Storr's Art of Psychotherapy 3E

Jeremy Holmes, Charles P. Nemeth

• Publisher: CRC Press
• Year: 2012
• eBook ISBN: 9781000687910
• Edition: 3
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Highly Commended, BMA Medical Book Awards 2013Sensitively updated and revised for modern practice, Anthony Storr's legendary work continues to be an indispensible introductory text for aspiring psychotherapists.Professor Jeremy Holmes, a friend and colleague of Anthony Storr's and himself a leading psychotherapist, has updated this accessible and h

1

The Setting

The ‘gift’ of psychotherapy (Yalom 2002) can be thought of in terms of space: a physical space where patient and therapist can meet, protected from intrusion; a ‘space in time’ that is sacrosanct and set aside exclusively for the patient each week. Above all, patients are offered a space in the therapists’ mind, free from extraneous concerns, where they can guarantee that all their attention and focus will be devoted to their clients. Without this psychic space no useful work can be done. Some therapists are oblivious to their surroundings – one devoted NHS analyst claimed that she was prepared to see her patients in a broom cupboard if needs be – but in this first chapter we shall look mainly at the externals and how they can influence therapy, for good or ill.

The room

A number of what commonly might be thought of as inessential details are highly important in psychotherapy. The room that the therapist uses, and the way it is arranged, are significant. In private practice, one is free to arrange and furnish one’s consulting room in any way one likes. In hospitals, clinics, social service departments, schools etc where trainees often take their first steps in psychotherapy practice, students are lucky if they have any choice in either the location of the room or in its furnishing and appearance. Nevertheless, there are defined features of how the space in which one is to practice psychotherapy should be arranged; we would urge all psychotherapists to insist that these basic requirements are met by their managers, and to express dissatisfaction when they are not.

Ideally, a room in which psychotherapy is to be undertaken should be furnished as follows. First, there should be a minimum of two comfortable chairs in which both therapist and patients can relax. Psychoanalytic therapy can be described as ‘symmetrical but lopsided’, a point to which we shall return. The physical manifestation of this is that both client and therapist should be seated on chairs comparable in height and comfort, and indeed ideally of the same design. Some patients will be so tense at first that they will be unable to make proper use of a welcoming chair; but one hopes that as the therapy progresses they will increasingly be able to do so. Being perched on the edge of a hard chair is not conducive to personal revelation, and may put the patient at a disadvantage compared with the therapist, especially if she is more comfortably seated.

Second, there should ideally also be a couch on which the patient can lie down. This should not be an examination couch of the kind which physicians use for physical examinations, but something far more comfortable. A divan bed often proves satisfactory. If suitably covered, this does not look like a bed, to which some patients might object, and which others might welcome with misplaced enthusiasm. It should have at its foot end an extra piece of the same material in which it is covered, which can easily be removed for cleaning. This enables patients to lie down without having to take off their shoes (although most don’t mind doing so), which might otherwise dirty the cover. At the other end of the couch should be a number of suitably covered cushions which patients can arrange in any way they find comfortable. The couch should be so placed that the therapist can sit at the head end, out of sight of the patient, without having to rearrange the furniture every time the couch is used.

The majority of psychotherapists, especially beginners, do not follow the psychoanalytical practice of using a couch. But it is useful with some patients, for reasons we shall discuss later; if possible, it is good to have it as an available alternative if the patient finds it easier to relax when lying down, or easier to talk if he is not face-to-face with the therapist (Holmes 2012b).

It is useful to have one or two extra chairs easily available in case it may be necessary to see relatives together with the patient. In the individual psychotherapy with which we are primarily concerned here, such interviews will be infrequent, and normally confined to the initial or second meeting with the patient; but there are exceptions, and it is therefore wise to be prepared to seat one or two more people when needed.

Where the therapists are in a position to exercise personal choice in the room’s furnishings, they may well like to hang some pictures on the walls, and fill the bookshelves (if there are any) with their own books. This is entirely reasonable; but it is important that the room should not contain anything which too stridently asserts the therapists’ taste or which is likely to reveal a great deal of their personal life. Suppose, to take a slightly unlikely example, that the therapist is a devout Catholic. If his or her bookshelf is full of devotional works and there is a crucifix upon the wall, this may well alienate the patient who is agnostic or a convinced Protestant; and patients become guarded in their speech for fear of offending the therapist’s religious sensibilities.

Photographs

Many professional people like to bring reminders of home into their offices by displaying photographs of their spouses and children. It is inadvisable for psychotherapists to do this. A degree of neutrality is essential, and is an aspect of the restraint and partial suppression of personality entailed in working as a psychotherapist. When patients become deeply involved in the psychotherapeutic process, they are likely to experience powerful feelings of love, hate, envy, or jealousy toward the therapist. Explicit reminders of the therapist’s life outside the consulting room of the kind provided by family photographs may inhibit the expression of these feelings (see Chapter 8 for further discussion of transference). Patients will certainly have thoughts about the therapist’s personal life, the content of which may be important in understanding them. For example, someone may be struggling with his sexuality or gender identity and have fantasies about the therapist’s sexual life. A photograph of the therapist’s spouse and children may convey a message of unattainable normality or marital bliss, and thus may inhibit the patient’s fantasy, or arouse envy. If the therapist is male, female patients may compare themselves, favourably or unfavourably with the woman depicted in the photograph; and, while this may prove to be a valuable piece of exploration of the patient’s psyche, it introduces a disturbing element of ‘reality’ into the psychotherapeutic relationship, which, as we shall see, is inimical to the analytic process. Conversely if the therapist is female and the patient male, the depiction of a male partner may inhibit a burgeoning idealization of the therapist, and/or reinforce a sense of inferiority in the patient, rather than letting these two feelings remain in the realm of fantasy where they can be explored.

Sound

It is important that, if at all possible, the room should be quiet. Extraneous noise is not only disturbing in itself, but may also cause the patient to feel anxious. Attachment theory tells us that anxiety inhibits exploration, including the self-exploration that is the essence of psychotherapy (Holmes 2010). If noise from without can come into the room, it is likely that sounds from within can be heard outside it. Nothing is more inimical to frank disclosure than the belief that one may be overheard. Clinic rooms usually contain a telephone. It goes without saying that during the time of a psychotherapeutic session the therapist does not make or take telephone calls. If the student is a doctor, she should arrange psychotherapy sessions at times when she is not ‘on call’, or at least ensure that a colleague covers during the time during which she is practising psychotherapy.

One one occasion, when JH was working in a hospital practice as both a psychiatrist and psychotherapist, engrossed at a particularly delicate moment in a psychotherapy session with a rather inhibited client, the door flung wide open and a patient from the ward, justifiably annoyed at his compulsory detention, burst in, shouted ‘Dr Holmes, you are an absolute fucking bastard!’, and then disappeared. There was a moment’s silence in which client and therapist looked at one another with a mixture of dismay, horror and amusement. The client, for whom difficulty in expressing anger had been a main theme, then commented ‘isn’t that exactly what you have been trying to get me to say to you ever since I first started!?’.

All these things are perhaps more easily arranged in private than in public service practice. But whether patients are paying for treatment directly by private fees, or indirectly by taxation, they are entitled to feel that the time spent with the therapist is their time; and that this will not be in any way disturbed by interruptions.

Note-taking

When one has had the opportunity of getting to know a patient really well over a period of time, taking notes may be superfluous. But for beginners, ‘process recording’ – i.e. writing as detailed notes as is possible recording the exact ebb and flow of the session – is essential. They form the basis of supervision, and it is in these ‘minute particulars’ that the really interesting and important issues emerge (Hobson 1985). Whether notes are written up immediately after the session or during it is a matter of personal preference. If done during the session it should be done as unobtrusively as possible, in order not to interrupt the patient’s discourse. Where the patient is seen sitting up, as they will be in most cases at least for the first session, JH uses a clipboard perched on his knee which permits eye contact to be maintained; the offending clipboard is then discarded for ongoing therapy. When process recording is performed post-session (our preference), students should allow enough time for writing up their notes before their next patient. Even if one is not writing extensive notes, it is important to arrange the times of psychotherapeutic sessions so that there is a gap of ten minutes or more between patients. This not only enables the therapist to relax in preparation for their next patient but, when the occasion demands, to deal with telephone calls or other matters which may have arisen in the meantime.

2

The initial interview

There is a game in which the participants are invited to boil down any chosen subject into two contrasting precepts. Of soccer one might say: the two things you need to know about soccer are that all that matters is scoring goals; and scoring goals is very difficult. Or philosophy is the most important branch of knowledge with implications for every member of the human race; yet there is only a tiny handful of people capable of thinking philosophically. Of psychotherapy one might say that the two most important things are that the therapist creates an utterly reliable, secure, and dependable setting; and that she fosters conditions of maximum ambiguity and possibility.

This Janus precept is what is known as the ‘analytic attitude’ (Lemma 2003). But how does one set about creating that attitude in oneself and communicating it to the patient, especially when one is caught up in a myriad of practical issues? As we have already outlined, the beginner therapist will inevitably feel somewhat apprehensive at having a new patient referred to him for treatment. Will she be able to do anything to help? Understand what the patient is talking about? Will the patient divine her inexperience? What will the patient think of her?

These worries are to a certain extent justified. The therapist is likely to be confronted with a wide variety of people with whose style of life and mode of expression she is not necessarily familiar. Many of the patients will be older than herself, some will be more intelligent. All this matters less than the inexperienced therapist commonly supposes. Provided she is genuinely interested in the patient as a person, she is likely to be able to overcome any initial difficulties which unfamiliarity with the patient’s type of social background may pose. Indeed enlisting the patient’s help in understanding, say, what it is like to be a child of first-generation immigrants, the mores of an English public school, the social milieu of a modern council estate, or the problems of growing up in a bilingual household, may in itself be beneficial, fostering the collaborative atmosphere which characterizes successful therapy. Occasionally, if the patient comes from an entirely different culture, the basic social assumptions of the therapist and patient may be so widely discrepant that communication becomes impossible, but this is rare. Let us for the moment assume that the therapist has been referred a patient who does not present any such problem. How does one set about conducting the first interview?

Increasingly, people seeking help with their personal problems present themselves directly to a psychotherapist. But in public service psychotherapy and training organizations the patient will be likely to have arrived via a referral pathway, the end result of which is arrival in the psychotherapist’s consulting room. This means that the therapist will have a letter about the patient, and possibly other notes. The therapist ought to familiarize herself with these well before the first appointment with the patient. Many patients are alarmed at the prospect of meeting members of the psycho-professions: psychotherapists, psychoanalysts, psychologists, psychiatrists. Confiding in strangers is not easy; and the patient who has been sitting apprehensively in a waiting-room for longer than he needs, is less likely to be at ease when the therapist finally sees him.

Greeting one’s patient; touch

Now we come to names. Christian or surnames? Professional titles (Dr, Professor, etc) or no monikers? There are no hard and fast rules. The important thing is a) to choose a mode of address (and dress) with which you feel comfortable and b) consistency. The patient is now to be collected from the waiting area. It is courteous to greet him by his name. ‘Mr Robinson? Good morning/hello. I’m Dr Y/Ms X/Joan Bloggs’. This both establishes that the therapist actually knows the patient’s name, and also indicates that he is to be treated as a person, not merely as a numbered case.

Ella Sharpe’s (1930) summary of the way the analyst should deal with these parameters was to ‘treat the patient as you would an informal guest in your office’. This raises the question of touch, its benefits and dangers (Casement 1985; Dimen 2011). JH’s routine practice is to shake a new patient’s hand at the first session but generally not thereafter. People vary in how ‘tactile’ they are. Some patients proffer a handshake at the end of every session. Very occasionally, after a very emotional session, one might lightly touch a patient on the back as they leave. On the whole bodies are rather rigidly kept at bay in consulting rooms, and when they intrude – the patient is cold and needs a blanket, or wet and requires a towel, needs to go to the toilet in the middle of the session, asks for a hug – it is always noteworthy and always needs to be thought about carefully afterwards.

A salutary example occurred for JH when he was conducting a ‘master class’ for therapists in a South American country. The presented patient was a teenage girl with an eating disorder; the therapist, a kindly and clever middle-aged married woman, reported that at the end of a particular session she had hugged her patient. JH questioned this, not, he hoped, in a critical way, but merely to explore its possible meaning – why hug in this session with this particular patient? What might it have been like for the patient had the therapist been male and hugged her? Would it matter if the patient had worries about homosexuality? The audience laughingly accused JH of being a typical uptight Anglo-Saxon male. It emerged that routine practice in that country involves kissing the patient on the cheek at the beginning and end of each session, it being normal to greet ‘informal guests’ with a kiss in that country. Since the therapist is always alert to departures from the expected, here the point to be noted would be the patient who shrank from such contact.

As with most phenomena in psychotherapy the important thing is a) to be on the look out for anomalies (which might be nothing more than: ‘you looked a little stressed as you came in today. I wonder if something has upset you’); b) to try to understand their meaning; and c) to find a way to bring up a) or b), or both, with the patient.

Preliminaries

Having invited the patient to sit down in a chair appropriately placed in the way already described, what does the therapist do next? In general it is a good idea to start with what might be called ‘preliminaries’. This entails checking that you have the patient’s correct full name, contact details, age, and the names of any other professionals with whom the patient may have seen. It is also an opportunity to set out the terms of this initial session. One might say something like ‘this is very much a first meeting. After we have talked, let’s decide at the end whether we feel regular therapy might be helpful, and if so, how often, when, and for how long’. Or: ‘I think it was your GP/psychiatrist/husband who set up this appointment. What do you think about the idea of coming into therapy?’.

With the therapist thus taking the initiative, this gives the patient’s anxiety levels a chance to lessen slightly. As always, the therapist has to tread a fine line between helping to lower the patient’s anxiety so that exploration can begin, while remaining non-seductively reticent and neutral, so that the patient feels the therapeutic space is theirs to make use of however they choose, rather than conforming to the therapists’ dictates. It also conveys, right from the start, that psychotherapy is a joint enterprise rather than a series of interviews in which the patient is given instructions or advice, as happens in ordinary medical consultations. Some therapists however like to impose as little structure on the session as possible from the outset, and to allow, as it were, the patient’s unconscious to guide proceedings. For them, the opening move might be no more than an encouraging grunt, or a gesture indicating to the patient that the floor is theirs. They assume that the issues and possible co...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Acknowledgements
• Prologue: Anthony Storr and the Art of Psychotherapy
• Introduction
• Chapter 1 The setting
• Chapter 2 The initial interview
• Chapter 3 Getting going: overcoming initial resistance
• Chapter 4 Making progress
• Chapter 5 Interpretation
• Chapter 6 Dreams, daydreams and creativity
• Chapter 7 The nature of the therapeutic relationship: boundaried intimacy
• Chapter 8 Transference and counter-transference
• Chapter 9 Diagnosis and psychodynamic formulation
• Chapter 10 Depression
• Chapter 11 Anxiety
• Chapter 12 Patterns of personality
• Chapter 13 The science of psychotherapy
• Chapter 14 The science of psychotherapy
• Chapter 15 The life and work of a psychotherapist
• Epilogue: Beyond therapy
• References
• Index