Stabilisation strategies

At the July  meeting of Fells and Dales Counsellors we considered the chapter Stabilisation Basics from the book, Neurobiology and Treatment of Traumatic Dissociation: Towards an Embodied Self, Lanius, Paulsen  and Corrigan, Springer Publishing Company, 2014

The stated purpose of giving this material was to prompt sharing about what each of the group recognised they did with clients to facilitate change. The context of the chapter was dissociated clients and their presentation of different ego states as an outcome of trauma in early life in particular and coupled with other traumatic experiences in life.

The discussion included reflections on the theme of meeting the client ‘where they are’ with unconditional positive regard on the one hand and sharing with the client our experience of them and offering education and understanding about the need to create and feel safe in the room and relationship on the other.

We recognised developments in the way in which we approach therapy and the therapeutic relationship and our shared awareness of the move towards perception of the ’embodied self’ and working with visceral somatic experience. Since many clients are not practised at such awareness it follows that facilitating that awareness is the responsibility of the therapist?

We noted that the focus of our chapter being dissociation and the different ego states that can result initially seemed specialised but then noted that creation of a safe place and good enough relationship for therapeutic work was the same. The ‘tools’ were recognisably the same and we were able to review and share what we each brought to that work.

We perhaps also recognised that the future of psychotherapy includes more realisation of ‘bottom up’ processes than the current tendency to focus in the NHS more on top down cognitive processes. If we know how brain processes change, and that a ‘safe place’ and ‘good enough’ relationship are core to that process, then are we not ethically and professionally bound to take responsibility to enable clients to experience calm in order  for change to take place?

Stabilisation strategies

Fragile Process

At the May 2017 ‘Fells & Dales’ meeting, we welcomed a new BACP-accredited member to the group, and discussed the paper on ‘Fragile Process’ by Margaret Warner (2011?) from the Illinois School of Professional Psychology.

 

We began by considering what we understand ‘fragile process’ to mean, and how prevalent this is amongst our clients  –  whether aspects of fragile process are frequently displayed, or whether it is a specific phenomenon experienced by relatively few.  It was agreed that it is closely related to early attachments and a client’s past experience of being understood (or not).  The discussion focussed on what we as therapists are empathising with :-  content or process?  –  what is actually being expressed, or what we sense might be difficult to express?  –   or what might be felt but for which words have not yet been found?  In other words, communicating with that which is fragile.  For example, we might empathise with the emotion a client appears to be suppressing, or with the client’s need to suppress it.  We also asked ourselves if we give evenly suspended attention to all that a client is experiencing, and the extent to which we are necessarily selective in our responses.  It was a salutary lesson to be reminded that clients might not feel properly heard by us, when we pride ourselves on being good listeners!  As Margaret Warner says, ‘Clients usually need more than an accepting presence.’  They crave our accurate understanding, and the validation of their experience, to help them to see that they have a right to have it (a recurring theme of Warner’s).

 

One of our members was able to recount first-hand experience of meeting Margaret Warner, describing the very slow, considered pace of her talking (and presumably her way of working with clients), thereby allowing herself time and space to pay meticulously close attention to her client’s moment-by moment experiencing, and an apparent ability to empathise with all of it, and modelling the ‘non-intrusive empathic relationship’ with which she concludes the paper.

 

As an interesting side-issue, we wondered whether clients might detect a ‘fragile process’ in us, and whether they sense a need to protect us, or to protect themselves from us?

 

We concluded by reflecting on how fraught a therapist’s task is, and asking ‘Who would do it?’!

 

 

Fragile Process

Verbal and Non-Verbal Communications

A reflection on the role of the unspoken elements of communication and on the dimensions of verbal communication beyond the literal meaning of words. 

Westland, G. Considerations on Communications – both Verbal and Non-Verbal in Body Psychotherapy (2009) Movement and Dance Psychotherapy 4:2: 121- 134.

The theme of the meeting of the Fells and Dales Counsellors was based around this paper by Gill Westland that focused on verbal and non-verbal communication.  Although this paper was written through the lens of a body psychotherapists we explored the relevance within our own therapeutic modalities.

This paper opened with the notion that communication and experience involves a verbal element and a non-verbal element.  Both have equal value in therapy.  The paper went on to reflect on language and how it is used to convey emotional communication to try to elucidate our inner world or conversely how language can serve as a defence against therapeutic contact with our inner pain and distress.  There is emphasis beyond the verbal meaning of words to the ‘energy’ communicated, the pitch, the tone and the context that surrounds the verbal and that this carries meaning.  Members of the group related this to Roger’s  – ‘Music beneath the words’.

The paper then went on to explore how aspects of our neural  systems might influence elements of our communication and how we may refer to these within therapeutic settings.  Westland notes the ‘dance’ between left and right hemispheres processes that may manifest as a client moving between factual (left-brain) and what Westland considers more unconscious, inner-process (right-brain).  This is also apparent between the sympathetic (arousing emotions such as rage and frustration) and parasympathetic (calming emotions such as sadness and joy) routes of the autonomic nervous system (ANS) and is useful in working with what Westland terms as therapeutic presence and resonance.

The discussions that emerged through the meeting were varied.

In one thread we further explored the way in which the left and right hemispheres influence the way we perceive and interact in different relational encounters and several interesting texts were noted Ian McGillorist The Master and his Emissary (Left and Right Brain).

We pondered on whether it was possible to offer interactions with clients that may help to build more balance between left and right processes and in emotional regulation or whether this tip-toed into leading clients or presenting an agenda in our work.  There was a shared sense that while we strive for those moments of resonance, we appreciate it is not always possible.  Questions then surfaced around whether the duration of work (mostly with the increasing need to adopt more focused-based approaches) would impact on the ability to truly achieve resonance/presence in the way described by Westland.

This left us with the on-going question of whether we align to a client’s stated verbal goals or whether we should address emerging needs that arise on a more subtle level in therapy, that are perhaps less consciously noted by the client themselves – particularly if working to a designated time scale?

Verbal and Non-Verbal Communications

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 Future of Psychotherapy

Peter Bowes introduced the UKCP Conference theme ‘The future of Psychotherapy’. He is to give a one hour workshop from the perspective of a trauma psychotherapist. He asked the group to watch and consider two TED talks on UTube and consider two questions;
1. What is it that each of us believes we are dong as a therapist when in touch with presentations of our clients that point to attachment issues?
2. And when we do what we do, how do we think change takes place?

The first TED talk featured Fin Williams who referred to her personal story that she had absorbed, which was probably an outcome of her parents’ self-perceptions and self-narratives and that those stories had shaped her development. She related how being aware of her own story eventually enabled her to think of herself differently and positively. She also told how she was then able to recall the positive memories of her parenting which had previously remained ‘out of sight’. Fin’s talk ended with her imploring the audience, to write their own narratives of their stories and share them with another trusted friend.

The second TED talk was one of many on UTube by Dan Siegel. He reviewed an aspect of disorganised attachment in five minutes by means of an anecdote of a father telling his son to brush his teeth. This father experienced an eruption of rage when challenged by an attempt at autonomy by his son to not be so instructed. In this presentation, Dan noted how a triggered rage shut down the father’s pre-frontal cortex and how that response might escalate and then lead to an attack on the child. He noted how mirrors neurons would have communicated in both directions the unconscious perceptions and read by both father and son with the concomitant emotions arising for both from the activated neural paths laid down by earlier attachment processes. The father is re-traumatised and the son traumatised (not for the first time one may assume!).

Each of the group courageously then wondered about how they thought as therapists about their client presentations. We challenged ourselves to wonder how we thought that change like that narrated by Fin Williams takes place. It was not easy for us to more beyond change of thinking for the client at first before moving into the awareness that change of feeling was essential. We probably agreed together that therapy required as a sine qua non an authentic unconditional positive regard in which the experience of the client is validated. Dan Siegel’s framework of neuro-biologically informed construal of what happens between human beings requires acknowledgement and awareness of the reality of mirror neurons however and thus the demand upon us as therapists to engage fully and genuinely in a relationship of love of the other. This brings also the demand on us to continuously develop acute sensitive empathic awareness of the other and the capacity and ability to sense whether that awareness is of the therapists feelings or those of the client. Any unacknowledged inauthenticity will be communicated through the activity of ‘mirror neurons’.

The discussion concluded with us thinking about the future of psychotherapy. It is possible that neuro-biological research may lead us to become more aware of the conditions that allow the brain to change and for the ability to reflect on one’s own inner world to develop. Thus self – regulation and personal resilience, deficient due to inadequate attachment processes, might be re-discovered and reformed at a fundamental neurological level. If we do get to understand the conditions that enable that brain change would we not ‘have to’ do what we can to bring about those conditions?

Authors and books mentioned were:
Ecker, Ticic and Hulley, Unlocking the Emotional Brain
Panksepp and Biven, The Archeology of the Mind
Lanious, Paulsen and Corrigan, Neurobiology and the Treatment of Traumatic Dissociation. Towards and Embodied Self.

The Future of Psychotherapy

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.

Clinical Practice

We met in October to listen to and discuss two pieces of recorded client work.

The first piece prompted discussion about the effects of apparent knowingness or certainty in the therapist. While therapist confidence might reassure some clients, we saw how it could also block the client’s process. We were particularly interested in the extent to which mis-communications between client and therapist were exacerbated when the therapist is insufficiently tentative . This style in the therapist  seems  to intrude in the development of a mutually understandable language and increases the risk that each person attributes his own meanings. In the extreme , the client is lost and confused.

The second recording provoked a lively discussion about possible ways of responding to the erotic transference, in particular when a client falls in love with the therapist. The main question to emerge was ‘at what point should it be made  known that there can be no romantic future.’ One opinion is that this information should be held back to allow the client to express as much about the loving feelings as he would wish. This approach risks inflating the client’s unrealistic fantasy but allows full expression of the client’s experience. An alternative view was that it is kinder and clearer to make an early intervention to explain that there can be no romantic attachment but the therapist is respectfully interested in hearing more. This might stiffle the clients ability to say fully what he wanted to say, but has the merit of clarity. It seemed to hinge on the extent to which the therapist can convey a quiet steady openness to the subject and the extent to which client is able to continue to explore his feelings in the face of a felt rejection. We were acutely aware of the effort required by the therapist to manage her own powerful feelings in response to a declaration like this from the client.

Clinical Practice