Challenges to Practice

Bernardine Bishop, Angela Foster, Josephine Klein, Victoria O'Connell, Bernardine Bishop, Angela Foster, Josephine Klein, Victoria O'Connell

• Publisher: Routledge
• Year: 2018
• eBook ISBN: 9780429911750
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

The first title in the Practice of Psychotherapy Series that explores the limits of psychoanalytic psychotherapy. Each of the five chapters in this book takes up an aspect of this challenge. In an open and enquiring manner, the authors invite readers to share in their thinking as they describe how they use their psychoanalytic skills to understand the nature of particular challenges. The Practice of Psychotherapy Series is intended to address a wide variety of important and challenging issues confronting those working in diverse contexts as psychoanalytic psychotherapists. Written by members of the respected London Centre for Psychotherapy, this volume offers an honest and stimulating first contribution.

CHAPTER ONE

When we counsel, when we analyse, when we therap

Josephine Klein

When we sing, to sing well, we have to learn to breathe from the diaphragm, open our mouths properly in a certain way, relax the throat in a certain way, and so on. That is what we do when we sing. That is not what we do when we eat, for instance. Though we open our mouths, it is not to sing but to put things in. In a day, we sing some of the time, and eat some of the time, and talk to people, spit, whistle, do many things. We do not just do one thing with our mouths.

Moreover, when we have learnt to sing, we are not obliged to sing all the time; singing is not all we can allow ourselves to do. We are not restricted to singing just because we have been trained to sing. We can still eat, talk, and so forth. The point I am making is that a person working with others in a helpful capacity may counsel some of the time and sometimes analyse and sometimes therap. All in the same hour.

The neologism “to therap” has had to be invented, not without reluctance, to distinguish counselling and analysing, both of them undeniably forms of therapy, from another therapy activity, which, for lack of a better word, may be called “to therap”. There are these three distinct activities, all therapeutic, and at any moment we ought to do whichever seems appropriate. Just as whether we sing, or whistle, or eat is determined by what we want to do, so, often, whether we counsel, or analyse, or therap is determined by what feels right, by what we feel the patient requires. The more talent we have, and the better we have been trained, the more often we make the right decision. Of course, if there is a contract to do only one of these things, that has to be respected.

Deciding what the patient requires is really difficult, and it is hardly ever discussed. The initial assessment ought to give us some clues, at least on how to start off (Klein, 1998). It certainly does not depend in any simple way on what we think we see, for we have been taught how to construe the situations before us, and this tends to be what we see. There is an important paper yet to be written on how we know what the patient needs. In my view, since we are usually not yet in a position to know what the patient needs, we might as well start off giving patients what they want, just as a first approximation. When we understand them a bit better, we may renegotiate, or change our ways, as appropriate. Some may need theraping to start off with, some analysis, some counselling.

When we counsel

We counsel when we enable people to reflect on the situation they have asked for help with, or, to put it the other way round, when we enable people to reflect on the situation they have asked for help with, we are counselling.

We counsel when we give advice, and we have learnt not to give advice until after we have the relevant information or, if advice is asked for, not until after we have looked at the relevant information together. When we do that, we are counselling.

When we counsel, we have an obligation to stick to the client’s definition of the problem, the thing the client had come for help for, in the client’s view, until, perhaps, the client changes his or her definition of the problem. This is unique to counselling: we stick to the client’s request as to what we should do.

When we counsel, we extract and explore relevant information. Often we are non-directive, as Rogers (1951) taught, more or less repeating the last three words the client said:

“... not what you wanted.”

“... you stayed in the garden.”

Or, summarizing rather more:

“. .. so he would not lend you the money.”

“... so you thought it best to leave it.”

Or, straightforwardly, we ask:

“And did you send the letter?”

“And who will pay the school fees?”

Or we say, in directive or negotiating mode:

“We seem to have come round to talking about your money worries [or, your uncle, or whatever]. Do you want to stay with that for a bit or do you want to talk more about yourself and your marriage?” [which is what the client had come for.]

Elementary, apparently, but it seems that only students on counselling courses are taught this simple technique for keeping the client going.

When we counsel, we are:

helping people to talk,

helping people to find the words to say it, which is part of

helping people name their feelings, which is needed for

helping people accept their feelings, which makes easier

helping people make connections conscious, and

helping people cut useless old unconscious connections and

be open to new ways of being and thinking.

[Klein, 1995, Ch. 3]

Let us imagine a woman who has come because she cannot manage money. She earns plenty, as we know already, and we know she makes herself only draw out spending money on Thursdays. If she runs out of spending money before then, she starves herself, does not use paid transport, does not use her plastic cards. We know she does not think this is working or is a good idea in the long run. At some point in the current session, the counsellor thinks she may be able to start thinking about her situation.

CLIENT: I am always skint by Tuesday, and sometimes already on Monday.

There is a little silence, which, of course, the counsellor hopes will encourage her to carry on, but she does not. After half a minute (this can feel very long), the counsellor says:

COUNSELLOR: You’re always skint on Tuesdays, and sometimes already on Monday.

CLIENT [quite vividly]: That’s right.

But there is another half-minute of silence, so to keep her going, he might say “How do you feel about that?” which is often useful, but the counsellor fears this might sound a bit mechanical, and also he does not want her just to say she feels awful about it and then get stuck again, so he says, quite bravely:

COUNSELLOR: What do you think that’s all about?

This is brave because this is only the third time they have met and she does not know him well enough to trust him yet, and then there is the gender difference, but on the other hand it might get her thinking rather than just feeling, and the worst that can happen is that she will say she does not know. Fortunately his gamble pays off.

CLIENT: Well...

There is another half-minute silence but he can feel something is happening and indeed, as it turns out, her unconscious processes have turned cooperative.

CLIENT: My father says I’m spoilt.

Another half a minute.

COUNSELLOR: Your father says you’re spoilt... [tiny silence]. Are you, do you think? Do you think that’s it?

CLIENT: Well, not exactly, but. ..

And it turns out that she knows what he meant by it, namely that she is used to getting her own way. Slowly, she works it out.

To make an end to this imaginary story, it turns out that she gets angry whenever thwarted, angry at fate, at shopkeepers, at herself, at everyone, and that is how she feels whenever she finds herself with the knowledge that she cannot afford something just then, so by buying it she is defying whatever is thwarting her, and showing them, and somehow coercing them. As it all unwinds over the next few sessions, she laughs ruefully at herself, and she settles down to discuss how she can work better around what she calls “this silly feeling”. Note that the counsellor does not take things an inch beyond what she is willing to explore. This is what we do when we counsel.

There is a problem, here, of professional demarcation lines. There are now many people called counsellors working in ways that include a good deal of theraping and analysis—in colleges, for instance, and in doctors’ surgeries. Well-trained people apply for posts as counsellors and do a good job. The important thing for the current argument is that they are not expected to confine themselves to counselling; they are expected, as professionals, to do whatever is technically and ethically correct to help their clients. Counselling is not what counsellors do; counselling is what any of us do when engaged in the activity called counselling.

When we analyse

Analysis, it must be stressed, is not the same as “what analysts do”: it is what we do when we analyse. When we analyse, we deconstruct—”deconstruct” is the Latinate version of the Greek word from which the English “analysis” is derived. When we analyse, we deconstruct, we take to bits what the client is saying, and we look at the pieces, and try to look behind the pieces to see what else there is. We also analyse when we weave pieces together and construct a pattern. When we do these things, we are analysing. For that moment of time, we are “analysts”.

One important way in which analysing is different from counselling is that we have no obligation to stick to the client’s definition of the situation or the problem. Indeed, one might argue the opposite—we have an obligation to help uncover any deeper problems that may lie behind the current situation.

We analyse when we talk about what is not the top layer of what we hear the client saying, and moreover, we do not respond to the surface of what the client is saying. It is often a waste of time to reply to the surface. “Did you have a nice holiday?” “Do you think Uncle Herbert stole that cheque?” “Why did Mrs Bloggs slam the door in my face?” Inexperienced practitioners waste hours speculating about the motivation or whatever of people who are not in the consulting-room; the client may feel enlightened for a moment but not changed in any way. We have to train ourselves to find a range of tactful, indirect responses. “It sounds as if you are quite worried about your uncle”, “That sounds awful for you (when Mrs B etc. etc.)”. Or, to take a really innocuous-sounding example at length, a patient may say “Did you have a nice holiday?”—saying “Yes, thank you” is usually the easiest way of not talking about one’s holiday without appearing to snub the patient. Or a patient may say:

“Oh, you have got a bad cold!”

The proper reply is:

“Yes, isn’t it.”

This is less mystifying or eye-catching than simply not replying, which used to be the recommended practice for analysts and psychoanalytically oriented psychotherapists. Many practitioners have given up on this because it is counterproductive. One should not respond in any detail about one’s personal things because that is not the level one was hired to work at, but, except in special circumstances, one was not hired to engage in wrangles with patients about lack of good manners either. The whole point is: not to intrude into the patient’s most urgent unconscious preoccupations.

Now here is a more awkward customer. The analyst may just have said “Yes, thank you” to the patient’s enquiry about her holiday, but he won’t let go:

“Where did you go?”

She can say “Spain” and hope that that is the end of it. Or she can stop responding and start analysing, looking at the bits below the surface. Deciding to take up the patient’s curiosity about something that is not going to get him anywhere with his problems, she might say:

“It is always fascinating to know where people have been during an absence, isn’t it?”

... hoping from there to get into a discussion about “Why did Mummy leave me so long?” or “Where did Daddy go when he went away?” or whatever other deep feeling may be underlying the query.

This customer is not giving up so easily, however. It is not absence that matters to him, so he does not respond to the “It’s-always-fascinating ...” gambit. It may be that he wants to win, to make her give in to his demands, it might just be about winning, in which case she has to say something like:

“You really want to win this one, don’t you?”

and take it from there. Or the patient might say:

“But I want to know where you went.”

and she:

“Yes, I see. Shall we explore why that feels so important to you?”

At that point, the conversation can go one of two ways. Either people can lose their temper and accuse their analyser of being too strictly professional, formal, unfeeling, heartless. These are genuine feelings with which most of us can easily identify. And some people benefit greatly by being allowed to show how upset they are—they may have had long experience of this not being allowed, and so the consulting-room has helped expand their conscious experience. These upset feelings need recognizing and validating. It is by no means always best to interpret them to the patient at this point. (Interpreting is analysing out loud what lies beneath the surface; the practitioner thinks he is aware of what there is but has to decide whether this is the moment to share the insight with the patient.) Or, on the other hand, the conversation may take a calmer and more obviously analytic direction: the patient responds as requested to the “Let’s-try-to-understand” gambit, and, as the two of them listen to the associations that arise from under...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Editors and Contributors
• Preface
• 1 When we counsel, when we analyse, when we therap
• 2 Exploring once-a-week work
• 3 Singular attention: some once-a-week therapies
• 4 Has anyone seen the baby? Analytic psychotherapy with mothers who are postnatally depressed and their babies
• 5 The duty to care and the need to split
• References
• Index