Tales from the Therapy Room: Shrink-Wrapped

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Phil Lapworth

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  • Praise for the book

    These engaging, moving, informative, warm and surprising stories convey the key points in counselling and psychotherapy practice. Overall, a beautifully written book that should be a real asset to the counselling and psychotherapy literature.

    MickCooper, Professor of Counselling, University of Strathclyde

    I've read each of these stories through several times, simply because to do so was a sheer delight. They are written with warmth and humour, and give a valuable insight into the world of therapy. Therapists regularly find themselves confronted with dilemmas and this book helps alert the reader to the importance – and everyday nature – of reflecting on these sorts of issues.

    MikeSimmons, University of Wales, Newport

    The topics reflect aspects of our studies and give an insight into how these might be identified in real life. Anyone on a counselling course will be looking for a book such as this, to lighten up the heavy load of academic reading. It makes you think, as well as backing up your learning.

    HNC Counselling & Psychotherapy student, Anniesland College

    As a student on a counselling course, I honestly thought this was the best book I have come across relating to therapy. The skills demonstrated by the counsellor were shown in short captivating stories that kept my attention throughout, meaning that I picked up more than I had in course handouts or from the reading list textbooks.

    HNC Counselling & Psychotherapy student, Anniesland College

    Copyright

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    Dedication

    To Leo and Laurie

    Acknowledgements

    My grateful thanks to:

    Charlotte Sills for having faith in my writing and for giving invaluable feedback.

    Alice Oven, at Sage, for being so encouraging and for taking a risk.

    Karnac Books for their kind permission to include ‘Dream On’ in this collection.

    My clients for sharing with me their real stories and teaching me so much.

  • Unwrapping through discussion

    I hope these short stories have been enjoyable for you to read simply as entertaining tales. Additionally, I hope you will enjoy ‘unwrapping’ them to discover how they may be helpful to you in your learning and reflection as a therapist. Each of the stories raises issues and challenges that might be faced by anyone preparing to engage, or already engaged, in the practice of counselling and psychotherapy. Maybe you have been critically assessing the style and interventions of the therapist as you have been reading each story and, as invited to do in the introduction, have been considering your own approach to these clients and the issues they present – in particular, identifying what you would have done or said differently. To assist your personal considerations and to stimulate discussion with your peers and colleagues, I draw attention below to some of the key challenges of each story and provide some questions for you to reflect upon from your own theoretical perspective. Where appropriate, I suggest further reading to explore these issues in more detail and refer to textbooks on specific theoretical and technical aspects in which you may be interested.

    If there is one belief I have tried to convey in these stories, it is that there is no single ‘right’ way to work therapeutically with another person and that each unique dyad will find its own way to be together (perhaps, struggling to do so some of the time) for the benefit of the client.

    The Carving

    One of the issues raised in this story is the ‘neutrality’ of the consulting room and the private person of the therapist. Here, the therapist rationalizes the benefits of a neutral environment as allowing clients and their therapeutic relationship with him to be ‘as unencumbered by extraneous intrusion or distraction as is possible’. The room is a ‘background’ to the relationship and the therapeutic work. It is an ‘exploratory space’ (p. 5). However, the story continues with descriptions of the various associations some of his clients make when a wooden carving is introduced into that space. The carving itself becomes a means of exploration of their fantasies and perceptions as well as a means of deflection.

    • Do you believe the consulting room should – or could – be neutral or not?
    • What for you might be the advantages or disadvantages of a neutral room?
    • Do you agree with the therapist in this story that ‘family photographs and personal memorabilia have no place here’. What might be the advantages or disadvantages of such things being present in the room?
    • What's your opinion of the therapist's introducing the carving into the consulting room?
    • What limits do you place upon yourself in terms of disclosure of your personal tastes and preferences to clients? What about details of your personal life? Are there occasions when sharing these might be appropriate? (In ‘Not Playing It by the Book’ the therapist discloses information about his father so we will be returning to the issue of self-disclosure again later.)
    • Or do you attempt to be ‘a blank screen’? To what end?

    The client Deborah (p. 8) is an actor as well as a psychotherapist in training. Seeing the carving as a mask, she introduces the idea of a ‘True’ and ‘False’ self (Winnicott, 1965) in relation to her acting. The therapist challenges her by suggesting that her false self was not restricted to the stage but was present in their relationship and that it was hiding her real self away.

    • • What do you make of this intervention? It seems to work in this instance but what might have gone wrong? What are the risks?
    • In suggesting Deborah talk directly to the carving/mask, what do you think the therapist intended by such a directive intervention?
    • What do you think happens in this process of Deborah talking to the mask?
    • How would you describe this process within your theoretical model?
    • Is this way of working something you would do in your practice? Again, what are the risks involved?

    You might like to explore ‘experiments’ as used in gestalt therapy (see Perls et al., 1951; Zinker, 1977; Sills et al., 1995; Mackewn, 1997; Joyce and Sills, 2010).

    The adolescent client, Brian (p. 10), presents a conundrum for the therapist. It is unclear whether how he presents in the consulting room is as a result of his regular use of skunk in the recent past or other factors. Eventually, the therapist becomes convinced that Brian's apparent ‘hallucinations’ are a deflection from facing the realities of life.

    • What would you be alert to when working with someone with a history of drug use?
    • Do the therapist's doubts ring true for you?
    • What might he have done differently to ascertain the possible effects of regular use of skunk?
    • If you consider the therapist to have been accurate in his assessment, how, from your theoretical perspective, might you describe Brian's presentation? This could be in terms of formal diagnosis (such as that of the Diagnostic and Statistical Manual of Mental Disorders, DSM-IV) or a description employing concepts from your own theoretical model (transactional analysis, gestalt, psychodynamic, person centred, etc.).
    • How would you distinguish your description or diagnosis from ‘normal’ adolescent development?
    Subterranean

    In this story, the client, Daniel, presents as an over-adapted, withdrawn and timid man who eventually begins to take small steps to becoming more confident and assertive. His therapist doesn't use the term, but could have described Daniel as someone with a ‘schizoid’ and ‘avoidant’ personality style. The therapist sees some positive development when Daniel appears to become, however slightly, more ‘passive–aggressive’. The reader may be interested in learning more about such descriptions of personality adaptations, or character styles, in the literature. As useful introductions, I recommend the books of Johnson (1994), Benjamin (1966) and Joines and Stewart (2002).

    • Do you concur with the therapist's view that Daniel's movement from compliance to mild rebellion is a positive one? Why?
    • What might be problematic with this development?
    • Have you experienced a similar process in the course of making changes yourself? What was that like for you? Did your shift from compliance to rebellion in the process of gaining confidence seem an inevitable step?
    • What might have been another sequence in your, or Daniel's, move towards confidence and assertion?

    At times the therapist is bored, frustrated, irritated and angry with Daniel's slow progress. At one point (p. 20) he says, ‘I felt so far it was I who was feeling all the anger’. However, he does not overtly express these feelings to Daniel in case he might ‘scare the little mouse back into his hole’ (p. 21).

    As well as not wanting to scare him, why else might the therapist have chosen not to share his feelings with Daniel?

    • Can you think of situations with a client where you might share such feelings?
    • What do you think the therapist meant by ‘I was feeling all the anger’?
    • How would you describe the possible transference and countertransference (or other descriptions of relationship dynamics provided by your model) that is occurring here?
    • In general, how would you describe the therapist's overall approach to Daniel?
    • Does this fit with your approach or would you have worked differently. How?

    Bion (1959) urged that we should be without memory and without desire when working with clients. Similarly, Lapworth and Sills (2010) write of staying ‘creatively indifferent’ (a term used in gestalt therapy). Yet in this story the therapist says, ‘I believe the therapist sometimes needs to hold the hope the client is unable to dream of’.

    • How do you understand these statements?
    • What's your opinion? Do you subscribe to one or both of these views?
    • If both, how would you explain the apparent contradiction?
    • When Daniel fails to appear for his session re-arranged at the new time, the therapist decides to phone him a quarter of an hour into the session (p. 26). He rationalizes this ‘unusual thing to do’ as ‘showing his concern’ and ‘holding him in mind’.
    • Would you have done the same?
    • What reasons would you give for phoning or not phoning a client who had failed to turn up for their appointment?
    • Do you have a hard and fast ‘rule’ concerning contacting clients outside of sessions?
    • What might be the exceptions?
    • What might be the therapeutic benefits or pitfalls of contacting clients in this way?
    • Would you feel justified in phoning a client for your own convenience (i.e. to know whether or not to continue waiting)?
    • If deciding not to phone, what would you do in the event of the client not appearing at the following session?
    Holding Boundaries

    The two previous stories have raised the issue of boundaries: the first in respect of the neutrality of the therapy room and the person of the therapist and, in the second, of making contact with clients outside the clinical setting. This third story presents as its central theme the boundary of confidentiality.

    O'Brien and Houston (2007) provide a useful general summary of the concept of ‘boundaries’ that permeates therapists’ language. They refer to the importance of stability – consistency and reliability – in treatment arrangements such as place, time, frequency, setting, role definition, fees and, most relevant to this story, confidentiality. They helpfully consider just why boundaries are important in therapy (which is sometimes easily forgotten when boundaries simply become a rule to follow) and they give a useful commentary, particularly applicable to ‘Subterranean’, on the potential unconscious dynamics on such occasions when the therapist changes the time or date of sessions. Jacobs (1988) and McLoughlin (1995) write of the importance of time and boundaries from a specifically psychodynamic perspective, while Clarkson (1995) writes of boundaries from a more integrative perspective and looks at some of the exceptions (or boundary breaks) that might occur within the therapeutic relationship. On this latter point, it is important to emphasize that ‘ruptures’ of the therapeutic boundary will happen. It is a rare therapist who does not take a holiday, need to alter an appointment time, increase fees or make some boundary error at some time – even making an ‘outrageous intervention’ (Pizer, 2005), which may cross the normally accepted boundary of the therapeutic relationship – however vigilant the therapist may be. Some would argue the necessity of such ruptures in the process of repairing relational deficits (see Mitchell and Aron, 1999; Stark, 1999; DeYoung, 2003; Maroda, 2004). What is vital is that the ‘rupture’ or ‘enactment’ be addressed, acknowledged and understood so that the relational experience becomes reparative rather than destructive. A strong working alliance (Gelso and Carter, 1985; Horvath and Greenberg, 1994) and a ‘safe container’ (Winnicott, 1965), need to be established as early as possible in the therapy in order to work through such ruptures at the therapeutic boundary. Confidentiality helps create this safe environment in which clients may explore the often hidden aspects of themselves.

    • Why do you think boundaries – of setting, frequency, duration, confidentiality, endings, etc, – are important?
    • What boundaries do you consider absolutely inviolate?
    • When might you break the confidentiality of the client? How would you justify this?
    • What does your own particular therapeutic model have to say about boundaries?
    • What action would you take, and how would you explain it therapeutically, if:
      • Your client persistently arrives late for their session?
      • Your client fails to pay you for several weeks?
      • Your potential client is the sibling of a previous client of yours?
      • Your client is temporarily housebound and requests a home visit for their next session?
      • Your distressed client asks you to hold them?
    • In the story, the client, Helen, has a history of abandonment, physical and sexual abuse. What particular boundary considerations would you make in working with her?
    • In an impulsive moment, the therapist asks his client, Lee, if he does salsa (p. 36), to discover if he has a connection with Helen. Why might this be ‘totally out of order’?
    • If Lee had wanted to know why the therapist asked such a question, how do you think the therapist could/should have responded?
    • The supervisor (p. 37) seems quite clear that the therapist should hold the confidentiality of both his clients and not divulge that they are both in therapy with him and that he knows they are having a relationship. Given that congruence and authenticity on the part of the therapist are often emphasized as central to the therapeutic endeavour, how would you justify the withholding of this knowledge?
    • What might have been the outcome of breaking confidentiality?
    • How might you have dealt with the situation differently?
    Not Playing it by the Book

    There are several issues raised in this story, including another boundary issue, that of self-disclosure on the part of the therapist, which I will refer to later. The first challenge the therapist faces, however, is that of working with a student studying transactional analysis (Berne, 1969/81, 1972; Stewart and Joines, 1989; Lapworth and Sills, forthcoming). I chose a TA student simply because I have some knowledge of this model. The student could just as easily have been a client of any other model whether from the humanistic, psychodynamic or behavioural schools. Whether or not you are familiar with transactional analysis, the concepts referred to in the story are explained to the extent that the questions below will still be relevant to all readers. For those interested in learning of TA's development as a relational approach (p. 50) I recommend Transactional Analysis: A Relational Perspective (Hargaden and Sills, 2002) and From Transactions to Relations (Cornell and Hargaden, 2005). For those interested in the general movement within psychoanalysis and psychodynamic psychotherapies over the past few decades towards a more ‘intersubjective’ and ‘relational’ perspective, I recommend Relational Theory and the Practice of Psychotherapy (Wachtel, 2008), Relationality: From Attachment to Intersubjectivity (Mitchell, 2000) and Psychoanalytic Treatment: An Intersubjective Approach (Stolorow et al., 1987).

    • If you are, or have been, a counselling or psychotherapy student and in therapy (as a course requirement or not), what was it like for you to be studying theory alongside your personal therapy?
    • Was it important to you that the therapist was ‘playing it by the book’ (of your particular model) or not? Why?

    Contracts are employed in many approaches to counselling and psychotherapy. The reader may wish to take a look at Contracts in Counselling (Sills (ed.), 2006) where Sills and others explore contracts and their applications from various perspectives. In the story, Mary seems to expect the therapist to make a treatment contract (p. 47) to which the therapist responds with some strong reservations.

    • Do you agree or disagree with the therapist's reservations?
    • What place do contracts (beyond practical arrangements) have in your model?
    • What different types of contract might you employ with clients?
    • What do you see as the advantages and disadvantages of contract making?
    • What's your opinion on ‘escape hatch closure’ as mentioned in the story (p. 49)?
    • Would you employ a ‘no suicide’ contract with a client and under what circumstances might you do so?
    • When discussing the renunciation of committing suicide, homicide or going crazy, the therapist says, ‘I don't want to preclude these options for myself’ (p. 49). Do you? Why or why not? How might your views affect your work with clients?
    • Would you make such a contract with your own therapist?

    In the story, there then follow some incidents of self-disclosure. After a brief glimpse of some emotional reaction in Mary's face (p. 51), the therapist attempts to respond to her differently. However, he is soon feeling frustrated and, in response to her challenge, gives his honest opinion of her via the theoretical construct of her Parent ego state (p. 51).

    • Whether you use the term Parent ego state, introject, internalized object or another term with which you are more familiar, what is your understanding of what is being described here?
    • How do you respond to the therapist openly describing Mary as ‘cold, angry and extremely critical’ (p. 51). What are your views on such an intervention?
    • How in your model would you conceptualize what is happening when the therapist realizes he was ‘becoming the very Parent ego state I was describing’?
    • Having made a breakthrough when Mary expresses sadness (p. 52), the therapist is ‘prepared for the backlash in the next session’. Why do you think he was prepared for this? How would you describe Mary's possible internal dynamics which may bring about the backlash?
    • When Mary asks ‘Was your father as smug as you?’ the therapist ponders on several responses he could have made (p. 53). What response might you have made and what would have been your intention in such a response?
    • The therapist chooses to disclose information about his father, describing him as not smug (as in Mary's accusation) but a very gentle and modest man. Why is such disclosure on the part of the therapist not ‘a perfectly straightforward and innocuous thing to say’ (p. 53)?
    • A little later, he makes the further disclosure that his father died when he was 7 years old. His rationale is that it felt relevant and right. What do you make of this? Is there justification in a therapist doing something because it simply feels right? What are the pros and cons in acting on intuition or ‘gut feelings’?
    • How, in your model, would you describe the changing overt and covert dynamics occurring between the therapist and Mary throughout this story?
    In at the Deep End

    Trust is the central theme here and though (for the sake of the story's drama) there is an ironic turning of tables, I hope it highlights well enough the importance of trust on the parts of both client and therapist. I hope it also emphasizes the need for discrimination in trust – sometimes taking an informed risk and sometimes having what might be called a ‘healthy paranoia’ – without which we may find ourselves ‘in at the deep end’ or only able to ‘hover about at the shallow end’ (p. 57) of life.

    Even prior to attending a therapy session, the need for trust in the ethicality and professionalism of counselling and psychotherapy is going to play a part in clients’ turning to a therapist. Recent moves to go beyond existing registration with professional bodies (e.g. BPS, BACP, UKCP) towards government regulation of the psychological therapies have been developing in an attempt to protect the public and inspire their trust in therapy.

    • Do you think that regulation will help public trust in the counselling and psychotherapy profession? Why or why not?
    • How might regulation have the opposite effect?
    • In what way do you think the public's trust might be inspired?
    • How might you promote yourself as a trustworthy, ethical and professional therapist as you are starting, or maintaining, your practice?
    • When looking for a therapist yourself, what would help assure you that you can trust a particular therapist?

    Most approaches to therapy stress the importance of the ‘working alliance’ (see Gelso and Carter, 1985; Horvath and Greenberg, 1994; Clarkson, 1995) in the building of which trust plays a central part. Conversely and additionally, through the working alliance further trust is established, assisted by agreement on goals, concordance regarding tasks and the development of personal bonds between therapist and client (Bordin, 1979).

    • What personal qualities as a therapist do you consider will facilitate your clients’ trust?
    • What other aspects of your practice will help the establishment and maintenance of trust?
    • What assisted you in trusting your own counsellor or psychotherapist?
    • Were there times when you had doubts in your therapist? Why and what could have been done to redress this?
    • In the story, how does the therapist work with Pauline to inspire her trust?
    • At one point, the session is interrupted by the doorbell ringing (p. 61) and eventually the therapist goes to answer it. How do you respond to the therapist's handling of this break in the therapeutic boundary?
    • How might you have handled the situation differently?

    Pauline's ‘paranoia’ is apparent throughout the story. (See personality adaptations or character styles in Johnson (1994), Benjamin (1966) and Joines and Stewart (2002).)

    • How would you define the term ‘paranoia’?
    • Which of Pauline's behaviours would indicate to you a paranoid adaptation?
    • How do you understand the aetiology of paranoid thinking and behaviour within your model?
    • What is your understanding of the psychodynamics that may be occurring when the therapist starts to show paranoid thinking and behaviour in relation to Pauline's mother?
    • It is only towards the end of the story (p. 70) that the therapist's suspicions turn from the mother to Pauline, by which time Pauline has left the therapy. But if, earlier in the work, he had been unable to trust the truth of what Pauline was presenting, what could he have done?
    • How important is it that you trust and accept all that your clients are telling you?
    • How might you handle a situation where your trust in your client's authenticity is in question?
    • There are several occasions in the story when the therapist chooses not to comment on some of the incidents that occur within or outside the therapy sessions. Reading of his increasing stress and anxieties, you may feel you can excuse him in the context of this story. However, how would you handle the situation and what would be your rationale for doing so in situations when:
      • Your client uses your first name (p. 64) for the first time or unexpectedly uses a term of endearment towards you?
      • You suspect your client is becoming sexually attracted to you (p. 65)?
      • You receive a letter from a hostile relative (p. 66) of your client expressing opinions of both you and your client.
      • You receive a phone call from a concerned friend or relative asking for information about the work you are doing with your client.
    • Further, would you:
      • Leave a message on your client's telephone answer-machine (p. 63)?
      • Inform your client of the reason for cancelling a session (p. 63)? With how much detail?
      • Work with a client who had turned up at the wrong time and you had time to see them (p. 64)?
      • Accept your client suddenly announcing taking a break from therapy (p. 68)? Why or why not?
    High Spirits

    In this story, the beliefs of the therapist and those of his client, Luke, are very much at odds. The therapist is not convinced by what Luke describes as a problem of being ‘spiritually lost and incomplete’. Rather, following his ‘rule of thumb’, the therapist suspects underlying sexual issues.

    • How do you respond to the therapist's ‘rule of thumb’ and his application of it in this story?
    • How would you have worked differently with a client presenting with similar ‘spiritual’ issues?
    • How does your model describe the redirection of energy (sexual or psychological) towards another aim or object?
    • Though he realizes he is ‘pompously wedded’ to his theory (p. 72), the therapist persists in applying it. If you were his supervisor, what questions might you want to ask him?
    • How does the therapist's attitude and behaviour in this story square (or not) with your personal and professional, ethical position? (You might like to refer to the BACP's Ethical Framework (http://www.bacp.co.uk/ethical_framework) to assist your discussion.)

    People with a variety of spiritual, religious, cultural and political beliefs will appear in our consulting rooms and we as therapists may strive to meet them with unconditional positive regard, a non-judgemental attitude and congruence (Rogers, 1990/1957). But when our own beliefs are in conflict with our clients’ beliefs, maintaining these core conditions is not an easy task. How might you respond to clients who:

    • Consider that women should play a subservient role to men?
    • Believe that contraception is a sin and condemn others’ use of condoms even in areas where HIV/Aids is widespread?
    • Use homophobic, racist or misogynistic language in the session?
    • Request that you pray, chant, meditate or perform a shamanic ritual with them during a session?
    • Believe that their god or higher power or karma or astrological chart accounts for their situation?
    • Ask you to share your religious or political views?
    • At one point Luke's therapist considered ‘referring him on to someone more on his wavelength’ but Luke ‘seemed the more determined that I was the right therapist for him’ (p. 75). In a similar situation, would you consider referring on a client to someone else you thought more compatible? If your client was determined to stay with you, would you agree or insist on another therapist? Why?
    • Having learned of Luke's abusive treatment by his mother, the therapist says ‘The cruelties parents inflict upon their children, in my opinion, are unforgivable’ (p. 78). Are you in agreement with this statement or not? If you learned of the abusive background of the client's parents (and, in all probability, their parents) would this affect your view?
    • What, for you, is the place of forgiveness in therapy?
    • Do you see your clients’ forgiveness of abusive parents as important in the healing process when working with traumatized clients? Either way, are there exceptions?
    • In light of the therapist, at the end of the story, having an experience that was ‘sexual and simultaneously … “spiritual”’, do you think he should share his experience with Luke? What might be the outcome of such a disclosure? Would you have shared it?

    Some approaches to psychotherapy explicitly contain a spiritual or transpersonal element (my colleague, Charlotte Sills, considers them to be ubiquitous enough to be seen as a ‘Fourth Force’ in the world of psychological therapies, alongside psychoanalytic, humanistic and behavioural forces). For those interested in this fourth dimension, I recommend Psychosynthesis (Assagioli, 1975), Zen Therapy (Brazier, (1995) and Mindfulness Approaches to Psychotherapy (Baer, 2006) as useful introductions, and, of course, the many relevant papers in The Collected Works of C. G. Jung (1970/1958).

    The Audition

    Central to this story of a film-star client who wants to ‘say goodbye’ to her father is the employment of the ‘empty chair’ technique from gestalt therapy (Perls et al., 1951; Sills et al., 1995; Mackewn, 1997; Joyce and Sills, 2010). It is used in this instance as an experiment to help Heather, the client, get in touch with and express her blocked feelings (p. 87). The therapist suggests she talks to her father, imagining him sitting in the vacant chair by means of which Heather finds an authentic voice to express her rage, her sadness and her love: in other words, her grief.

    • What do you think are the advantages and disadvantages of the use of this technique?
    • Do you agree with this therapist's rationale for using it with his client? Why?
    • In what circumstances might you consider using the empty chair technique in working with a client. How, in your model, would you explain the dynamics of this experiment?
    • Apart from imagining a person in the empty chair, how else might you use it?
    • This technique is sometime referred to as ‘two-chair work’ where the client is invited to move from one chair to the other and create a dialogue as they alternate between the two. Similarly, several chairs may be employed. How might this be useful?
    • In what circumstances might you use these variations of the technique for yourself?
    • In the story, Heather is a film star of whom the therapist has no prior knowledge and is unaware of her fame. Why might this be blissful ignorance?
    • What might have been the potential difficulties had he recognized her and known her as a famous person? And what might be the disadvantages of not recognizing the celebrity of a client?
    • It becomes apparent towards the end of the story that the therapist has disclosed his client's fame to his supervision group (p. 92). Would you have done the same? Why or why not? What level of client confidentiality do you think is important in supervision?
    • Do you feel critical of the therapist agreeing to work with this client despite the six-month time constraint and the nature of the work (p. 85)? Why?
    • Do you think there is a case for taking on clients when we feel ‘excited’, ‘seduced’ or challenged by them (p. 85 and 86)? How might this be problematic? How might this enhance the therapy?

    In the final session of this short-term therapy, the therapist and client spend some time summarizing the work and acknowledging each other's participation (p. 89).

    • Do you consider this to be important when ending with clients? Why?
    • What else do you consider important when dealing with the end of therapy?
    • What would you do differently if you were ending with a client after several years of therapy?
    • As a client, what have your experiences of therapeutic endings been like?
    • In retrospect, is there anything you would have done differently?
    • What's your opinion on the following:
      • Lessening the frequency of meeting en route to the end of therapy?
      • Devising together an ending ritual?
      • Exchanging cards or gifts at the end of the work (or even after the end of the work)?
      • Being available to the client should they want to return in the future?
    Dream On

    True to its title, the theme of this story is a dream. It follows two possible ways of interpreting the same dream's symbols and finding meaning: one being prophetic (the romantic client's wish fulfilment), the other the unconscious resolution of early loss and grief (the ‘realistic’ therapist's preferred understanding). In the event, though the therapist's interpretation seems to be a potentially useful one, the symbolism of the dream turns out to be prophetic.

    The prophetic qualities of dreams have probably existed throughout history. Dreams as the ‘royal road’ to understanding unconscious processes, particularly wish fulfilment, came in the late 19th century when Freud first published his work The Interpretation of Dreams. Jung in the early 20th century perceived dreams, informed by the collective unconscious, as a form of psychic regulation brought about by access to all that is repressed, neglected or unknown. For those interested in Freud's and Jung's thoughts on dreams, I recommend Freud's The Interpretation of Dreams (2001) and On Dreams (2001) and Jung's Dreams (2001) and Memories, Dreams, Reflections (1995).

    • What are your thoughts on dreams? Do you think they are:
      • Prophetic?
      • Resolving past repressed, neglected or unknown issues?
      • Simply ‘junk’ left over from the day's events?
      • ‘Communal’ or shared by others?
      • Integrating disowned or ‘split off’ parts of oneself?
    • Have you had experience of dreams that would support your view of each or any of these?
    • In the story, the client and therapist refer to the dream in the present rather than the past tense (p. 97). What might be the advantage of this?
    • What's your view of the therapist questioning Cheryl at each point of the dream? What do you think he is facilitating by doing this?
    • How else might he have facilitated his client through the dream? (For a gestalt approach to dream-work, see Mackewn, 1997; Joyce and Sills, 2010.)
    • What do you understand by the client's reference to her ‘masculine and feminine aspects’ (p. 98) and how does your model conceptualize these aspects?
    • How might you use them in your therapeutic work with clients?
    • Would you have explored Cheryl's ‘round the bend’ Freudian slip in her telling of the dream (p. 99) or, as the therapist did, would you have joined in the laughter? Why?
    • Do you subscribe to the view that dream symbols have direct correlation to specific meanings (for example, Cheryl's assumption that a therapist would interpret ‘snakes as sexual symbols, phalluses’ on p. 100)?
    • What might be the advantages or disadvantages of such a ‘dream dictionary’ approach?
    • How does your model's theory encompass dreams and how does it suggest working with them?
    • If you had a dream that involved your client, would you share it with them? Why?
    • Throughout the story, there is a discrepancy between Cheryl's ‘romantic’ optimism and the therapist's ‘realistic’ pessimism and between Cheryl's view of the dream as ‘saying something positive’ and the therapist's perception of it as a means of grieving the early loss of her father.
    • What do you think of the therapist's handling of this discrepant situation?
    • What would you have done differently?
    First Nature

    This story is based upon the idea that our ‘first nature’ (our unadulterated self) becomes subsumed under our adaptive and compromising ‘second nature’ in the course of growing up, and that the task of therapy is to discover and free the authentic person beneath these adaptations. Most developmental theories subscribe to this idea, describing such adaptation in terms of the formation of a ‘False Self’ (Winnicott, 1965), ‘internal working model’ (Bowlby, 1969), ‘life script’ (Berne, 1972), or ‘organizing principles’ (Stolorow et al., 1994) and so on.

    • From your theoretical perspective, what word or phrase might encapsulate this adapted self?
    • How does your model describe the formation, development and maintenance of this ‘second nature’?
    • What therapeutic processes or techniques might you employ in facilitating the emergence of a person's ‘first nature’ self?
    • Rogers (1990/1957) suggests that the ‘core conditions’ of unconditional positive regard, empathic understanding and the therapist's congruence are necessary and sufficient to facilitate self-actualization. Do you agree? What else do you consider might be necessary?
    • How centrally do you place the therapeutic relationship in this process of change and how do you explain its importance?
    • To Sarah's rather servile, ‘please others’ adaptation the therapist responds, at least internally, with irritation, even wanting to wipe the smile off her face (p. 106). Assuming the therapist is not usually an aggressive person, how do you understand this dynamic theoretically? The therapist suggests one possibility of what might be occurring here, potentially providing him with useful information. What other possibilities are there?
    • How might you handle your own feelings – anger, sadness, fear or delight – in response to a client?
    • Do you think it might be appropriate to share them – in what circumstances, how and to what purpose?
    • What's your opinion of Sarah's motivation to train as a counsellor being to ‘lend something of a helping hand in someone's less fortunate life’ (p. 107)?
    • Do you consider it a sound motivation? Why or why not?
    • If you are a counsellor or psychotherapist, what is or was your motivation to enter training? What do you see as the originating and reinforcing influences of your choice?
    • What's your take on the idea of the ‘Wounded Healer’?
    • What influenced you towards your choice of your particular model?
    • Later (p. 108), with some forceful interventions (comparing her to the obsequious Uriah Heep, telling her not to say what she is about to say), the therapist challenges Sarah to express what she wants. How do you respond to these interactions?
    • What are the pros and cons of this ‘authenticity’ on the part of the therapist?
    • What might you have done differently?
    • Sarah begins to loosen her self-destructive beliefs through ‘catharsis rather than insight’ (p. 109). What does this mean to you and how might you explain this from your theoretical perspective?
    • How else might you intervene to challenge and change negative self-beliefs?

    Central to this story, change occurs through the dynamics of the relationship between therapist and client – often referred to as the transference and countertransference. For those interested in exploring these concepts further, I would recommend Freud's (1935) seminal work A General Introduction to Psychoanalysis, Clarkson's (1995) integrative and comprehensive overview in The Therapeutic Relationship and Lapworth and Sills’ (2010) 2nd edition of Integration in Counselling and Psychotherapy where an updated relational view of these dynamics in psychotherapy can be found.

    • Your own model of therapy will likely have its own terminology for these projective (and introjective) dynamics. Relating them to the story's development of the therapeutic relationship, how would you describe the interactions that take place between the therapist and his client?
    • How do you see the part played by the therapist's errors and absence?
    • Would you, like the supervision group, consider these developments as ‘positive and constructive’ (p. 114)? Why?
    • How might you have handled such eventualities differently?
    Chance is a Fine Thing

    Concluding this collection, this story takes a light-hearted, tongue-in-cheek look at the role of chance and serendipity in the life of the therapist. It also brings us back full circle to the issue of boundaries. Early on in the story, the therapist refers to Heidegger's expression ‘the thrown-ness’ of life. According to Cohn (1997), ‘this points at the limits of our control over existence’ and the fact that many situations in life are not chosen. He and other existential writers emphasize that though this limitation is a given, and cannot be changed, our response to it (as to our past history) can. Readers may be interested in existential approaches to therapy and I would recommend Yalom's (1980) Existential Psychotherapy, Cohn's (1997) Existential Thought and Therapeutic Practice and van Deurzen-Smith's (2001) Existential Counselling in Practice.

    • How do you view ‘chance’ and the ‘thrown-ness’ of life, and incorporate it as part of your therapeutic approach and practice?
    • Similarly, how do you integrate other existential givens such as freedom, death, separateness and meaninglessness within your approach and practice?
    • The existential therapist mentioned in the story, rather than setting objectives and having ‘a relentless focus on change’, ends each session with ‘Well let's see what happens, shall we?’ (p. 120). What is your reaction to this?
    • Do you consider this an appropriate attitude? How do you see it as being useful or not?
    • In the story the therapist, on meeting his client at the conference, says he will leave (p. 121). What else could he have done?
    • In explaining that his attendance was a last minute decision, he says perhaps he should have phoned his client. Should he have done? Why?
    • If you met one of your clients by chance outside of the therapy setting how would you handle the situation?
    • What agreements might you put in place prior to this eventuality that might help the situation?
    • Would you make differing allowances, and what might they be, if you met your client:
      • At a party or other social event?
      • At a weekly choir or yoga class?
      • At a funeral?
      • In a local supermarket?
    • How would you handle meeting a friend or relative of your client in these same situations?
    • Imagine accidentally meeting your own therapist outside of the therapy room. What might that be like for you and how would you like your therapist to behave?

    By the way, if you see me at a conference – or anywhere else for that matter – and you aren't a client of mine (in which case, we'll know what to do), please come and have a chat.

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