Where do we draw the line as therapists on who we see?

I feel rested and ready for the new term of my course following my return from holiday having enjoyed the sunshine in the south of France. I always find the power of now to be easier to achieve in hot and sunny climates, where every day feels like a holiday.

It seems that there are many unpleasant news stories around at present from hit and run cases involving children visiting their sweet shop to unsuspecting pensioners being duped of their savings by con-men posing as utility inspectors. It is a constant ethical challenge for me when I assess which type of client I would refuse to work with.  Some colleagues draw the line at paedophiles whilst others refuse to see murderers. I am reassessing these ethical issues after watching some disturbing television documentaries on serial killers.

Endgames of a Psychopath

The first, Endgames of a Psychopath,  concerned the life and times of one Ian Brady.  Ian Brady was born in a Glasgow slum in 1938, to single mother Peggy Stuart and he never knew his father’s identity. Known as the Moors murders the crimes were carried out by Ian Brady and his accomplice Myra Hindley between July 1963 and October 1965.  The murders took place in an area now known as Greater Manchester, North West England. The victims were five children aged between 10 and 17, Pauline Reade, John Kilbride, Keith Bennett, Lesley Ann Downey and Edward Evans. At least four of whom were sexually assaulted. These crimes became known as the Moors murders because two of the victims were discovered in graves dug on Saddleworth Moor. A third grave was discovered there in 1987, over 20 years after Brady and Hindley’s trial in 1966. The body of a fourth victim, Keith Bennett, is also suspected to be buried there, but despite repeated searches it remains undiscovered.

The killer’s mental health advocate Jackie Powell  was interviewed in the programme and she talked at great length about her relationship with Brady. Keith Bennett’s mother, Winnie Johnson, died at the weekend oblivious that Brady was apparently ready to reveal the whereabouts of the remains of her son. Quite apart from realising the horror suffered by Winnie Johnson for the past 50 years what also struck me whilst watching Endgames of a Psychopath was the dilemma of seeing a client such as Ian Brady in a therapeutic environment whilst striving for the unconditional positive regard. How could I remain open minded, patient, non judgemental and empathic with such a client?

I felt challenged by assessing how I could stay committed to unconditional positive regard knowing the horror of his past

Similar concerns were raised in my mind when I watched last night’s programme on serial killer Colin Ireland.  This individual tortured and then killed 5 gay men in 1993 in London and died in prison earlier this year.  His victims were Peter Walker, Christopher Dunn, Peter Bradley, Andrew Collier and Emanuel Spiteri. In May 2007, a report by the independent Lesbian Gay Bisexual Transgender Advisory Group found that the Metropolitan Police inquiry was ‘hampered by a lack of knowledge of the gay scene in London and the special culture of S&M bondage’.

In the programme last night there was an opportunity to witness his total lack of remorse as he chillingly described how he killed his victims in a confession captured on video by the police.  Again, I felt challenged by assessing how I could stay committed to unconditional positive regard knowing the horror of his past.  However, when discussing these concerns previously with a psychiatrist, she pointed out that it can be further compounded when a violent client can even be directing their aggression against you in the consulting room.

issues spanning wide pendulum

The crucial issue here is where does it stop if as therapist we begin to lay down conditions on who we will see.  Invariably clients present with issues spanning a wide pendulum. So, whilst at one extreme end of the pendulum of violence, for instance, there may be multiple murders whilst at the other end there may be a history of street brawling.  Where does one draw the line if you start laying down conditions on who you see? This will always be a personal matter for each individual. It is perhaps crucial that we have a robust awareness of transference and counter-transference issues and to be as knowledgeable as possible about our own areas of emotional vulnerability and unresolved emotional issues.

Resources

Motivating treatment-resistant clients in therapy
Safety issues for counsellors who work with violent clients
Therapeutic issues for counsellors
Experiencing a horrific crime can be hugely traumatic
Living with and creating a spirituality of loss in a forensic context

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The relevance of early life and psychodynamic ideas in transpersonal integrative psychotherapy?

the journey in transpersonal integrative psychotherapy is to seek one’s essence, one’s real self

 

I often wonder if early life experiences are important in shaping adult character and whether unconscious communication such as transference and counter-transference is integral to transpersonal integrative psychotherapy.  Perhaps transpersonal integrative psychotherapy presupposes psychoanalysis or, rather, include it as a first and necessary stage in helping us to name what is going on in the therapeutic relationship.

Whilst unconscious communication is important in psychotherapy, is it that we need to go further than psychoanalysis to understand the client?  Yes, we all have early life issues and we perhaps might have early life developmental ruptures, and thus an analysis of these issues can be a useful insight.  However, such analysis can ultimately limiting as the journey in transpersonal integrative psychotherapy is to seek one’s essence, one’s real self. Therefore, we need to understand the client in a more holistic manner, the assumption being that we are more than the sum total of our personal history whether in families, schooling or working situations.  The journey in therapy is to uncover our inherent soul nature, that which gets blocked through our lived experience, whilst we are struggling to build a healthy ego.

I believe that early life experiences are indeed important in shaping adult character and that non-verbal and unconscious communication such as transference and counter-transference is integral to transpersonal integrative psychotherapy. I accept that transpersonal integrative psychotherapy presupposes psychoanalysis or, rather, include it as a first and necessary stage in helping us to name what is going on in the therapeutic relationship. However, I believe that we need to go further than psychoanalysis to understand the client. Indeed, we all have early life issues and we perhaps might have early life developmental ruptures, and thus an analysis of these issues can be a useful insight. The nigredo stage is necessary in the alchemical journey or we risk a spiritual bypass.

Psychodynamic therapy can, however, be limiting as the journey in transpersonal integrative psychotherapy is to seek one’s essence, one’s true self. Therefore, I believe that we need to understand the client in a more holistic manner, the assumption being that we are more than the sum total of our personal history of being in families, schooling or working situations and of being in our various relationships. To this end, we need to uncover soul qualities in our search for our true selves.

Ultimately, I agree with Jacobs when he says that in psychotherapy clients make theory rather than theory making therapy. I need, therefore, to remain open-minded and use early life theory as a map which might be helpful in the navigation rather than as a set of rules. Pattern recognition is essential to good therapy. The primary difference between talking to our friends or Aunt Dorris is that counsellors are trained to look for patterns.

Resources

Transpersonal interventions
Explanation of therapeutic approaches
Transpersonal techniques
Transpersonal psychology

 

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Transference when seeing clients in prison

 

I have previously discussed the issues surrounding transference and indeed pre transference where I wondered how the circumstances and location of the therapy session affected the minds of both the counsellor and the client. This week I attended a ward round in a health-care setting in a prison as part of psychiatric placement.

The unit serves the prison community which is comprised of adult men, with no upper age limit and accepts patients who have mental health problems. It incorporates those suffering from acute psychotic episodes and/or other mental health illnesses, patients with a personality disorder and some patients with a learning disability. Occasionally a patient with a mental health problem and a substance misuse problem may be admitted. It excludes those patients who primarily have a substance misuse problem.

I was speculating with myself about the type of patient that would present at the ward round. Some of the patients were lifers and seemed resigned to their sentence, others were on remand awaiting a court date.  Seeing patients with suicide ideation can be draining especially when some talk at length and in great detail about how they would seek to end their life.  I felt helpless and powerless, was this my counter transference?  It is also frustrating to hear the evident need for talking therapy resources in such institutions at a time of cut backs and limited resource. However, I was there in an observing capacity and actually witnessed an upbeat and cheerful psychiatrist who seemed to take the ward round very much in his stride.

Resources

RAPt delivers drug and alcohol services – in prisons and in the community – which help people move away from addiction and crime.
Mental Health Care in Prisons a guide to mental ill health in adults and adolescents in prison and young offender institutions.
CARAT (Counselling Assessment Referral Advice and Throughcare) is a drug service that is available in every prison in the UK. CARAT teams were introduced in 1999 as part of HM Prison Service’s strategy to tackle drugs in prison.
Prison Reform Trust a registered charity that works to create a just, human and effective penal system. The organisation was established in 1981 in London by a small group of prison reform campaigners who were concentrating more on community punishments than on traditional prison reform issues.
Evaluation and Treatment of Patients with Suicidal Ideation  

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How big a factor is pre-transference in the therapeutic relationship?

 

A lot has been written about transference and counter transference from the therapeutic relationship between counsellor and client.  Of course we do not approach people in any walk of life as a blank sheet but rather we ‘transfer’ what we have already learned from the past to the present.  However, in psychotherapy it is more intense and potentially more powerful that which we transfer.  This is due chiefly to two reasons.  Firstly, the therapist adopts comparative anonymity.  The refusal by the therapist to correct the client’s misconceptions can offer the opportunity to explore and discuss these misconceptions.  Secondly, the clients are asking for help and this can create a useful parental authority figure dynamic in which to work with.

But what about pre-transference when seeing clients?  Clients will have preconceived ideas about the therapy as well as preconceived ideas about the therapist before they arrive at the first session. They might already have had dialogue with the administrative staff before the initial consultation if the sessions are to be held within a counselling centre or they might have had telephone contact with the therapist before the first meeting.

Pre-transference is not, of course, restricted to the client.  The therapist will also have pre-conceived notions about the client based upon the preliminary discussions that have taken place before the initial meeting. For example, a client could perhaps have outlined a brief summary of the presenting issues before the initial meeting.  Or they might have revealed their expectations of therapy and this might tempt the therapist to fantasise about the client before they meet.

How can you deal with your pre-transference as a therapist? It is essential to be aware of what is happening in the room. You need to stay conscious.  As a therapist we ask ourselves who does the issue belong to? Is it mine or someone else’s? Are we in touch with our own centre and in touch with our essence? If we are truly in touch with our own baggage, then we can be better protected from bringing our own agenda into the therapeutic relationship.

Empathy and compassion can create a safe environment in order to allow difficult issues to rise to the surface.  If we explore the fantasies of the client then they could lead us somewhere. It is important for a therapist to remember that resistance is not malicious ill will but a coping strategy on the part of the client to avoid pain. In other words the defence systems are there for a reason and you are advised to ensure that the client has a healthy ego before you engage in challenge.  You must avoid the temptation to take client resistence personally. It can be argued that transference and “acting out” are at one when the client is acting in a way that repeats “the cycle” with the therapist, thereby exploring the core issues.  A lot of the material with a client is pre verbal and pre conscious.

Related posts. 

The 1-1 relationship between psychiatrist and patient
The importance of challenge in the therapeutic relationship 
Transference and counter transference
Resistance in therapy
Dr Marie Keenan interview
Why some patients trigger stuff and not others

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It is intriguing how some patients can invoke certain feelings and not others.

It was good to get back to my psychiatric placement at an NHS Mental Health Trust today and to a ward review meeting.  I have been sitting in on clinic sessions at a university hospital with consultant psychiatrists covering new assessments, outpatient follow up appointments as well as team meetings discussing the management of care. It was two weeks since I was last at this ward review and it was heartening to notice the visible improvement in some patients in the intervening period.

There were a couple of patients who had regressed and this was producing some feelings in me (what is called counter transference). One patient, a middle aged man suffering with severe depression, was continuing to present with anxiety and helplessness.   I felt like wanting to hug him.  However, his depression is so severe that he has been prescribed a course of ECT. It is intriguing how some patients can invoke certain feelings and not others. Perhaps counter transference is when our own stuff and issues have been triggered and when we identify with the personal circumstances. I was particularly taken by the love and support of his partner (who was present in the session) and who appeared to be a rock of support in spite of very challenging circumstances.  The experience made me aware of the vital role that carer groups undertake in the management of support networks for families and friends of those suffering from mental illness.

Related posts. 
The 1-1 relationship between psychiatrist and patient
The importance of challenge in the therapeutic relationship 
Transference and counter transference
Resistance in therapy
Dr Marie Keenan interview

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Transference and counter transference

The past two weeks have been concerned with transference and counter transference. Transference had been identified by the great Sigmund Freud when he noticed that his patients often seemed to fall in love with him – including the men. Transference occurs when a person takes the perceptions and expectations of one person and projects them onto another person. They then interact with the other person as if the other person is that transferred pattern. In the way we tend to become the person that others assume we are, the person who has patterns transferred onto them may collaborate and play the game, especially if the transference gives them power or makes them feel good in some way. Typically, the pattern projected onto the other person comes from a childhood relationship. This may be from an actual person, such as a parent, or an idealized figure or prototype. This transfers both power and also expectation. If you treat me as a parent, I can tell you what to do, but you will also expect me to love and care for you. This can have both positive and negative outcomes.

Types of transference

Paternal transference When we create paternal transference, we turn the other person into either our father or an idealized father-figure. Fathers are powerful, authoritative and wise. They protect us and tell us what to do. They know many things. They provide a sense of control in our lives. They make us feel safe. We often transfer as a four or five-year old child, where ‘father knows best’ and the pattern is one of trust and compliance. When we regard higher-level leaders (e.g. a company CEO), the transference may be as a baby, where the father is distant, powerful and protective. Male managers in companies often encourage paternal transference by taking on the mantle and behaviours of classic fathers. They assume wisdom. They speak with authority. They reassure us that all will be well if we do as they tell us.

Maternal transference We develop relationships with our mothers at much earlier dates, and so take on roles of babies more than children. In our early years in particular, mothers are the source of unconditional love. After the separation of birth, they recreate unity by holding us and making us feel as one. Mothers also are the source of ultimate authority, and the threat of separation is very powerful. Mothers appear in myth as both the fairy godmother and also the wicked witch, and we often have ambiguous relationships with them. We can also become Oedipal in our desire to be the sole focus of attention of our mothers. Maternal transference is thus often deeper, with more primitive and emotional elements than paternal transference. Women managers often have excessive expectation put on them that they will nurture their staff, who then become disillusioned when this does not happen (hence the manager becomes cast as a witch).

Sibling transference When parents are absent in our childhood, we may substitute these with sibling relationships, either with brothers/sisters or with friends. This is an increasingly significant pattern as families fracture and mothers spend long hours at work and are often away from the child during the critical early years. People with preferences for sibling transference work well in horizontal, team-based organizations, as they do not fall into the leader-seeking behaviours of parental transference. This can also lead to greater anarchy as we ignore leaders and work through networks rather than needing a controlling authoritarian hierarchy.

Other transference We also transfer non-familial patterns onto other people. In fact we invariably treat others not as they are but as we think they are, and often as we think they should be. Thus we form stereotypes, and transfer these patterns onto others. We also form idealized prototypes, for example of policemen, priests, doctors and teachers, and project these onto people when we need the appropriate roles. Thus when a person is hurt in the street and another stops to help, they may have a doctor pattern transferred onto them. Erotic transference can be ordinary and delusional. Transference is the ego trying to protect itself.

Counter-transference (concordant and complementary) occurs where a person who is a recipient of a transference activity accepts this and engages with the client at an emotional level. Remember as therapist you have no business allowing the client work become personal. Your job is to fail the client but in a manageable way. Just like the child needs to realise the disappointment that their parents are not actually the greatest and most idealised people in the world, so the client needs to realise that the therapist is not the ideal subject of the fantasy. “As if” consciousness needed. When to make something conscious depends how well you know your client. What hasn’t been worked through will be repeated and repeated and repeated.


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