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.

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Clinical Practice

Is the analyst central to the process of therapy?

How do we use dreams?

In our September meeting, we explored the transference that occurs between therapist and client which, put simply, involves the client projecting onto the therapist feelings about significant figures in their own past. The therapist’s counter-transference is their response to those feelings and can be a useful tool in the therapy.

The article we read was entitled: “Mapping the landscape: Levels of transference Interpretation” by Priscilla Roth from the international journal of psychoanalysis, 82:533-543, 2001

The article looked at transference in a deeper and more complex way and defined four different levels of transference which may be used in the psycho-analytic process and which are considered key to that way of working.  These levels were summarized at the beginning of the article as ranging from:

“ interpretations that point to links between current events in the analysis and events from the patient’s history, through interpretations that link events in the patient’s external life to the patient’s often unconscious phantasies about the analyst and the analysis, to interpretations that focus on the use of the analyst and the analytic situation to enact unconscious phantasy configurations, sometimes pulling the analyst into the enactment”.

We grappled to understand these concepts and how they would operate, in particular the phantasy “configurations”. a  It was helpful that four consecutive sessions of the analysis of a client were presented and demonstrated how the level of interpretation could shift as the level of understanding on the part of both analyst and patient deepened also.

We did, however, have some reservations. We questioned whether the analyst was always such a central figure for the client but could at times be more tangential without this being a form of defensiveness on the part of the client/patient!

We also prefer the more person-centred notion that it is preferable for the client to make sense of their experience

before the therapist offers an interpretation. We had some distrust of the certainty shown by the analyst in the way interpretations are stated and given to the client almost as fact while respecting that this method is based on extensive training and clearly can be effective with long-term clients

who are being seen three, four or five times a week.

The article also contained a fascinating analysis of a dream which was seen as an integral part of the therapeutic process and did yield some rich material.

That led to a brief discussion of how we all work with client’s dreams in different ways, two of us liking the gestalt notion of each part of a dream representing something about the client.

As always, we had a useful sharing of views and support for each other.

Rosemary Pitt, Fells and Dales Counsellors

Is the analyst central to the process of therapy?

Dare Psychotherapists Reinterpret a Mental Illness Diagnosis?

This month the group came having read a chapter from Isabel Clarke’s Psychosis and Spirituality, published by Wiley-Blackwell in 2010.

The chapter was entitled ‘Transformative Crisis ‘ written by Caroline Brett.

 

This theme came about from the recognition that clients who present with a diagnosis given by a psychiatrist, for example, can bring also the fear that they are  ill, and a reluctance to engage in ameliorative therapy for fear of the return of former symptoms.

We recognised that therapists are more familiar than some other mental health practitioners with comparisons of spiritual crisis or transforming experiences with those attributed to mental illnesses, and we wondered about the similarities with those who do not make a meaning of their experience in this way. The latter however, can be helped to think of their previous distress in different paradigms. We shared evidence from our own practices.

Familiarity with the ‘window of tolerance’ could invite awareness that hyper-arousal of the autonomic nervous system can be alarming but is in truth the human mind-body protecting that individual from intolerable stress.  Managing stress differently means that that arousal will not re-occur and medication may not be appropriate. Awareness of different ego-states and dissociative identity disorders, and the way in which dissociated ego states come into existence often, albeit mistakenly, to protect another part of that person, can become the insight that brings about the integration of those separate parts which have led to extravagant and diagnosable behaviours.

Some therapists in private practice, and this was true our group, can be a little nervous  because they are aware of the presence in the consulting room of ‘white coated’ mental health practitioners who have given their client a DSM category and treated them according to current NICE guidelines. Having the courage to explore alternative paradigms to make meaning of the client’s experience is what we do in therapy and such an approach anticipates what therapeutic experience has shown, namely that clients do reinterpret their experience given the constructs they need in order to do so and no longer think of themselves as mentally ill.

One of our number was fortunate enough to be offered supervision from members of a mental health team in a frontline psychiatric hospital. Encouragement was gratefully received when it was noted that the team concerned was asking the same questions about the meaning of mental illnesses. That team is using EMDR therapy with those formerly labelled psychotic and schizophrenic patients and indeed looking at the role of anti-psychotic drugs. The changes in perception encouraged by emerging neuro-biological research is evident. The challenge to all therapists must be therefore to try to keep up to date with that research. A significant challenge.

A useful reference work is that by Paul William Miller, EMDR Therapy for Schizophrenia and other psychoses, published in 2016 by Springer Publishing Company.

The value of supervisory processes taking place across the divide between private and institutional practice is recognised therefore within the group and should be promoted.

Dare Psychotherapists Reinterpret a Mental Illness Diagnosis?

Pluralistic Counselling

Pluralistic Counselling

Narcissism

The most recent meeting of Fells and Dales Counsellors explored Grandiose Narcissism as an adaptation in response to an early lack of empathy. Kohut’s Self Psychology Model was used as an initial stimulus to the debate.

It was noteworthy that people with narcissistic traits present for therapy relatively rarely. However, a good proportion of clients in therapy are the children of narcissists.

We used professional and personal experience to think and talk about the particular challenges of working with people who relate in this way. We recognised that we are best serving these clients when we can meet the vulnerable parts of the individual. These parts might have low self esteem or  feel shame and inadequacy , or be interpersonally isolated. The therapeutic challenge is to access this suffering through the thicket of a complex defence mechanism. When defences include a sense of entitlement, grandiosity or bravado, and an extreme sensitivity to criticism, the work is delicate.

Narcissism

ADULT TWIN RELATIONSHIPS

For our May meeting of Fells and Dales counsellors, we explored the relationship between twins, and in particular to what extent the twin bond is “special”. We read a research article by Tancredy and Fraley on ” The nature of Adult Twin relationships: an attachment-theoretical perspective” from  the Journal of Personality and Social Psychology,2006, vol.90,no1,78-93.

 The article defined the main characteristic of attachment relationships as comprising proximity seeking, separation distress, and the use of one another as a secure haven and safe base. Twins were then measured against non-twins to assess whether twins used each other as attachment figures rather than mother in the first instance and then siblings or other key figures.

 An interesting finding was that twins do not fully acknowledge the presence of their co-twin until the end of the separation-individuation process at around 36 months so until then are more focused on the mother to meet their needs. However, for identical twins who share the womb space, there can be ” an embodied sense of the other” which creates a lasting attachment greater than that between fraternal twins or non-twins.

 We then discussed the relevance of these findings for the therapeutic relationship and the extent of sibling rivalry between twins.

ADULT TWIN RELATIONSHIPS

Gender Dysphoria in Counselling

For the early April FellsandDales Counsellors, Arlene Istar Lev’s book, Transgender Emergence, (Therapeutic Guidelines for working with Gender-variant People and Their Families, Haworth Clinical Practical Press, 2004,) provided background reading. Chapter 6 explores ‘Learning to Listen to Gender Narratives.

Peter, who provided this material for this CPD session, presented some of his experience in previous years of clients with gender dysphoria. He shared the experience he had had of being disoriented and his experience of considerable incongruence within himself.

The Lev chapter was significantly helpful in its description of three approaches that others have noted are commonly identifiable:

  • Client struggling with Gender-Dysphoria feelings
  • Clients seeking Medical Treatments
  • Clients presenting with Family-Related issues.

Lev’s research and survey of therapists experience includes therefore that the client’s ‘transsexual narrative’ might be the basis for ‘diagnosis and treatment’ and that that narrative contains certain basic criteria without which the term transsexual cannot be valid. These are (p.213):

  • Non erotic cross-dressing and cross-gender behaviours, interests, and expression starting at a young age
  • Disgust regarding genitalia and secondary sex characteristics with a desire to change or remove them
  • And an ability to “pass the real-life test” which includes full-time living in the new gender, often including paid employment or full-time school attendance and proof of legal paperwork changes.

The group members were aware that clients who knew about these themes whether or not they meet the criteria do, if for example they are seeking medical treatment and gender reassignment in particular, will demonstrate compliance by dissembling or lying.

The group were also able to share various experiences with clients where the complexities of our own conditioning, when faced with gender ambiguities, bring about uncertainty and difficulty in listening empathically to our clients. Clients, of course, are likely to sense our uncertainty, and possibly therefore intuit that their own agenda is not going to be met, or register discomfort and give meaning to  it that confirms their repeated experience of not being listened to by professionals.

The chapter, it was acknowledged, does provide very helpful analysis of what may be in the room with us. It would therefore be of  great benefit for reading in preparation should we be fortunate enough to know that gender dysphoric issues were to be  presented. It is possible that such preparation might enable us as therapists to stand on firmer ground from which to observe the array of themes, characteristics, and personalities that are in the room with us. It is possible that such preparation might permit us to really be listening to the client, perhaps to different ego states, maybe to evident mental health issues, and therefore be better able to explore client history objectively without the tangle of counter -transferential responses that otherwise can destabilise us.

Gender Dysphoria in Counselling