Stress in Psychotherapists

Ved P Varma, Ved Varma, Ved P Varma, Ved Varma

• Publisher: Routledge
• Year: 2003
• eBook ISBN: 9781134807482
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Those who spend most of their time dealing with other people's stress are most vulnerable to stress themselves. Stress in Psychotherapists highlights the pressures experienced by psychotherapists and examines how the effects vary according to the problems they treat, the settings in which they work and their professional and personal development. Written by a team of experienced practitioners this book is important reading for all those in psychotherapy training and practice.

Chapter 1
The experience of being a psychotherapist

Christopher Dare

A recently appointed high-up official in a Mental Health Trust had courteously set up a meeting with me in pursuit of his conscientious wish to understand more of the services provided within his new responsibilities. He naturally wanted to know of what psychotherapy consisted. He displayed a genuine curiosity, a wish to learn and to place the psychotherapy business alongside his previous experience of other businesses. He had worked in industry and he wanted to make a parallel between the activity of the psychotherapist and his own experience of giving career advice to junior staff in his previous executive positions. At the same time, he displayed a characteristic fear: people could get an excess of advice and support and might grow to rely too much upon it. He feared that receiving psychotherapy might become an indulgence; it might create a risky dependence. He also displayed a belief that there could be something unhealthy about talking a lot about feelings. In saying such things he revealed all that characterises a very English attitude towards the subject. In many ways it is surprising that someone accepting a position in a Mental Health Trust in the United Kingdom at the present time would be comfortable with his own attitude. The field of psychodynamic psychotherapy owes a great deal to the British school of psychoanalytic thinking. It is also true that the subject, as a professional practice, is now undergoing a veritable explosion in the numbers of psychotherapists within Britain. The recently established register of psychotherapists demonstrates how many organisations are currently developing standards of practice and are training psychotherapists. At one time such trainings were almost exclusive to London (with one training each in Aberdeen and Edinburgh). Now psychotherapy courses are available in many centres throughout Britain, with, for the first time, an evolution of university-based diplomas and masters degrees in the subject. There is an even more marked development in the more ‘sanitised’, apparently cheaper form of talking treatments which are encompassed by the concepts and practices of counselling. In my discussion with this senior executive, I chose not to confront the inconsistency in his attitude and side-stepped the issues. I talked of the particular psychiatric conditions that interest me and for which ‘psychological treatments’ alone are the only ones that have been shown to work. (These are, specifically, the so-called eating disorders, especially those associated with self-starvation, which have been shown to be singularly unresponsive to pharmacological therapies, and for which effective residential treatments are expensive and scarce; see Dare et al. 1995). My response was tactical and I failed to talk with him about the origins of his beliefs about what is for me my life’s work. Of course, his views are indeed common and representative and have an important place in any understanding of the phenomenon of psychotherapy. The common attitude to psychotherapy includes two persistent myths.

THE FIRST MYTH

Psychotherapy is nothing much more than an everyday matter of a cheerful and friendly chat, commonly available over the garden fence. Contrary to this belief, psychotherapy is a highly technical professional activity that uses a wide range of complex intellectual models, one class of which (that derived from the scientific psychology of learning and cognition) is justified by detailed and sophisticated psychological experiments. The other main class (psychodynamic or psychoanalytic psychotherapy) is sustained by a century-long process of changing and refining complex and subtle views of mental function through clinical experience with tens of thousands of patients. It is disheartening for those of us who work in this field that even apparently informed criticism of our subject addresses psychotherapy as though it were a unitary and essentially unchanging body of knowledge and practice. A ‘sound-bite psychiatrist’, much used by the media to comment upon the passing scene, derided psychotherapy because there were so many named varieties of the activity, as though it could not possibly be evidence of the multiplicity of practices in response to the multiplicity of problems and situations in which people need psychological help.

THE SECOND MYTH

Psychotherapy (specifically psychoanalytic psychotherapy) probably does not work to any beneficial ends but is potentially dangerous. Psychoanalytic psychotherapy, in particular, is portrayed as an implausible and futile mish-mash which has no claims to efficacy but which can cause dangerous dependence and even suicide. Again the facts are in opposition to this myth. Psychotherapy has been shown by large numbers of studies to be a powerful treatment. It has been shown that the common ingredient of all psychotherapies, the provision of warmth and empathic understanding, has such potency that it is technically quite difficult to show the specific ingredients of different forms of psychotherapy, the variance deriving from different techniques being swamped by the non-specific power of talking treatments (Luborsky et al. 1975). Studies of the changes people experience in the course of therapy show that there is a very rapid response indeed to the provision of a thoughtful, caring, professional listening (Howard et al. 1986). The proportion of people reporting marked improvement in their subjective feelings rapidly increases within a few sessions of treatment (in comparison with matched groups who are not getting help). This ‘dose effect’ has been shown in many studies. The rate of change of objective measures of psychological state, that is, of changes that an external investigator reports, is also quite steep, but not as much as that of the subjective feelings. Symptoms, anxieties, depressions and so on change quite quickly, whilst self-esteem difficulties and relationship problems take much longer to improve. Specific psychological treatments directed at a particular focus or target can produce rapid change, although it is not always well sustained. For example, in the field that I know best, that of eating disorder, we are some way along the path of showing just the sort of specific effects that different psychotherapies exert on different patients, in different contexts, with different sub-groups of the conditions. In addition, there is a beginning literature on the risks of psychotherapy, which, none the less, are often considerably less than the risks of not giving psychological treatment, in those situations where it is indicated. For example, in young adult patients with schizophrenia, whose families are critical of their diagnosed family member, the patient’s risk of relapse is seriously heightened if specific psychological help is not given to the patient and family to help cope with the criticism.

THE ORIGINS OF PSYCHOTHERAPY

Psychiatry, as a medical sub-specialty, has existed for perhaps two centuries, although physicians have had a role in the care of those designated as mentally ill for very many centuries. (The psychiatric hospital at which I work, the Bethlem Royal Hospital, joined with the Maudsley Hospital, is shortly to celebrate its 750th anniversary). Some aspects of this medical help have had a psychological intent. For example, the moral treatment developed progressively in the first half of the nineteenth century, initiated by such as Philippe Pinel in Paris, and continued by Hack Tuke in York and John Connolly in Colchester, implied an essentially psychological approach. The giving up of constraint and the attempt at a moral reorientation constituted an early form of something like psychotherapy. Likewise, philosophers from Immanuel Kant onwards have believed that their special preoccupation with reason and morality offered an approach to mental disorder. The ideas of the philosophers and the humanisation of the hospital management of the mentally ill certainly have an honourable claim to the history of psychotherapy.

It is more often proposed that the likely antique origins of psychotherapy are the advice and support that pastors and priests have been offering since such roles became differentiated within human society. Such an idea is commonly offered in the somewhat derogatory manner that I had felt was behind the senior manager’s conversation with myself reported above. I think that it is linked to the proposition that psychotherapy, particularly psychoanalytic psychotherapy, is in any case quasi-religious, the underlying ideas depending more on faith than on reason.

It is obvious that the activity now known as psychotherapy had some antecedents in age-old human concerns. Since time immemorial, it would seem, one person would offer another support and advice out of their own shared and different experiences of life’s problems and their solutions. In a non-professional setting, a priest or a pastor has a greater duty towards his faith and the wider body of the flock, than to the one person alone. A friend or relative, likewise, will have responsibilities, when giving advice, to be concerned with other family members and mutual friends. There are limits imposed by tact, courtesy and convention within the informal setting that need not oblige the professional. A complementarity can be expected in the social give and take of supporting and advising. Love will provide an unconditional form of personal support and care, but the long-term nature of such a context makes it quite different from a professional activity. The care given will be part of the maintenance of the relationship concomitant with the expectation of the enduring future that is implicit in love relationships. Likewise a priest or family practitioner can offer personal psychological help, but everyone knows that if such occurs, it is only a part of the relationship, being offered alongside the principal project, priestly or medical. However, psychotherapy is, historically speaking, a new and distinctive activity. First, the personal support and psychological help is the purpose of the meeting. It is not incidental to the other things. Second, it is conducted professionally, that is to say, the one person, the client or patient, goes to the psychotherapist, expecting that the latter will be functioning as best he can in the patient’s or client’s interests. (It is probable that most psychotherapists are women. However, the present author is male and ‘he’ is used to mean ‘he or she’ when referring to a psychotherapist.) The psychotherapist tries to have a point of view that is specifically and only for the other. This is the problem of being a psychotherapist. However, the professional activity poses peculiar difficulties for its practitioners. The implication that psychotherapy is nothing new, except for its mumbo jumbo, is part of a suspicious response existing not only in the minds of intelligent members of the public, in academics, in doctors and in psychologists but also, I believe, in ourselves, the psychological therapists. I think that psychotherapy is beset by the uncertainties of its practitioners. The reasons for and consequences of this uncertainty are the main focus of the remainder of this chapter.

THE UNCERTAINTY OF THE PSYCHOTHERAPIST

For most occasions in which we meet with another person, we know the point of the contact. Meetings with friends and family may seem to be exceptions to this but the family is a social organisation, usually essential, existing for the support, nurturance and care of its members, but having a corporate as well as an individualistic function. Meetings with family members have a function, but one that is so intrinsic to our lives that we never need be aware of the purpose, except when there exists an obligation above our own active volition. We are so used to knowing what families are for, have been socialised to perform properly from such a young age, that we do not realise how precisely and accurately we fit in with our family role.

The strong tendency to fit in with the expected role is strong, something for which we are precisely, psychologically adapted. Indeed, it is clear that when we enter any new social situation, in our formal professional life or in the course of our social meetings, we carefully observe the rules of communication and the structure of the power and allegiances of the situation. We do this swiftly and outside of consciousness, in order that we do not offend and so that we can find out how we ourselves will fit with this new situation. It is with these highly refined and well learned social skills that a psychotherapist meets a patient or client. However, in the usual social situation of leisure, travel, work or play, we are trying to adapt and accommodate ourselves in as gracious and comfortable way as possible, so as not to challenge the given order, to intrude on private closeness or to offend those upon whom we depend in a novel setting. In the process of meeting with a group or an individual, family members as well as friends or acquaintances not only have an axe to grind—the fulfilment of their own purpose and role in the meeting—but this interest is accepted as having self-serving aspects since the social context acknowledges a process of mutually beneficial social exchange. A psychotherapist has to strive to be truly altruistic and this goes against the grain. Customarily, we are all highly orientated towards maintaining a social and family order derived from our own wider culture and the particular religious, political and family points of view. The professional activity of a psychotherapist requires attention to be paid to those things that are expected and to which social custom would require conformity, not in order to comply, but to use this as information about the problem to be faced. For example, it is quite natural, in a social situation, to ask for and obtain reassurance. A stranger on a station platform will ask of a passer-by whether or not the train that is about to leave is going to a particular destination. The passer-by will answer straightforwardly. A psychotherapist in response to a comparable request for reassurance, as to where things are going, may not simply give the automatically reassuring answer, but must question the process itself. Is the question realistic? Can anyone know where a particular psychological process is leading, or if the outcome will be satisfactory in relation to some as yet unknown, future psychological state?

The psychotherapist has to restrain the customary response, or, finding himself blurting out a social response, has to try to understand what the pressures are that led him so to do, to use the reaction as a piece of information about the processes that the patient or client tends to evoke. That is, the therapist has to treat with suspicion his own normal social reactions. The reaction must be taken as evidence of counter-transference acting out; not a forbidden process, for such enactments are inevitable, but as a phenomenon to be understood very specifically in context. Such events in the here-and-now can have a potential for usefulness but are also a source of possible error. For example, in a diagnostic interview with a patient with long-standing and distressing preoccupations for which many people had unavailingly tried to give help, I found myself feeling quite controlled and disconcerted. The patient repeatedly demanded that I tell him whether or not I could offer help, before I even knew what the problem was. I inadvertently showed my own responsive impatience. The patient burst into tears of anger and hurt, saying that he always upset people from whom he wanted advice. It slowly became apparent that he was someone who had had to look after himself from an early age, had managed to do so quite extraordinarily well, through many hard times, but he had never been able to form sustained, close love relationships. It was easy to see that he had a set, a tendency to prevent himself getting the closeness for which he so longed in relationships. Patients express the nature of their problems not only in their account of their history and their current life, but in the sort of incidents and processes that occur in their relationship with the psychotherapist. This discovery of the transference process that Freud made upwards of one hundred years ago has conflicting effects. On the one hand, it means that the psychotherapist can find himself being inducted into repeating the patient’s problems in a very painful manner. On the other hand, the vivid quality of such events, occurring not as part of a reported experience but in the exact present in the therapy room, are especially powerful, showing the problem, facilitating an exploration of its accompaniments and suggesting possible routes for the avoidance of like difficulties. The psychotherapist has to take up a position that has many of the qualities of an intense closeness with the patient or client. This is necessary in order to know what the problem is for the patient or client, it enables appreciation of the feelings as accurately as possible, and is essential to make a therapeutic relationship with the patient. Within psychotherapy patients are usually confronted with difficult, often hidden parts of themselves. The revelations are embarrassing and painful. This is only likely to occur if patients feel respected and know that their pain is sensitively heard. However, in order to manage the tendency to enter into a relationship that is too social to be helpful, the psychotherapist has both to be an emotionally present and empathically effective presence for the patient but also has to preserve a distance. Some separation from the patient is required so that the professional scrutiny of the relationship is maintained. The psychotherapist cannot afford to become so involved as to be unable to make forceful therapeutic responses, if indicated and timely. For a specific patient, in a particular setting within which psychotherapy can occur, there is much variation of the precise nature of the balance of emotional directness and responsiveness within a professional framework, the psychotherapist assessing the meaning of what transpires and retaining the capacity to make helpful interventions.

EFFECTS OF THE AGE OF THE PATIENT

Working with children is quite different from working with adolescents and adults. It is very easy for children to feel very attacked in therapy. It is unusual, especially in the early phases of treatment, for children to believe that the therapy is for them. Commonly parents, teachers, social workers or courts recommend psychotherapy for a child because of worries about behaviour. Children are capable of communicating their own distress, but help can be experienced as being to do with misbehaviour or badness. Adolescents often believe that their problems are unique, and cannot be accepted or felt by others. The psychotherapist can be seen as both alien and intrusive. Adults, especially perhaps men, in our culture believe that there is shame in experiencing panic, in being overwhelmed and helpless.

The aim of life, and therefore of psychotherapy, differs with different age groups. An adolescent is trying to maintain a pathway that shows allegiance to the past, to childhood relationships, but which takes a track which specifies the adolescent’s own needs and individuality. The elderly are usually engaged in a survey of their life achievements and how these fit with earlier hopes and expectations. The needs and therapeutic aims of a person with children and grandchildren are likely to be different from those of people who find their social support and companionship in non-family relationships.

CONJOINT RELATIONSHIP THERAPIES

In the last twenty-fi...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• CONTRIBUTORS
• PREFACE
• CHAPTER 1: THE EXPERIENCE OF BEING A PSYCHOTHERAPIST
• CHAPTER 2: STRESS AND THE PERSONALITY OF THE PSYCHOTHERAPIST
• CHAPTER 3: STRESS IN TRAINEE PSYCHOTHERAPISTS
• CHAPTER 4: STRESSES IN CHILD PSYCHOTHERAPISTS
• CHAPTER 5: RISKS TO THE WORKER WITH DISTURBED ADOLESCENTS
• CHAPTER 6: STRESS IN PSYCHOTHERAPISTS WHO WORK WITH ADULTS
• CHAPTER 7: STRESS IN PSYCHOTHERAPISTS WHO WORK WITH DYSFUNCTIONAL FAMILIES
• CHAPTER 8: STRESS IN THE THERAPIST AND THE BAGSHAW SYNDROME
• CHAPTER 9: STRESS IN COUNSELLORS AND THERAPISTS WORKING WITH BEREAVEMENT
• CHAPTER 10: THERAPEUTIC WORK AS A MINISTER
• CHAPTER 11: STRESSES IN COGNITIVE BEHAVIOURAL PSYCHOTHERAPISTS
• CHAPTER 12: STRESS IN GROUP PSYCHOTHERAPY
• CHAPTER 13: STRESSES IN PSYCHOTHERAPISTS INSIDE THE NATIONAL HEALTH SERVICE
• CHAPTER 14: STRESS IN PSYCHOTHERAPISTS WORKING OUTSIDE THE NATIONAL HEALTH SERVICE
• CHAPTER 15: STRESS AND PSYCHOTHERAPY: AN OVERVIEW