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.

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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

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