When and how does Transference link to Harm in Therapy?

It can be argued that transference and countertransference are ubiquitous phenomena in the therapeutic relationship, and much of the time the multi-layered relational responses that occur for both therapist and client either do not dominate the therapeutic work or become a fertile and productive means of gaining relational understanding and effecting therapeutic growth. In my work as a therapist, my understanding of the feelings and interactions which transpire between myself and a client play a crucial role in how I make sense of the therapeutic process and my client’s way of being in the world.

I believe wholeheartedly that transference and countertransference can hold great value in the therapeutic process (from my experiences as a client as much as anything else) so  how do I understand the significant prevalence of transference being cited as a cause of harm in books, articles, internet forums and in blogs, most frequently cited first-hand by the people who have experienced harm in therapy?

Often, when people experience difficulties in their feelings towards their therapist, they Google it. That’s what I did, and it’s also how I make sense of the fact my blog posts on transference, countertransference, and particularly, erotic transference receive more worldwide hits than any of my other posts.  When clients type ‘feelings towards my therapist’ into Google, they receive access to thousands upon thousands of resources and online discussions on transference. They will probably read that it’s important to talk to their therapist about how they are feeling, and those who feel able to, might attend their next session ready to tell their therapist about their understanding of transference and desire to talk about it. What happens next can vary widely.

In her 2016 article for Therapy Today, Dawn Devereux writes “The risk of AIT [adverse idealising transference] can also be reduced by responding appropriately when clients bring up transference concerns, as AIT is much more likely to occur if the first indications are ignored.”.

I would posit that the transference is far more likely to have a long-term adverse effect (distinct from here-and-now discomfort) if the therapist shows discomfort, rejection or denial towards the client’s feelings. Devereux continues “We have observed that therapists whose clients develop AIT are unlikely to discuss transference, and are dismissive or hostile when clients suggest it. Clients also describe therapists becoming irritated, defensive and rejecting in response to discussion about the adverse effects on the client’s life.”.

What is happening for therapists here? It is tempting to say “What terrible therapists; how dare they respond in such a way to a client!” however I think the uncomfortable truth is that any therapist could be vulnerable to responding in a hurtful way to their client and when we ‘other’ the harmful response, we avoid the necessary self-reflection for safe and ethical practice. I really want to take a look at why therapists might respond in this way and how the risks of such a harmful (and potentially retraumatising) response can be reduced.

I have experienced some mixed responses from therapists about my interest in harm in therapy, and I sometimes wonder when I receive confrontational correspondence whether this might relate in part to a reluctance on the therapist’s part to acknowledge their own potentiality to do harm (in fact I recall that this sense was once freely admitted to me). When I hear of therapists’ dismissive or rejecting responses to a discussion of transference, I wonder whether a similar avoidance occurs. It’s almost as though we can, as therapists, bask in our sense of doing good, yet have trouble reconciling ourselves with the inevitable shadow of our virtue. So how can we manage that response as therapists? I would argue that the only way we can reconcile this shadow, is by facing it head-on. I often retweet Carl Jung quotes, because he professes it so boldly and so unequivocally: “People will do anything, no matter how absurd, in order to avoid facing their own soul.”. If we find ourselves shaming and invalidating our clients in order to avoid facing our own soul, we do ourselves, our profession, and crucially, our clients, a terrible disservice.

Hostility as a response to idealising transference is an interesting one; it seems counter-intuitive to meet positive feelings in an ill-disposed manner, particularly as therapists. It seems to me that the therapist who acts with hostility (and quite possibly those who act with defensiveness and rejection too) are likely to be chin-deep in countertransference without the first idea about it. After all, I think it unlikely that any therapist would say it’s okay to act in a hostile and rejecting way to a client expressing such feelings, so if it’s happening, something may well be occurring for the therapist outside of awareness.

My supervisor said to me recently “Awareness is key, and always in the service of the client”. With that in mind, I would say, awareness, reflection, robust scrutiny, and a crucial container for all of these processes: supervision, each have a role to play in managing our own responses to our clients’ feelings in a way that reduces the risk of adverse effects when transference and countertransference emerge in the therapy room.

I don’t think this is by any means a comprehensive exploration of this huge and under-researched area, however I have tried to touch on some of the ways in which we might work to mitigate harm and engage positively with this fascinating and valuable area of the relational dynamic.

For the Love of Therapy – How the Exploration of Harm and a Love of the Profession go Hand-in-Hand for me

I have begun researching literature for my master’s research into harm in therapy. I am reading reams and reams of accounts of harmful experiences as well as many cynical , even disparaging articles about the therapeutic process and the profession as a whole.

As I read all of this, I am reminded of a question I have been asked on more than one occasion – How can you claim to love the profession when you focus on the harm it could do?

This question can come from two angles –

Some might wonder how I can still love therapy, given that I have experienced harm as a client, conversed with many others who have experienced harm, and immersed myself in narratives of harm and sceptical viewpoints.

Others might wonder why, if I claim to love the profession so much, would I highlight its harmful elements, rather than focus on the great contribution it makes to healing and wellbeing in society. Do I wish to damage the profession in some way?

Well, of course I don’t wish to damage the profession. It would be counter-intuitive to spend years training, to laud the profession, to work with dedication with clients, and to endeavour to engage with all elements of theory and practice if that were my intent. It is my belief that, because harm undoubtedly exists in counselling and psychotherapy, engaging with it is our responsibility, as well as being important if we are to honour our integrity as individuals and as a united profession.

Like our individual shadows, if we ignore what lurks in the shadows of the profession, it is likely to pose a greater risk than if we seek to engage with it and address it.

So how about the trickier question of how I can still love this profession, given the energy that I put into exploring its harmful elements? Well, starting with my own experiences as a client, good therapy has had a transformative effect on my self-concept, my self-compassion, my relationships and my outlook on life. I am fully aware that this was made possible by being ‘in relationship’. By being fully accepted, to the point where I no longer needed to fear verbalising my internal experiences, and could hear them for the first time, without judgement or risk of being shamed. To me, that experience is magical. The healing and growth which I know can occur when those necessary and sufficient conditions are met tells me categorically that this is a worthwhile endeavour for me and that the therapeutic relationship is a very special thing indeed.

How do I begin to offset that sense against harm, and place value judgements on the benefits and the risks? I can’t. Not for anyone else but myself (it is for this reason that I believe a client’s autonomy is of paramount importance in the work.). For me, the journey so far has not only been worthwhile, but has been life-changing, and this has to be where my frame of reference grows from.

Of course, my frame of reference is ever-growing. As a therapist,  my work with clients informs my view of psychotherapy as do my conversations with other therapists, with clients, many of whom are my friends, acquaintances or colleagues. The literature I read and my online engagement with therapists and clients alike all form part of this great tapestry that forms in my mind when I think of the role of psychotherapy, both for individuals and for wider society too.

Right now I am brimming with enthusiasm for the future of psychotherapy. I feel that the internet has provided a way for therapists at all levels of training and experience, as well as clients and interested members of the public to get involved with conversations around therapy, and I think that this growing dialogue can only help to improve transparency and credibility of the profession. After all, if we are to help clients to become their authentic selves, we must too demonstrate authenticity, and not shy away from the shadow.

Harm in Therapy Revisited – What’s it Like for a Client Seeking a New Therapeutic Relationship?

Last week I went to the first meeting of the small group undertaking a research master’s in psychotherapy at Leeds Beckett this year. My research idea is still in the planning stage, but I am essentially interested in what happens for therapists when a client comes to them wishing to talk about a previous distressing, harmful or traumatic experience of therapy. One reason I am interested in researching this topic is that it appears to me to be a common presenting issue in therapy, yet I cannot find a single thing written for therapists who work with therapeutic harm (I live in hope that this will change as my research deepens!).

In terms of my research, I don’t want to say anything more until the wheels are in motion, but I do want to talk broadly about what it can be like to experience harm in therapy, because among those who have never experienced it, I imagine it could be difficult for some to appreciate the nuances of this particular issue.

I have touched on the definition of harm in therapy before in this blog, so I won’t dwell on it here, except to say that as an integrative, person-centred practitioner, I believe the phenomenological perspective of the client is of paramount importance, therefore, if a client comes to me saying they have been harmed in therapy, then, as far as I am concerned, they have been harmed in therapy.

Here are some of the themes I have been aware of when in conversation with people who have returned to therapy after a previous harmful experience:

Grief: If a client comes to therapy to discuss harm in therapy, more often than not, this client will have been through a painful termination with their previous therapist. I have heard people in this position speak of carrying the great pain of this disenfranchised grief, and feeling as though those around them see the loss as little different to changing dentist or optician. Carrying this grief alone can be a weighty burden, even accompanied by a sense of shame and ‘unworthiness’ as a result of invalidation from a society that rarely acknowledges the depth and significance of the therapeutic relationship from the perspective of the client. While, of course, the therapeutic relationship does not hold tremendous significance to every client, for many, the relationship is not only central to the work, but also holds a significant, often reparative role in the client’s wider relational landscape. In my experience, it is often (though not always) clients for whom the relationship itself holds greatest significance, who are most vulnerable to experiencing harm in therapy.

Vulnerability: At the root of harm in therapy, as all iatrogenic harm (harm which occurs via contact with the helping professions – therapist, doctor, dentist, surgeon etc)  is vulnerability. When we go into surgery, when we see a doctor, when we meet with a psychotherapist, we inevitably make ourselves vulnerable to some degree. We must trust that the person in front of us wishes to do us good, not harm, and that they will do us good, not harm. When we experience harm in this vulnerable state, whether intentional or, as in most instances, purely accidental, it is shocking and very scary. I can only liken it to the reliance a child has on their caregivers – children are necessarily vulnerable; they rely on those around them to ensure their safety and security. To be in this situation as an adult and for it to backfire is an acute pain indeed.

Fear of a repeat performance: Clients are likely to return to therapy with their defences fortified. I certainly spent the first year or so telling my therapist that I didn’t have any feelings towards him one way or the other and that if I never saw him again, that would be fine by me. I look back on that wondering who I was trying to convince – myself, I am sure. I suspect it was my way of ensuring I was the guardian of my own vulnerability.  As I reflect on what was happening outside of my awareness, I actually praise the wisdom of my unconscious, and I am grateful to my inner world for the way in which it worked to protect me. When this particular defence realised it was safe to step down, it did, and the next phase of therapy could begin, but I learnt much about myself from its presence and the love I showed myself at this time.

I think, when a client returns to therapy after a harmful experience, it’s important that every feeling, even the kind I describe above, which might appear to be a barrier to relating, are recognised and treated as part of the process. In my view, defences are not a barrier to relating, they are a means of relating. As my supervisor says, the unconscious just does it’s thing, and it knows what it’s doing. It shifts as it receives new information, and in my view, there is no more healing a new experience than an unconditionally accepting, patient and trusting relationship.

 

* If you are a UK-based therapist who has worked with clients who have been harmed in counselling or psychotherapy and you would like to express an interest in participating in my research, please drop me an email at erinstevenscounselling@gmail.com . The research is likely to involve exploring your experiences and responses to working with clients who have been harmed in therapy. The focus of the research will be on your experiences and feelings, and not details of your client’s experience of harm in therapy, and will be anonymised. At the moment, the research is in the early stages of planning and I will not be officially recruiting participants until after Christmas. At this stage you would be expressing interest only. Thanks!

Parallels in the Therapeutic Relationship – Synchronicity, Unconscious Knowing, Coincidence and Disclosure

I’m sure many therapists can relate to those internal “me too!” moments where a client speaks about a thought, an attitude or an experience that the therapist can relate to on a profound level. Perhaps things  emerge which we might think are improbable, bizarre or inexplicable, which leave us gesticulating in supervision as we emphasise just how incomprehensible the parallels seem.

So how do we explain such experiences?

Synchronicity:

Carl Jung introduced us to the term Synchronicity – meaningful coincidences which, far from being random, are connected by their meaning and without obvious causality. I find this explanation for some of the parallels which have emerged in my own therapy very intriguing. It feels good to imagine a mystical and intangible influence in my choice of therapist, whom I now know to be rather similar to me in unexpected and charming ways. The party-poopingly rational part of me, however, won’t allow me to fully indulge in the pleasure of imagining this explanation to be so (though I do not intend to dismiss the potential existence and influence of synchronicity out of hand).

Unconscious Knowing:

As I have developed a deeper understanding of unconscious processes through my own therapy, my studies, and my work with clients, I have become increasingly interested in the role of our unconscious in our lives and the way in which we form relationships. It is my feeling that unconscious knowing plays a significant role in the way therapeutic relationships are selected and formed, and that our unconscious creates opportunities for parallels to emerge in our awareness.

My therapist once said to me that sometimes it seems as though our unconsciouses are having an entire conversation that we know nothing about. I feel that this is a likely explanation for  many of the feelings that sometimes occur in therapy which appear inconsistent with what I am aware of happening in the room.

My supervisor, quite delightfully, prefers to refer to the unconscious as the “greater mind”, finding the term unconscious does not do justice to its role, its significance and its value to us as organisms. While a large function of my therapy continues to be a process of allowing unconscious material to become conscious, I am also learning that my unconscious knows what it’s doing – that I can trust it, and my ability and willingness to listen to my intuition is growing all the time.

So to what extent do these unconscious conversations influence the way in which we form relationships? I am certain that my unconscious knew that my therapist is as introverted as I am, long before I was consciously aware of it. I am equally certain my unconscious picks up on certain cues from him,  seeking out our similar processes, and that I say things that resonate because my unconscious wants to nurture the connection between us. In my view, this relational process is likely to echo the way in which an infant seeks attunement with their caregiver.

Equally, I have sat in the therapist’s chair and thought that emerging parallels, and the way they are emphasised in my client’s narrative, are likely to be more than mere coincidence.

Coincidence:

Coincidences, of course do happen. One day I showed my therapist a photo on my phone. His response was muted and I noticed. I asked him what was wrong. I watched as he considered whether a disclosure was appropriate, and clearly he came to the conclusion that I had noticed something was up, and he had better tell me rather than risk falsely invalidating my experience of him. “Have you got a new phone cover?” he asked. Indeed, I had a new phone cover, and apparently it was identical to one he had just bought for himself (which I had never seen). As far as I am concerned, it was clearly a coincidence (though it’s still fun to imagine that it has a quality of synchronicity). We enjoyed the curiosity of the situation, and I think my therapist was relieved when I told him he had definitely not seen my phone case before; the notion that his choice had been unconsciously influenced by my phone case would give rise to some interesting reflection in his supervision, no doubt!

Disclosure:

On that occasion, my therapist chose to disclose the parallel between us. In my view there had been a clear therapeutic purpose to doing so, as I have described. This leads me to wonder, how do we go about ascertaining therapeutic purpose when making decisions about whether to disclose similarities between ourselves and our clients?

I imagine there are a number of reasons why it might be helpful to disclose when similarities emerge – validating client experience (as in the case described above), building relational depth, normalising feelings, perhaps even helping to model a way of being. And I suppose there are reasons to be cautious too – there could be a risk of invalidating a client’s experience, taking up too much space in the relationship, assuming to understand the client’s experience, and missing the client’s frame of reference by imposing our own meanings and value to parallels in the work. I think, as with all self-disclosure, it’s a case of being mindful of the client’s process, and having a clear therapeutic purpose.

I like Val Wosket’s ideas, described in her book The Therapeutic Use of Self, where she highlights relational self-disclosure (disclosure about the therapist’s experience of the relationship, and things that are directly pertinent to the relationship) as often having more value to the therapeutic relationship than a biographical self-disclosure. With self-disclosure, I would say: the experiential learning in the here-and-now is usually more valuable than the anecdotal learning from the there-and-then. I feel this is likely to be equally true when parallels emerge in therapy.

Reference :

Wosket, V. (2016) The Therapeutic Use of Self: Counselling practice, research and supervision. 2nd ed. Oxon: Routledge.

The Autonomy Dilemma

One thing that being a client, a therapist and a student of therapy has taught me, is that when we are trusted, we can learn to trust ourselves. When we are allowed to make autonomous decisions, we can grow towards our authentic selves.

Of course, the ethical principle of autonomy is emphasised in the BACP ethical framework. We should, according to the BACP, “respect our clients’ right to be self-governing.”. How does this work in practice, and how do we manage the conflicts this principle raises in the work?

Recently I have been considering the ways in which the counselling profession manages the autonomy of clients, therapists and student counsellors, and where the balance lies between the philosophy of self-determination, and the expectations placed upon those groups.

My interest was recently piqued around a study from the University of Nottingham which found “serious ethical considerations” about mandatory personal counselling for counselling students. One of the prominent issues raised in the study was the conflict mandatory therapy raised with the ethical principle of autonomy. Most therapists would agree that clients get the most out of therapy when they come voluntarily, and that it is important that they seek therapy, and agree to therapy willingly. So it seems like a double standard when it comes to counselling students, with no easy resolution.

I want to qualify this by saying that I think that all therapists should experience counselling as a client. I think that trainee therapists should have a passion for self-exploration and growth, and that ascertaining and exploring this passion should be part of the selection process at universities and colleges. I might be idealistic, but I feel that if that philosophy is communicated and nurtured, we wouldn’t need to mandate therapy – students would feel compelled to sit in the client’s chair and learn about themselves!

I have two friends who went to university with established therapeutic relationships, only to be told that they would have to leave their current therapists and find new ones who had been accredited for a minimum of three years. This experience has been exceptionally upsetting and seems to me to defeat the object entirely. Are universities teaching students to value the therapeutic relationship by arbitrarily causing helpful, established therapeutic alliances to come to a premature and forced end? Where is the autonomy in that? And where is the non-maleficence? It seems that the decision-makers in these situations (at two separate universities) have chosen bureaucracy over common sense and the very values they are aiming to teach.

Many counsellors develop a policy whereby they will not see clients who are also seeing another therapist, even of a different modality. In the spirit of autonomy, I think the therapist has every right to manage their own policies and make their own best decisions about their practice, however I also wonder whether such a policy may miss opportunities for clients to develop their self-determinism and use therapy autonomously, and in a way that works for them.

If a client wishes to see two therapists at once, they may choose to simply not tell their respective therapists, out of fear of termination, which may limit the efficacy of the therapy. My view is that different therapists may be useful to clients for different reasons, and the client is the best person to make decisions about that.

It hasn’t escaped my attention that my philosophy around autonomy poses difficult questions about my pro-regulation stance. If we are to trust in clients to make their own best decisions for their therapy, if we are to trust in students to make their own best decisions about their engagement with therapy, isn’t it incongruent to imply that I don’t trust in therapists to make their own best decisions about their practice?

For me, this is where we have to look at a way to balance our ethical principles where we find them in conflict, and to balance the conflicting needs of clients and those within the profession.

When it comes to regulation, my first thought is the safety needs of clients, because clients are the people we serve, and when harm occurs in therapy, it can have a devastating effect. I feel that it is of paramount importance to mitigate risk of harm however we can without compromising the service we offer. Fears within the profession about regulation restricting the creative and diverse interpersonal way we practice need to be taken seriously in the regulation debate.

It is the danger of therapists losing more autonomy than is necessary to protect the interests of clients, which has led me to the conclusion that compulsory regulation by a range (and choice) of PSA accredited regulatory bodies would be preferable to statutory regulation. I feel that therapy needs to be kept in the hands of therapists, not government regulators.

Autonomy is a tricky issue, and runs through the very heart of our profession at all levels. I don’t have any definitive answers as to how we manage these conflicts, but I hope my thoughts on the matter can provide some platform for reflection and discussion.

Dual Relationships, During and After Therapy

I’ve been thinking about dual relationships, what exactly they are and why they sometimes exist between a therapist and client.

I’m going to start by offering my own ideas about what a dual relationship is in the context of counselling. When we form a therapeutic relationship between therapist and client, we do so with the understanding that this relationship will offer something different to other relationships; it will offer confidentiality, an ethical frame and, in particular, carefully considered boundaries which allow the relationship to exist, uncomplicated by the typical demands and counter-demands of human relationships. We do this to allow a safe space for the client to freely express and explore their most difficult experiences, and hidden areas of self.

A dual relationship arises when the client and therapist have an additional relationship which exists outside of the therapeutic frame. Perhaps a business relationship, a family connection, a friendship, a teacher/student role, colleagues or neighbours, members of the same congregation – some relationship which necessitates a different dynamic, different expectations and different boundaries.

My title for this blog acknowledges dual relationships which occur after therapy, and this is because I believe the therapist’s ethical responsibility towards their client exists beyond the termination of therapy. When friendships, business relationships or even romantic relationships occur between therapist and client after therapy, this, in my view, still represents a dual relationship, no matter how much time has passed.

So how do we navigate dual relationships? Well, I suppose I think, for the most part, we ought to avoid them. As anyone who reads this blog regularly is probably aware, I am particularly keen that the counselling profession does more to acknowledge the potential for harm to occur in therapy, and to take collective responsibility for the harm that does occur, and has occurred for many clients.

For me, dual relationships are one, largely avoidable area where harm could foreseeably occur. This is particularly true in relationships where there is a shift from the relationship serving the emotional needs of the client only, to emotional needs of both parties being met within the relationship.

A major benefit of therapy is that the client need not worry about having to hold the emotional energy of the therapist. As soon as the relationship requires two-way emotional holding of the other, there is a shift in the dynamics which is unlikely to meet with the expectations of either party. When this gap between expectation and reality presents itself, there is great potential for hurt to occur, and potentially for this to taint any positive outcomes achieved in therapy.

I find the idea of therapists forming sexual relationships with clients or former clients particularly troubling. The BACP ethical framework states that “exceptionally”, such relationships post-therapy may be permissible, however here I must diverge from the guidance of the framework and say that in my view, there is never a good reason to form a sexual relationship with a former client.

Where an additional business relationship occurs, it is equally important to consider the potential harm to the therapeutic alliance and therefore to the client. Is such a relationship completely necessary? I would think very rarely, and if there is another option, in my view it should always be perused before a dual relationship is arranged.

If a dual relationship is unavoidable, like anything, it needs to be discussed carefully with the client to manage boundaries and reduce the risk of harm. I would also emphasise the importance of ongoing supervision and consultation with colleagues (as per the BACP ethical framework 2018) in order to obtain more objective views on the necessity and ethics of any dual relationship.

Above all, in my view it is vital to be mindful of what it can feel like to be a client. The inevitable imbalance of power in the relationship, the strong feelings that a client can have for a therapist (and vice versa) could easily impact on clear decision-making from either party. Perhaps some clients may feel reluctance to say ‘no’ to a dual relationship, even if they are not sure whether it is what they want – in instigating a dual relationship, I would argue that we cannot always be certain that we are properly upholding the ethical principle of client autonomy.

 

 

The Meaning of Silence

How comfortable are we with silence? Are you somebody who will happily sit for hours and enjoy the peace and tranquility of a silent place? Or are you somebody who will immediately switch the radio on the minute things go quiet?

What about in the therapy room? (and I think we can ponder this either from a therapist or client perspective). Do silences bring with them, anxiety? Do you find yourself thinking “Has this gone on too long?”; “Should I speak?”; “I can’t think of anything to say!”; “Aaargh!”?

I think most people can probably relate to that at some time or other. I particularly remember feeling that way in my early experiences of working with clients. I think my anxiety was about not feeling ‘enough’ and that this silence would lead me to be ‘found out’ by the client. What those thoughts did, of course, was draw me away from the present moment. I became so anxious about what was to come next that I probably missed a great deal of what was happening in the here-and-now.

Silence often takes place in my own therapy. My therapist has taught me that I don’t need to have a response straight away, and nor does he. I can now give myself permission to sit with what I am feeling and see what emerges. This gives me an opportunity to communicate with myself, find out what is happening for me, and also to notice what is being communicated, unspoken, in the therapeutic relationship.  I have also grown to be comfortable when silence emerges with clients. In my view it can be a vessel for trust and connection, when its value is recognised, and we remain present, in the moment, noticing our own responses and what we can see occurring for a client. There is also value in discussing silences, how they are experienced and what meaning they hold for the client. Far from being a hindrance or awkward exposure of my impostor status, silence is our teacher and an invisible facilitator of therapeutic movement.

Ancient Chinese philosopher Lao-Tzu told us that “silence is a source of great strength”. I do think it has the power to strengthen our relationships with each other and with ourselves. I think it also provides energy, shifts energy, and allows us to notice where our energy is focused, offering us the opportunity to refocus if we feel stuck, or in need of redirection.

I am not somebody who leaps for the radio when things fall silent, so my understanding of the value of silence in therapy is somewhat shaped by personal attitude to silence in general. But I do want to encourage anybody, not just in therapeutic relationships but anywhere, with anyone, or even by yourself – just notice what happens when things go silent; notice where your thoughts go, what happens to your breathing and where your energy is. So much of what is happening in our bodies and our psyche goes unnoticed as we rush from one thing to the next. Let’s experience the unexperienced, both in therapy and beyond.