Men at work

It is one of those situations where you are asked a question and you give a response. Sort of a spontaneous response that just comes out of your mouth and you have not given it much thought. It is then when your own ears hear the answer that it surprises you! You kind of realise that you didn’t know, what you obviously did know, because you just said it.

I was reading a research report on police and stress as I have a bit of time to read such things over the festive season. It was saying that many who enter the police force self select in that they are looking for a stressful job as indeed being a police officer is. That reminded me of a question I was asked some time ago.

I was asked, “What was it like working in a prison?”
My answer, “I liked it because it was exciting. There is always the threat of physical violence in the air”.



This just kind of came out of my mouth and I didn’t even realise I thought it until I said it. Probably not the most politically correct answer in the world but it does indicate that I was self selecting for a stressful job.

And it is true there was always the threat of physical violence and whenever I was in the presence of inmates there was always a kind of hypervigilance on my behalf and I kind of liked that. Especially for me because the inmates that I usually dealt with were experiencing some kind of distress or psychological pain.

The most common form of physical violence that happened was usually inmate on inmate. Two prisoners had a physical fight for some reason. However inmate on staff member violence also happened at least every week or so but it was less common.

Even just entering the prison set the stage. You walk up to this large complex of buildings to enter through the gatehouse. On either side are wire fences, electrified fences and these long circular tubes of endless razor wire all over stretching for hundreds of meters. It actually presented quite an engaging scene. The fenced area is immaculately kept. All the lawns are mowed, there is no rubbish or objects lying about and all the wire and razor wire have that clear shiny stainless steel look to it. There was never any rusted wire.



I always thought you could get some great photographs with perspectives looking along the fence and long tubes of razor wire. But of course permission would never be granted to take such photographs.

Only once did I feel there was some kind of physical threat made directly to me but I backed off, talked my way out of it and it defused into nothing. There were verbal threats made on staff but these were also not so common as they would likely result in the prisoner being charged. I recall one prisoner threatened to have his friends on the outside kill the family of a staff member who I knew quite well.

Those inmates who wanted to threaten would most often do so more subtly. If he was a big man he may stand close to you and kind of lean over a bit. Others who had done particularly unpleasant crimes may recount them in loud detail to you seemingly relishing in what they had done. Most often this was just to test you to see how ‘hard’ you were. If you took it with disdain then they would respect you and that was the end of that.



I always never compromised my physical safety. Because of my role I had access to all the inmate files and whenever meeting an inmate unknown to me I would have a detail read of their crimes and how they handled prison life. Had they been on any charges in the past and so forth.

If I felt there was some risk then I would have an officer with me in the interview room when we met. There was few times when there were two officers in the room with me and the inmate. I always found this some what farcical. How can you counsel someone with one or two large prison officers standing behind him. With a couple of very violent men they were standing right at the side of us, almost inbetween!

One thing that did surprise me was that never did any prisoner ever question this. Not once did anyone ever say, “What are they here for?”, or “They don’t need to be here”. How can you counsel an inmate when there is no confidentiality and by me requesting the officer be there shows I have little trust of the inmate not attacking me. How does that impact on the therapeutic alliance. Well you can hardly call it an alliance, can you?



But my answer was true. I did find it exciting and that did appeal to me and made the work more fascinating and interesting to me.

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Dependent personality type

This person is typified by a difficulty in making their own decisions. Difficulty initiating things. They will readily give up responsibility to others for major areas of their lives, they can lack self confidence and avoid having to rely on self.

If no one is there they will experience a strong urge to look around for and to attach to what they see as a strong authority figure and then seek for that person to make decisions for them. Hence we end up with the symbiosis diagram.



In this theory the dependent personality seeks to give up their Adult and Parent ego states and allow the other person to assume ’control’ of them. At the same time the other person is usually looking for some one of this dependency type so they can either control them. Or they are looking for some one they can rescue or ‘save’. The woman who seeks to save the man from prison, drugs, gambling and so forth.

At this point we need to define two different types of dependent personalities. The one diagrammed above essentially results form a lack of skills. The person lacks assertion skills, they lack practice and experience at using their Adult ego state independently or exercising their Parent ego state in the ways they can. Thus they lack confidence and a belief in self. This may happen because mother never gave the child the chance to practice such things or maybe father undermined the child’s confidence but putting him down or deriding him.



If this is the case then treatment is not too difficult. The individual is afforded the opportunity to learn assertion skills, use their own Adult ego state to change the tyre on a car, manage their money, practice setting their boundaries around others and expressing their opinions from their Parent ego state. When this happens their self confidence will usually slowly rise as well for which they get lots of positive strokes along the way.

The other dependent personality type does not result just from a lack of skills as described above. Instead it results from a disturbance in the structure of the personality. Thus one can say it is a ‘deeper’ kind of problem that is more difficult to remediate.

To explain this type we don’t use the symbiosis diagram but use the attachment diagram.



As the diagram shows this person has a poor sense of self as an individual. For some reason in childhood they did not successfully separate and in particular individuate from mother. As we know a child is born and it then develops an attachment to mother in the first two years of life. After that it uses the three separation/individuation stages of 2 yo, 4 yo and adolescence to separate and individuate from her.

The more the child separates the more it can individuate. That is discover who it is as an individual. The more it individuates the more it can then separate. The person who has successfully individuated can answer the question - Who am I? Not in the practicalities of gender, marital status and so forth, but in the feeling sense of who I am. The dependent personality will find it very difficult to answer this question.

The parents may have kept the child cocooned for some reason or children of rich parents can have this problem as well. Parents can use financial ties to make it harder for the child to leave. If a child has always been given lots of money that can at times significantly hamper the individuation process.

The person does not develop a strong sense of who they are.
Exercise: When I first moved away from my parents as a young adult what did I learn? What did I learn about me and about life?



As there is an under developed individual self this person seeks to form attachments to others. Once done they assume the the identity of the other as their own and thus feel better psychologically. An example of this is the woman who says: “I don’t feel complete without a man”. She recognises that she ‘lacks’ some sense of identity and discovers that if she forms an intimate relationship with a man then that lack of identity gets filled up with his and thus she feels more complete.

This woman is then in very difficult circumstances as she will find it very difficult to leave the relationship. All people find it difficult to leave a intimate relationship with a strong attachment. But she will find it 10 times harder because her basic sense of identity is also connected with staying attached to the man. For her to leave its like psychologically having her arm ripped off.

This woman is domestic violence waiting to happen. If the man is violent he discovers that he can hit her and she wont leave. She may threaten to leave or even leave for short periods but she always comes back for the reasons I mentioned above. When asked why she moved back she may say, “He said he loved me and wont do it again”. Of course the real reason is that she finds it intolerable to loose part of her very identity or sense of self.



The dependent personality of this type is harder to treat as it is not merely the acquisition of new skills that is required. She has to acquire a sense of herself as an individual human being which is not easy to do and will take time and money usually. However these people can end up in counselling because they will be attracted to the strong counsellor for the same reasons. In this case one can get the rapid development of strong transference feelings from the client to the therapist. The client does the same and takes on the therapists identity as her own and thus will get that sense of ‘completion’ again.

This can be a good thing in that then she can separate and individuate using the therapist as the parent figure but it takes time. On the down side this client is primed for financial exploitation by the unscrupulous therapist. Sensing her high level of dependence the therapist can propose multiple sessions per week and expensive workshops and training which she takes up because of her dependency needs as described above.

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The hysteric and obsessive-compulsive personalities

Histrionic

This personality type is more common in women and with males it is more common amongst the homosexual community

A very Child ego state personality type. The Child is dramatic, reactive and intense and thus the relationships are usually not easy going. (Sometimes referred to as a ‘small dose person’). Initially it seems that they are having Free Child reactions to situations but the reactions are exaggerated and overly-dramatic so that it is more correctly diagnosed as being Adapted Child ego state.

Their feelings can have a lack of authenticity and can change rapidly. Quickly develop love and then it switches to someone else. Be very sad about loss of goldfish and then ten minutes later be jovial about something. Pyrotechnics and you need to cut off the top of the feelings chart. They need to have considered and controlled feeling expression. Thinking and feeling often do not go together, which is another treatment goal. To learn to think while they are feeling.

Adult and Parent are often minimal and thus they tend to be quite symbiotic and require someone else’s Parent and Adult ego states to function in life.


Symbiosis

Obviously treatment will involve the development of the Adult and Parent ego states and breaking down current symbioses which means you are effecting others who may not like the change. The hysteric can often marry the O/C or paranoid. They are quite impressionable and may be quite suggestible in relationships

They often sexualise transactions and play the game of Rapo (flirtation) and thus can have poor boundaries which shows up the lack of Adult and Parent ego states. They can quickly develop romantic fantasy and have sexual attraction to the other which of course male therapists need to be careful about and manage well.

Historically the girl may have had a romanticised, sexualised quality of relationship with father. This does not mean sexual abuse at all. They will report a special quality of connection between daughter and father. This can lead to later problems in their relationships with partners as no man in her mind can ever match up to father and her reluctance to break the attachment to father. Focus of treatment is this historical relationship.



Their actual sexual relationship can cover the whole range from promiscuity and highly sexually responsive, to naive and sexually unresponsive, to apparently normal sexual behaviour. This can also change over time in the one relationship. Initially it can be highly sexually charged but then she can become sexually unresponsive as in her mind the historical relationship with father interferes.

The also somatisize feelings which also shows the strong Child ego state responses to the environment. This gets caught up with the hypnotic suggestibility.
. Their bodies will be very reflective of their emotional and psychological status so it is useful diagnostically in this way.

They can be diagnosed as hypochrondrical as they can seek medical intervention for their somatic complaints which can be common. This is probably an inaccurate diagnosis because it is not a preoccupation and fear of having some serious disease. Their psychology simply gets reflected in their body and they are not lying or trying to rort the system (at least initially). They do feel the pain its just that it does not have a physical basis which can lead those medically examining her to suspect she has ulterior motives. Hence we end up with more dramatic conditions like hysterical conversion such as hysterical paralysis.



Often there is an abrupt onset of the physical condition that may be relate time wise to a particular traumatic event by the person. Argument and so forth. It is seen to have two psychological causes

Primary gain - by somatisizing the pain of say an argument it allows the person to keep the internal conflict out of their awareness. They get distracted to the physical condition and the psychological problem can be forgotten.
Secondary gain - It can allow the person to avoid the noxious activity. The soldier who gets hysterical paralysis or the woman whose husband has said he is going to leave her feels her can’t whilst she is physically infirmed.

Hysterics can often end up in counselling for the reasons just described (frustrated medical professionals refer them) and some therapies are also a great place for venting emotions loudly which may appeal. Often the hysteric can use the defence mechanism of denial steadfastly. It is always someone else causing her the problem. So in this way they lack considerable introspection whilst initially may seeming to be quite introspective.

Attachment style weak and difficult to form due to self centeredness



Obsessive compulsive


Magical thinking is prominent in the personality structure. Scare and anxiety based difficulty so they feel unsafe. I can make myself feels safe if I just - wash my hands, switch the lights three times, check the windows and so on. This activity will make me safe.

This can take one of two forms
The person is aware of the irrationality and thus aware of the magical thinking



Or the person seeks to convince self that there is a factual basis for their behaviour and thus one gets Child contamination of the Adult.
“I read in a magazine that there is this new bacteria that means you have to wash your hands 10 times.”
“there are lots of robberies in this area so it pays to check the window's many times a night”.



Thus one looks for the original source of the anxiety. Possible hurried child, C > NP but no NP back. Either C or A back or nothing back emotionally. This often is a major focus of treatment helping the C2 to feel safe.



Obsessive thinking may simply be a cover for or distraction from feelings. “I you were not allowed to think what would happen” and it is usually that uncomfortable feelings would come up.

Layering process

thinking
------------
feelings


Get the feelings to come up and have them dealt with. That is cry (or scare) and get acceptance and the NP back. Get anger expressed with no terrible thing happening usually the expectation of violence or pain to child. Also possible shame feelings due to anal phase problems, sexually based, encropesis or enuresis or used as a parenting style.

Modelling of obsessional behaviour.

They tend to be dependable, neat, dutiful, inhibited which is all Parent and Conforming Child ego state. They lack Free Child which needs to be increased. Even contracts to have fun obsessionally and compulsively. Have a special meal or movie every second Wednesday night at 7pm.

Redecison work to be a child and enjoy and get needs met.

Relational patterns
The obsessions and compulsions can significantly impair ones everyday life, such as with cleanliness. This means that those others also living in the house have their lives effected as well. The O/C can thus ‘make’ others do the right thing (e.g. be clean) with Controlling Parent if the Parent ego state is strong. Or they can control from the Child ego state by being terrified of things (e.g. lack of cleanliness) and others will respond from their Rescuing Parent ego state. This can destroy relationships if too severe.



Often Adult ego state is well functioning and they use it to be perfectionistic and in the service of refining the obsessions and compulsions. Although decision making can be poor because the Adult can think of all the possible permutations and consequences of every option and thus can’t make a decision in the end. The get bogged down in too much information.

The Conforming Child ego state can also be high as they can be reliable, responsible, hardworking, dutiful, always punctual and so on. In this way they can make good employees as long as they do not waste too much time and energy with their obsessions and perfectionism.

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Book club

The book publisher - JKP - did an interview with me and you can make a comment if you like, here.




The book is now available online from the publisher. If you want to wait three more weeks you can get an autographed copy from me! A much better idea I think!



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Imagination and two chair

KYLady and Roses talk about the two chair exercise and imagination which raises a good point and probably a common misunderstanding of the process. But it does afford the opportunity to further understand this therapeutic procedure.

It seems fairly safe to say that when I ask a client to see their Child ego state in an empty chair that would require imagination on their behalf. It would also seem safe to say that those with a good imagination would find this easier than those without a good imagination.

However imagination is but one small part of the overall process. What we are really talking about here is experiencing aspects of the personality. People who find this process difficult are not those with a poor imagination but those who are either very shut off from some part of the personality or they find it is too scary or onerous to experience that part of the personality.


Imagination

In two chair there is usually a quick shift in ego states. Initially it is an Adult ego state process where the person takes on the intellectual task of visualising them self as a child in an empty chair. Once done the therapist asks questions that are meant to facilitate a switch in ego states for the client. He may ask questions like:
“What is the look on the child’s face?”
“What is the child feeling?”
“What is the child wanting?”

When the client considers these questions most often they become emotional and thus the intellectual task of the Adult ego state stops and the person begins to experience that part of their personality. They begin to reexperience the feelings that the young child had. They experience that part of their personality first hand and thus have shifted ego states from the Adult to the Child. It is not imagination and it is not role playing. It is reexperiencing one part of the personality first hand in the here and now.

Now we must remember that the second chair is actually EMPTY. All this process has allowed the client to do is identify a specific aspect of their personality and to reexperience it first hand. There are many and varied therapeutic reasons for doing this and indeed it is a powerful therapeutic technique.

The point at hand is that this is not about imagining self as a child but reexperiencing a specific part of the personality such as the Child ego state. When a client says they find it hard to imagine the child what is probably happening is they do not want to reexperience the Child aspect of their personality.

Case example.

If a person drew a picture like this



The child is in hospital and mother comes to visit. As mother leaves the child cries. The mother finds the child’s sadness distressing so she tells the child not to cry or she cannot visit again. The child takes this on and decides that it must hide its sadness away. (It may also decide that it does not like hospitals and medical procedures).

In adulthood when asked to do the two chair exercise this person may have some difficulty because they quickly realise that it involves reexperiencing the early feelings. In this case the sadness at being left by mother.

(If you want it removed Roses let me know)

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Personality types and disorders - Part 2. (Editted)

In discussion today with one of my very good psychologist supervisees I was discussing this topic and more explanation came to light. In the previous post I made the distinction between personality disorders and personality types. One of the key factors in the distinction is that those with what is called a personality disorder have a characterological problem.

This person has a disturbance in their basic character or sense of self. They feel wrong, bad, not right, empty or simply Not OK in their basic sense of self. As mentioned before this is only a small group of people, say around 5%. These people will report that this sense of badness is in their very bones or the cells of their body. The feeling has a somatic quality about it. They will also report that they have always felt like this, that there was never a time where they felt OK about self. In Transactional Analysis theory they feel this badness in their C1 or C0 part of the personality. Thus one can say that this persons sense of badness is experienced as ego syntonic.



Most others do not have this basic sense of badness about self. They feel a sense of basic OKness in self. Later in their development they may suffer various trauma. These can lead to painful feelings like depression and anxiety but these are not experienced as being part of their character or who they are. In this sense they are felt as ego dystonic.

One way to diagnose this is with a relatively easy therapeutic technique. A two chair situation is set up with the client in one chair as the Adult and Parent ego states and they are asked to see the young Child part of self out there in front of them. Most do this relatively easily and will see that small child part of self there.

The client is then asked what is their reaction to the Child? What do they think and feel about the Child part? The vast majority of people will have some kind of positive reaction to the Child. It will be sympathetic in some way and be wanting to help or assist the Child part.



There is a small group where one does not get this reaction. The person will state that there is nothing good or positive about the child and they may indeed state that the child is worthless, disgusting, just full of needs and so forth. The therapist will then hunt around a bit for any positive responses but none are found. This indicates a character problem where the person has a basic sense of dislike or worthlessness. It is this type of person who is most often diagnosed with a personality disorder. It should be noted that a person with a personality disorder may not have such a third degree impasse or character problem but if someone does then a diagnosis of personality disorder should be strongly considered.

Harriet has provided a possible example of the sort of comments one would get in such a two chair exercise as described above. She states:

" I was telling my therapist a couple of months ago that if I ran into myself as a child I would throw her under a bus. I don't like her at all. She was weird, embarrassing, had no social skills, not good at making friends, etc. "

The therapist would need to make further enquires to make sure this was the dominant attitude of the person to the Child part of their personality. If one did not find contrary attitudes of liking or sympathy for the Child then it would be tending to signifiy a third degree impasse.

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Personality types and disorders

Everybody has a personality and thus every personality can be diagnosed into one of the ten types that one finds in the DSM. I am yet to meet a person who does not have a personality.

Personality type and Adaptation
Paranoid - The world is hostile so don’t trust anyone and deal with people by being angry and attacking
Schizoid - The world is scary so withdraw from it (people) and don’t show any of your feelings
Schizotypal - The world is scary so withdraw from it (people) and don’t think clearly by being a bit crazy
Antisocial - You can’t trust anyone & life’s unfair so take advantage of people and do what you like
Borderline - Relationships & life are very unreliable so frantically do anything to keep people around
Histrionic - I must be the centre of attention so I will be dramatic, flirtatious and highly emotional
Narcissistic - I have always been told that I am very important and the best so I will behave and feel like that
Avoidant - Life is scary and rejecting so I will withdraw and feel worthless
Dependent - I can’t cope with life and am worthless so I will cling to others and do what they tell me
Obsessive/compulsive - I have to feel in control of life and myself so I will be orderly and perfectionistic



So when working with people who have personality types the more abnormal or dysfunctional they are depends on how much they use their personality in self defeating ways. The goal is not to change the personality but to get the person to use its pluses and minuses in the most productive way for them in relationships and life. The more they do this the more normal or functional they are on the scale and the less they do this the more they are abnormal or dysfunctional on the scale.



A distinction can be made between personality disorders as one finds in the DSM and what are known as personality types. The personality types constitute about 95% of the population. The rest are what are called personality disorders which make up about 5% of the general population. However it is this small group that uses up many of the resources provided such as counselling, mental health services, hospitals, trouble with the law and so forth. So whist they are small in number one does often come across them because they fit poorly into society and thus they get noticed more often.

The personality disorder is what can be described as the person with a character problem. There is a flaw or problem with their basic character. The vast majority of people in society have basically a sound character and it is the psychological material on top of that which can be disturbed. This is what mainly separates the personality disorders from the personality types.

In Transactional Analysis terms the individual is said to have a third degree impasse.

1st - 6+ years, drivers
2nd - 6 months to 6 years, injunctions
3rd - 0 to 6 months, character, pre-verbal

Types
1 degree impasse. Generally developed in later childhood through internalising verbal instructions (counter injunctions) such as please others, try hard. These are most accessible to awareness as the person can usually easily recall how they were delivered and by whom

2 degree impasse. Internalised in early childhood, often through non-verbal commands. Based on injunctions such as don’t grow up or don’t feel. Not so easily recalled as to how they were developed; however the person can usually identify with impasse conflicts

3 degree impasse. The earliest form of impasse, usually developed in the pre-verbal phase. Here the conflict is held in the body through tensions and psychosomatic complaints, or maybe experienced through symbolic images, for example, “I feel as if I am in a fog, lost, cold and alone”.

This views impasses developmentally. The type 3 impasse develops in the very young child, the type 2 in a less young child and the type 1 impasse in late childhood.



3rd degree impasse happens through the basic attachment between mother and child. It refers to how they relate each day and day after day, so the child is retraumatized consistently each day.

If mother has a problem with her C1 (or C0, A0, P0) then this gets communicated to the child each and everyday. She can’t fake it. In her Adult and Parent ego states she can learn and change her parenting styles but this cannot happen in her little C1 ego state as it is part of her character.

The mother who is depressed who each day can feed and look after son, but the son also knows mother is emotionaly bereft. He learns that he needs to take care of mother and she may some how leave him (die). So he develops a system where he feels of little worth and has anxiety day after day. thus his basic charater is formed in a way where it is dysfunctional.

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Therapists, clients and trust

In a previous comment Harriet stated:

“But I am sorry that his lack of disclosure led to distrust on your part.”

This comment resonated with me and led me to muse on the topic of clients, therapists and trust. (I like words such as resonate and muse, they make me sound like I know what I am talking about!)

I mused - do I have a sense of trust or distrust with clients? The answer I came up with was in one specific sense yes, but I would say generally, no.

In my work circumstances of private practice I do trust clients in our business relationship. I deliver a service, then they pay once they have received that service. There is a small group of clients who come to therapy and have no intention of paying. Over the years I have seen all sorts of methods employed by people who are wanting to get sessions without paying for them. I never let new clients accumulate any significant debt so those who are not intending to pay may get a few sessions for free but that is all. Then they leave and I never see them again.



This indeed raises another interesting question in terms of the therapeutic relationship. If a client enters into a therapeutic relationship with no intention of paying how does that effect the therapeutic relationship. Perhaps I will muse on this some more for a later time. However in terms of our business relationship, I do have a sense of trust and distrust with a client.

Other than this the concept of me trusting or distrusting a client kind of does not make sense. In particular, as Harriet was mentioning, I don’t have a sense of trust or mistrust about a client telling me the truth and the whole truth. I just don’t see it that way. It does not ‘compute’ like that.



Clients, like everyone else have a Child ego state that is struggling to cope the best way it can, with the psychological resources it has, at a particular point in time. If the Child ego state feels it necessary to tell me a falsehood or not tell me the whole truth then I accept that. I do not feel like my trust has been betrayed by the client. I see it as them coping the best way they can.

I also know that clients, like everyone else, will behave in consistent patterns over time. I know that if a client tells me a significant falsehood about the facts of their life, then it is likely that they will do so again in the future in some way. Not because they are trying to trick me or deceive me but because they are coping the best way they can at that time. I don’t ‘win’ or lose’ anything if the client tells me the truth, just like I don’t ‘win’ or lose’ anything if the client tells me a falsehood.



Thus in relation to Harriet’s comment I don’t get led to distrusting a client if they tell me a falsehood. Instead I accept they are doing their best they can at the time and I know they may employ the same coping mechanism of telling falsehoods in the future.

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What would I do?

Harriet raises an interesting point in her comment on the previous post. So I will ponder the hypothetical.

If a client told me he had a terminal illness with a few years to live but did not want to talk about it or deal with any emotions about it what would I, as the therapist, do?

According to contract theory, therapy cannot progress unless both the client and therapist agree on the goals of the therapy. Would I be prepared to work with a client on things like loosing weight, dealing with past issues about siblings and so forth and not discuss the impending death?

My initial reaction to this is probably yes, but maybe only for a limited period of time. If the client wanted to make the contract to give up smoking cigarettes, I would feel some need to ask them why they want to do that? If they enjoyed smoking and were going to die reasonably soon, why give up.


Possible or impossible?


I have worked with clients in the past who did not want to discuss certain matters and I have agreed, but their very life is clearly a very significant matter that to my mind could not simply be ignored. So it is quite possible that at some point I would raise this issue and we may part company as therapist and client because we could not agree on the contract.

To me it involves too much pretence or as it is called in Transactional Analysis a discount of reality. I would not be willing to have a relationship with the client which involved such a discount of reality. I would not be willing to have a relationship with a client that included such a profound level of fantasy.

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The truth and the whole truth

Many clients don’t tell me the truth and the whole truth, its part of the job. I do not take offence at such a thing and realise that it is easy for me as the therapist and much more difficult for the client to talk about the things which they talk about.

Most often when they are not being fully candid it involves something which they are embarrassed about. That usually involves something sexual, or they may have done something illegal and done prison time, treated someone else very poorly or it involves something like self harming or an eating disorder which some people tend to be quite secretive about. These are to be expected and just a part of normal human behaviour which clients like every one else exhibits.



However on occasions one gets another circumstance which intrigues me. It happens when a client with holds a piece of information that significantly alters the therapy. I had been seeing this man for about two years. Not once a week type of thing but usually a number of sessions in a row, then he would stop for a while and then start again.

He did some good therapy particularly about his early relationships with mother and his siblings. Then after two years he informed me that he had known for a number of years that he was going to have to have a heart lung transplant which the doctors had told him he could die from. He stated that he was told he had a 50% chance of survival from the operation and the longer he waited the worse the prognosis. He always had breathing problems which he mentioned on many occasions and I observed but he never mentioned his dire physical circumstances. He had always passed it off as asthma.

If you are working with a client who may soon die and the longer he did not have the operation the more likely he would die then the goals and process of therapy change significantly. For two years he had worked with me and paid his hard earned money to me and the ‘success’ of the therapy had been significantly hampered by this non disclosure.



I understand he did not want to tell me and he is under no obligation to tell me. The outcome of therapy and his value for money would have significantly increased if he had told me. It’s like going to the doctor to have your bursitis treated and not mentioning that you have cancer. For two years they work on the bursitis so by the end of it you are completely bursitis free but then you die from the cancer.

The other problem this creates is that once a falsehood of this significance and type (ie not embarrassment based) is disclosed then I don’t know if what is now being disclosed to me is yet another falsehood or at least partial falsehood.

Therapists obviously can ever only work with what they are told be the client. Most falsehoods do not significantly change the therapy as described above. When they do it leaves me wondering a bit about the point of it all. Why would a client spend all that time and effort and money engaging in an exercise where the gain is going to be limited. And yes I understand it may be very difficult for a client to discuss such things. It’s just something that I, as a client, would not do and just another odd permutation of the human psyche which clients are for ever presenting to me.

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