The therapist’s conflict – a precious ingredient in the therapeutic encounter

How to Work When the Client’s Conflict Becomes the Therapist’s Conflict

Traditional academic teaching of counselling and psychotherapy assumes that our discipline is similar to any other subject - whether we are learning history or engineering or psychology, there is a body of knowledge and a range of models that we need to absorb and apply, and that we get examined on in order to achieve our qualification. And like a 'doctor for the feelings', our work supposedly consists of applying our theoretical understanding to the particular person (or the specific 'case') in front of us, much like a doctor would apply medical understanding and scientific theory.

Whether our theoretical understanding is based on person-centred assumptions of the core conditions, self-actualisation and our own congruent presence, on transactional analysis or CBT assumptions about the client's scripts or schemas, or on psychodynamic assumptions regarding developmental stages, object relations and the transference, supposedly - across the modalities - we are all applying our particular theories to our particular clients.

Admittedly, as the only tool of our work is our own complex 'self', our discipline distinguishes itself from history or engineering in that we obviously need to develop our own self-awareness, through our own process in therapy, through experiential group work, through continuing self-reflection and supervision. But in terms of the actual academic element, the assumption is that we learn our theory, particular to our therapeutic approach, with its corresponding models and concepts and assumptions; and out of that theory arises quite logically a particular way of working: a set of interventions and techniques and methods which are designed to apply the underlying theory and make it ‘work’. And the assumption is that if we - as well-intentioned and empathic practitioners - apply these sets of theories and techniques thoroughly and coherently, the therapy we will end up practising will have the desired effect on our clients.

However, the more we learn and develop and practice our craft, the more we tend to feel that these assumptions do not capture the heart of what we actually do and what we struggle with every day.

For a start, we know - and we are quite explicitly told by our elders - that the therapeutic space does not depend predominantly (let alone exclusively) on quick thinking, assured interventions and a sense of certainty. On the contrary: the therapeutic process appears to become deeper and more effective, the more uncertainty the therapist can allow as a significant feature of the atmosphere and their own inner experience.
And the longer we practice, the more obvious it becomes that any idea of a linear process, which supposedly takes the client out of the depths of their problem towards the heights of a ‘solution’, is misguided. The idea of such a linear process, as if therapy was a simple journey up a predictable mountain, with the client getting better from session to session until they reach the lofty heights of insight, self-understanding and psychological health, does not match our day-to-day experience in the consulting room – we find that such ideas and ideals of a linear process are actually inhibiting and destructive to what we are trying to do.

Yes, to the unsuspecting public it may seem fairly straightforward to listen actively and empathically like a good friend would, to provide insight and psycho-education, to deliver reassuring and normalising interventions, to take the client through relaxation and mindfulness exercises, to offer links and interpretations. But in order for any of these offerings and interventions to actually have the desired effect, to reach the client where it matters, to connect with the client's inner world, to link with their 'neuro-plasticity', it is not enough to deliver them effectively and professionally.

As Winnicott observed: it is not mainly the therapist's 'doing' of interpretations, but the therapist's 'being' which they arise out of that matters more. It is at that point that being a therapist stops being straightforward, and becomes a complex vocation, where unlike medicine and engineering we find ourselves in a hall of mirrors, where our own subjectivity becomes an inexorable part of the job.

When we pay attention to the detail of our ‘being’, our inner experience as therapists moment to moment (especially when we do not just include our stream of consciousness in terms of thoughts and fantasies, but also our whole bodymind experience), we notice it is full of conflict: conflicting feelings, conflicting perceptions, conflicting thoughts, conflicting ideas and therapeutic impulses, conflicting notions of what is going on or what is important, conflicting tendencies towards self-disclosure or not, conflicting theories and interventions which may be appropriate or not.

It is in processing these conflicts that we discover parallels to the client's conflicts (even though these may be unspoken, unthought and unconscious) which we have absorbed via empathy, through active identification with the client's experience or more passively via projective identification. As Freud observed, although it flies in the face of modern conceptions of individuality and though he did not understand the mechanism by which this occurs, the unconscious of one person can communicate and is linked directly with the unconscious of the other.

The laboratory of the therapeutic hour gives us privileged insight into human relationship, in a way that is rare in other contexts. In attending to our own conflicted experience and subjectivity within the therapeutic position, we recognise manifestations of the client’s unconscious conflicts.

For teaching purposes (see workshop on 21 March 2015) I summarise this recognition as: the client’s conflict becomes the therapist’s conflict. This is the key insight which constitutes what in the history of psychoanalysis we call the 'countertransference revolution': the recognition that our inner experience as therapists - our countertransference in the widest sense - is not only a disturbing obstacle to our otherwise neutral therapeutic position - it can also be another 'royal road' into the client's inner world and into the heart of the therapeutic encounter.

What appears to be - in humanistic terminology - our own 'stuff' (to be taken away and processed in our own therapy) is interwoven and interlinked with the client's 'stuff' in a way that cannot be neatly divided apart and segregated.

This is what two-person psychology and intersubjectivity is all about: we are engaged in a co-created encounter, where we do not have the privilege of a secure, outside position - no fixed point from which we can use some Archimedean lever to leverage the therapeutic process when it appears to be going down the plughole.

When the working alliance breaks down and we are caught in destructive or negative enactments, there is no way out, only a way in: the transformation of the enactment needs to occur from within the dynamic that we feel caught in. What helps us in these moments is not theory or understanding, but to surrender to what these days is called ‘implicit relational knowing’.

CPD Workshop in Brighton: 21 March 2015

 In the workshop I will be running on 21 March 2015, we will explore ways of enhancing our embodied understanding and our capacity to access such ‘implicit relational knowing’.

The vicissitudes of therapeutic assessment

The following piece was written in preparation for a training day on “First Sessions and Initial Assessments”.

Whether it is an assessment at school, university or at work, or by a medical specialist or other expert, the question always is also: “do I feel seen as a person?”
It is in the nature of assessment that a supposedly uniform, objective set of criteria gets applied to us, raising the question as to whether our subjective sense of self is being recognised, taken into account and appreciated in the assessment.
This tension between an objective, outer description versus the subjective inner reality becomes more charged and obvious in counselling and therapy, whether we are being assessed as clients, students in training or as qualified practitioners.
When coming to therapy, many clients demand from us a quasi-medical diagnosis of their ‘condition’ and ‘prognosis’, and some feel relieved when they get it. However, the longing to feel deeply seen and met in our unique subjectivity – with all our flaws, wounds and potential – is just as present.
As practitioners, how do we do justice to that tension, which is present especially in a first meeting and initial assessment?
How do we establish a working alliance, when the client is both demanding to be judged as well as afraid of it or resistant to it?

On the level of the words and explicit communication, the client may be asking whether they are indeed a borderline, or a manic-depressive or whatever label they are fishing for, and these are - of course - legitimate questions. But implicitly, there may be other questions which would simultaneously be asked and answered: "am I hopeless case?" "is it all my own fault?' "is my pain real?" "did I bring this upon myself?" "am I just being a bit lazy or stupid, when really I should pull my socks up?" Whose questions are these? Whose opinions and perceptions are we confirming or opposing?
The presupposition of such questions is that the problem rests in one individual (usually presumed to originate in some genetic disposition or biochemical given) - there is very little room for exploration of the possibility that 'the problem' may be co-created, that a family's biochemistry is interwoven with each other and that the symptom may be systemic and not reducable to one pathological individual. These kinds of considerations are already ruled out by the way the questions get asked, creating dilemmas for the therapist who rightly finds it impossible to give straight 'yes' or 'no' answers to them.
Therefore, what is omitted in this assessment set-up is the recognition that the question lies in the eye of the beholder - and not just the therapist, but also the client's internal and external beholders, observers, judges who constitute the intersubjective context in which the client is being pathologised. This intersubjective field exists long before the therapist is asked to step into it and perform the assessment, which can therefore never be 'objective' and 'neutral'. A good therapist doing an assessment perceives, responds to, takes into account this pre-existing field of opinions and judgements and identifies with or against them, creating an intersubjective entanglement which underpins any attempt at 'objectivity'.

The therapeutic professions have not entirely emancipated themselves from the idea that impersonal objective assessments - in and of themselves - are either possible or useful. However, our therapeutic principles and understanding tell us that “it is the relationship that matters”. Therefore, the heart of our work depends on our subjectivity – the only tool we have at our disposal is our self; that is all we can work with, for better or for worse. If – in pursuit of exclusive objectivity, academic uniformity and quasi-medical accountability – we try to eradicate the vagaries of our subjectivity from our practice, we destroy the essential foundations upon which our work depends.
Any supposedly 'objective' assessment is situated within and contextualised by the intersubjective relationship in which it occurs - whether the supposedly 'objective' facts or 'truths' are helpful or not does not mainly depend on the information that gets imparted in the assessment: the effect of the assessment depends on the relational dynamic within which it is delivered.

The same thing is true, of course, in our training as practitioners: many students who enter counselling or therapy training of some form or another regress back to school, assuming that success depends on similar principles and therefore take refuge in similar roles and survival mechanisms (becoming good, cooperative pupils or delinquent, protesting renegades, or anything in between).
This kind of transference which a student brings to their training is not dissimilar from the kind of transference that occurs in therapy: the same schemas, scripts and adaptations which we developed in school become reactivated in training. And to some extent the success of any therapeutic training depends upon the degree to which the student’s ‘habitual position’ (with its characteristic defences, anxieties and underlying impulses) can be addressed and worked through during the training, in therapy, in experiential groups but also in the training itself.
It was Carl Rogers who recognised that counselling training is likely to be more effective and productive if it encourages students’ self-directed learning, i.e. if the means and the ends of the training are congruent and coherent: if we are aiming for a profession of practitioners capable of independent reflective practice, then a traditional educational paradigm with its hierarchical and ‘other-directed’, pre-defined and imposed curriculum, format and structures is likely to create more problems than it solves. However, since the early 1990’s most counselling and therapy training has shifted significantly towards a standard academic paradigms, even if that does include some experiential process and practice.
What we notice in supervision is that many therapists arrive in their practice as supposedly independent reflective practitioners with ingrained ‘super-ego’ projections onto the profession and its organisations: many supervisees come out of training carrying fairly linear assumptions about ‘correct’ practice, and the supposed ‘rights’ and ‘wrongs’ of how to be a good therapist. These kinds of assumptions and habitual patterns effectively undermine the therapist’s sense of therapeutic authority and therefore the therapeutic space they are able to provide for their clients: in very immediate, nitty-gritty terms, these unresolved transferences (to the supposed authorities of their training and their profession, manifesting in compliant, inhibiting and deferential attitudes) interfere with the therapist’s responsiveness, spontaneity and creativity in relation to their client. The therapist does not feel free to follow their intuitions, lest they are in danger of being sued and struck off the register.
This kind of defensive practice in an increasingly litigious culture is well-recognised in medical circles – in the end, it does not serve anybody: it fails the client, and it fails the vocational passion of the practitioner, who resigns themselves to going through the motions.
These kinds of tendencies in ourselves, in our colleagues and in the profession at large are inimical to the depth of relational practice which we want to pursue (and which attracts us to the profession in the first place). The more we explore the depths of the relational encounter at the heart of the therapeutic process, the more we recognise that the traditional models of therapy do not do justice to the vicissitudes and dilemmas which the therapist experiences.
Following Petruska Clarkson (1994), we recognise that the therapeutic space consists of diverse, distinct and mutually contradictory relational modalities, which each have their validity, but are in constant tension with each other. As a therapist, I cannot hope to do justice to the client and to their psychological conflicts if I short-circuit the inherent relational complexity by imposing simplistic, linear instructions upon myself. The psyche is not linear, the therapeutic process cannot be linear, so my relational response must not be linear, so ideally my training and supervision and professional community does not model, uphold or insist upon linear ideals, borrowed and imposed from other scientific disciplines and educational paradigms.
As many of the elders of our profession have expressed: uncertainty, ‘negative capability’ and a capacity for sustaining helplessness are more important qualities and faculties for a therapist than knowledge, skill and competence. We want to be as open as we can to a multitude of relational configurations and relational spaces. Conversely, we want to impose as little dogmatism and habitual fixity on the therapeutic position and how we construct the therapeutic space (in order to maximise our capacity to be sensitive to how the client’s unconscious constructs the space).
Whether we use Martha Stark’s seminal distinction between ‘one-person’, ‘one-and-a-half-person’ and ‘two-person psychology’, or Clarkson’s distinction between working alliance, reparative, authentic and transference/countertransference modalities, ideally the therapeutic space I provide allows for all of these possibilities, unimpeded by linear ideas of the ‘rights’ and ‘wrongs’ of what should happen. This then allows me to notice that these different modalities are in constant dynamic tension with each other, creating transformative rupture-and-repair cycles in the therapeutic relationship which therefore can become as developmental as a ‘good-enough’ early attachment relationship.
These ideas become relevant in any kind of assessment we conduct: from the first moment that a client (or a student) makes contact with us, we attend to the particular atmosphere of the relational space we are transported to and co-create. Even when our task includes and requires an explicit assessment and the application of a set of standard criteria, we can notice the particular meaning and function these idea acquire in this particular relationship, knowing full well that these same ideas can have a completely different relational effect and meaning with somebody else.
One client is convinced that the rudimentary fixed points of the therapeutic framework apparently imposed on her necessarily put her into an inferior, compliant position; the next one is as convinced that therapy is an un-holding, wishy-washy useless environment, which fails to give him direction and security.
One client is convinced that the therapist treats her as one more miserable burden in an assembly line of rote, clinical cases treated according to the same manual; the next one is as convinced that the therapist’s attention to the way the two of them are making contact with each other in the room is a pointless, distracting irrelevance.
One client is convinced that the therapist’s empathic attitude is an invitation into a friendship which is supposedly the only place where this kind of warmth and acceptance can happen as by definition it is impossible in the cold clinical context of a consulting room; the next one is as convinced that the therapist’s boundaried and apparently cold clinical presence is a sign and conclusive evidence of a personal dislike.
In all of these situations, the therapist is the same personal-professional presence, but it gets perceived and experienced and constructed in very diverse and contradictory ways by different clients, who bring their wounds – their woundedness and their protection mechanisms against it – into the room and into the relationship.
In conducting an assessment, we recognise that this process is well under way by the time the client picks up the phone or enters the room. What kind of working alliance is available to be established depends upon how we navigate these pre-existing perceptions and assumptions: how do we engage with the client’s unconscious construction of the therapeutic space and our therapeutic presence?
Inevitably, as the therapist I am floating in a sea of contradictory currents, and it is understandable that I have the impulse to seek refuge in some guideline, some fix point, some standard procedure. As Bion said, there should be two frightened people in every consulting room. However, in attempting to assure my composure and portray a semblance of therapeutic authority by imitating some mould of ‘correct’ procedure, or reaching for some linear policy of how to be a good therapist, I lose access to the rich, paradoxical quicksilver complexity of the relational moment (in Ehrenberg’s felicitous phrase: “the intimate edge”).
The client can legitimately expect at least three aspects from an assessment:
– the therapist’s expert judgement as to whether therapy would be suitable, productive and a good investment, and if so, what kind of therapy – this is the equivalent of a medical examination, diagnosis and proposed treatment
– some negotiation of the business realities of therapy, i.e. mainly the financial deal
– but in order to make an informed, emotional decision about therapy, the client also needs a relational experience of what therapy would actually be like, and how the therapist engages in the relational multi-verse that has already been co-constructed

In offering a training day on “First Sessions and Initial Assessments”, these are some of the ideas and dilemmas we want to explore.

The therapist's habitual position

Morit Heitzler will soon be running a workshop in Oxford on the topic of "The therapist's habitual position".


Traditionally, when we describe a therapist's way of working, we think about theory and technique:
• what kind of concepts, models and theoretical framework underpins the approach?
• and what kind of interventions and therapeutic responses flow from this?

In simple terms: the theory is what I THINK about as a therapist, and technique is what I DO in response to the client.

However, this way of thinking about our work does not do justice to the roots and the essence of our work. It is a way of thinking borrowed from science and the ‘medical model’: it is not different from a doctor, who uses their scientific medical knowledge to examine, diagnose and administer a treatment to a patient.

The more we think about therapy as an intersubjective two-person encounter in which the quality of relationship is what matters, the more we recognise that the therapist's being - their underlying relational presence and stance - is a third significant factor alongside theory and technique.

What determines the therapist's implicit relational stance is a complex mixture of the therapist's own wounds, biography and background as well as their therapeutic training(s) and their own therapeutic process.

Just as people in general have habitual relational styles and patterns, therapists have habitual therapeutic positions (which we can think of as 'habitual countertransference' - attitudes on the part of the therapist which they take on as soon as they enter the therapeutic position, irrespective of the particular client in front of them). It is the therapist's habitual position which generates a particular therapeutic space - an atmosphere which may be more or less conducive, more or less transformative, depending on the client's character.

We can think about the therapist's habitual position in terms of certain stereotypes (the fairy godmother, the wise man, the stern interpreter, the challenger, the witness, the advocate, the doctor, etc), or in terms of the basic relational modalities or different kinds of therapeutic relatedness.

Most impasses in therapy and most breakdowns in the working alliance involve the therapist's habitual position somehow, and it is therefore an important and worthwhile focus for exploration for every reflective practitioner.