There Is No Such Thing As A Therapist

An Introduction to the Therapeutic Process

Carol Holmes

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855750661
• eBook ISBN: 9780429922947
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This book deals with the link between the purpose of therapy and the boundaries of the therapeutic situation, which - the author argues - derive from the omnipresence of the anxiety surrounding separations and death. The theoretical framework of this book is part of a developmental line from Freud, Klein and Winnicott to Langs, via Sartre and Buber.

CHAPTER ONE
Ground rules

The term "framework" was first proposed by Marion Milner (1952) to describe symbolically the therapeutic setting. It suggests a basic structure that outlines, limits, and defines the therapeutic environment and relationship, thereby distinguishing it from other kinds of environments and relationships.

Psychotherapy in general has viewed the framework or ground rules of therapy as a necessary but relatively peripheral element of therapy, in contrast to the more significant position given to the content. Day and Sparacio (1989) explain: "Although structure is fundamental to counselling, structure is often a neglected dimension of the counselling process" (p. 17). This neglect is evidenced by the absence of literature on this topic.

One of the aims of this book is to attempt to redress this balance and to offer the reader a convincing argument for considering the integral role that the therapist's framework management has for the ongoing therapeutic relationship.

Donald Winnicott, an analyst who devoted many years to working with children, developed a theory of emotional development which informed his therapeutic practice. He stated: "Spontaneity only makes sense in a controlled setting, content is of no meaning without form" (cited in Davis & Wallbridge, 1981, p. 144).

Many of Winnicott's ideas were adaptations from the theories of Melanie Klein; he underlined and linked the infant's emotional development and stability with a consistent maternal environment. The initially bizarre and apparently absurd statement expressed by Winnicott at a meeting of the Psychoanalytical Society—that "there is no such thing as an infant" (Winnicott, 1975)—was intended by him to bring into sharp relief the importance of the mother-baby unit and the inherent interconnectedness that exists between both parties. By the same token, it may be inferred that there is also no such thing as a therapist and no such thing as a patient—only a patient-therapist system, with each individual reacting and influencing the other in myriad overt and subtle ways. These ideas suggest that the manner in which the therapist structures the environment can demonstrate and reveal to the patient the type of relationship that the therapist intends both explicitly and implicitly to establish with the patient.

Although Winnicott drew comparisons between the infant's maternal environment and the therapeutic setting, he nevertheless decided that the ground rules were only a central feature in the treatment of severely regressed or disturbed patients and of little significance for patients who would be described as neurotic. Despite Winnicott's claims that it is only a specific category of patients who are in need of a stable therapeutic environment, other writers have attested to the relevance that the therapist's behaviour has for the patient: "Any analysis, (even self-analysis) postulates both an analysand and analyst. In a sense they are inseparable" (Little, 1951, p. 33). Little goes on to describe the dual and intimate connections that exist between therapist and patient: "We often hear of the mirror which the analyst holds up to the patient, but the patient holds one up to the analyst too" (p. 37).

More recently, the clinical work of Robert Langs and the communicative approach to psychotherapy have supported the idea that one of the most salient aspects of the therapeutic process resides in the therapist's capacity to offer the patient a clearly defined therapeutic framework. Langs considers that patients are generally highly perceptive, sensitive, and vigilant to any modifications by the therapist. He asserts that most patients require, on an unconscious level, a stable, consistent set of therapeutic ground rules: "The deep unconscious system expresses an extremely consistent and evidently universal need for an ideal set of ground-rules" (Langs, 1988, p. 135). The extent to which the therapist deviates from these ground rules is considered implicitly to inform the patient of the therapist's personal and interpersonal difficulties that are influencing and disturbing the interaction.

Nevertheless, the ideal set of ground rules that Langs proposes is, of course, very difficult to adhere to, especially for those therapists who work in a National Health Service or agency setting, where availability tends to take precedence over regularity. However, even when there is little opportunity for providing an appropriately stable therapeutic environment, the therapist's acknowledgement of the patient's messages that link to framework disruptions may still tender the patient a more honest and reciprocal image of the therapeutic interaction. Langs refers to this as "secure-frame moments".

The next section is devoted to defining and describing a number of elements that go to make up the therapeutic ground rules and the implication that these have for the patient-therapist relationship.

Confidentiality

The dictionary defines "confidential" as private, intimate, faithful and trustworthy.

At first sight, the significance of the rule of confidentiality for the patient's well-being may seem an obvious one. Yet there are many ways in which the therapist may reveal to the patient her lack of trustworthiness in this area. The patient may also relay his concern about confidentiality in many varied and often covert ways.

Although patients rarely raise any conscious objections to the therapist's request to take notes or to tape-record a session, they will tend to communicate their concerns in a disguised or symbolic way due to heightened levels of anxiety (see the Introduction).

After complying with the therapist's request to tape-record the session for supervisory purposes, a patient related a story about having hassle at work. He then went on to say: "Some of the people there really don't know what they are doing. They just try to ingratiate themselves with the bosses. Its hard for me to speak openly and honestly, I'm worried that some of them may even be eavesdropping and putting me in a vulnerable position. They have no integrity, it really annoys me. I wish they would just let me get on with my job." The patient speaks of people who are incompetent and unprofessional, who are trying to curry favours with their supervisors. He then goes on to explain his concern about speaking openly, which under these conditions would leave him exposed. Finally, he speaks of their lack of integrity and of his wish merely to get on with the job in hand.

This final statement may be viewed as a symbolic request for the therapist to stop impeding the therapeutic process, by introducing a third party into the relationship, after which the patient would be enabled to get on with his therapeutic work. If the patient relates a number of messages with a similar theme, then the therapist should be alerted to the particular significance of the ground rule for the patient. However, communications from the patient that allude to unhelpful and damaging behaviour are also likely to give rise to anxious feelings in the therapist and, therefore, to a natural reluctance to focus on these deprecating messages. Nevertheless, if the therapist neglects to verify the patient's selective perceptions of the encounter, she is at risk of excluding crucial information from the patient that links to the here and now of the therapeutic process.

The therapeutic relationship, by its very nature, places the patient in a vulnerable position, as he will be revealing information to the therapist about himself that is extremely personal and sensitive. Patients are therefore inordinately susceptible to issues that relate to the trustworthiness of the therapist.

As noted by Fong and Cox (1989): "Each counsellor needs to develop an 'ear' or awareness of when a client is testing trust. This comes, in large measure, from experience, because clients' testing behaviours are usually disguised" (p. 28).

As therapists, it is our responsibility to be vigilant constantly to the patient's very real anxieties which are fundamental aspects of any intimate relationship and may ultimately depend upon the patient's commitment to therapy and to the therapeutic outcome. For example, an adolescent girl who had been referred for counselling by her social worker started the initial consultations by stating: "I'm sure you know why I'm here." The patient's statement seems to suggest that the counsellor may have received some information about the patient prior to this meeting. The therapist should be alert to this concern as it is the patient's opening message and refers to information that inevitably came from a source other than the patient.

The therapist who agrees to liaise—even at the patient's behest—with a member of the patient's family, his employer, or any third party is likely to tender an image of someone who is unreliable and untrustworthy.

Privacy

Privacy and confidentiality overlap and in many ways go hand in hand, as information regarding the patient may be passed on to others either directly or indirectly. Ideally, sessions should be held in a consulting-room that is totally private, without the possibility of being either overheard or disturbed by outsiders. The relationships should be on a one-to-one basis without the inclusion of any third parties. One of the prime purposes of therapy is to offer the patient a private space in which he can feel safe and secure to disclose his deepest dreads. All therapeutic approaches should, by definition, be patient-centred, and any violation of this individual focus may be deemed as counterproductive. It may, therefore, be considered that the conditions of the therapeutic encounter need to be suitable before the patient can begin to endure and gain some relief from his most distressing emotional burdens.

Comparisons have been made between the therapist's role and the religious confessional. The practice of confession is made individually to the priest, who is bound to absolute secrecy: "The whole procedure is somewhat reminiscent of present-day short term psychotherapy" (Ellenberger, 1970, p. 44).

It is also interesting to note that the priestly confessional is circumscribed by the priest retaining his anonymity in total privacy, which may be viewed as a necessary procedure for the individual to be able to express his or her most disturbing concerns.

Unfortunately, in the clinic or hospital setting the consulting-rooms used for routine medical examinations are also used for therapy and are rarely sound-proofed; they may also have glass panels in the door. From a practical point of view, a blind or curtain can be used to cover the see-through partition. However, the general lack of privacy under these conditions is likely to elicit narratives from the patient that link to themes that relate to eavesdropping, detection, interference, and voyeurism.

There are a number of procedures that can be employed to create a private setting and to reduce the likelihood of being disturbed while a session is in progress. If there is a telephone in the room it can of course be taken off the hook. A "Do not disturb" notice on the outside of the door will, hopefully, ensure that there are no disruptions while the session is in progress.

A young female patient, in response to her male therapist's apology on receiving a telephone call in the middle of her session, replied, "That's OK, I know you're very busy". She then went on to relate an event that had occurred at work. She talked of her anger when a male colleague had "barged in" on a private conversation that she was having with her male boss. The patient's initial reaction to the intrusion was positively toned. She then proceeded to relate an event that had as its central theme the invasion of privacy and her negative response to the infringement. It seems likely that the patient's symbolic communications may be a more reliable measure of her emotional attitude towards the disturbed ground rule than her preceding rational comment.

This example is also in accord with the principles of the communicative approach, which suggest that symbolic communication offers a more precise indication of the person's current concerns but which tend to be denied and refuted by the individual's reasoned judgement.

"As a result", Langs (1988) states, "derivative communication is quite common in situations that evoke anxiety. ... It has been clearly documented clinically that patients are exquisitely sensitive to the therapist's management of these tenets. Because ground rules constitute the basic core of the therapeutic relationship" (pp. 26-27).

It therefore seems both vital and professionally appropriate for the therapist to be alert to the implications that her behaviour can have on the relationship.

Fees

From a psychoanalytic perspective, the way in which we respond as adults to issues associated with money are considered to be linked to fixation at the early stage of psychosexual development. The anal erotic character is reported to exhibit traits that have been described as orderly, neat, obstinate, and mean, with the emphasis on control and the need to accumulate rather than spend money. Fixation at the anal stage is considered to be related to the need to control the bowels as a method of gaining power. Gold and money are viewed in this light as a symbolic form of faeces (Kline, 1984).

Psychodynamically, difficulties associated with fees may represent other underlying concerns. The manner in which the therapist handles the ground rules of the fees of therapy may therefore have implications for the ongoing relationship.

Towards the latter part of the initial consultations, if the patient has agreed to enter therapy, the therapist should state clearly and concisely all of the ground rules of therapy including the fees for the sessions. Langs (1973) has proposed a number of guiding principles:

Your fee should reflect your training, years of experience and competency. A single on-going fee should be stated directly and the patient should be allowed time to react. If the patient feels he cannot afford the stated fee, you should have a lower one ready to offer him.

[pp. 91-92]

If the patient seems reluctant to accept the stated fee and there are no apparent practical difficulties, there is the possibility that there may be some underlying resistance to the therapy, which may be related to external factors such as coercion to receive treatment from a family member, employer, and so forth. These factors need to be explored with the patient at the initial consultation. Ideally the fee and motivation to attend therapy should come from the patient and not from any third party. The patient should also be made aware that he is liable for all missed sessions that are available to him. Generally speaking, once the therapy is under way and the fee agreed, it should not be increased; otherwise, the therapist is likely to be experienced by the patient with resentment and anger.

Regarding the request for a reduced fee, Langs (1973) states: "Be as certain as possible from the outset that the fee agreed is a realistic one for the patient. Deal with requests for a reduced fee directly in the initial hour" (p. 93). Before agreeing to a reduced fee, there are a number of oblique but vital factors that are worthy of consideration. The therapist's compliance to the patient's request for a reduced fee may in part be related to the therapist's need to have a grateful and dependent patient. The reduced fee may be viewed on an underlying level by the patient as a gift. There is also the possibility that the therapist may be concerned that if she does not reduce the fee she may lose the patient. The therapist may also have anxieties related to concerns around greed. To agree to reduce the fee out of hand may also foster a dependent attitude on the patient's part. The patient who is offered a reduced rate may also view his relationship with the therapist as being exceptional and special. The extent to which the therapist feels secure and confident in her professional role, which requires her to be alert continually to the way that her personal difficulties can impinge upon the therapeutic interaction and process, will be reflected in her ability to offer the patient a consistent therapeutic framework.

It is the therapist's responsibility to take heed of the conscious—and especially unconscious—reactions of the patient, as they relate to the ground rules and the implications of them for the ongoing therapeutic relationship.

There is, however, always the risk that the therapist may unwittingly collude with the patient, by representing and re-enacting the disturbed, unstable relationships from the patient's past (see the Introduction).

Langs gives the example of the patient who, after having his fee reduced, then went on to describe the therapist as a "provider of boundless supplies of food". His associations revealed that the patient unconsciously viewed the reduced fee as a gift from a mother-figure who would gratify his every need. The link between the lowered fee and the patient's associations were interpreted to him and seemed to be confirmed by the patient's subsequent recollection of other memories regarding his mother's over-indulgence and seductive manner towards him (Langs, 1973, p. 93).

The negotiation of fees and its influen...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• FOREWORD by Christopher Dare
• PREFACE
• Introduction
• 1 Ground rules
• 2 Communication and the therapeutic process
• 3 The limits of therapy and existential conflicts
• 4 Anxiety and the therapeutic process
• 5 A sense of the absurd: contradictions and paradoxes
• 6 Boundary issues in alternative therapeutic settings
• Conclusion
• REFERENCES
• INDEX