Psychotherapy and the Nature of the Psychotherapeutic Relationship

This paper below is an unpublished talk that I gave in Sydney in July 2005 to a Professional Development Meeting of the Australian Somatic Integration Association (ASIA) which is a sister organization of my own association, the Australian Somatic Psychotherapy Association (ASPA).

“Psychotherapy and the Nature of the Psychotherapeutic Relationship – Issues dear to my heart”. By Alison Ball

•Introduction
•The Privelege
•The Spectrum of Counselling, Psychotherapy, “Real Psychotherapy” and Psychoanalysis
•The making of a “real psychotherapist”
•Who wants or needs “real psychotherapy?”
•The Process of “real psychotherapy”
•Who needs “real psychotherapy”
•How we do the work of “real psychotherapy”
•Conclusion:The interaction between the personal and the professional

Introduction

I took the title of this talk from the actual content of the brief given to me by your Professional Development committee. My first thought at being offered the opportunity to talk to you on this topic was, “Wow, what a gift and a privilege”. Thank you so much for that and I can only hope that I can do it in a way that is satisfying for me and useful for you. Until I started writing I had only some vague notion of what I would talk about and was somewhat surprised myself as to what came out of my head and onto the computer and what it was that I wanted to say. I should state at the outset that I am here probably taking a lot of very important basic aspects of psychotherapy and the psychotherapy relationship for granted. For example empathy, our capacity to listen, congruence and authenticity. But at present this is what I am quite passionate about and it is certainly dear to my heart.

The Privelege

The privilege of being a psychotherapist seemed like a good place to start. As psychotherapists we are in a very privileged position. People give us their trust and open up to us in a way that can fill us with awe and brings with it a huge degree of responsibility. We frequently are told things that the person has never ever spoken about before. That requires from us a great deal of respect for the teller along with an enormous admiration for their courage in daring to tell us. Our job does mean that we have real effects on people and we have a lot of power to influence lives. At the same time we have to remain extremely mindful that the impetus for change, growth and development must ultimately come from the client and at times we have to give up our wish for them to fulfil the potential we might see in them and /or give up our wish for them to really live, grow or even survive.

Being in such a privileged position also has the possibility of going to our heads. We can be sucked into believing that we are who our idealising clients think we are and I shall say more about this later. It is though, critical to keep our feet very firmly based in the reality of the ground. Fortunately, if we are open to it, our privileged position can also give ample opportunity to learn about and, in our own time (and through our own therapeutic journey) hopefully to deal with our many weaknesses, faults and human frailties. At the same time we can only hope that these human weaknesses, faults and frailties do not adversely affect the client to the degree that we bring about some iatrogenic (therapist induced) condition that is permanently damaging for the client. Clients are sometimes damaged by therapy and even die during therapy. This could happen to me and it could happen to you and such possibilities must serve to keep our feet on the ground and not get hooked into our own omnipotence.

The Spectrum of Counselling, Psychotherapy, “Real Psychotherapy” and Psychoanalysis

That all brings me to the main point of this talk which is about what we are doing in this job and what is the nature of this work and of the therapeutic relationship? My current passion in relation to that seems to be primarily about what it takes to become what I think of as a “real psychotherapist” who can do what I often think of as “real Psychotherapy”. These are quite extremist terms and might sound rather elitist but it suits my purpose here tonight. I will gradually, I hope, make it clear what I mean by a “real psychotherapist” and “real psychotherapy”. Incidently, there are also distinctions that can be drawn between “real psychotherapy” and psychoanalysis but tonight I will not deal with that.

Even before the invitation to talk here tonight I had recently again been thinking a lot about this subject because of a discussion with Liz.Sheean, owner and publisher of the Psychoz Journal and also an ex member of ASPA. On her website she has minimised any difference between counselling and psychotherapy and I had some discussions with her about that. And also in PACFA circles, in the name of unity there is this same wish to minimise the differences. Now, perhaps typically of me, I want to swim against the tide. I think there is real value in preserving a distinction between counselling and psychotherapy. There is nothing wrong with difference and individuation.

Preserving a distinction between counselling and psychotherapy does not necessarily mean that one is less than the other; just different. In the same vein, I believe there is a whole spectrum of what is called psychotherapy. When I hear some people talking about their work and they are calling it psychotherapy I can feel my contempt rising at times, as if I would never do what sounds to me like such superficial work; but that is rubbish. Of course I do at times. But, nevertheless, I do think that there is something qualitatively different at either end of the counselling/ psychotherapy/ psychoanalytic spectrum. And while some counsellors may do psychotherapy with some clients and many times, we as psychotherapists, are acting as counsellors with our clients, I am quite passionate about the nature of this “real psychotherapy” and what it takes for us to be able to do it or rather what it takes to be a “real psychotherapist”.

When I think of my version of this “real psychotherapy”, I want to stress that it is certainly not possible or realistic to consider it for most of our clients. Much of our time and much of our work will quite legitimately be valuable, therapeutic, and useful but not necessarily at the end of the spectrum I am focussing on here tonight. By no means do I want to devalue it. Here I am thinking of much of psychology, much of the body-work that is practiced, supportive psychotherapy, cognitive work, short term therapy, lots of counselling and even one- off sessions. For a lot of people that will be exactly what they need and/or be enough. It will support them in their way of being in the world, bolster their coping self and/or enable them to move forward on their own. I often think for instance, of some very good work I did as a social worker around the kitchen table. Or I think of the 20 minute, one- off session I had in the 1970’s with a cognitive behavioural psychologist which was the beginning of real change for me and for our family dynamics. And indeed, clients who want or need this level of counselling or psychotherapy will leave us if we go in assuming they want my version of “real psychotherapy”. We should never aim to give anyone more therapy than what they want or demand.

We must therefore really consider why it is that people seek us out in the first place and we must spend a good bit of our time with them exploring what it is they want from us or need from us or are able to take from us. Many at first do not have a clue nor perhaps do they care much about who is this professional they have come to see or how is it exactly that they might work or what they might be getting themselves into. They just know they are in pain or have some problem within themselves or in their relationships. They do not know the difference between psychology, psychiatry, counselling, therapy, psychotherapy, somatic psychotherapy or indeed psychoanalysis or somatic integration. Most wish that we will be able to wave the magic wand and produce the McDonalds quick fix and some can indeed get all they need or want from us at that time in a very short space of time. What I have problems with and what leads me to an interest in the differences along the spectrum of counselling/ psychotherapy, is when cognitive work or other short term quick fixes are used for people who have deep dependency needs or have severe attachment problems and most especially when these problems are accompanied by experiences that have been traumatic.

The making of a “real psychotherapist”

As I was writing this paper, I realised that I am willing to talk to you about these issues because I think that your training offers the hope that you are people who have the potential to do (in your own way) my version of “real psychotherapy”, provided you do the necessary work in your own psychotherapy. I was not always so convinced because I had the idea that your training had been largely quite similar to my own in terms of the Neo-Reichian/ group process/ Boyesen model. And, although I gained a huge amount from my training and although a primarily body work training enables us to work with very strong emotions and feelings, it does not necessarily equip everyone to do “real psychotherapy”. I think it does not on its own offer enough structure and containment to hold the space for the work to be safe enough. The boundaries are often too loose. As well, that training devalued the mind and the link between words and feeling. We now know that that link leads to the capacity, as Fonagy calls it I think, for mentalization. In broad terms I think that means the capacity to make sense of our lives which in turn is a marker for secure attachment.

It is, I think, those lacks in the body work trainings that have meant we have had to turn to the analysts of one kind or another for some help. We need their concepts and language to make sense with our clients of their process. And from what I have understood, it seems that in your training you folk have, in recent years, primarily turned to Bion to give you the structure, the containment and the depth of thinking required. That sort of input, along with good enough personal psychotherapy and good supervision, sets you up to be able to do real in -depth work with people if you are inclined to do so and, if you can seize and stay with the opportunities that some clients do provide us with. To do this “real psychotherapy” you need all the above input because it is extremely hard for both therapist and client. It is very, very intense, takes years and years and is usually only entered into by the desperate or the totally dedicated and most of this latter dedicated group of clients are either training or already practicing themselves as psychotherapists. And although my version of “real psychotherapy” is not what a lot of clients want from us, in my opinion, the test of being a “real psychotherapist” is when we can meet and match the needs of those who do.

Perhaps it is my own grandiosity but I think that many people who are trained as counsellors or psychotherapists simply are not willing or more likely, they do not have the personal capability to go to the depths of what working at this end of the spectrum requires. And it is very difficult to talk to them on this subject because they simply do not know what they do not know. The absolute bottom line is that they have to have gone to the depths in their own psychic realms in their own long term and intense psychotherapy process. And I can be quite a fascist in my thinking around this. I am not talking simply about a lot of the personal development work we do in group settings, even training group settings though that is a great way to start. And I am not talking about three years work with one therapist and another year or two here and there with another one or two. I am talking about the absolute essential experience of the long term, one on one process with a therapist who can take us where we need to go into our own psychic depths. And for those of us who want to be able to do real work that is likely to be at the very least about 7 years. It may well entail sessions two or three times per week and in my opinion is almost never only fortnightly.

Who wants or needs “real psychotherapy?”

Of all the people who come to us only a few will be at all interested in or in need of what I am calling “real psychotherapy”. The ones most likely are those who have some innate knowing that psychotherapy is what they need because of their particular issues and/or who have in fact tried all the quick fix therapies and have come to us almost as a last resort. These people may be ready for the sort of psychotherapy that I am speaking of and a trickle of them may be desperate enough to embark on my version of “real psychotherapy”. Of course along the way, even many of these will decide that it is much too hard or too frightening and will come up with all sorts of good and real reasons why they cannot continue; eg. “I have to move to the country or interstate for work”, is one of the very legitimate favourites. All we can do at these times is to help them understand what might lie underneath all the rational, “out in the world” reasons and why at that unconscious level they feel compelled to do what they are doing; that is, escape the therapy. That way, at least they will have some understanding of their own psychic processes and may later be more able to seek further help if life events or their inner turmoil force them to feel that they must go further in their psychotherapy..

This above touches on what I find to be a most intriguing and interesting phenomenon that is almost universal though in varying degrees and intensities. The phenomenon is that just as soon as we find the therapist who might be able to really help us work on our issues and we begin to build trust and can see the beginnings of change then every fibre of our being rises up to scream, “No, no, don’t do it, at least we’ve survived this way.” Our fear of changing our embodied and long held ways of being is enormous; better the self or patterns of coping and habits we know than face the unknown and perhaps risk the very stability of the often precariously balanced self we have built up.

And we as psychotherapists must really respect this fear, as it is, I believe, the major reason why so many people drop out of therapy. And it is for this reason I frequently say to supervisees that in the first session or the first weeks of therapy and even at many stages thereafter, the main thing to focus your attention on is all the reasons why this person will not want to stay in therapy. This fear which I think we greatly underestimate, is the fear of what growth and change will mean. It is feared because of what it may mean for how they have managed to cope so far in their lives. They fear that they might disintegrate and/or will not be able to go on doing what they do. People rightly fear that one of the main things that “real psychotherapy” does is challenge their very patterns of survival and the self they have lived with most of their lives. Additionally my version of “real psychotherapy” ultimately challenges them to grow up, take responsibility for themselves, learn to be separate but loving and learn to differentiate as much as possible between what belongs to them and their own mind and what belongs to the other.

The Process of “real psychotherapy”

So, how do we get to this point above with this trickle of people who come to us driven to search for “real psychotherapy” and how do we marry this with what they seem to be searching for? Depending on their experience in their original primary relationships and the life events that follow, the road can be very long and very slow as well as intense and at times extremely hard for both therapist and client. The main group I will speak of are those who come to us wanting, hoping, wishing and searching for that idealised parent who will give them all they missed out on as a child. They want us to hold them, to heal them and to nurture them and most of all never to leave them (and I will say more on this latter matter of leaving later). We can give them a lot and most certainly we can give them much that they missed out on and this is what I think of as the re-parenting element of therapy.

To some degree all therapy has elements of re-parenting in it, even if it is no more than through the provisions of the environment we offer where our time and our attention is regular, reliable and non-judgemental. And when we give so much it can induce that idealisation I mentioned earlier. Most especially this can be so if we nurture them with massage and/or our endless empathy and mirroring. And being idealised is, as I indicated above, terrific fun and very, very seductive for us as therapists. We can really get caught up in the good feelings engendered. And I think some therapists or therapies never get past this stage either because it is so seductive or they just do not have the capacity and/or the willingness to go further. And, don’t get me wrong as I have indicated some people can make major changes when they are at this stage of therapy. Through our nurturing, our empathy, our mirroring some people can really blossom and maybe for some this is all they need or want and through it they can move forward in their lives. For some or maybe many, this is good enough therapy or good enough psychotherapy. It is enough, and there are many counsellors and psychotherapists out there who can do this sot of therapy. In my opinion however, for those needing my version of real psychotherapy, it is simply the start, the tip of the iceberg.

In trying to convey to my supervisees who I think are capable of offering my version of “real psychotherapy”, I say something like:: “During these idealising times make the most of it, enjoy it while you can because if you are doing your job it won’t last and you will sooner or later get the other side of the coin. It may be weeks, months or years but eventually you will fall from the heights and in some cases become totally denigrated. You will be told of all your faults and foibles and you can only hope that enough good will has been built during these good times that you and they can hang in when things go bad. And, if you and they can hang in, finally they will get what they really missed out on, in the form of a good enough parent/therapist rather than an idealised one. This good-enough parent/therapist can give them what they really need; one who can tolerate all their hate and their fury and still be there for them.”

So when I talk about “real psychotherapy” or the capacity to offer “real psychotherapy”, this is what I think it offers; a relationship with a real human being who can be good enough and constant enough to invoke love and who is also able to tolerate all the hateful and unbearable feelings so that ultimately each party in the relationship will grow and the client can individuate and grow into a fully mature, independent and real adult who can themselves value the good as well as tolerate and accept their own unbearable feelings and the strengths and human frailties of the other.

Who needs “real psychotherapy”

I want to come now to what I think of as the guts of the psychotherapy relationship and what are the critical issues we are dealing with in “real psychotherapy”. I think much of therapy for these people is focussed on issues related to leaving and being left, to the presence or absence of the primary other or in short on mourning and loss. And I do not only mean physical absence. Emotional absence through depression, neglect or dissociation can be just as damaging and there can be traumatic experience even in the physical presence of the parents which leads to a similar sense of loss. It is through absence that we learn to think and to have a mind and a life that is truly our own but this is only OK if the original experience of absence is not too traumatic. And of course for many people the original experience has been traumatic and not good enough in Winnicott’s terms. The absences have been too cruel, too harsh or too long, too young. For some people these issues are basically all of the therapy. For most people they are critical in some way.

The issues show themselves in a variety of ways. For some they will be seen in the dependent nature of their out in the world relationships where they may have been completely merged so they never have had to bear the reality of being alone. They will want to merge with us or will come into therapy only when their merged out in the world relationship is under threat. If they are not ready for a therapeutic relationship they will avoid these issues with us if their partner returns to them or by finding a new partner. Some others will have avoided being attached to any other real human being. Some will have disappeared or be able to disappear when intimacy threatens them. Others will have become addicted to a bottle, drugs, gambling, the internet or a myriad other things. They will most certainly struggle against becoming attached to us because the bottle does not leave them as we will do.

Some others will have built up all sorts of defences against their need of the primary carer including through what I call a precocious but sort of false “grown-up-ness” or excessive levels of “being responsible”. Others will be bulimic as their way of rejecting what the primary carer has to offer. Still others have developed the classic body rigidities that bolster their coping self while underneath they remain fearful of real commitment to an other. Some can let themselves be attached to us and then find our absences unbearable. One way or another a lot of therapy time will be spent understanding how people cope with absence and their allied fears about: “What if I become attached and then they die or leave me?” And it is not just about our physical absence either. Many remain for a long time extremely sensitive to any evidence that we may leave them either by going into our own mind or in other ways leave them even momentarily at an emotional level. This whole group of people do need to become dependent on the therapist, sometimes for a long time but ultimately they need a therapist who can help them grow into independence.

How we do the work of ‘real psychotherapy”

At this level of therapy the work is almost always based on our countertransference or in other words, on our own subjective response to being with the client in any particular moment. We must be able to use our own internal response as a signal to ourselves of what might be happening for the client and what response from us they might need. And this is the reason why we must be as clear as possible about what our own issues are while, at the same time, being able to stay as attuned to the client as possible. It is also why we need good weekly supervision

I want to re-iterate that to do this sort of psychotherapy and be willing to cope with all the sadness and hurt, all the hate, rage, fear, envy, jealousy, feelings of vengefulness, and just plain madness that underlies the most extreme forms of traumatic dependency and attachment issues means that the psychotherapist themselves must have been willing and able to have entered these psychic places in their own therapy. It can be very, very difficult and at times with some people it can be very gruelling. We do even run the risks with this depth of work of ultimate “failure” to help the client come through and out the other side.

This thought is quite frightening and the responsibility big as so often, just as we think we have brought them through, yet another layer of madness surfaces and further levels of destructiveness work yet again to attempt to wreck all that has been good and all that is new. At these times we must sustain our faith in our client and their capacity to grow and change. And we can only hope that they do have enough resilience within and enough good has been introjected that they too can stay the distance for themselves. Central to my talk tonight is my belief that not all counsellors or psychotherapists can do the sort of work I have outlined at this more extreme end of the spectrum and I know my bias is to think that those who can are the “real psychotherapists”.

Conclusion:The interaction between the personal and the professional

I want to finish on a more personal note. I am probably interested in this sort of psychotherapy because of my own background and my own experience in therapy. To make sense of my own experience I had to turn to analytic theory. First of all I discovered Harry Guntrip and his book called “Schizoid Phenomena, Object Relations and the Self”. Then I could begin to understand Freud a bit. Then ultimately I could make sense of it through those analysts who were associated with the British Independent School of psychotherapy as well as the theories of Melanie Klein and the post Kleinians. I love the humanity and the groundednesss of Winnicott and the phenomenal dissection of the innermost workings of the psyche that comes from Melanie Klein and her followers. I love the depth of thinking about thinking that is the gift that Bion has given to us. Not only do these theorists and clinicians make sense for me of my own experience and that of many of my clients but they are the ones that I am most excited by and from whom I feel most fed and most challenged. When I go to seminars from people from this strand I come away feeling like I have had a huge feast.

I have only very belatedly come to appreciate the good offerings that belong to self-psychology and intersubjectivity. The major value I have taken on from self-psychology and intersubjectivity is in relation to technique. While I love Klein’s theories, her technique I think, would have driven away many more clients than ever profited from it. I greatly value the truth and clinical usefulness in Klein’s ideas but we can learn a huge amount from the self-psychologists and intersubjectivists about the way of being as a psychotherapist in relationship with our clients and the way in which we interact with them. One of their greatest gifts I think, is their notion of disjunctions or empathic failures between therapist and client and the growth that is possible in the healing work of interactive repair.

This way of being as a psychotherapist in relation to clients seemed to me to be a natural outcome of my experience and of having been trained as a social worker in the late 70’s. Not directly, I might say, through the social work course but through my social work mentor. He directed me toward reading Carl Rogers book, On Becoming a Person. That book said it all for me. I had permission from Rogers and my mentor that, as a social worker or therapist it was OK just to be ME and to listen to the person in front of me. My mentor told me that that was enough to start with and that yes, along the way I would learn a lot more and develop more skills but when I thought that I knew it all, was the time to give it up. It was a wonderful set of premises from which to start being a therapist. Not long after that I read Carcuff and Truax from cover to cover and in that I learned that about 95% of the help we give is in just being there and providing the space. For me that has been a wonderful gift. It took the pressure off me to provide magical answers or to feel like I must DO something.

And what I most love about being a psychotherapist with an abiding interest in psychoanalytic theory is that it will be impossible ever to feel like I know it all. So with a bit of luck health wise, I am hoping to go on working for a lot more years to come. The depths and riches of the psychoanalytic gold mine seem endless and I believe, are on a par with mathematics, languages and music as always offering the challenge of newness and the opportunity to be creative.

It is a good idea to ask ourselves why it is we want to do this work. If it is just about “wanting to help people” then I think we should forget it. As my supervisor has said that may be just a defence against our own sadistic impulses. I’ve always thought that what really motivates me is that just as some people like to explore Mt.Everest or the Antartic or the jungles of South America, I love to explore just what it is that makes any individual tick. How is it that this person thinks, what is it that is really meaningful for that person, why is it that this person responds to this in that particular way, how has it come about that this person feels this way? That’s what I love. It seems like a continual adventure to be with another person and explore both the relationship between us, how that impacts on us both and by exploring that, help us both to understand what this person has created in his or her own mind, in their body and in their emotional life out of all the experiences that life has brought them. In doing so I can only hope that the client is also helped along his or her path.

Thank you for your attention and the privilege of talking to you about my ideas of what constitutes “real psychotherapy”.