This paper below is an unpublished
talk that I gave in Sydney in July 2005 to a Professional Development
Meeting of the Australian Somatic Integration Association (ASIA)
which is a sister organization of my own association, the Australian
Association of Somatic Psychotherapists (AASP).
“Psychotherapy and the Nature of the Psychotherapeutic
Relationship - Issues dear to my heart”. By Alison Ball
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Introduction
I took the title of this talk from the actual content of the brief
given to me by your Professional Development committee. My first thought
at being offered the opportunity to talk to you on this topic was, "Wow,
what a gift and a privilege". Thank you so much for that and I can only hope
that I can do it in a way that is satisfying for me and useful for you. Until
I started writing I had only some vague notion of what I would talk about
and was somewhat surprised myself as to what came out of my head and onto
the computer and what it was that I wanted to say. I should state at the
outset that I am here probably taking a lot of very important basic aspects
of psychotherapy and the psychotherapy relationship for granted. For example
empathy, our capacity to listen, congruence and authenticity. But at
present this is what I am quite passionate about and it is certainly dear to my heart.
The Privelege
The privilege of being a psychotherapist seemed like a good place
to start. As psychotherapists we are in a very privileged position.
People give us their trust and open up to us in a way that can fill
us with awe and brings with it a huge degree of responsibility.
We frequently are told things that the person has never ever spoken
about before. That requires from us a great deal of respect for
the teller along with an enormous admiration for their courage in
daring to tell us. Our job does mean that we have real effects on
people and we have a lot of power to influence lives. At the same
time we have to remain extremely mindful that the impetus for change,
growth and development must ultimately come from the client and
at times we have to give up our wish for them to fulfil the potential
we might see in them and /or give up our wish for them to really
live, grow or even survive.
Being in such a privileged position also has the possibility of
going to our heads. We can be sucked into believing that we are
who our idealising clients think we are and I shall say more about
this later. It is though, critical to keep our feet very firmly
based in the reality of the ground. Fortunately, if we are open
to it, our privileged position can also give ample opportunity to
learn about and, in our own time (and through our own therapeutic
journey) hopefully to deal with our many weaknesses, faults and
human frailties. At the same time we can only hope that these human
weaknesses, faults and frailties do not adversely affect the client
to the degree that we bring about some iatrogenic (therapist induced)
condition that is permanently damaging for the client. Clients are
sometimes damaged by therapy and even die during therapy. This could
happen to me and it could happen to you and such possibilities must
serve to keep our feet on the ground and not get hooked into our
own omnipotence.
The Spectrum of Counselling, Psychotherapy, “Real
Psychotherapy” and Psychoanalysis
That all brings me to the main point of this talk which is about
what we are doing in this job and what is the nature of this work
and of the therapeutic relationship? My current passion in relation
to that seems to be primarily about what it takes to become what
I think of as a “real psychotherapist” who can do what
I often think of as “real Psychotherapy”. These are
quite extremist terms and might sound rather elitist but it suits
my purpose here tonight. I will gradually, I hope, make it clear
what I mean by a “real psychotherapist” and “real
psychotherapy”. Incidently, there are also distinctions that
can be drawn between “real psychotherapy” and psychoanalysis
but tonight I will not deal with that.
Even before the invitation to talk here tonight I had recently
again been thinking a lot about this subject because of a discussion
with Liz.Sheean, owner and publisher of the Psychoz Journal and
also an ex member of AASP. On her website she has minimised any
difference between counselling and psychotherapy and I had some
discussions with her about that. And also in PACFA circles, in the
name of unity there is this same wish to minimise the differences.
Now, perhaps typically of me, I want to swim against the tide. I
think there is real value in preserving a distinction between counselling
and psychotherapy. There is nothing wrong with difference and individuation.
Preserving a distinction between counselling and psychotherapy
does not necessarily mean that one is less than the other; just
different. In the same vein, I believe there is a whole spectrum
of what is called psychotherapy. When I hear some people talking
about their work and they are calling it psychotherapy I can feel
my contempt rising at times, as if I would never do what sounds
to me like such superficial work; but that is rubbish. Of course
I do at times. But, nevertheless, I do think that there is something
qualitatively different at either end of the counselling/ psychotherapy/
psychoanalytic spectrum. And while some counsellors may do psychotherapy
with some clients and many times, we as psychotherapists, are acting
as counsellors with our clients, I am quite passionate about the
nature of this “real psychotherapy” and what it takes
for us to be able to do it or rather what it takes to be a “real
psychotherapist”.
When I think of my version of this “real psychotherapy”,
I want to stress that it is certainly not possible or realistic
to consider it for most of our clients. Much of our time and much
of our work will quite legitimately be valuable, therapeutic, and
useful but not necessarily at the end of the spectrum I am focussing
on here tonight. By no means do I want to devalue it. Here I am
thinking of much of psychology, much of the body-work that is practiced,
supportive psychotherapy, cognitive work, short term therapy, lots
of counselling and even one- off sessions. For a lot of people that
will be exactly what they need and/or be enough. It will support
them in their way of being in the world, bolster their coping self
and/or enable them to move forward on their own. I often think for
instance, of some very good work I did as a social worker around
the kitchen table. Or I think of the 20 minute, one- off session
I had in the 1970’s with a cognitive behavioural psychologist
which was the beginning of real change for me and for our family
dynamics. And indeed, clients who want or need this level of counselling
or psychotherapy will leave us if we go in assuming they want my
version of “real psychotherapy”. We should never aim
to give anyone more therapy than what they want or demand.
We must therefore really consider why it is that people seek us
out in the first place and we must spend a good bit of our time
with them exploring what it is they want from us or need from us
or are able to take from us. Many at first do not have a clue nor
perhaps do they care much about who is this professional they have
come to see or how is it exactly that they might work or what they
might be getting themselves into. They just know they are in pain
or have some problem within themselves or in their relationships.
They do not know the difference between psychology, psychiatry,
counselling, therapy, psychotherapy, somatic psychotherapy or indeed
psychoanalysis or somatic integration. Most wish that we will be
able to wave the magic wand and produce the McDonalds quick fix
and some can indeed get all they need or want from us at that time
in a very short space of time. What I have problems with and what
leads me to an interest in the differences along the spectrum of
counselling/ psychotherapy, is when cognitive work or other short
term quick fixes are used for people who have deep dependency needs
or have severe attachment problems and most especially when these
problems are accompanied by experiences that have been traumatic.
The making of a “real psychotherapist”
As I was writing this paper, I realised that I am willing to talk
to you about these issues because I think that your training offers
the hope that you are people who have the potential to do (in your
own way) my version of “real psychotherapy”, provided
you do the necessary work in your own psychotherapy. I was not always
so convinced because I had the idea that your training had been
largely quite similar to my own in terms of the Neo-Reichian/ group
process/ Boyesen model. And, although I gained a huge amount from
my training and although a primarily body work training enables
us to work with very strong emotions and feelings, it does not necessarily
equip everyone to do “real psychotherapy”. I think it
does not on its own offer enough structure and containment to hold
the space for the work to be safe enough. The boundaries are often
too loose. As well, that training devalued the mind and the link
between words and feeling. We now know that that link leads to the
capacity, as Fonagy calls it I think, for mentalization. In broad
terms I think that means the capacity to make sense of our lives
which in turn is a marker for secure attachment.
It is, I think, those lacks in the body work trainings that have
meant we have had to turn to the analysts of one kind or another
for some help. We need their concepts and language to make sense
with our clients of their process. And from what I have understood,
it seems that in your training you folk have, in recent years, primarily
turned to Bion to give you the structure, the containment and the
depth of thinking required. That sort of input, along with good
enough personal psychotherapy and good supervision, sets you up
to be able to do real in -depth work with people if you are inclined
to do so and, if you can seize and stay with the opportunities that
some clients do provide us with. To do this “real psychotherapy”
you need all the above input because it is extremely hard for both
therapist and client. It is very, very intense, takes years and
years and is usually only entered into by the desperate or the totally
dedicated and most of this latter dedicated group of clients are
either training or already practicing themselves as psychotherapists.
And although my version of “real psychotherapy” is not
what a lot of clients want from us, in my opinion, the test of being
a “real psychotherapist” is when we can meet and match
the needs of those who do.
Perhaps it is my own grandiosity but I think that many people who
are trained as counsellors or psychotherapists simply are not willing
or more likely, they do not have the personal capability to go to
the depths of what working at this end of the spectrum requires.
And it is very difficult to talk to them on this subject because
they simply do not know what they do not know. The absolute bottom
line is that they have to have gone to the depths in their own psychic
realms in their own long term and intense psychotherapy process.
And I can be quite a fascist in my thinking around this. I am not
talking simply about a lot of the personal development work we do
in group settings, even training group settings though that is a
great way to start. And I am not talking about three years work
with one therapist and another year or two here and there with another
one or two. I am talking about the absolute essential experience
of the long term, one on one process with a therapist who can take
us where we need to go into our own psychic depths. And for those
of us who want to be able to do real work that is likely to be at
the very least about 7 years. It may well entail sessions two or
three times per week and in my opinion is almost never only fortnightly.
Who wants or needs “real psychotherapy?”
Of all the people who come to us only a few will be at all interested
in or in need of what I am calling “real psychotherapy”.
The ones most likely are those who have some innate knowing that
psychotherapy is what they need because of their particular issues
and/or who have in fact tried all the quick fix therapies and have
come to us almost as a last resort. These people may be ready for
the sort of psychotherapy that I am speaking of and a trickle of
them may be desperate enough to embark on my version of “real
psychotherapy”. Of course along the way, even many of these
will decide that it is much too hard or too frightening and will
come up with all sorts of good and real reasons why they cannot
continue; eg. “I have to move to the country or interstate
for work”, is one of the very legitimate favourites. All we
can do at these times is to help them understand what might lie
underneath all the rational, “out in the world” reasons
and why at that unconscious level they feel compelled to do what
they are doing; that is, escape the therapy. That way, at least
they will have some understanding of their own psychic processes
and may later be more able to seek further help if life events or
their inner turmoil force them to feel that they must go further
in their psychotherapy..
This above touches on what I find to be a most intriguing and
interesting phenomenon that is almost universal though in varying
degrees and intensities. The phenomenon is that just as soon as
we find the therapist who might be able to really help us work on
our issues and we begin to build trust and can see the beginnings
of change then every fibre of our being rises up to scream, “No,
no, don’t do it, at least we’ve survived this way.”
Our fear of changing our embodied and long held ways of being is
enormous; better the self or patterns of coping and habits we know
than face the unknown and perhaps risk the very stability of the
often precariously balanced self we have built up.
And we as psychotherapists must really respect this fear, as it
is, I believe, the major reason why so many people drop out of therapy.
And it is for this reason I frequently say to supervisees that in
the first session or the first weeks of therapy and even at many
stages thereafter, the main thing to focus your attention on is
all the reasons why this person will not want to stay in therapy.
This fear which I think we greatly underestimate, is the fear of
what growth and change will mean. It is feared because of what it
may mean for how they have managed to cope so far in their lives.
They fear that they might disintegrate and/or will not be able to
go on doing what they do. People rightly fear that one of the main
things that “real psychotherapy” does is challenge their
very patterns of survival and the self they have lived with most
of their lives. Additionally my version of “real psychotherapy”
ultimately challenges them to grow up, take responsibility for themselves,
learn to be separate but loving and learn to differentiate as much
as possible between what belongs to them and their own mind and
what belongs to the other.
The Process of “real psychotherapy”
So, how do we get to this point above with this trickle of people
who come to us driven to search for “real psychotherapy”
and how do we marry this with what they seem to be searching for?
Depending on their experience in their original primary relationships
and the life events that follow, the road can be very long and very
slow as well as intense and at times extremely hard for both therapist
and client. The main group I will speak of are those who come to
us wanting, hoping, wishing and searching for that idealised parent
who will give them all they missed out on as a child. They want
us to hold them, to heal them and to nurture them and most of all
never to leave them (and I will say more on this latter matter of
leaving later). We can give them a lot and most certainly we can
give them much that they missed out on and this is what I think
of as the re-parenting element of therapy.
To some degree all therapy has elements of re-parenting in it,
even if it is no more than through the provisions of the environment
we offer where our time and our attention is regular, reliable and
non-judgemental. And when we give so much it can induce that idealisation
I mentioned earlier. Most especially this can be so if we nurture
them with massage and/or our endless empathy and mirroring. And
being idealised is, as I indicated above, terrific fun and very,
very seductive for us as therapists. We can really get caught up
in the good feelings engendered. And I think some therapists or
therapies never get past this stage either because it is so seductive
or they just do not have the capacity and/or the willingness to
go further. And, don’t get me wrong as I have indicated some
people can make major changes when they are at this stage of therapy.
Through our nurturing, our empathy, our mirroring some people can
really blossom and maybe for some this is all they need or want
and through it they can move forward in their lives. For some or
maybe many, this is good enough therapy or good enough psychotherapy.
It is enough, and there are many counsellors and psychotherapists
out there who can do this sot of therapy. In my opinion however,
for those needing my version of real psychotherapy, it is simply
the start, the tip of the iceberg.
In trying to convey to my supervisees who I think are capable of
offering my version of “real psychotherapy”, I say something
like:: “During these idealising times make the most of it,
enjoy it while you can because if you are doing your job it won’t
last and you will sooner or later get the other side of the coin.
It may be weeks, months or years but eventually you will fall from
the heights and in some cases become totally denigrated. You will
be told of all your faults and foibles and you can only hope that
enough good will has been built during these good times that you
and they can hang in when things go bad. And, if you and they can
hang in, finally they will get what they really missed out on, in
the form of a good enough parent/therapist rather than an idealised
one. This good-enough parent/therapist can give them what they really
need; one who can tolerate all their hate and their fury and still
be there for them.”
So when I talk about “real psychotherapy” or the capacity
to offer “real psychotherapy”, this is what I think
it offers; a relationship with a real human being who can be good
enough and constant enough to invoke love and who is also able to
tolerate all the hateful and unbearable feelings so that ultimately
each party in the relationship will grow and the client can individuate
and grow into a fully mature, independent and real adult who can
themselves value the good as well as tolerate and accept their own
unbearable feelings and the strengths and human frailties of the
other.
Who needs “real psychotherapy”
I want to come now to what I think of as the guts of the psychotherapy
relationship and what are the critical issues we are dealing with
in “real psychotherapy”. I think much of therapy for
these people is focussed on issues related to leaving and being
left, to the presence or absence of the primary other or in short
on mourning and loss. And I do not only mean physical absence. Emotional
absence through depression, neglect or dissociation can be just
as damaging and there can be traumatic experience even in the physical
presence of the parents which leads to a similar sense of loss.
It is through absence that we learn to think and to have a mind
and a life that is truly our own but this is only OK if the original
experience of absence is not too traumatic. And of course for many
people the original experience has been traumatic and not good enough
in Winnicott’s terms. The absences have been too cruel, too
harsh or too long, too young. For some people these issues are basically
all of the therapy. For most people they are critical in some way.
The issues show themselves in a variety of ways. For some they
will be seen in the dependent nature of their out in the world relationships
where they may have been completely merged so they never have had
to bear the reality of being alone. They will want to merge with
us or will come into therapy only when their merged out in the world
relationship is under threat. If they are not ready for a therapeutic
relationship they will avoid these issues with us if their partner
returns to them or by finding a new partner. Some others will have
avoided being attached to any other real human being. Some will
have disappeared or be able to disappear when intimacy threatens
them. Others will have become addicted to a bottle, drugs, gambling,
the internet or a myriad other things. They will most certainly
struggle against becoming attached to us because the bottle does
not leave them as we will do.
Some others will have built up all sorts of defences against their
need of the primary carer including through what I call a precocious
but sort of false “grown-up-ness” or excessive levels
of “being responsible”. Others will be bulimic as their
way of rejecting what the primary carer has to offer. Still others
have developed the classic body rigidities that bolster their coping
self while underneath they remain fearful of real commitment to
an other. Some can let themselves be attached to us and then find
our absences unbearable. One way or another a lot of therapy time
will be spent understanding how people cope with absence and their
allied fears about: “What if I become attached and then they
die or leave me?” And it is not just about our physical absence
either. Many remain for a long time extremely sensitive to any evidence
that we may leave them either by going into our own mind or in other
ways leave them even momentarily at an emotional level. This whole
group of people do need to become dependent on the therapist, sometimes
for a long time but ultimately they need a therapist who can help
them grow into independence.
How we do the work of ‘real psychotherapy”
At this level of therapy the work is almost always based on our
countertransference or in other words, on our own subjective response
to being with the client in any particular moment. We must be able
to use our own internal response as a signal to ourselves of what
might be happening for the client and what response from us they
might need. And this is the reason why we must be as clear as possible
about what our own issues are while, at the same time, being able
to stay as attuned to the client as possible. It is also why we
need good weekly supervision
I want to re-iterate that to do this sort of psychotherapy and
be willing to cope with all the sadness and hurt, all the hate,
rage, fear, envy, jealousy, feelings of vengefulness, and just plain
madness that underlies the most extreme forms of traumatic dependency
and attachment issues means that the psychotherapist themselves
must have been willing and able to have entered these psychic places
in their own therapy. It can be very, very difficult and at times
with some people it can be very gruelling. We do even run the risks
with this depth of work of ultimate “failure” to help
the client come through and out the other side.
This thought is quite frightening and the responsibility big as
so often, just as we think we have brought them through, yet another
layer of madness surfaces and further levels of destructiveness
work yet again to attempt to wreck all that has been good and all
that is new. At these times we must sustain our faith in our client
and their capacity to grow and change. And we can only hope that
they do have enough resilience within and enough good has been introjected
that they too can stay the distance for themselves. Central to my
talk tonight is my belief that not all counsellors or psychotherapists
can do the sort of work I have outlined at this more extreme end
of the spectrum and I know my bias is to think that those who can
are the “real psychotherapists”.
Conclusion:The interaction between the personal
and the professional
I want to finish on a more personal note. I am probably interested
in this sort of psychotherapy because of my own background and my
own experience in therapy. To make sense of my own experience I
had to turn to analytic theory. First of all I discovered Harry
Guntrip and his book called “Schizoid Phenomena, Object Relations
and the Self”. Then I could begin to understand Freud a bit.
Then ultimately I could make sense of it through those analysts
who were associated with the British Independent School of psychotherapy
as well as the theories of Melanie Klein and the post Kleinians.
I love the humanity and the groundednesss of Winnicott and the phenomenal
dissection of the innermost workings of the psyche that comes from
Melanie Klein and her followers. I love the depth of thinking about
thinking that is the gift that Bion has given to us. Not only do
these theorists and clinicians make sense for me of my own experience
and that of many of my clients but they are the ones that I am most
excited by and from whom I feel most fed and most challenged. When
I go to seminars from people from this strand I come away feeling
like I have had a huge feast.
I have only very belatedly come to appreciate the good offerings
that belong to self-psychology and intersubjectivity. The major
value I have taken on from self-psychology and intersubjectivity
is in relation to technique. While I love Klein’s theories,
her technique I think, would have driven away many more clients
than ever profited from it. I greatly value the truth and clinical
usefulness in Klein’s ideas but we can learn a huge amount
from the self-psychologists and intersubjectivists about the way
of being as a psychotherapist in relationship with our clients and
the way in which we interact with them. One of their greatest gifts
I think, is their notion of disjunctions or empathic failures between
therapist and client and the growth that is possible in the healing
work of interactive repair.
This way of being as a psychotherapist in relation to clients seemed
to me to be a natural outcome of my experience and of having been
trained as a social worker in the late 70’s. Not directly,
I might say, through the social work course but through my social
work mentor. He directed me toward reading Carl Rogers book, On
Becoming a Person. That book said it all for me. I had permission
from Rogers and my mentor that, as a social worker or therapist
it was OK just to be ME and to listen to the person in front of
me. My mentor told me that that was enough to start with and that
yes, along the way I would learn a lot more and develop more skills
but when I thought that I knew it all, was the time to give it up.
It was a wonderful set of premises from which to start being a therapist.
Not long after that I read Carcuff and Truax from cover to cover
and in that I learned that about 95% of the help we give is in just
being there and providing the space. For me that has been a wonderful
gift. It took the pressure off me to provide magical answers or
to feel like I must DO something.
And what I most love about being a psychotherapist with an abiding
interest in psychoanalytic theory is that it will be impossible
ever to feel like I know it all. So with a bit of luck health wise,
I am hoping to go on working for a lot more years to come. The depths
and riches of the psychoanalytic gold mine seem endless and I believe,
are on a par with mathematics, languages and music as always offering
the challenge of newness and the opportunity to be creative.
It is a good idea to ask ourselves why it is we want to do this
work. If it is just about “wanting to help people” then
I think we should forget it. As my supervisor has said that may
be just a defence against our own sadistic impulses. I’ve
always thought that what really motivates me is that just as some
people like to explore Mt.Everest or the Antartic or the jungles
of South America, I love to explore just what it is that makes any
individual tick. How is it that this person thinks, what is it that
is really meaningful for that person, why is it that this person
responds to this in that particular way, how has it come about that
this person feels this way? That’s what I love. It seems like
a continual adventure to be with another person and explore both
the relationship between us, how that impacts on us both and by
exploring that, help us both to understand what this person has
created in his or her own mind, in their body and in their emotional
life out of all the experiences that life has brought them. In doing
so I can only hope that the client is also helped along his or her
path.
Thank you for your attention and the privilege of talking to you
about my ideas of what constitutes “real psychotherapy”.
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