When Therapists Cry

 

At today’s meeting we used several chapters of Amy Blume-Marcovici’s  book ‘When Therapists Cry’ as a stimulus for this complex topic.

We noted that crying is a spectrum of visible emotion from glistening eyes to sobbing. Most therapists have experienced occasional tears in their work, yet it is surprisingly difficult to know exactly what they signify. The book had three helpful categories – empathic tears, care givers tears and proud parent tears. The suggestion is that each type arouses the therapist’s attachment system. Tears resulting from feeling touched by the client’s humanity and therefore deeply connected sat more easily with us than tears coming from a therapists own losses or feeling of being overwhelmed.

A psychodynamic concern is that the therapist should avoid interactions that gratify the client’s emotional needs. One possibility is that the therapist cries as an unintentional reaction in response to the client’s transferences. The client is unconsciously triggering the therapist to feel and respond in ways that are in line with the client’s hopes or fears. This is called enactment – the therapist’s inadvertent actualization of the client’s fears or fantasies.  Enactment might be viewed positively – evidence of an authentic emotionally alive experience, or it might be viewed negatively as a sign that the therapist cannot contain him/herself and is therefore not safe. We were intrigued at the reference to a paper by Slochower  postulating that tears are ‘one of the quiet disengagements we make by temporarily and secretly withdrawing our attention away from clients’

Since tears are autonomic, the question arose – can they be controlled? And if so, should they be controlled? There may be no willful control possible.  We discussed the difference between crying gently at the same time as a client versus the therapist crying while the client is dry eyed. This lead to a discussion about how we give the client the opportunity to explore how he/she experienced the therapists tears .

The last sub topic was tears in therapy with men. We all felt that men generally find it harder to cry but that when they do cry, it is often a dramatic a release, possibly because they have been constrained from crying for so long. It seemed important to realise that a bigger volume of tears is not an indicator of more distress.

We recognised the importance of being able to explore our tears (and our clients’ reactions to them) with our supervisors. Since tears are spontaneous and unplanned, they can only be reviewed retrospectively. We don’t have a choice about when we cry, but we can think about what the tears signify and how we might use them in the therapeutic setting.

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When Therapists Cry

Schema Therapy

The fells and dales group met on Friday, 17/9/19 to discuss a paper on schema therapy which was published in the BACP journal, therapy today in March this year entitled “Attachment is key” by Dan Rivers. The article states that “ we all have schemas” and, similar to the notion of “drivers” in transactional analysis, these are imprinted from an early age.They are identified by the client filling in a questionnaire. Rivers suggests that there are 18 early maladaptive schemas and that these influence us for good or ill but mostly ill until recognised and worked through in a positive therapeutic relationship. The list is well worth perusing and reflecting on- the one that linked particularly for me with recent clinical work was “abandonment or instability “ when you fear constantly that relationships will end. Most point to low self- worth as the main underlying issue. Another useful one was “Defectiveness/ Shame” when the client feels a failure and has strong self- critical beliefs possibly stemming from harshly critical parents or failing at school perhaps due in part to being dyslexic – whatever the cause, we felt that these categories were a helpful way of conceptualising and making sense of distress while also being wary of pigeonholing or over- simplifying what  the client is bringing. They could also be a useful mirror or prism for reviewing and re- evaluating our own experience.
We liked Rivers’ emphasis on an integrative approach which acknowledges the value of different ways of working including object relations and attachment -he states that schema therapy is essentially a mixture of CBT, gestalt and psychodynamic theories and originated in the mid 1980’s in the work of Jeffrey Young who was an associate of Aaron Beck, the founder of cognitive therapy.
Our meeting then mainly focussed on an exploration of the power dynamic in therapy including transference and how the counsellor accepts and views their authority and/or are uncomfortable with this to the extent of denying and being blind to their own effectiveness when they have achieved “good” work with a client who has a positive outcome- an example given was a possible tendency( which most of us owned and recognised) to say to a client at the end of the work together that they, the client, had “ done most of the hard work” so avoiding/ denying our own positive input! We then discussed why this might be, stemming from our own childhood experience and conditioning.
Schema Therapy

Is It Possible to be Authentic

The ‘Fells & Dales’ group of counsellors met on 12th April, to reflect on the subject of ‘Authenticity’.  The paper for discussion was entitled ‘Authenticity: A Goal For Therapy?’ by Miriam Donaghy (Practical Philosophy Autumn 2002).  We also listened to a recent broadcast of Radio 4’s ‘In Our Time’  –  a panel discussion chaired by Melvyn Bragg on the theme of ‘Authenticity.

We had a wide-ranging conversation about the meaning of authenticity, as generally understood but also as applied particularly to the work of therapy.  It is, perhaps, a given that as therapists we aim to model authenticity, our hope being that our clients might also discover a way of living authentically.  However, we asked ourselves what being “true to oneself” actually means, and how it relates to other concepts such as congruence, transparency, integrity, honesty, genuineness and autonomy (the latter meaning literally ‘giving oneself the law’).  We noted how helpful clients might find our occasional self-disclosures (judiciously used), and how authenticity might mean revealing our humanness and our fallibility.

A concern was raised over the possibility of authenticity leading to narcissism, self-centredness or isolation (“I’m OK, never mind anyone else”), but this was countered by the notion that self-acceptance and self-awareness tend to result in both greater acceptance of others, and an ability to receive others’ acceptance, and an enhanced capacity for empathy.

We concluded, as we often do, that it is a great privilege to draw alongside our clients for part of their journey towards authenticity.  However, we acknowledged that authenticity is an ideal, rarely achieved and only sustainable for brief spells.  For some, the cost of being fully authentic might be too great, if it puts relationships with significant others at risk.  But at least there could be something ‘authentic’ about recognising and perhaps finding a place for whatever inauthenticity is within us.

Is It Possible to be Authentic

When Does a Therapy/Helping relationship End?

Organisations such as Cruse proved a quality assured service provided by volunteers which is maintained by what happens in supervision.

The need of the client maybe for befriending, advice, guidance, counselling or psychotherapy. What is important is for supervision to work with the need of the client and the understanding of the role the helper takes on for that client. This understanding will also include espoused theory about how the role and the work ends.

The discussion noted that this understanding of the role is necessary if an ending is to be made. Working in supervision is necessary to help understand the process when either that role is no longer appropriate or the relationship moves onto a different dynamic. This was understood to be what is required of the professional helper.

Here the idea of espoused beliefs and theories-in-use (Chris Argyris) is helpful. The supervision process needs to pay attention to what is said to be the role and its justification, and what the helper is observed to actually be doing and justifying. It is likely that the helping service is enhanced by both supervisor and supervisee consciously seeking to bring this consideration into the supervisory relationship.

One of the sub-conscious theories-in-use in voluntary organisations is likely to be that of voluntarism itself. There is a commonly held and unquestioned assumption that volunteers are not professionals and even that this might mean that as volunteers, we are somehow excused the rigours we expect of ourselves as professional therapists. This has to be challenged in supervision but depends upon supervisors challenging their own theory-in-use of being a volunteer. The notion of professional volunteers is not widely held.

Regarding when the helping process ends, it was remarked that we were all familiar with awareness of ‘who is doing the work’ in the helping/therapeutic relationship. Again, awareness that perhaps the counsellor finds him or herself ‘trying to hard’ or ruminating over when s/he is doing enough, needs to be brought out in supervision. The espoused theory may be that the client does the work, but theory-in-use that I must be helpful and give wisdom to the client can easily lead to taking over the work of change.

Sometime was given to wondering about espoused theory of person centred therapy and that of cognitive behavioural therapy and how you know when the helping process ends. It is expected, in our discussion, that  in CBT we might work according to espoused theory so that the client becomes their own therapist (and with positive cognitions identified to manage a more healthy way of managing change). In PC the continual review of the process with the client so the client articulates for themselves their readiness to be autonomous is an expected outcome. In this process incongruence (spoken of in this context as intuition) informs the therapist that that change is taking place or not as the case maybe. It is helpful in supervision to bring the ‘shoulds’ we carry about our processes and those of the client to the surface for reflection.

Hopefully, helpers can and do keep a reflective journal to capture the thoughts and feelings before leaving a client and going on to the next encounter. In this way the knowing when the helping process ends is a collaborative process in supervision.

When Does a Therapy/Helping relationship End?

When does a helping/therapeutic process end?

Organisations such as Cruse proved a quality assured service provided by volunteers which is maintained by what happens in supervision.

 

The need of the client maybe for befriending, advice, guidance, counselling or psychotherapy. What is important is for supervision to work with the need of the client and the understanding of the role the helper takes on for that client. This understanding will also include espoused theory about how the role and the work ends.

 

The discussion noted that this understanding of the role is necessary if an ending is to be made. Working in supervision is necessary to help understand the process when either that role is no longer appropriate or the relationship moves onto a different dynamic. This was understood to be what is required of the professional helper.

 

Here the idea of espoused beliefs and theories-in-use (Chris Argyris) is helpful. The supervision process needs to pay attention to what is said to be the role and its justification, and what the helper is observed to actually be doing and justifying. It is likely that the helping service is enhanced by both supervisor and supervisee consciously seeking to bring this consideration into the supervisory relationship.

 

One of the sub-conscious theories-in-use in voluntary organisations is likely to be that of voluntarism itself. There is a commonly held and unquestioned assumption that volunteers are not professionals and even that this might mean that as volunteers, we are somehow excused the rigours we expect of ourselves as professional therapists. This has to be challenged in supervision but depends upon supervisors challenging their own theory-in-use of being a volunteer. The notion of professional volunteers is not widely held.

 

Regarding when the helping process ends, it was remarked that we were all familiar with awareness of ‘who is doing the work’ in the helping/therapeutic relationship. Again, awareness that perhaps the counsellor finds him or herself ‘trying to hard’ or ruminating over when s/he is doing enough, needs to be brought out in supervision. The espoused theory may be that the client does the work, but theory-in-use that I must be helpful and give wisdom to the client can easily lead to taking over the work of change.

 

Sometime was given to wondering about espoused theory of person centred therapy and that of cognitive behavioural therapy and how you know when the helping process ends. It is expected, in our discussion, that  in CBT we might work according to espoused theory so that the client becomes their own therapist (and with positive cognitions identified to manage a more healthy way of managing change). In PC the continual review of the process with the client so the client articulates for themselves their readiness to be autonomous is an expected outcome. In this process incongruence (spoken of in this context as intuition) informs the therapist that that change is taking place or not as the case maybe. It is helpful in supervision to bring the ‘shoulds’ we carry about our processes and those of the client to the surface for reflection.

 

Hopefully, helpers can and do keep a reflective journal to capture the thoughts and feelings before leaving a client and going on to the next encounter. In this way the knowing when the helping process ends is a collaborative process in supervision.

 

Notes from Fells and Dales Counsellors cpd event on March 15th 2019

When does a helping/therapeutic process end?

Behavioural Activation Treatment

Fells and Dales CPD group. 15/2/19

Today we reviewed Behavioural Activation Treatment for Depression: Returning to Contextual Roots by Neil S Jacobson , Christopher Martell and Sona Dimidjian 2001. Along with this we looked at the NHS guidelines on the stepped process of mental health care and how Behavioural Activation fits within step 3 of the model.

Behavioural Activation is a stand alone treatment for depression which attempts to help depressed people  to re-engage in their lives through focussed activation strategies.  Rumination and worry is seen as an avoidance strategy and the contents of the worries are not considered relevant to this approach.

Deficiencies are seen as residing in the life of the sufferer rather than within that individual where avoidance patterns narrow the repertoire of behaviour for the individual eg they may stay in bed.

The significance of a persons behaviour is largely driven by the reinforcers maintaining them  and stopping the avoidance behaviours is seen as key to the recovery of the depressed client. The acronyms TRAP and TRAC are used to conceptualise the old and new behaviours as Trigger, Response leading to avoidance pattern leading to response leading to avoidance behaviour (TRAP) and graded activities are created to promote the alternative Trigger, Response leading to alternative coping (TRAC) which in turn leads to breaking the feedback loop and modifying the contextual trigger .

Behavioural activation is seen as necessary and sufficient in and of itself in the treatment of depression and challenging core schema and automatic negative thoughts as in classic CBT are unnecessary.

We considered the effectiveness of such an approach if only parts of it are integrated into therapeutic counselling such as psychoeducation, exercising more, recognising and exploring avoidance patterns  and how that can be rationalised along with the need to believe the whole of the paradigm in order for any of it to be effective.

We then considered the underlying principles of therapeutic change for each of us and the importance of being genuine and congruent  and not necessarily instrumental  in our approach. We looked at how elements can be ethically integrated without totally believing in the paradigm.

A limit of the approach is the presupposition that a person is able to engage in activities and  will be compliant with home work assignments such as keeping a diary or exercising regularly.  Its overt directivity is also noted setting the therapist as expert who may even contact the client in-between sessions to check on compliance with activities.

It was noted that as it is straight forward to conceptualise Behavioural Activation can be and is included in the NHS stepped care process and psychological wellbeing practitioners (PWP’s)  who deliver first step are trained in the approach and the ethic of using  this approach for all when it might not be suitable considered.

Behavioural Activation Treatment

Psychosomatic Illness

Our prompts were: neurologist  Dr Suzanne O’Sullivan’s prize winning book ‘ Its All In Your Head’ where she respectfully tells the stories of numerous patients with extreme symptoms which have originated in the mind – what she calls conversion illnesses; a lecture by Dr Howard Schubiner where he describes the development of neural pathways which lead to an over sensitivity to danger and therefore to symptoms like pain and an interview with Dr John Sarno about his book ‘The Divided Mind’, where he has written about working for 50 years with people who have mindbody back pain.

The medical practitioners we listened to are confident that 25 – 30% of all illness is psychosomatic. These illnesses have real and often debilitating symptoms but are not organic in origin – there is no tissue damage. Instead, neural pathways have evolved to unconsciously distract from emotional suffering by converting the mental pain  into physical symptoms. The assumption is that the unconscious mind has found a creative way to repress the mental pain.

Certain characteristics of a person’s experience are indicators of psychosomatic illness. For example, a person will typically have been unwell for many years, often with a variety of different conditions. They are usually not helped by conventional medicine. The illnesses that come up most often are  pain especially in the back and neck, fatigue, skin conditions, IBS, fibromyalgia and allergies. In terms of personality, Dr Sarno has noticed that these conditions are commoner in people with a tendency to perfectionism, a need to be good and its common for people with this kind of illness to be preoccupied with their health. Many become anxious and depressed and we are therefore likely to meet  them in counselling. It should be noted that all of us have psychosomatic illness to some extent – skin problems when stressed, abdominal reactions to anxiety, headaches when over pressed etc.

Our discussion lead from wonder at the prevalence of psychosomatic illness, to conjecture about some clients’ illness as well as our own. We also talked about  different family cultures and attitudes around illness – especially the shame of illness or incapacity versus illness as a way of being cared for. We touched on some experience of ME.

When it is suggested to people that their symptoms might be psychosomatic , many are angry and offended if they understand it to imply that the symptoms are imaginary. They aren’t. However, for those who can be at least partially open minded, education about the workings of the brain and an opportunity to explore the original root of emotional distress are the ways to recovery. Clearly this is in the realm of counselling and psychotherapy. We were energised to think of the therapeutic opportunities these clients present.

 

Psychosomatic Illness