The Presence of the Therapist

Treating Childhood Trauma

Monica Lanyado

• Publisher: Routledge
• Year: 2004
• ISBN:
  9781135451790
• Edition: 1
• Topic: Psicología
• Subtopic: Psicología del desarrollo

The Presence of the Therapist uses clinical studies based on the author's publications over the past 18 years to illustrate work with severely distressed children. The reader is encouraged to enter a dialogue with the author to explore the many dilemmas and difficulties of working with a person who has become highly defensive or fearful as a result of what has happened to them. This book is a highly stimulating account of psychotherapeutic practice. It facilitates careful and broad thought about the therapeutic process and relationship that will improve clinical practice. The practical advice on how to survive in this demanding work will be of great benefit to all psychotherapists.

Part 1
The presence of the therapist

Chapter 1
The presence of the therapist and the process of therapeutic change

When the psychoanalytic psychotherapist enters the consulting room trying to be ‘without memory or desire’ (Bion 1967), what aspects of the therapist are actively left outside the door and what does the therapist enter the consulting room ‘with’?

Some of the answers to these questions are comparatively straightforward and relatively uncontroversial. For example, the therapist actively tries to put aside personal preoccupations and concerns about his or her private life as well as thoughts about other patients, even though at times of worry or stress at work or at home this can be extremely hard to do. The therapist strives not to introduce his or her agenda into a session other than in highly unusual circumstances or in relation to practical arrangements. The therapist makes efforts to hold back his or her opinions about difficult issues that the patient is trying to resolve, as the therapist’s opinions do not belong in the psychotherapeutic session in which the patient has to try to find his or her own solution. However difficult it is to meet these standards, it is still comparatively easy for the therapist to identify when these hallmarks of good practice have not been met, and to attempt to consciously improve on them. We are all human, and inevitably at times painfully aware of how difficult it is to meet these exacting standards.

The answers to my opening questions become increasingly difficult and controversial the closer they get to the inner world of the therapist. For example, the therapist tries to be as open as possible to the patient’s communications—that is, the therapist tries to leave as many personal defences as possible outside the room. The therapist knows that his or her ego, in the way that it is popularly understood, does not belong in the room. Neither does the therapist’s judgemental superego. It is difficult to do this and it requires a level of self-discipline and self-awareness that it can at times be hard to find. These are complex and subtle ideals to uphold, as their roots lie in aspects of the therapist’s personality that it is much more difficult for the therapist to observe and identify, or indeed to try to change.

But it is still easier to think about what does not go into the consulting room with the therapist than to think about what does. While there are the obvious conscious skills, insight and knowledge that result from the many years of rigorous training and supervision that the therapist has undergone, there is always the question of how much the training analysis has helped the therapist to be aware of his or her weaknesses, strengths, defences, vulnerabilities and blind spots. The need for the therapist to continue to scrutinise his or her inner world, to sift the impact of the patient from the background noise of the therapist’s personal domain, remains throughout the therapist’s working life.

These lines of thinking contribute to the concept of the therapist trying to put the patient in the foreground, while seeing him or herself as offering a service to the patient, in the more old-fashioned meaning of the word. However, as psychoanalytic psychotherapists do not take any standardised tests or treatment programmes into the sessions but ‘only’ take themselves, the process of therapeutic change is particularly reliant on how the individual therapist uses his or her training, clinical experience and ultimately his or her self.

This is not an easy theoretical place to be, and it would feel much more comfortable to be able to believe that it does not matter who gives the therapy, or who gives the interpretation. However, common sense as well as personal accounts from therapists who have had experience of more than one psychoanalyst, confirm that therapy feels very different with different analysts.

These are difficult and problematic issues to address and yet it is timely to attempt to take this area of discourse within psychoanalytic thought to a new stage. Much of the theoretical discussion about the personality of the therapist, the new relationship and the formation of new attachment relationships within therapy, has taken place in the psychoanalytic literature based on work with adults (see, for example, Baker 1993; Holmes 1998, 2001). I think that work with parents and infants, children and young people has much to offer to this debate, and that there is a body of knowledge, observation and clinical acumen that can make an important contribution to psychoanalytic insight in this area. Much of this clinical knowledge has arisen from work with the kind of traumatised, abused and deprived children that form the bulk of the clinical population seen by child and adolescent psychotherapists today.

Face to face encounters with child and adolescent patients mean that not only are the therapist’s facial expressions available for the patient to perceive, but so is the therapist’s body language. While we know that these perceptions are read in particular ways by patients according to their preexisting internal worlds, there is also a reality to what they read about their therapist. Not all therapists will respond in the same way to a patient, and the face and body of the therapist conveys a great deal of important information to the patient, whether the therapist wants this information to be conveyed or not. Additionally, therapists working with children and young people may actively have to set boundaries on reasonable behaviour in the room. They may find themselves being touched by young patients in an entirely appropriate manner for the patient’s tender years, and may need to practically help young children—for example, helping them to wash themselves after very messy play. The therapist as a person is a very real presence and body in the room.

I think that it is important to try to understand how the ‘presence’ of the therapist functions in the therapeutic process. This is rather like the attempts to understand the complexities of the use of counter-transference in understanding the patient’s communications. Indeed, some would argue that it is no different to this debate. But I feel that the debate can be expanded considerably by thoughts about the presence of the therapist, which are the leitmotif of what is explored in this book. The clinical studies gathered together here paint pictures and provide illustrations of this process in action and how it intertwines with the transference relationship. Based on papers published over the last 18 years about work with children who were referred for a variety of reasons, but who all had traumatic experiences underlying their distress, the questions of therapeutic technique and how therapeutic change emerges have been an organising theme.

I have come to the concept of the ‘presence’ of the therapist as a way of thinking about what the psychoanalytic therapist takes into the room, from a convergence of two different trains of thought. The first of these is interpersonal and unique to a particular relationship at a particular moment in time (Tronick 2003), which is why I think of it as the present relationship; the second is deeply personal, relating to what might be thought of as the essence of the individuality of the therapist, which try as he or she may, cannot be kept out of any human relationship.

The ‘present relationship’ is now captured by the frame by frame analysis of video material from a wealth of developmental psychology research in parent-infant communication, as well as in parent-infant psychotherapy (Baradon et al. 2001; Woodhead 2002). This video evidence of the minutiae of interpersonal perceptions and interactions which become a part of implicit (that is, unconscious) memory, is happening in the consulting room, just as it happens in ordinary life. While many of the perceptions will be based on previous good and bad experiences, they are not all based on the past. There has to be a way for novel, different, current experience to be processed as well, otherwise nothing could ever change in the internal world. I now hesitate to use the word ‘new’ experience, because it is so easy to get into a semantic debate about what is ‘new’, in the context of ongoing human growth and development. Perhaps ‘new’ is somewhere well along a continuum of development from ‘old’ or past experiences into the present.

Another way of thinking about this is in terms of pathways or roadmaps in a lifetime’s journey. Before a patient is referred to therapy, he or she is usually rather entrenched in following a route which seems to be going round in circles, or clearly in a direction that is destructive to self and possibly others. The patient comes for therapy because it is felt that nothing will change without treatment. After successful therapy, the patient is no longer going round in the same circles and feels set on a different course in life. The difference, which might have started with a very small change of direction at first, can lead to a big change in location over time.

It is in the fact that the therapist, while perceiving and trying to process the transferred relationships from the past, responds differently to the way in which important people in the patient’s past responded, that the potential for therapeutic change lies. This differentness, which relates to the way in which the therapist listens and uses psychoanalytic insight to understand the patient’s many forms of communication, takes place in the current, that is present, relationship between patient and therapist. This is not the same as offering a corrective emotional experience to the patient, which gratifies the patient’s longings. For example, an important part of what the therapist may be offering that is different may be a refusal to gratify Oedipal longings, or infantile omnipotence which might have consciously or unconsciously been confirmed in relationships of the past.

The second train of thought that contributes to the concept of the ‘presence’ of the therapist relates to the difficult question raised at the start of this chapter. That is, that while it is fairly clear what the therapist leaves outside the room, when going into a session what is it that he or she takes in? It is certainly not all of the therapist’s personality, but it is a kind of abstraction of it, a meta-level which relates to what might be thought of as the essence of the person and which cannot be kept out of any human interaction that the therapist engages in. This is very hard to define. It is better described, and I hope indirectly experienced and sensed in the pages of this book, through the accounts of therapy that follow this more theoretical chapter.

It is important to remember that there are established safeguards that protect patients from the possible and thankfully rare dangers of therapists who might misuse the professional therapeutic relationship. Poor practice can take place within work in the transference relationship as well as within work in the present relationship. The profession of child and adolescent psychotherapy has very rigorous selection procedures for prospective trainees, and careful monitoring of the trainees’ work through seminar presentations and individual supervision. The training takes place within small groups or in one-to-one contacts with senior members of the profession and lasts on average at least five years. This puts in place very high standards regarding who is allowed to qualify as a member of the profession. On qualification, the therapist joins a profession with a strict code of conduct and an ethics committee to uphold it. Membership of organisations that have their own similarly rigorous code of practice, and an ethics committee that investigates breaches of good practice, are safeguards for other professions, such as psychologists and medical practitioners.

To return to the book itself. While each chapter can be read independently as a clinical study of a particular aspect of the treatment of traumatised children, there are a number of concepts which link them together which I hope it is helpful to outline here.

An eclectic approach and thoughts about the process of change in therapy

Perhaps I should start this brief overview of the key concepts that are used in this book by stating that an eclectic approach to theoretical concepts has been very clinically helpful and liberating to me. I do not have a problem in taking different useful ideas out of this theoretical ‘bag of tools’, as seems appropriate to the differing clinical situations encountered during therapy. These are some of the ideas that I find useful and will outline below: thoughts about the naturally occurring processes of growth and decay; different types of processes of change; moments-of-meeting in therapy; the therapist’s personal signature; therapeutic attunement; the total therapeutic relationship; and therapists’ reverie. For clarity, I have left a further group of ideas, which centre on thoughts about transitions, play and creativity to Chapter 5.

It is important to remember that patients, who in the past might have been thought to be unsuited to psychoanalytic psychotherapy, are now being helped because of a flexibility of approach and a willingness to adapt and apply psychoanalytic thought to new areas. Here I am thinking of parentinfant psychotherapy, work with severely deprived, traumatised and multiply abused children including refugees, work with multiply disabled patients, and therapy with children with autism (Sinason 1988, 1991, 1999; Daws 1989, 1999; Tustin 1990, 1992; Alvarez 1992; Hopkins 1992; Melzack 1999). Work with children, young people and their families requires this pragmatic approach in which if it can be seen that a change of technique seems to work, it is likely to be cautiously used first and theorised about a good deal later. This time lag can be considerable, with clinicians often working in very different ways from those that they believe to be ‘orthodox’, without sufficiently sharing their findings with colleagues. If they did, they might find that their ways of working are less unorthodox than they fear, and more in keeping with contemporary clinical practice. There is a pressing need to place these findings in the public arena, and this is one of the moving forces behind this book.

The first idea that I want to discuss is that therapy must be alert to, and continue to try to utilise, the natural processes of recovery and change that surround us. Within the natural world, we have many obvious illustrations of this. For example, in London where the four seasons are very evident, we never fail to emerge into spring with its wonderful flowering of bulbs and blossoms despite the darkness of the cold and gloomy winter that precedes it. Similarly, on a daily basis the light of day inevitably follows the darkness of night. Some may say these are just trite and somewhat sentimental statements. I do not agree. I think it is all too easy to lose sight of just how remarkable these processes are. They illustrate how we live in a world that is full of naturally occurring rhythms and changes. Nothing naturally stands still.

The ideas of ebb and flow, and movement in life as well as the possibility of a natural harmony within it, are prominent in our culture. This can be seen in the tremendous growth in the acceptance of ‘natural’ remedies and the worldwide concerns that are now expressed about the dangers of interfering with the harmony of our ecological systems. The corresponding view of emotional ill health rests on the assumption that this arises from an impediment, which stands in the way of the natural unfolding of processes of emotional growth and development. This is the view expressed by Winnicott whose writings on playing, creativity and the therapeutic process have had a great influence on my work (Winnicott 1971).

There are of course also natural cycles of decay as well as very powerfully destructive natural forces such as storms, earthquakes, floods and fires. Similarly, there are powerful destructive forces within all of us which even with the best of experiences in life have to become an important part of self-knowledge if a balanced way of living is to be achieved. Life is full of duality —of strengths and weaknesses, positives and negatives, creation and destruction, love and hate, war and peace, light and darkness. Detecting, accepting and understanding the destructive forces which act in opposition to the creative forces, and learning how to rein these forces in, is as vital as nurturing creative potential. The ebb and flow of both of these forces— creative and destructive—needs to be followed during therapy so that creative potential is increased and destructive potential reduced.

On reflecting on the therapeutic process itself, I have found myself thinking about two types of process of change. There may well be others. There is the kind of change that is built up from many tiny, quiet changes, which are incremental and essentially developmental. Hurry and her colleagues have discussed this in detail (Hurry 1998). For example, to return to thoughts about natural processes, this is rather like the gradual emergence of a daffodil from the darkness of the bulb in the soil. On a day-to-day basis, only very small changes are seen, and then only if they are looked for. But on a week-to-week basis there are dramatic changes, climaxing in the flowering of the plant. This is the kind of change that emerges from the quiet type of therapeutic ‘holding’. In many respects this could be thought about as a therapeutic ‘background noise’ that is present all the time during the course of a treatment. Examples can be found in the case studies, particularly ‘Lesley’ and ‘Derek’ in Chapter 2, and ‘Sammy’ and ‘Pete’ in Chapter 6.

The second kind of process of change has more of a ‘before and after’ feel to it. By contrast to the quietness of incremental change, it could be thought of as ‘noisy’ and very noticeable change, rather like the climax of the plant flowering referred to above. It is important to note how impossible it is to separate the one kind of change from the other. In a negative sense, traumatic experience itself has this quality of dramatic change with the sufferer often expressing the feeling that he or she will never be the same again. For traumatised patients, this sense of the potential for discontinuity and catastrophic change in life is part of what needs to be addressed in therapy, so that change does not automatically remain equated with disaster. However, change in a positive direction can also feel like a terrifying prospect. Patients can cling to what they intellectually know to be destructive ways of living and relating, but feel too frightened of being without these familiar patterns to let go of them. This was the situation with ‘Hilary’ in Chapter 7, which led to the title of the chapter based on the well-known Bible story of Lot’s wife, who could not let go of the past.

Thoughts about the fear of change and one of the ways in which this is overcome in therapy, relate to the significance in the therapeutic process of what Stern and his colleagues in the Process of Change Group in Boston have helpfully called ‘moments-of-meeting’ (Stern et al. 1998). They came to the conclusion that at these times the therapist and patient ‘are meeting as persons relatively unhidden by their usual therapeutic roles, for that moment’ (p. 913). They argue that these moments were identified as being the point at which meaningful change took place in the treatments that they studied. The kind of change that they seem to be referring to is the ‘noisy’ change which has a ‘before’ and ‘after’.

Thinking about the present relationship, I think that it can be argued that the presence of the therapist and his or her ability to truly ‘meet’ with the patient at critical points in the therapy can be pivotal at these times. Trust in the therapist’s capacity as another human being to bring about positive change may be the determining factor in a pa...