NEWSLETTER
2004 Articles
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Rarely a week will pass without a journal article or information in some format relating to depression, or the management of depression, crossing my desk. Depression has become a much-discussed topic in our society. Learning to live with it and manage our lives when impacted upon by bouts or episodes of depression, can be a challenge.
How many of us as counsellors and psychotherapists work not only with the depression experienced by our clients but also with our own episodes of depression? Do we sufficiently consider our own experiences with this issue in the same way as the clients with whom we provide support? The articles included in this issue speak in different ways about working with depression. Perhaps it behoves us as counsellors and psychotherapists to reflect upon ourselves as well as our clients as we consider the immense challenges that working with depression can present. Karen Anderson
Reference: McWilliams, N. (1994) Psychoanalytic Diagnosis: Understanding Personality Structure in Clinical Practice. New York: The Guilford Press, p.229 |
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Depression has been the focus of a growing amount of publicity, as there is understandable concern about the prevalence of depression in various sections of the population. The concern has been such that the Federal Government has funded treatment programmes via general practitioners. While psycho-therapists and counsellors can applaud the recognition that is now being given to the problem of depression, something important can become lost in the process; namely, the recognition of the complex and multi-faceted nature of depression. Depression is not an homogenous or single entity. Not everyone experiences depression in the same way, or responds to their depression in the same way (Yapko, 1988). Not everyone has the same degree of depression, and certainly, many may not fit the DSM IV criteria for Major Depressive Disorder, but they're still depressed. And, the reasons for the depressive experience are not the same for everyone (Blatt & Bers, 1993). Recognizing these individual differences in the experience of depression has important implications for our psychotherapy with depressed people. In this article, I will look briefly at areas of individual differences in the experience of depression, and their implications for psychotherapy. These differences will be familiar to most counsellors and psychotherapists who work with depressed clients. INDIVIDUAL DIFFERENCES IN THE EXPERIENCE OF DEPRESSIONThe Phenomenology of Depression Michael Yapko (1988) has pointed out that people experience their depression in some domains more than in others, and he provides a helpful summary of these different domains. For some people it is predominantly in the physiological domain, such as sleep disturbances, lack of eating, reduced libido, while for others it is predominantly in the relational domain, where they isolate themselves or become increasingly dependent on other people. Or, it may be in the cognitive domain where there are obsessive, negative ruminations, and a global thinking style. For others it is predominantly in the affective domain where there are feelings of apathy, inadequacy and worthlessness. The poet Les Murray has indicated that one of the domains that is predominant for him in his experience of depression is the symbolic, as he refers to his depression as ‘the black dog’ that regularly visits him. Secondary Contributing Factors For most people who present to psychotherapy with depression, there is a range of factors in their life that have either precipitated the depression, or that contribute to its continuation. Each individual has their unique set of contributing factors, ranging from relationship problems, unemployment, work stress, relationship violence, destructive family systems, grief, or health problems. These factors may not be the primary cause of the depression, but they may prevent resolution of the depression if they are not addressed. Sometimes, they are not easily separated into primary and secondary factors, as for example when the work stress or the involvement in family systems is inextricably tied up with the primary issue of unmet emotional needs from early childhood. Primary Underlying Factors The primary basis of a person’s depression can be one or more different, and sometimes interacting, factors in a client's life. For some people, the origins may lie in early childhood experiences of loss, deprivation, insecure attachment, abuse, or rejection. For others, the depression is primarily due to existential difficulties, such as loss of meaning, an identity crisis, or becoming inauthentic in response to work or relationship demands. For others again, their emotional style is the primary underlying factor, such as being unable to experience or express the normal range of emotions, or turning unexpressed anger at others onto the self. Or, the depression may be based on identification with a pessimistic and self-critical parent. Co-Morbid Factors I am sure that many psychotherapists share my experience that few people present to psychotherapy with depression alone. It is often accompanied by co-morbid characteristics such as posttraumatic stress disorder, panic disorder, obsessive-compulsive characteristics, irritability, or emotional dysregulation. The client, the referring doctor, and the particular psychotherapist may have differing opinions about how these difficulties are related to each other, and which needs to be the priority in psychotherapy. To add to these problems, some people may not describe their experience as ‘depression’, referring to it in more colloquial and minimizing terms such as ‘a bit down’, ‘got the sads’, or ‘going through a rough patch’. Psychotherapy with Depressed People These individual differences suggest that we need to have some flexibility in our approach, so that we can adapt to the particular needs of the client. To begin with, the client’s unique phenomenology needs to be heard
and understood, while also discerning whether that domain is necessarily
the appropriate focus of therapeutic change. Decisions need to be made
by both the therapist and the client about the degree of priority that
is given to addressing primary, secondary contributing, and co-morbid
factors. The decision that is made will vary with each individual. Finally, the individual differences raise questions about the view that one particular approach constitutes the best, evidence-based practice. Apart from being based on a selective reading and interpretation of the research literature (King, 1998; Robinson, Berman, & Neimeyer, 1990), this view does not recognize the complex nuances of depression. Dr John Manners
References: Blatt, S.J., & Bers, S.A. (1993). The sense of self in depression: A psychodynamic perspective. In Z.V.Segal & S.J. Blatt (Eds.), The self in emotional distress: Cognitive and psychodynamic perspectives NY: Guilford Press. King, R. (1998). Evidence-based practice: Where is the evidence? The case of cognitive behaviour therapy and depression. Australian Psychologist, 33, 83-88. Robinson, L.A., Berman, J.S., & Neimeyer, R.A. (1990). Psychotherapy for the treatment of depression: A comprehensive review of controlled outcome research. Psychological Bulletin, 108, 30-49. Yapko, M.D. (1988). When living hurts: Directives for treating depression. NY: Brunner/Mazel. |
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This article is targeted specifically to improving co-operation between the different systems, agencies and professionals who may treat a given depressed patient from the perspective of a Public Sector Psychiatrist. In my experience the key factors in successful treatment of depression are:
Most care in the Public Mental Health System is provided in a multidisciplinary team context. The allocation of input is based on a combination of client need, staff roles and skills and resource availability. If the clients are in the community they have an allocated case-manager who is usually the best person to contact initially. The primary nurse or psychiatric registrar is the person to contact if the client is an inpatient. While clinically in charge of a team or service the Consultant Psychiatrist usually delegates the day to day running of the team to the attached Psychiatric Registrar or Trainee, as well as providing clinical input and oversight of the team The main underpinning models used are the: 1. BIOPSYCHOSOCIAL MODELThis model assumes that a person’s presentation at a given time is due to a range of biological, psychological and social factors and that these need to be understood and taken into consideration during management of the patient. Pragmatically this also involves an understanding of the available resources within the patient, the clinician and the system. Often a key resource for psychiatrists is their in-depth knowledge of the use of medication, their ability to prescribe and their access to institutional facilities. 2. STRESS VULNERABILITY MODELThis model assumes that all people have an underlying vulnerability to most disorders to a greater or lesser degree. The disorder then only becomes clinically significant if triggered by significant stress which could be psychological, physiological, pharmacological, social or a combination of these. Strengths have a protective factor. While most people are highly resilient, the higher the level of vulnerability, requires the least amount of stress as a trigger. The likelihood of recurrence is also greater and more input is required to gain a satisfactory outcome. Treating Depressed Clients Interventions and strategies proposed by most mental health practitioners are intended to create an effective emotional container, provide explanation and education and create a safe physical environment by some combination of:
The strategies will be identified after exploring vulnerabilities in order to identify any that are amenable to modification (family history, birth trauma, medical illness, early abuse or neglect). The selected interventions will range from providing counselling/psychotherapy for chronic stressors (relationships, financial, interpersonal, psychological, substance abuse, legal etc) through to physical treatments such as medication, ECT or hospitalisation depending on the range of resources available to the practitioner. We need to acknowledge that we are usually seeking similar intended outcomes for clients. We need to remain open to finding the specific mix that works best for THIS client, at THIS time, given THEIR current circumstances and OUR resources. As none of us can specialise in the full range of support services, and resources are limited in all sectors, especially public health, we need much greater levels of co-operation. Medication and ECT as Treatment Regimes As a psychiatrist, I want to conclude by presenting some of the benefits of including medication and ECT into a total treatment regime. Both are aimed at making the person more available to benefit from other treatment modalities. There have been considerable advances in psychotropic medications, particularly anti-depressants with some gains in effectiveness but mainly reduction in side effects. As a general rule of thumb, if a person has a particular indicated psychiatric disorder, a first line medication works for about 60% of people if taken long enough (>6 weeks) and high enough (up to the top of the recognised range – most respond before this) and consistently enough (most people have difficulty adhering to a medication regime – me included). If a medication doesn’t work, the options are to re-check compliance, diagnosis and other factors (eg recreational drugs, alcohol), change to a different class, increase the dose or add an adjunct (a booster medication). Most medications are required for at least 6 months, many for years and some are life long. Stop gradually, with a plan of action for a future relapse. The most effective treatment for a moderate to severe mood disorder by far is a course of electroconvulsive therapy (ECT). This works for about 85% of people with mood disorder and consists of a series of treatments (usually for 6-12 in all) 3 times a week, where a controlled seizure is triggered while a person is under a brief general anaesthetic with a muscle relaxant to minimise muscle movement to brief twitches lasting about 30 seconds. On awakening, they may be a bit groggy for a few hours and have a headache. The main risks, apart from memory disturbance which is primarily of non emotive life events around the time of ECT, usually returning over the next few months, are those associated with having a brief anaesthetic and very low. Some memory disruption is common when a person is at their worst as part of depression, under stress and as a side effect of medication. As a therapist dealing with a client who has had, or may need to have ECT, the main issues are likely to be fear of the procedure, and impaired retention of memory of therapy sessions held during a course and in the weeks soon after. A good source of information on mental health as practiced in Australia, and pitched at a health professional level, including learning packages is published by the Medical Journal of Australia and can be found at www.mja.com.au/public/mentalhealth. Dr Steve Baily
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This is a case study utilising movement with a client presenting with suicidal ideation and self-harming behaviour. In using the medium of movement, this client was able to express, explore and reflect on his movement experiences and work towards implementing strategies to resolve feelings of alienation and helplessness. Neil is a 24-year-old who attempted suicide by hanging. He is the youngest of three siblings and lives with his father, who is frequently away from the family. His mother is described as being "distant and aloof". She was treated for postnatal depression following Neil’s birth. At university Neil was described as an "A" grade student although he has always felt alone and unable to establish friendships with his peers. Neil stated that his girlfriend terminated their six-month relationship and following this he began to drink heavily. He indicated he remains isolated and disengaged from family and friends, becoming anxious and distressed when required to socialise. At the initial assessment Neil indicated he felt dead inside, frustrated, anxious and angry at the world, describing his mood as depressed. He felt it was impossible to change his world in anyway, depicting himself as being crushed inside a dark box, unable to see the world outside, feeling trapped with no way of escape.
Neil was extremely cautious and apprehensive about revealing his inner emotional state through the movement. On each occasion Neil attempted to open out the movement from the central axis of his body, his breathing became increasingly rapid and shallow. He developed a sense of increased nervous tension, evident through the fine motor tremors observed in his hands and the increased level of perspiration. In terms of time, his movement was sustained and delayed, as if he was lingering
in the space, very apprehensively moving forward. Neil very much
held back in his movement, rather disconnected and isolatory as
if fighting to protect ‘the self’ from further rejection
and psychological trauma, expressing strong feelings of fear and
anxiety. These characteristics suggest a personality, which is closed,
passive and aggressive. I could see reflections of rejection and
a sense of despair in a young man unable to articulate verbally
his inner turmoil. As a practitioner it was important to understand
the meaning of Neil’s recent suicidal attempt. This was not
a case of him seeing his life as being futile with no hope but of
expressing the emotional turmoil experienced within, a cry for understanding,
and for help to work through the turmoil and survival.
Neil was invited to explore the immediate space and encouraged to do some basic relaxation, the focus initially on regulating his breathing into rhythmic cycles before moving onto gently contracting the various muscle groups in his body. Whilst lying prone on the floor Neil began to shape his body into the foetal position and began to roll from left to right in a ritualistic type fashion. As Neil rolled from side to side he became increasingly absorbed and focused on the repetitions, with the movement becoming frenetic until it reached a crescendo where upon stillness and silence transcended into the space. He would hesitate and then reach directly upwards into the space as if reaching out for life. Facial expressions projected an image of desperation and sadness. Neil’s movement would become still and lifeless after he had recoiled back into the foetal position. This sadness experienced was reflective of a deeper plane of inner turmoil, trauma and depression. Levels of pressure were sustained, increasing as Neil repeatedly performed the ritual pattern of movement. The high level of sustained energy required resulting in Neil becoming physically and emotionally exhausted by the experience. Symbolically Neil described how his posture in this state was representative of being unconsciously crushed inside his mother’s womb, later identifying a similar experience visualized in his dreams. Neil interpreted the reoccurring movement patterns as being a representation of early experiences of abandonment and rejection during his developmental years. This symbolic interpretation became a constant reoccurring theme expressed through a repetitive use of space where Neil would run through the space, his arms spread out wide from his upper torso head extended and slightly tilted backwards as if ready to enter into flight. This represented to Neil a running away from rejection and the release of his inner anger. Through the movement experience, Neil began to develop an understanding of the psychodynamics that were impacting upon him and an awareness of the significance of the harsh contractions that he had experienced within his abdomen that then radiated throughout his body and limbs. Neil symbolically identified this as a representation of his birth into a world of rejection. Neil focused on this aspect of the movement with the objective to incrementally reframe the movement thereby empowering ‘the self’ to move forward. Through this process Neil was able to project the raw emotional characteristics and permitted the turmoil he experienced deep within, to be consciously reflected outwards in the movement. Neil stated that he felt emotionally and physically exhausted by his experience but on a second level that he experienced a sense of empowerment having been able to articulate, through the movement experience, reactions that otherwise were deeply suppressed within the self and projected outwards as depressive symptomatology. Neil sought closure by;
As the facilitator I stopped to consider what emerged for me from this experience? What increasingly became apparent to me was the role movement plays in addressing the real issues of ‘connectiveness’ in empowering clients to become involved within ‘the self’, using a framework of movement. Empowerment becomes the positive triggering force that enables a person to move forward in confidence. This was clearly observed in the change of movement patterns that previously were controlled, hesitant, closed and bound. Neil was able to move with confidence; his body movement being in rhythm, open and through all the dimensions of space. In conclusion, movement is the vehicle through which goals can be realized. The emphasis is on the movement, not necessarily the cognitive, behavioral, spiritual and psychodynamic dimensions. It is through the movement that the client is able to discover ‘the self.’ Stephen K. Hale
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Supervision within the fields of counselling and psychotherapy has gained its own unique position over the years and may be viewed as one of the central defining aspects of professional counselling. It forms part of reflective practice and is a source of support, learning and understanding (Carroll, 1996). It is quite separate from counselling and psychotherapy, from training, and from personal therapy. Like each of these, supervision is open to numerous approaches, styles and formats. Any discussion about supervision raises significant issues pertaining to responsibilities, ethics, relationships, core constructs about the therapeutic encounter, values, and contracts for debate. Most readers will have their own memories of supervision experiences - productive, insightful and otherwise. What makes for purposeful supervision? What are the key elements you, the reader, look for when undertaking your own supervision? In learning how to become a supervisor, one of my own trainers, Dr Anthony Williams, refers to ‘clinical wisdom’, ‘wisdom atmosphere’ and ‘supervisors striving to develop an ecological consciousness in which events and actions are related, and their long-term consequences reviewed’. Anthony’s excellent and resourceful text "Visual and Active Supervision: Roles, Focus, Technique" (1995) is highly recommended. Karen Anderson
Reference: Williams, A. (1995) Visual and Active Supervision: Roles, Focus, Techniques.
New York: Norton
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For over a decade counsellors have become increasingly attracted to narrative ways of working. While there are numerous narrative approaches in the field presently, this brief article on supervision as storying professional identities leans towards reflexive and interpretive understandings, and draws on the work of Michael White and David Epston (1990). In counselling and therapy people have the opportunity to speak about themselves; about other people who play, or have played, an important part in their lives, and the wider world in which they live. They tell and re-tell their experiences through personal narratives and cultural stories that weave together as they make meanings about events that have occurred over time. These narratives shape their sense of identity and provide the principal frame through which they interpret the past, form their views about the present, and influence the prediction of future possibilities. Similarly, supervisees’ professional identities will be created by the relational stories they hold about themselves and their practice. A supervision context will influence the selection and sequencing process of the storytelling, as will the hopes and purposes of the narrator (whether supervisor or supervisee) at the moment she or he is speaking. Supervisees will choose to talk about certain aspects of their counselling and leave out other features which the supervisor might commend or challenge. It is prevalent, and understandable, that supervisees often recount struggles and failings in their work, as they can be considerably troubled or confused about the progress of counselling sessions and unsure what step to take next. Supervisees may internalise these difficulties concluding that the lack of progress must be due to some personal or professional deficiency (or both) or, alternatively, an insufficiency in the client. The relational narrative practice of externalising conversations can assist them to step back from these negative personal and professional identity conclusions, and the dispiriting notions they may have reached about the people they are counselling. This provides a space for other, less immobilising, stories to emerge that in turn can bring promising options for assisting clients. As well, the narrative approach encourages supervisees to tell and retell stories of optimistic directions, breakthroughs, or turning points in their work. They are supported to perform and re-perform those facets of their practice that they, and the recipients of their services, consider to be life enhancing, invigorating and advancing of preferred ways of being in the world. Bringing forth these beneficial events into a storyline of professional competence for the supervisee has the potential to be positively transformative. As the stories of clinical work are told and re-told by the supervisee, questions are designed to elicit vignettes and reflective comments on values, attitudes, beliefs, and skills. When practitioners meet in a group, it is possible to structure these conversations along the lines of an outsider-witness collective (White, 1997) where colleagues join together to address similar struggles and contribute encouraging ideas. All practitioners work towards credible stories underpinned by the principles and morals of contemporary practice. While universalised codes of ethics or conduct are necessary for a variety of reasons, it is the lived enactment of those codes in the complexity of daily professional practice that is brought to the fore in supervision. A narrative approach recognises that these conversations are linguistic descriptions and do not simply re-present individual reality or the world as it is. As language is a social and cultural practice, supervision seeks to make transparent the relations of power that are always present. Any supervisor and supervisee do not just gather facts from which to make a better intervention; they are generating experiences from particular positions of power which contribute to the creation of identities - professional and otherwise. Conversations, and accompanying physical gestures, privilege at each moment certain realities and have profound consequences for the unfolding trend of the supervision. I believe potential supervisees must make informed choices regarding their participation in any supervisory relationship. At a first meeting with a prospective supervisee, it is my usual practice to interview the person about various matters (such as how they came to think of me as a possible supervisor, their histories of past supervision, and how they believe a narrative approach might fit with their counselling philosophy), and I encourage them to interview me about subjects they consider relevant (such as my values and beliefs on relevant issues, my professional and ethical stances on different topics, and my relationship to narrative practices). Expectations are clarified, responsibilities decided upon, and our positioning in the context of supervision made as transparent as possible. It is intended that this co-interview be carried out in a spirit of respectful enquiry and openness to possibly uncharted territories for both of us. Crucially, we participate in an ongoing appraisal of the possibilities and limitations of the meetings, and the specifics of what might enhance or inhibit the storying. Harvard psychologist Elliot Mishler (1999), in his narrative study of craftartists’ lives, questions the view that identity development is a linear sequence of coherent and continuous stages achieved individualistically. He takes a relational view of identity formation and reports significant discontinuities and variabilities. I believe these observations are highly pertinent to the supervisory relationship. Re-imagining supervision as the narration of professional identities that are in some ways continuous and coherent, and at other times discontinuous and contradictory, emphasises the multistoried and relational nature of our lives. Both supervisees and supervisors are required to discern and negotiate together their self-narratives and identities, embracing a day-to-day practice that is congruent with the values and ethics of professional counselling. Ian Percy References: Mishler, E. G. (1999). Storylines: Craftartists' narratives of identity. Cambridge: Harvard University Press. White, M. (1989). Family therapy training and supervision in a world of experience and narrative. Dulwich Centre Newsletter, Summer 1989/90, 27 – 38. White, M. (1997). Narratives of therapists' lives. Adelaide: Dulwich Centre Publications. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton. Winslade, J. (2002). Storying professional identity. The International Journal of Narrative Therapy and Community Work, No. 4. |
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Reflective Supervision I believe it is necessary for counsellors to go beyond the certainty of training programs, the confidence of qualifications and the comfort of the model, framework and techniques that provide us our initial bearings. Regular supervision over a year or over many years with quality supervisors is worth every penny (dollar) and effort to procure. Supervision based on an alliance with a practitioner’s unique learning style and personality structure opens doors, enabling the paradox and complexity of human beings to be welcomed into the consulting relationship. The melting pot of supervision can shine light on client work, the counsellor’s identity, role boundaries and ethical challenges, as well as the powerful collective forces in society impacting on ordinary people. Supervision at its best is a re-sourcing well, allowing for spontaneity and creativity to arise alongside the testing measure of collegial practice. It is the antidote to burnout, staleness and grandiosity. I have noticed a curious phenomenon following my own supervision and in providing supervision to others: the solutions and ideas developed in the supervisory session are seldom what is acted on with clients. Rather supervision seems to free the practitioners’ confidence and creativity to respond with freshness in the moment. The reflective process continues to be active for some time following supervision. Often a shift occurs in the counselling stance or way of holding the client in the mind resulting in a leap forward just before the next client session. Occasionally these shifts in awareness occur whilst sleeping. I awake knowing what needs to be attended to or how to be in the next session with a client. Even more curious are the times when clients arrive already in a new place as if they were aware of the shift in the practitioner, as if they had participated in the supervisory process. The Supervisory Lineage I consider myself fortunate, indeed blessed in having at every point of my professional developmental pathway a supervisor of exceptional quality. Each provided a strong sense of personal connection and a daring degree of freedom in which to explore the reality of my professional experience. The challenges in my earlier work as an occupational therapist and lecturer and more recently as a psychotherapist and trainer were engaged with in such a way that my supervision sessions consistently made a difference to my practice. They provided encouragement to enquire, reveal, wonder, feel, and think rather than intellectualise, worry or self-doubt - all of which I am prone to. The fruit of sharing with my supervisors the struggles and uncertainties in my consulting work over the years has become a solid confidence, calmness and willingness to be surprised. This lineage of supervisory engagements is alive and active within my flow of consciousness, available as an ongoing inner dialogue. Images, or rather presences arise in moments of musings -about sessions, about me in my work, about my client adding to the reflective conversation. As I write, moments of connection, insights and people who have been there for me come to mind: Joyce Reid’s pacing as she smoked in our weekly ‘meetings’, passionately respectful of the paranoid man who knew things through the television and trusted no one (1967); Dr Ron Hemming’s warmth and delight in the depths and uniqueness of the undercurrents in a person’s life drama as expressed through their psychosis, his fine psychoanalytic musings that revealed a secret garden of meanings to a young O.T. (1970s); Dr Max Clayton’s persistence when a year of weekly supervisory sessions conducting my first psychodrama group would regularly trigger a shame attack before I arrived, leaving me speechless and minus memory (1979); Lynette Claytons’ rock steadiness in the supervisory hour following the weekly three-hour psychodrama session which she was present at, her later insistence when supervising me as a trainer to focus through holding authority in relation to the training standards rather than my favoured fallback of self-doubt (1980s), her unshakeable belief that I could do it; Dr John Manner’s willingness to share the shadows that fall on the therapist in walking alongside the terrible experiences of traumatised people (1990s); Dr John Penman’s sustaining attention to the nuances of connection in the long dry work of extraordinary minutia in my traumatised client’s struggle (2000s). I am not alone in my consulting room. I am in good company. The supervisory process is with me and sends me awareness, ideas, dreams and, sometimes, disturbed sleep. My inner supervisor is there to appreciate a particularly satisfying launching session when the sparkle returns to a client’s eyes and life is juicy again. The inner supervisory relationship formed from the experience of supervision carries depth, colour, fearlessness, enduring reliability, and a power of attention and thought-fullness that is sustaining to the practice of counselling. Group Supervision There are special opportunities for learning when practitioners form small groups or pairs for supervisory purposes. There are also some pitfalls. Because people seek supervision to both validate competence and expand learning there are special vulnerabilities and dilemmas of power that make supervision more prone to the possibility of shaming and anxiety than does the counselling relationship. This is particularly sensitive in group supervision where people are exposing their competence and (fear of) inadequacy before peers and perhaps line supervisors and managers. In addition there may be rivalry elements emerging from differences in therapeutic training and traditions as well as differences in personality structure and style. The stakes are high in terms of standing-in-the-world, relationships between equals, social friendships, referral systems and indeed financial generativity. Because of the potential for shaming, flooding, or fragmenting the counsellor
in their role, I like to negotiate a clear structure for group supervision
that reduces the risk for individuals in group supervision. I work to
avoid a supervisee presenting a concern then having the experience of:
There is some danger in group supervision that the supervisee might end up feeling like a client who is too dysfunctional to ever be a counsellor and then needs a recovery process from the ‘supervision’ (visit to the dentist phenomenon). At some time, I have experienced being on the receiving end of all of these responses in a group supervision. The comfort is that the recovery process has produced a more sensitive supervisor. Sharing a common training experience or psychotherapy model as a basis for a shared language and picture of the work reduces the risk of being critiqued, discounted or intruded upon by colonising forces in a group. I participated in a one-year study group with people of diverse training and qualifications which focussed on a common interest in self psychology and engaged a number of self psychologists as supervisors. This group was able to maintain mutual respect and increasing freedom of professional disclosure as trust developed in one another. Similarly I have been part of a supervision group formed following a workshop on counselling sexually traumatised clients. The group included those from diverse professions and continued to meet regularly for a year. In my own workplace at The Wasley Institute we have experimented with a number of versions of peer supervision. The current model involves the presenting supervisee first informing the peer group as to the form of participation requested in responding to the material presented e.g. ‘what I am most interested to hear from you is what you notice your inner experience/response to be as I talk about my work with this client’, or ‘I want to hear your associations to this client’s story’, or ‘I want to hear what premises you would use to think about this ethical dilemma I am facing’. Whilst not absolute about this, on the whole I do not view group supervision as a forum for resolution of interpersonal collegial conflict arising from organisational structures and authority relations. While such concerns are well managed in individual supervision these can easily contaminate the reflective group space in which client-counsellor relationships need protection. Collegial conflicts may emerge in the group supervision setting, however they are better managed in meetings designed to attend to colleague relatedness and may benefit from the assistance of an organisational consultant or group facilitator. Susanna Howlett |
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I am a great believer in supervision as one of the key activities to learn psychotherapy or counselling as a clinical practice. I was fortunate to receive supervision that was so compelling that I simply wanted to continue long after I graduated from training. I saw R.D. Laing weekly for 8 years and John Heaton over the course of 17 years, mostly weekly. John and I discussed texts as well as cases. I also had group supervision with Christopher Bollas. In Australia, I was fortunate to receive a profoundly understanding and supportive supervision from a senior therapist some years ago when I was struggling with a boundary issue with one patient. In addition, I have both given and received some stimulating peer supervision with a number of colleagues and especially with my Churchill Clinic partner, John Lunghi, who has an incisive and highly psychoanalytical understanding of clinical material. I’ve been asked to write something about my supervision experience with Ronnie Laing and the following excerpts have been extracted from my chapter in a book called "R. D. Laing Creative Destroyer".
I will close with a brief suggestion for supervisees. If you want to make the most of the opportunity of supervision, then try to capture significant vignettes of dialogue between your clients and yourself. Therapy is a relationship that revolves around (usually) verbal exchanges. Filling supervision sessions with potted biographies of your clients misses the relational and specifically linguistic exchanges that constitute the therapeutic inter-action. Especially if we work with the unconscious, then we need to attend to the flow of language and its confusions, distortions and omissions between us. Jan Resnick References Laing, R.D. (1985) Wisdom, Madness and Folly: The Making of a Psychiatrist. McGraw-Hill Mullen, B. (ed) (1997) R.D. Laing: Creative Destroyer. London: Cassell
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Newsletter No. 29 March 2004
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Viewed by some as a dull topic, obtaining an understanding of ethics is nonetheless crucial in forming a sense of self, as both a professional and personal ‘self’, contributing to life within a community – at a local, national and global level. Most professional associations and organizations have within their structure a Code of Ethics governing standards of practice. What do codes of ethics tell us? How relevant and important are these codes? Are codes of ethics simply a set of rules and guidelines for knowing how to act and behave – a set of do’s and don’ts? Sophie Holmes, Chair of the Ethics Committee of PACFA writing in the recent PACFA News challenges this thinking. She raises the concept of thinking about a code of ethics as a process for decision-making and as a form of procedural knowledge. She aptly indicates that: "Professional Ethics now becomes a quality and characteristic of the relational and clinical expertise of the counsellor or therapist, implying a desire to learn, to critically evaluate what we do and why we do it, to accept that we make mistakes and that we need to learn from them." When pondering how to tackle the subject in preparing this newsletter I kept thinking about the questions, "What is the difference between a person who lives by ethical standards and one who doesn’t?" and "Where did my knowledge of being ethical originate from?" Refining a discussion more specifically to the field of counselling and psychotherapy, Rosemary Kent states, "Some colleges and university based courses place more emphasis on intellectual ability than on personal suitability as a practitioner and do not have systems in place for preventing trainees who are inappropriate on personal or practice grounds, from qualifying." So, from the point of entry into the professional field of counselling and psychotherapy, ethics has a place of significance. As practitioners we’re exposed to dilemmas involving relationship, competency, confidentiality, responsibility and referral issues to name just a few. An ethical framework helps to guide and inform our clinical practice. But what is it that we really need to know about ethics in order to become effective practitioners? Dr Grace Tarpey, provides us with a good entrée in her article in this newsletter, "The Ethics of Psychotherapy and Counselling from a Philosophical Perspective". It is food for thought, before the presentation being given by Dr Susan (Pradip) Griffiths at the Professional Development Seminar to be conducted on Wednesday 3rd March. In the course of her presentation Dr Griffiths will be referring to the PACAWA Code of Ethics. I recommend readers to read the PACAWA Code of Ethics again prior to attending the presentation. You may also be interested in reading some of the references listed in Worthwhile Resources. Karen Anderson
References: Holmes, S. (2003), Ethics and Excellence in Clinical Practice. PACFA News Edition 10, p.9 Kent, R. (2003), Can therapists be taught to be ethical? Counselling
and Psychotherapy Journal Vol. 14 No. 2, pp. 18-21, British Association for Counselling and Psychotherapy, March 2003
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According to the philosopher, G. E. Moore, "ethics is a subject about which there has been and still is an immense amount of difference of opinion" (Moore, 1958, 7). Consequently, Moore argues that ethics cannot be defined and calls instead for a simple negative doctrine of ethics, focussing on what ethics is not. He does however end up with a minimalist idea of the "Good" that is based upon the enjoyment of aesthetic life and personal relationship. This position stands in direct contrast to classical ethics as it was initially set up by the ancient Greek philosopher, Aristotle. Very generally, Aristotle defined the ethical goal of life as eudaemonia or long-term happiness. For Aristotle, happiness is accomplished by living a good life and, in order to attain the good life, there is a need for virtuous character. In turn, virtue can only be brought about by critical reflection and rational deliberation as well as training our habits to follow the middle path of moderation, especially between the two extremes of pleasure and pain. Virtue then is a trained habit but, more fundamentally, ethics, as Aristotle stressed, requires complex rational thought. Furthermore, through the human faculty of reason, ethics can only achieve its realisation in the good and just order of the polis or society. In classical Greek philosophy, ethics and politics were inseparable. In a parallel fashion, the individual and the state were also understood as inseparable. Self and society both shared the same ethical end of achieving the absolute good. Most recently, contemporary philosophers argue that ethics should not be equated with pure reason or absolute truth, nor with politics or how to live one’s life in accordance with a universally defined good society; rather they contend that ethics belongs primarily to the realm of the personal self-other relationship. The contemporary philosophical milieu is oriented towards understanding ethics as approaching the other personally as different from oneself. It highlights difference - the other person as other then me, whether the other is from another society, female, black, homosexual, religious, whether the other has blue or green eyes… This means that ethics involves the self as separate enough to live within the boundaries of its own self so as not to project into the being-ness of others. Ethics occurs when the individual makes the effort to be separate, to be singular, for the sake of avowing the other person in terms of their own unique difference. Separation of the self then is absolutely crucial if the other is to be respected as other, different from the self. Arguably the most significant philosopher of ethics today is Emmanuel Levinas. For Levinas, ethics is always a question of difference and alterity - that is, the radical heterogeneity of the other whereby the other is irreducible to me. Ethics means that I cannot reduce the other to the same as myself. S/he is fundamentally different. Nowhere can this be discovered more than in the personal face-to-face relationship. For the face-to-face relationship is fundamentally particular and specific in itself and in the way that the self can approach the other. It is unsurpassed by the sheer positivity and enjoyment of sincerity, vulnerability, sensibility, sensitivity and sensuality. The most recent and adamant statement Levinas makes about ethics is that it is essentially related to responsibility. He argues that the very meaning of the self is responsibility for others. The self is a self as such in that the "I" exists in relation to an other. This is a paradox but I interpret this to mean that the starting point for ethics is the responsible self, responsible in terms of an "ability-to-respond" to others. And the ability to respond comes from the self, a singular being who is separate. For Levinas, separation is accomplished by holding oneself up within the interiority of the self. In order that the ethical relation exist, there must necessarily be a "unity of the I". The self can welcome the other only by being separate, by being "implanted in itself", in its "own dwelling space", in its own "interiority". My question to Levinas is "how"? Clearly, the individual is understood now as the site of ethical possibility. However, philosophers including Levinas cannot respond to the question of "how" it is an individual can sustain dwelling within the ideal "unity of the I" without projection and internal conflict. How does a self become integrated and sustained enough beyond the traumas of abuse and violence, depression, narcissism, neurosis, etc, and separate enough in order to be rational, responsible, mature? It is my contention that the point of how to be ethical essentially goes beyond philosophical solutions and truths to "process". The ethical needs to be processed and practised beyond a mere application of knowledge – and this is where therapy is helpful. For me, Aristotle’s ethics most closely approximate cognitive behavioural therapy with his emphasis on rational thinking and changing habits and behaviour – this ethic primarily involves an application of the "right" social knowledge. Moore’s ethics on the other hand pertain to classic psychoanalytic therapy because it allows for an aesthetic ethics of negativity, while Levinas’ ethics embrace the positivity of the increasing emphasis on relationship in psychotherapy. In order to appreciate how the individual accomplishes an ethical disposition I focus on psychoanalysis as a philosophy largely because it offers a powerful account of the singularity of the human subject in terms of the internal otherness of the self. Unlike Levinas’ "unity of the I", psychoanalysis deems the self as split between conscious and unconscious forces, divided between rational thought and imaginary pre-linguistic fantasies, fragmented between language and culture on the one hand and emotional experience on the other. It is in this way that psychoanalysis offers ways of thinking that open up an understanding of "internal" subjective life that actually realistically allow for the human capacity to be ethical. Psychoanalysis leads us to the question of what motivates a person in the first place to desire to make the effort to be ethical in the face of an other, for that other. I want to make it clear here that, although I refer to psychoanalytic philosophy for an understanding of ethics, I am writing about the use of this kind of thinking to inform principles at work in the multifarious practices of psychotherapy and counselling as well as the practice of psychoanalysis itself. Philosophy asks the "what is" and "why" questions but I am arguing that it is the practice of therapy which can deal with the "how" question. Nonetheless it is still my belief that psychotherapy and counselling need to be informed by philosophy, not least because ethics is fundamentally a branch of philosophy. The infamous psychoanalyst Jacques Lacan wrote a book entitled "The Ethics of Psychoanalysis". In it he states categorically that in the final analysis, ethics requires the reconstitution of the self in relation to one’s own desire. Ethics, for Lacan, is the "activity of living in conformity with the desire that is within you". Desire, he argued, emanates from lack. What is desired is what the self lacks, what is other to the self. Projection occurs when what is desired (the Ideal Other - whether that be the perfect romantic partner, God, country, creed, etc) is looked for in others. However, if in therapy we can look at and live with our own desire, where we lack, we can avoid the unethical behaviour of projection and create a simultaneous space for the other to be and become who s/he desires. This is clearly in keeping with Levinas’ ethics. The main difference for Lacan is that he emphasises how this is an arduous task related to the unconscious; that it is psychoanalytically informed therapies which challenge projective forces because they involve dealing with the distress and anguish which each self bears in her or his relationship to the abyssal weight of the interior void and to death. Therapy is a difficult process of enduring the conflictual relation between death and desire within - for the therapist as well as the patient. Ultimately though, it is the therapist’s ethical responsibility towards the patient, which allows space for the painful experience of enduring desire. In turn this creates the ethical condition for an opening of the patient to others who are different. Julia Kristeva, a Freudian psychoanalyst, acknowledges Lacan’s contribution to psychoanalysis on the nature of desire. She maintains that it is ethical for the subject to confront one’s own relation to desire evolving from lack. However, in addition to the ethical imperative of separating the subject’s desire from others, she also maintains that it is fundamental to imbue desire with the meaning that desire has for an other, in relationship with others, in emotional bonds. She shows how historically psychoanalysis has developed more and more to understand internal otherness in relationship with the other as mother. The concern is the singular separate self still but we need to understand this separateness in the light of how we come into being in relation to maternal otherness. The mother as other is understood here as internalised otherness and it is heterogeneous. Kristeva says " it is of course a body that invites me to identify with it but it is a non-me in me, beside me outside of me, where me becomes lost". What we are discussing here then, in terms of the actual singular self, is the way the mother as object becomes internalised in the child’s mind as phantasmatic. This is very important in the practice of therapy for the phantasmatic mother is the sin qua non of separation. She is the fantasised, idealised and hated mother who, if not separated from, (s)(m)others singularity. Primarily, we have to separate from the (m)other if we are not to project her, emotionally and psychologically, onto other persons. Therapy practices confront the phantasmatic mother thereby opening the self to the letting go of and the mourning of her. Though mourning may seem impossible, it is through this grief - psychic space and time – that subjective life is given. Moreover, the loss of the mother is our first step towards being autonomous and therefore sovereign in love. In separating from the mother, the "I" assumes singularity, and therefore a time and space for love. Here then is elaborated an ethics of love, in that ethics allows for bonds as well as desire, albeit bonds based fundamentally on loss. The self evolves ethically – in relation to others - the more s/he allows for loss. In sum, the bottom line for the ethics of psychotherapy and counselling practices is that of being in a relationship that commands responsibility, that is, the ability to respond to the other as other. The concern for us as clinicians lies with the singularity of the wounded self, their otherness. The ethical task of the therapist is microscopic – to listen, to listen as attentively as possible to the soul of the subject. For, before we can destroy the suffering we have to connect with the soul it inhabits. Empathic connection with the soul in turn allows for enduring the painful and difficult separation from within the realm of maternal otherness. Accordingly, we can adumbrate an ethos for psychotherapists and counsellors to actively not give in where the patient’s singularity is at stake. We are responsible for an ethical space that allows the singular self to evolve out of the ashes of loss and I believe we need to bear up to the work by having gone through the process ourselves. Therapy that provides the patient with a space to withstand loss can only do so because the therapist can withstand it. Ethical therapeutic practices tolerate and even rejoice in the difference of others and in turn generate this capacity in patients. Psychoanalysis simply acknowledges the internal fission of being a self. Lest we forget, there is a war going on inside. With some, there are terrorist activities operating. Psychotherapy and counselling practices attend to wars of all kinds, to the cataclysmic violence of the death of otherness and its un-hole-y projection – in order to let others be-come, in order to love. This is ethics. Holding this in mind, processing it within oneself as a therapist, it follows that ethics can be adhered to in terms of both general and specific principles as well as the spirit of therapeutic relational practice. Thus the PACAWA code of ethics can only but be spontaneously embraced. Dr Grace Tarpey
References: Kristeva, (1989), Black Sun: Depression and Melancholia. New York: Columbia University Press. Kristeva, (1987), Tales of Love. Trans. Leon S. Roudiez. New York: Columbia University Press. Kristeva, (1987), In the Beginning was Love: Psychoanalysis and Faith. Trans. Arthur Goldhammer. New York: Columbia University Press. Kristeva, (1994), New Maladies of the Soul. New York: Columbia University Press Kristeva, (2000), Melanie Klein. New York Columbia University Press Lacan, J., (1992), The Ethics of Psychoanalysis 1959-1960: The Seminar of Jacques Lacan. Ed. Jacques-Alain Miller. Trans. Dennis Porter. London: Tavistock/Routledge. Levinas, E., (1979), Totality and Infinity: An Essay on Exteriority. Trans. Alphonso Lingis. The Hague: Martinus Nijhoff. Levinas, E., (1986), Dialogue with Emmanuel Levinas (Interview with Richard Kearney), in Face To Face With Levinas. Ed. R.A. Cohen. Albany: State University of New York Press. Moore, G.E., (1958), Ethics. London: Oxford University Press |
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Like
many colleagues I was delighted to have the opportunity in May to
participate in the seminars conducted by Dr Nancy McWilliams, a
gifted psychoanalytical psychotherapist and stimulating trainer.
As Dr McWilliams reminded us, "… a substantial proportion
of psycho-therapists are characterologically depressive. We naturally
empathise with sadness, we understand wounds to self-esteem, we
seek closeness and resist loss, and we ascribe our therapeutic successes
to our patients’ efforts and our failures to our personal limitations."
In her book titled "Psychoanalytic Diagnosis: Understanding
Personality Structure in the Clinical Process" (1967), Dr McWilliams
quotes Greenson and writes "in commenting on the connection
between a depressive sensibility and the requisite qualities of
successful therapists (Greenson) went so far as to argue that analysts
who have not suffered a serious depression may be handicapped in
their work as healers." (p.229).
From a movement perspective, Neil’s body movement broadcast the message
of a person who was in conflict within, clearly identified by his body
being curled, head looking down, shuffling, arms bound in front close
to his torso. His movements were sustained, slow moving, hesitant, creeping,
while also avoiding eye contact. He was unable to follow through with
clear stepping movements, appearing to have heaviness in the quality of
his movement. Such characteristic restrictiveness is indicative
of his presenting symptomatology of depression.