Winnicott’s Theory of Breakdown

We discussed firstly an article on Winnicott’s theory of fear of breakdown, the basic premise being that the “real” breakdown has occurred much earlier in a client’s life when some rupture occurs in the mother-infant bond and relationship. This forces the infant “to take on, by himself ,emotional events that he is unable to manage”.

The breakdown, claims the author of this article, “ Fear of breakdown and the unlived life” Thomas H.Ogden (international journal of psychoanalysis,2014 95: 205-223) is survived but not actually registered internally which results in a sense in the adult that “..parts of himself are missing”; the client then feels he “must find them if he is to become whole” as otherwise he will have to continue to live with the feeling that “what remains of his life” becomes “like a life that is mostly an unlived life”, a feeling perhaps of inner deadness and a potential not fulfilled. We grappled with this concept and felt it needed more elucidation with clinical examples, particularly his references to “psychotic defense organizations” which serve to keep unmanageable feelings at bay.

 

We moved on then to discuss two papers by Neville Symington which we found illuminating and well-written: “Healing the mind-what is the process?” followed by “Healing the mind-what is the healer’s task?” He draws on his own experience and shows humility in his assessment of what the patient is seeking in therapy- namely that hie is asking the therapist to “..help me create a mind that can cope with these disasters that are overwhelming me”. He believes that the therapist must understand the workings of the mind and avoid psychological “muddle” since the therapist has to be able to create a representative image of the client’s pain that fits his experience and he believes that the patient is then able to “embrace” his pain and start to process it. The therapist cannot programme this creation since, states Symington, it is “an inner spontaneous act” but there are outer factors which he claims can facilitate this creation- this is the thrust of the second article where he outlines the four main components of effective therapy as: freedom, the personal, scientific enquiry and compassion.

By the personal, he means : “Don’t ever say anything which is not a personal statement”- he illustrates this idea by describing a friend who “did not generalize, give advice or say how he thought people should act” and who fostered an atmosphere of “freedom” which should be based on a wide-ranging spirit of “scientific inquiry” including a knowledge of the self since he claims that “all personal difficulties flow from our own areas of narcissism”. As therapists we should strive to be “natural” since “the more natural you are, the more a patient will reveal the secrets of the heart”. He tries to define what natural means by saying you have to be “in a role, not acting a role” and the role is combining compassion with a scientific-like probing and curiosity.

We found his two papers interesting and refreshing and less dense than the one on Winnicott.

We then went on to a discussion of whether it is helpful or not for a therapist to cry in the consulting room when affected and moved by a client’s pain. There was some disagreement about whether this demonstration of empathy, whether chosen or out of the therapist’s control, is therapeutic for the client or the opposite. We agreed this would be a useful topic for a future meeting.

 

Rosemary Pitt

6/12/18

Advertisements
Winnicott’s Theory of Breakdown

The Use of Self

19 Oct. 2018  The Fells & Dales group of counsellors & psychotherapists met today to discuss two papers:  ‘Interview with Carl Rogers on the Use of Self in Therapy’ – chapter 2 in ‘The use of Self in Therapy’ ed. Michele Baldwin, Haworth Press, 2013, and ‘The Use of Self of the Therapist’ by Wendy Lum, Contemporary Family Therapy, March 2002.

We discussed in some detail what ‘use of self’ means:  the in-the-moment awareness of felt sense, experienced when with our clients;  allowing ourselves to be impacted by our clients, and trusting both ourselves to find a way of conveying, and them to be able to receive, what we are experiencing.

Yet this can feel risky at times, as the outcome of such an expression is unknown at the time.  In the very act of reaching out to the client, there is the risk of alienating or confusing them, but hopefully our intention to honour them with our honesty, genuineness and integrity will be received and reflected upon.  Indeed, it can model to the client the value of transparency and self-awareness.  It might be easier to ‘play safe’ and not make the effort or take the risk, thereby depriving the client of what could be a significant learning opportunity to reflect and grow.

Perhaps no one has been able to improve on Carl Rogers’ own descriptions of this process:

Perhaps it is something around the edges of those [core] conditions that is really the most important element of therapy – when my self is very clearly, obviously present.

The important thing is to be aware of this feeling, and then you can decide whether it needs to be expressed or is appropriate to express.

I want to be as present to this person as possible.  I want to really listen to what is going on.

At those moments, it seems that my inner spirit has reached out and touched the inner spirit of the other.  Our relationship transcends itself, and had become part of something larger.

To be congruent means that I am aware of and willing to represent the feelings I have at the moment.

We acknowledged how difficult it is for this level of congruence, or ‘use of self’ to be taught within counselling training courses, and how the (necessary) breaking it down into teachable and observable units somehow diminishes it and misses the point, as perhaps is a danger in Virginia Satir’s model described by Wendy Lum.

Despite the threats of the medical model dominating the helping professions, and despite our kind of work being at times extremely demanding and exhausting as we give of ourselves, we agreed that it is a tremendous privilege to be able to relate to others at such depth and intensity  –  to experience what some might describe as a ‘meeting of souls’.  Where else can clients be met with such realness, at the same time as being held in such deep respect and trust?!

The Use of Self

Fat Lady by Irvin Yalom

We used this chapter from ‘Love’s Executioner’ to consider out personal responses to obesity. While we had varied experience of obesity in clients, we agreed that it is vital to find a way to talk about it. We acknowledged that it may take courage to broach such a potentially sensitive aspect of a client’s body image but that it was imperative to create  the space to  explore it.

A member of F and D with professional experience of disordered eating pointed out that many overweight people are blind to their size. She thought there would invariably be a reason for a person’s weight to be out of control and therapy is an opportunity to try and find the reason. Emotional emptiness seemed to be a common feature .

We considered the effect of gender on our responses to obesity and decided that social and cultural expectations were harsher on women than men.

Fat Lady by Irvin Yalom

Self Harm

Our meeting on March 23rd looked at several papers on self harm, with particular emphasis on self harm in adolescents. We learned something about the on line presence of websites and chat rooms dedicated to self harm and frequented by young people. The positive side being a source of support for young people in unbearable pain.  The negative being a peer group which might encourage self harm and could even promote it.

Chapter 3 of Antonia Murphy’s book ‘Out of This World’ discussed the relationship between self harm and suicide. She sees a difference in intentionality though they are both acts of self aggression. People harming themselves generally want to feel more alive whilst those who are suicidal wish to die. We quickly saw a blurred area where the two acts overlap where long term self harm can lead to ‘acquired capability’ of suicide. Both behaviours come, of course,  from psychic pain and we discussed the importance of investigating the pain and its origins by empathic atunement in therapy. Barent Walsh’s paper on Clinical Assessment of Self Injury concentrates on extracting the details of the client’s harmful behaviour in what he calls  ‘respectful curiosity’ , a term which did not sit well with all of us as it implies therapist distance rather than involvement. We were however agreed that seeking detail might make the behaviour feel more real for the client and conveys a willingness to bear this reality collaboratively. The client’s prior experience of other people is likely to have been avoidant or squeamish.

We came up with a very interesting new idea (for most of us) that morbid jealousy is itself a form of self harm stemming from early inadequate attachment –  the pain of feeling unloved  at the same time as feeling unworthy to be loved and re creating this distress in the self inflicted pain of jealousy.

 

Self Harm

Vulnerability

At today’s Fells and Dales meeting we used a TED talk by Brene Brown to stimulate further discussion about shame and newer discussion on vulnerability.
Vulnerability requires courage to be willing to be emotionally exposed, unsure or seen by another. The reward is the possibility of connectedness and furthermore ‘it is the birth place of creativity,innovation and change’.
There was general agreement that supervision is most effective when supervisor and supervisee are willing to be vulnerable together. In this environment, creative exploration of new territory becomes possible.
The extent to which a counsellor should show vulnerability in a therapy session seemed to be more nuanced. Sharing uncertainty or disclosing our own vulnerable experiences can be a way of connecting. It might also create what Brene Brown calls ‘Me too’ and reduces any client fantasy that the counsellor is infallible. With many clients, our honesty about not knowing where the therapy will go or if it will help is enabling for the client. Others need to feel something of our experience, and steadiness to enable them to feel hope. This lead us to think about clients who have unrealistic hopes – hope to be rescued for example. We identified that ‘learned helplessness’ can be seen as an adaptive behaviour created to avoid change. It is therefore distinct from vulnerability .
We recognised that becoming vulnerable can be excruciatingly painful and even in a safe environment it is natural to be tentative and  reveal oneself in small steps. We discussed some of the faces of our own vulnerabilities – the pain of being seen (and therefore judged), the pain of being unseen and over looked, the feeling when we let people down, of not being good enough.
Shame and vulnerability and guilt inevitably tangle together and fester in secrecy.
‘Guilt expects punishment while shame expects abandonment’. Guilt comes from a cognitive process while shame is embodied. We were cheered by the good news that ‘The antidote to shame is empathy’.

Vulnerability

Any correlation between expertise and length of experience ?

On 24 March, our discussion was based fairly loosely on ‘Expertise in Psychotherapy An Elusive Goal?’ by Tracy, Wampold, Lichtenberg and Goodyear. The paper largely supports the view that experience as a psychotherapist leads to increased confidence but does not lead to expertise.

The group found it problematic to define expertise or to accept the definition in the paper which discussed it in terms of reputation, performance or client outcomes. The paper seemed more concerned with measurements and techniques used in psychology than psychotherapy.We were particularly unhappy with the authors’ promotion of  a ‘ disconfirming stance’ which for some of us suggested experimenting  with a different approach to the one we believe to be efficacious in order to make a comparison.  Others of us felt that it might be understood to mean having a questioning attitude to our practice and a lack of assumption that we are already working in the optimal way.

We felt that if we have a body of knowledge to bring to our work, a recognition of our limitations, ever developing self awareness, good use of supervision, we were likely,over time, to develop something that might be called expertise. The discussion progressed to the more attractive goal of becoming a peer-reviewed  Master Practitioner  rather than an expert.

A frank conversation followed in which we admitted how difficult it is to tolerate the low status we are given in the eyes of other health professionals and some lay people. We noticed how hard it is for the quality of our work to be rated or for meaningful comparisons to be made between therapists . Consequently, much of our competence goes unrecognised. The depth and quality of the therapeutic relationships we make are impossible to measure. The private nature of therapy means that any skill we may possess is not seen. This invisibility can lead to attacks in the form of contempt or envy. Contempt from those who feel threatened by or ignorant of therapy and envy from those who resent us the privilege of holding  secrets .  We tend therefore to be generally under estimated ,given low status and only feel valued  by peers in the therapy world.

We bolstered ourselves by each focusing on what we perceive to be our strengths. Some members found it easier than others. We noted that the personal qualities which correlate positively  with a good outcome for clients  included a degree of self doubt, deliberate practice, an ability to form working alliances across a range of clients, a high level of facilitative skills, keenness and curiosity. Qualities all members of this group possess.

Any correlation between expertise and length of experience ?

The ‘Fells & Dales’ group of counsellors in Cumbria/North Lancs met for our monthly meeting today, 9th December, and a new member was welcomed to the group.  We discussed two chapters in Sheldon Kopp’s book ‘If you meet the Buddha on the road, kill him!’

Sheldon Kopp wrote, ‘A grown-up can be no man’s disciple’, and ‘The most important things that each man must learn no one can teach him.’  Our discussions began with considering the extent to which we, as counsellors, have an ‘expertise’ to offer our clients.  We may claim to be non-directive, to have no agenda, to seek to empower the client rather than exerting any power of our own, and yet what is it that clients come to us for?  Are they not needing help and expecting a service, which we have been trained, qualified and experienced in providing?  How to we steer a middle course between counsellor over- and under-involvement? 

We agreed that there is a valid place for psycho-education, and that we are more than merely observers or witnesses of the client’s process, but in fact play an instrumental part in that process ourselves.  On the other hand, we want to disabuse clients of the myth that there’s an answer/solution ‘out there’ somewhere, waiting to be grasped  –  a fixed end-point, and that all will be well if only we can reach it.  Perhaps the best that we can offer is to accompany the client as closely as possible on their journey,  tolerating the ‘stuckness’ and the not-knowing, despite being made to feel useless and inadequate in the process, rather than trying to (mis)lead them to a non-existent destination.