance (Comstock et al„ 2002; Duffey,2005a; Hartling et al , 2000; Jordan & Dooley, 2000), and restrict an individ-ual's authentic development.

Rather than diagnostic labeling, RCT counselors help clients conceptualizethemselves within a broader context, one that moves them out of a position ofshame, defectiveness, and isolation toward genuine authenticity and connectionwith others (Hartling et al,, 2000; Walker, 2004a), Mutual empathy and agrowth-fostering counselor-client relationship provide the vehicle for change.However, before discussing the related therapeutic process, let us first considerRCT's theoretical underpinnings.

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CORE PRINCIPLES OF RCT

Jordan (2000) succinctly summarized RCT's basic tenets:

1. People grow through and toward relationship throughout the lifespan.2. Movement toward mutuality, rather than movement toward separation,

characterizes mature functioning.3. Relational differentiation and elaboration characterize growth.4. Mutual empathy and mutual empowerment are at the core of growth-

fostering relationships.5. In growth-fostering relationships, all people contribute and grow or bene-

fit; development is not a one-way street.6. Therapy relationships are characterized by a special kind of mutuality.7. Mutual empathy is the vehicle for change in therapy.8. Real engagement and therapeutic authenticity are necessary for the devel-

opment of mutual empathy, (p. 1007)

These principles suggest that people are hard-wired to desire connection.While growth occurs in connection with others, disconnections are an undeni-able aspect of life. In growing through disconnections to reconnection, how-ever, and in distinguishing between growth-fostering connections and toxic orabusive relationships, we become more relationally competent. To clarify thesecore principles, we describe eight key RCT concepts: growth-fostering relation-ships, empathy, mutual empathy, authenticity, strategies of disconnection, thecentral relational paradox, relational images, relational resilience, and rela-tional competency.

Growth-Fostering RelationshipsWhen people are involved in growth-fostering relationships, each party's

growth and the relationship itself become a priority (Miller & Stiver, 1997).Jean Baker Miller (1986) gave the following example of a growth-fosteringexchange: One person expresses thoughts and feelings to another. The otherperson is empathie, and responds with his or her own thoughts and feelings,adding "something more" (Miller, 1986, p. 4). As this exchange continues, eachexpression of thoughts and feeling creates a progression or flow, enlarging andexpanding the feelings and thoughts of both people. This experience bringsincreased awareness and understanding of one's own and the other's thoughtsand feelings. This process can also occur in relationships with more than twoparties.

Miller (1986) described five observable "good things" that result fromgrowth-fostering relationships:


• Each person feels a greater sense of "zest" (vitality, energy).• Each person feels more able to act and does act.• Each person has a more accurate picture of her / himself and the other

person(s).• Each person feels a greater sense of worth.• Each person feels more connected to the other person(s) and feels a greater

motivation for connections with other people beyond those in the specificrelationship, (p. 3)

Thus, growth-fostering relationships are characterized by mutual empathyand relational authenticity, and result in mutual empowerment.

EmpathyAccording to Jordan (1991a), empathy is a complex cognitive and affective

process that involves understanding the experiences of others while resonatingwith their feelings. The affective component entails feeling ernotions similar tothe other person's. The cognitive process entails gaining both awareness of thesource of the emotional arousal and clarity about one's own experiences andfeelings as compared to the experiences and feelings of the other. Empathy cre-ates increased awareness and clarity about the meaning of another's experience(Jordan, 2010).

Empathy has long been recognized as an important counseling component.Carl Rogers (1957) identified empathy as a necessary condition for therapeuticpersonality change. However, RCT theorists posit that the one-way empathythat characterizes many theories is not enough to make a difference for theclient. They adopted the concept of mutual empathy, an experience involvingboth people that promotes relational healing and psychological growth (Miller& Stiver, 1997).

Mutual EmpathyMutual empathy is pivotal to understanding therapeutic change (Jordan,

2000). RCT counselors not only understand the experiences of clients but alsohelp move clients out of isolation into connection. It is the process of mutualempathy that relieves a client's isolation (Jordan, 2010). If clients are to bene-fit from the empathie responses of counselors, they "must see, know, and feel"that they are having an impact on the counselor (Jordan, 2010, p. 4). Whenclients see and feel this, they feel less alone.

Mutuality does not imply equality of power, and counselor responsivenessdoes not suggest full disclosure. The client's growth and healing is the primarygoal of counseling. According to Jordan (2010), the guiding question for acounselor when deciding whether to be transparent is, "Will this facilitategrowth?" (p. 52). This anticipatory empathy involves anticipating the client's

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response based on the counselor's emotional knowledge of the client (Jordan,2010).

Mutual empathy is created when both participants in a relationship areaffected by the other (Jordan, 2000, 2010). In other words, rather than hidingbehind a mask of neutrality, counselors not only allow themselves to be affectedby the experiences of their clients, they communicate this to the clients throughwords and actions. This responsiveness allows clients to experience being fullyunderstood by another person. When clients see and feel that their pain isreceived and felt by another person, and that their pain matters, they begin tofeel less isolated and hopeless (Jordan, 2010). They begin to realize that theycan have an impact on people who are important in their world, and this aware-ness contributes to a sense of client empowerment (Walker, 2004a).

In the past, the sense of mattering may have been lacking, especially amongmembers of minority groups who have experienced a history of oppression andmarginalization. When these clients experience a sense of having impactedtheir counselors, and their differences are accepted, they feel validated (Jordan,1991b). This allows clients to risk being more fully present and honest in therelationship, thus continuing the movement from isolation into connection.

In the example of Diana, mutual empathy is pivotal to the therapeuticprocess. For example, as Diana felt increasingly comfortable in counseling, shebecame better able to articulate the shame and feelings of unworthiness she hascarried since childhood. She described her father as a loving but distant man,and her mother, who had been emotionally battered as a child, as impossible toplease. In fact, Diana brought in recorded messages where her mother repeat-edly called to tell her what a bad daughter she was and how she needed to dobetter as a daughter and as a person or she would surely regret it. Diana wouldlook intently at the counselor's face as she played multiple messages of hermother screaming. She stmggled with the messages and fought hard to see her-self differently. The counselor was not only moved but humbled by Diana'sstmggle to accept herself as a worthy person and by the shame she carried. Itwas important that Diana know her stmggle had affected the counselor. Dianaexpressed relief when she recognized that impact. She would smile and say,"You get it, right?"

RCT practitioners believe clients must feel the counselor's empathieresponse and suggest that a counselor taking a neutral, uninvolved stance mayactually interfere with therapeutic healing. This is in contrast to more tradi-tional models that suggest the counselor must remain non-expressive ordetached (Jordan, 2000, 2010). Indeed, it is the counselor's capacity to remainauthentic that supports opportunities for growth in the counseling relationship.

AuthenticityThe notion of authenticity is fundamental to growth according to RCT.

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Authenticity here refers to the capacity to fully represent ourselves honestly inrelationships (Miller, Jordan, Stiver, Walker, Surrey, &. Eldridge, 2004; Miller& Stiver, 1997). According to RCT theorists, we become more able to know,understand, and state our own feelings and thoughts when we can be authenticwith the people in our lives (Miller & Stiver, 1997). However, authenticity fromthis perspective can be a challenge for many, especially for people who sufferfrom experiences of shame-based oppression and marginalization or for peoplewho feel defective or insignificant (Hartling et al., 2000; Jordan, 1997). Further,power differentials, particularly harmful abuses of power, and inequities in gen-der and cultural experiences, health, socioeconomic status, and other factorscan undermine our capacity to authentically represent ourselves. These experi-ences may lead to pattems of disconnection that impede authentic relating andgrowth.

Self-empathy is a catalyst for authenticity (Jordan, 1991a). As clients cometo look at themselves and their experiences with compassion and understand-ing, their intemal voices no longer carry messages of self-blame or criticism(Banks, 2006). Nakash, Williams, and Jordan (2004) believe that authenticityand the capacity to form and maintain growth-fostering relationships rely onclients' intemal awareness. Thus a counseling goal for clients is to look forways to become more intemally connected and relationally engaged.

Strategies of DisconnectionBesides understanding the benefits and conditions of growth-fostering rela-

tionships and ways that people form and sustain connections, RCT theoristsexplore the inevitability of disconnections and their impact on mental health(Jordan, 2000, 2001, 2010; Miller & Stiver, 1991). Disconnections areundoubtedly part of every relationship, occurring when people let each otherdown, fail to respond empathically, behave in hurtftil ways, or inflict or expe-rience a myriad of other relational injuries (Jordan, 2001). Disconnections arelikely to occur when members of minority groups are marginalized and dis-counted by people in power. Social injustices and the myth of meritocracy con-tribute to feelings of shame and isolation (Comstock et al., 2008; Hartling et al.,2000; Walker, 2004b). This sense of disconnection is reinforced if counselorsfail to understand and acknowledge these contextual factors.

Disconnections result in experiences directly opposite to the "five goodthings": a decrease in energy, an inability to act, confusion or a lack of clarityabout self and other, decreased self-worth, and withdrawal from social contact(Comstock et al., 2002; Jordan & Dooley, 2000; Jordan & Hartling, 2002).However, as people work through disconnections, they become more relation-ally resilient; as they come to feel competent in their relationships, theyincrease their relational resiliency.

Conversely, when injured persons are not able to fully represent themselves


and their feelings in relationships, or when the response to their attempts at con-nection is indifferent or injurious, they may begin to keep parts of themselvesout of relationship to preserve whatever form of relationship they can. Theyoften blame themselves and become more intemally disconnected. In time,their understanding of reality is altered. By hiding their genuine feelings andthoughts, even from themselves, they may feel less real, less understood, andthus more helpless and ineffectual in relationships (Jordan, 2001 ), People expe-riencing such chronic disconnection often feel shame, isolation, self-blame, asense of defectiveness, and immobilization. This was the case with Diana,Using a traditional theoretical lens, her behaviors could be interpreted as patho-logical. From an RCT perspective, the behaviors were in fact self-protectivestrategies for survival. Unfortunately, such strategies ultimately lead to furtherdisconnection.

The Central Relational ParadoxAlthough these strategies of disconnection are intended to protect individu-

als from both perceived and real risks of hurt or rejection, they also keep peo-ple out of the connection they desire, RCT refers to this dynamic as the centralrelational paradox (Miller & Stiver, 1997), Chronic disconnections can lead tocondemned isolation, a feeling that human connection is not possible becauseone is not worthy (Miller & Stiver, 1997), This experience is all too familiar formany members of devalued and marginalized cultural groups who carry per-sonal shame and blame themselves for failures resulting from social injustices.Understanding and working through feelings of condemned isolation is integralto facilitating movement toward healing (Dooley & Fedele, 2004),Acknowledging the possible impact of sociocultural factors is critical to thiswork (Comstock et al,, 2008; Hartling et al,, 2000; Walker, 2004b),

Relational ImagesOne way of working through this paradox is to explore relational images.

These images are concepts people hold about relationships that guide behavior(Miller and Stiver, 1995), Generated from previous experiences, they act as atemplate for how relationships are perceived to be. People develop expectationsof how they will be treated in relationships, and these expectations influencehow they interpret relational dynamics. The relational images and pattems ofrelating produced by experiences of chronic disconnections or abusive behav-iors can be very difficult to change (Miller & Stiver, 1995), However, as peo-ple experience growth-fostering relationships and become more authenticallypresent, even in the face of conflicts, and as they develop self-empathy andcompassion for their experiences, they can revisit these images and increasetheir resilience and relational competence.

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Relational ResilienceAlthough the literature on resilience has historically focused on how an indi-

vidual functions after experiencing adversity or trauma. Hartling (2004) andJordan (2004,2005) discuss resilience from a relational standpoint. "Relationalresilience involves movement toward mutually empowering, growth-fosteringconnections in the face of adverse conditions, traumatic experiences, and alien-ating social-cultural pressures. Resilience is the ability to connect, reconnect,and/or resist disconnection" (Jordan, 2005, p. 83).

Resilience, from an RCT perspective, involves the following paradigm shifts:

. 1. From individual "control over" dynamics to a model of supported vulner-ability;

2. From a one-directional need for support from others to mutual empathieinvolvement in the well being of each person and of the relationship itself;

3. From separate self-esteem to relational confidence;4. From the exercise of "power over" dynamics to empowerment, by encour-

aging mutual growth and constructive conflict;5. From finding meaning in self-centered self-consciousness to creating

meaning in a more expansive relational awareness. (Jordan, 2004, p. 32)

Relational CompetenceAs individuals become increasingly resilient, they also develop their rela-

tional competence. Relational competence involves moving toward mutualifyin relationships (Jordan, 2004). People care about one another and learn fromtheir experiences with each other. They also consider the impact they have onothers, while becoming open to the influence of others. They are willing to bevulnerable and choose mutuality rather than power-over relational strategies(Jordan, 2005). Competence fi-om this perspective promotes depth of relation-ship, even when relating superficially or remaining detached might feel morenatural or safe. A recent survey dealing with the understanding of relationalcompetence found support for the relational constructs of authenticity, mutual-ity, and power (Duffey, Haberstroh, & Trepal, 2009).

THE RCT COUNSELING EXPERIENCE

Because RCT practitioners consider isolation to be a primary source ofhuman suffering (Jordan, 2000, 2010), movement out of isolation is a principaltherapeutic goal. Counselors and clients work collaboratively to understand theclients' patterns of connections and disconnections. Clients explore their rela-tional images and releam their relational expectations (Jordan, 2001 ). As clientsrework these unproductive patterns through the therapeutic relationship, theyexperience growth (Jordan, 2000).


The Counselor-Client RelationshipCounselors employing an RCT philosophy have "deep respect and mutual-

ity" (Jordan, 2001, p. 97) for their clients. RCT counselors believe it is not help-ful to remain disengaged and neutral during counseling sessions; rather,detachment and counselor non-responsiveness are seen as hurtful to manyclients (Jordan, 2000; Miller et al., 2004). RCT counselors are characterized by(a) an understanding of the client, (h) concem for the impact on the client ofwhat is said, and (c) careful clinical consideration based on knowledge of theclient and an understanding of what would be therapeutic (Jordan, 2001,2010).This understanding of the client is built on both knowledge of the client's rela-tional history and the history of the therapeutic relationship (Jordan, 2001,2010). Thus, the counselor works to help clients enhance self-empathy and self-safety (Miller et al., 2004).

RCT stresses the importance of acknowledging the cultural context of theclient's experiences as well as the context of the therapeutic relationship. Thisensures that the counselor does not unintentionally reinforce or replicate cul-tural practices that encourage disconnections and feelings of shame (Walker,2004b).

In Diana's case, an RCT counseling experience gave her the opportunity toexplore her relational images from a place of safety. In time she began to under-stand how the context of her life contributed to her pattems of connection anddisconnection. Diana has by now gained considerable insight and is showingconsiderable courage in her relationships. Recently, she invited her roommateto attend a counseling session with her in which she acknowledged that she hadspoken negatively about the roommate to a mutual friend. Diana explained thatshe envied her roommate because she perceived her life to be much easier thanher own, and she apologized for acting from this place of envy. The exchangebetween Diana and her roommate was a growth-fostering one. Both left theconversation feeling understood and cared for. The counselor considered it aprivilege to participate in this process. Diana continues to practice creating sup-portive relationships and is becoming increasingly able to represent herselfauthentically and responsibly.

Central Techniques and MethodsAlthough RCT is not technique-driven, creative and innovative media can be

used successfully in tandem. RCT counselors have effectively used psy-chodrama (Vogel, 2006/2007); music (Duffey, 2005b; Duffey, Somody, &Clifford, 2006/2007); art (Sassen, Spencer, & Curtin, 2005); expressive writingand photographs (Vogel, 2005); and many other creative techniques. However,"RCT therapy is largely based on a change in attitude and understanding ratherthan a set of techniques" (Jordan, 2010, p. 5). Therapeutic authenticity andmutual empathy are central to this work, and RCT counselors consider mutual


empathy to be flindamental for growth (Jordan, 2010; Ruiz, 2005). Through theRCT counseling process, clients (a) recognize the pattems of connections andstrategies for disconnections they are using, (b) understand what brought aboutthese pattems of relating, (c) recognize that they now can choose how theyrespond to disconnections, and (d) collaborate with the counselor on ways towork toward growth and connection.

Counselors can demonstrate empathy and connect with clients by being tmst-worthy and authentic. They can express, verbally and nonverbally, their under-standing of the client's experiences and worldviews, demonstrating andarticulating respect for the client's emotional experience. RCT counselors alsoconsider the context of the client's relationships, worldviews, relational images,and current relational dynamics. They empower clients by communicatingwhen they are moved by the client or the client's experience. They encourageself-empathy by helping clients (a) develop compassion for themselves; (b)articulate disconnections as they arise within the therapeutic relationship; and(c) negotiate disconnections and reconnections in their relationships. Thesecounseling skills can be applied with individuals, couples, families, or groups.(Comstock et al., 2002, provide infomiation about the group process from anRCT perspective.)

RCT in ActionCounselors who wish to incorporate RCT into their practice might consider

the following suggestions:

1. During the assessment phase, evaluate the client for (a) strengths andcoping skills, (b) indications of self-empathy, (c) signs of relationalresilience, including support systems available, (d) whether they feelthey belong and matter somewhere in their lives, (e) societal sources ofdisempowerment, (f) whether they have experienced discrimination orsocial exclusion, and (g) whether they have experienced personal orsocietal trauma (Jordan, 2010).

2. Explore client relational images (also referred to as relational expecta-tions) and ability to engage in constructive conflict. Help clients leam torepresent their own needs and views to others when in conflict (Jordan,2010).

3. Explore client strategies of disconnection, acknowledging contextualand cultural factors that may have contributed to these strategies. Helpclients recognize the impact of oppression and marginalization so thatthey can move away from uneamed feelings of guilt and shame. Jordan(2010) recommends affirming the wisdom of clients' strategies of dis-connection and cautions against dismantling these survival strategies tooquickly.

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4. Be cognizant of how the counseling process can threaten the client'sstrategies of disconnection and trigger fear. The counselor needs to"[follow] the client's lead and help titrate the movement toward connec-tions appropriately, in such a way that the client is not triggered into ter-ror" (Jordan, 2010, p. 40).

5. Validate clients realistically. Show, verbally and nonverbally, that youunderstand their experiences of life and the world. Make it clear that yourespect their emotional experiences. Flesh out the context of relation-ships and the client's interpretations of them.

6. Empower clients to name destmctive social practices, build support sys-tems, and recognize that it may be impossible to make changes alone.Help clients leam to resist shaming practices at societal and personal lev-els (Walker, 2004b).

7. Be authentic. When you are moved, say so, though this need not requirefull disclosure. Use anticipatory empathy when deciding how much toreveal to clients (Jordan, 2010).

8. Encourage self-empathy. Resonate with client experiences and expresscompassion. Encourage the client's observing self to have compassionfor the client's experiencing self. When clients are especially self-criti-cal, ask how they would view the situation if it involved a friend or lovedone (Jordan, 2010).

9. Be aware of and express your knowledge that the relationship is mutual.Stay attuned and talk about your sense of connection with the client. Stayconnected to the wholeness of the client—all the parts you have leamedabout. Be open to teaming about parts you do not yet know. Talk abouthow the client has connected. Talk about disconnections and the possi-bilities for reconnecting.

10. Be open to feedback from the client and avoid defensiveness. Let go ofthe need to be right or in control, which can lead to distancing from ordemeaning of clients (e.g., "She's confusing me with her father," "He'sresisting my interpretation" [Jordan, 2010, p. 42]). The client's healingis more important than the counselor's ego (Jordan, 2010).

RCT as Short-Term TreatmentBecause RCT is based on deepening connections and relational capacity, it

was primarily considered a long-term counseling approach, but many clinicianshave adapted it for short-term use. Unlike most short-term counseling models,Jordan (2010) explains, short-term RCT counseling does not focus on separa-tion and termination from the outset. The emphasis is on developing relationalawareness, understanding relational pattems and images, encouraging connec-tions, and building skills for developing new relationships (Jordan, 2010).Much of the work in short-term counseling is similar to long-term work, but the


counselor does not stress termination. Rather, Jordan recommends that theprocess be intermittent,

RESEARCH IN SUPPORT OF RCT

Many writings on RCT are based on single case studies or practitioner expe-riences, which provide helpful qualitative data. More recently, empiricalresearch is supporting RCT concepts. The JBMTI (2010) formed a research net-work of scholars interested in this work and for 10 years has hosted an annualRCT research symposium. Research from related fields also supports RCT the-ory (Jordan, 2010),

OutcomesSeveral studies have looked at counseling outcomes. Tantillo and colleagues

used an RCT approach with a psycho-educational multifamily group for treat-ing eating disorders (Tantillo, 2006), A pilot study found that using short-termRCT focused on relational issues was effective in treating bulimia and depres-sion (Tantillo & Sanftner, 2003), Research suggests that eating disorders arediseases of connection, and increasing perceived mutuality in relationships withothers and decreasing disconnections are important for motivating change andreducing symptoms (Sanftner, Tantillo, & Seidletz, 2004),

Growth-Fostering Relationships and Relational QualitiesOther studies have investigated the effects of growth-fostering relationships

as defined by RCT using the Relational Health Index (RHI), an assessment toolthat measures three dimensions: engagement, authenticity, andempowerment/zest (Liang, Tracy, Taylor, & Williams, 2002), Relational healthwas found to be positively associated with mental health and adjustment in col-lege-age women, and growth-fostering community relationships were associ-ated with lower stress and depression (Liang et al,, 2002), Similarly, mentoringstudies indicate that relational qualities in the mentoring relationship, includingempathy, authenticity, and emotional support in a safe place, strongly influencethe success of mentoring (Liang, Tracy, Kauh, Taylor, & Williams, 2006;Spencer, 2006, 2007; Spencer, Jordan, & Sazama, 2004),

Research on coping with cancer also supports the concepts of RCT, Studiesof women's adjustment to cancer found that mutuality was highly correlatedwith quality of life and self-care agency and negatively correlated with depres-sion (Kayser & Sormanti, 2002; Kaiser, Sormanti, & Strainchamps, 1999), Forcouples coping with cancer, the relational qualities of mutuality, awareness, andauthenticity were important (Kayser, Watson, & Andrede, 2007),

A qualitative study by Paris, Gemborys, Kaufman, and Whitehill (2007) usedRCT principles to help new mothers. Volunteers using the RCT concepts of


authenticify and mutuality made home visits to 15 new mothers suffering fromisolation, anxiety about parenting, and postpartum depression. Qualitative datafrom the mothers were positive, indicating an increased sense of competence,connection, and empowerment.

RCT theory was also used as a foundation for studying relational competenceand ethical issues that support creative counseling practice. A grounded-theorystudy by a task force of the Association of Creativity in Counseling (ACC)identified subthemes in three main categories: relational competencies, creativ-ity in counseling, and the intersection of power (Duffey et al., 2009). A visualrepresentation of the axial coding paradigm illustrates the relationship betweenthese themes (see Figure 1 ).

Figure 1. Relational competencies and creativity.

AbusivePower

I' Controls Exploits

Dismisses

Axial coding paradigm presenting a visual representation of the relationship between themes in agrounded-theory study of relational competencies and creativity. Reprinted from "A GroundedTheory of Relational Competencies and Creativity in Counseling: Beginning the Dialogue," by T.Duffey, S. Haberstroh, and H. Trepal, 2009, Journal of Creativity in Menial Health, 4, p. 96.Copyright 2009 by Routledge: Taylor & Francis Group. Reprinted with permission.


Neuroscience ResearchRecent neurological research supports the importance of relational connec-

tions and suggests that human beings are "hard-wired to cormect" (Jordan,2010, p. 20). Neuropsychological assessment of Romanian orphans indicatedthat brains grow in connection, and lack of connection results in loss of neuronsand brain dysfunction (Chugani et al., 2001). The brain research of Goleman(2006) supports the RCT concept that personal growth results from relation-ships. Eisenberger and Lieberman (2004) found that the social pain of exclu-sion—even the anticipation of exclusion—follows the same neural pathways aspain created by physical injury. These findings support the work of RCT theo-rists who posit that marginalization and social isolation resuh in enormous pain(Jordan, 2010). However, new information on brain neuroplasticity indicatesthat interactions can reshape the brain, validating the RCT belief that growth-fostering relationships can rework destmctive neural pattems (Jordan, 2010).

Future ResearchFurther examination of RCT in practice is needed. Because RCT grew out of

work with women, study of its effectiveness with men and children is needed.There is hope that new technology for registering brain functioning will allowresearchers to assess relational interactions that enhance personal growth(Jordan, 2010).

LIMITATIONS

The RCT model seems to work with a variety of clients, but as with anycounseling theory, RCT has limitations. Jordan (2010) suggests it may be difft-cult to help clients who are entrenched in sociopathic pattems of behaviorbecause their avoidance of authenticity and their vulnerability may be tooentrenched and unyielding to respond. Other limitations mentioned by Jordanmay be a result of common beliefs in the dominant therapeutic culture. Forexample, the emphasis on therapist neutrality may make it difftcult for mentalhealth counselors trained in other approaches to embrace the importance ofcounselor responsiveness. Finally, because RCT counseling is driven by philos-ophy rather than technique, it poses special challenges for students and teach-ers. Careful supervision and ample opportunity for discussion and consultationare necessary (Jordan, 2010).

FUTURE DIRECTIONS AND APPLICATIONS

RCT offers promise for other fields beyond mental health counseling. RCTtheory is the basis of the first scale designed to assess the impact of humilia-tion, a highly destmctive form of disconnection (Hartling & Luchetta, 1999).

238 JOURNAL OF MENTAL HEALTH COUNSEUNG

ítems from this scale are being used in a research initiative in England and nineother countries to examine the intensity of shame and humiliation resultingfrom economic hardship (Jordan, 2010). Researchers are also applying RCTtheory to the study of organizations and the work place, where relational skills,empathie teaching, and mutuality are important leadership skills (Fletcher,Jordan, & Miller, 2000). Finally, other scholars are seeking a better understand-ing of men and boys (Pollack, 1998; Dooley & Fedele, 1999) and of relational-cultural ethics (Birrell, 2006).

CONCLUSION

Professional counseling is the mental health discipline of choice for anincreasing number of counseling and psychology consumers, rather than themore traditional medical and psychopathology models. Particularly attractive isthe Wellness perspective on client diagnosis, treatment, and process. RCT givescounselors a theoretical foundation that considers the role of gender, socioeco-nomic status, ethnicity, and a myriad other variables. It also gives counselors aphilosophical base from which to view the counselor-client relationship, themeans by which growth occurs, and the mutuality that is integral to the processof growth. As counselors continue to establish their identity within mentalhealth disciplines, exploring theories that align more clearly with counseling'sidentified perspective could better distinguish counselors from other mentalhealth practitioners and clarify their role in society. Counselors can thusdemonstrate the uniqueness of mental health counseling and its purpose andvalue within the larger mental health arena.

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