Therapy and emergence of the self

Been working with this woman over the past few months and I am doing almost completely relational work.  She is pleasant, well versed in therapy, quite capable of introspection and seems motivated. All the qualities are there for a good prognosis.

But it is one of those times where you know something is wrong but you don’t know what it is. You know something is not going right but you can’t articulate it. My Free Child is reacting to her and the therapeutic relationship with disquiet. We have discussed this “problem” I have but it still is not getting to the core of it. My feeling reaction is one of unease. Not in a bad way but in a way of, “I know there is something going on here but I don’t know what it is”.

The work we are doing would be consistent with what Winnicott called the holding environment. I am psychologically ‘holding her”. This of course fits with a relational approach where the focus is on the relationship we have. I have come across the term in relational theory called - the emergence of the self. This fits for what I am doing here. I am simply letting myself go in the relationship with the client not knowing what is going to emerge for me personally.

Winnicott's therapeutic approach of the holding environment does this, but only psychologically. I must say I have always been a bit surprised how people can regress as they do in the holding environment. Indeed some people can become highly regressed. The perfect opportunity for hypnotic suggestions. Getting the client out of the chair down on the floor to do floor work can result in a signficant and abrupt change in ego states especially when they have done it a few times before and are used to it.

I have always thought this a little odd as the therapy in one sense is more about me than about the client. The focus is on my FC and how it is reacting and emerging in relation to the client. Of course the positive for the client is that as I become aware of my personal emergence I report this to her which benefits her. In this instance I don’t feel I have a choice. The conventional approach of analyzing the client, is going OK, but my intuition tells me I am missing something.

What is going to happen? I don’t know. I will have to wait and see what emerges.

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Stroke deprivation

As Eric Berne said, “A stroke is a unit of attention” and one can have positive strokes and negative strokes. As a therapist it is easy to forget the importance of strokes and the important therapeutic role they can play.

The importance of them is no better demonstrated than by looking at a whole discipline or aspect of the science of psychology that is based on the psychology of strokes and that is behaviour modification. 

Humans began to realize that how you respond to another person then influences how that person will think, feel and behave in the future. In behaviour modification terms you can respond to others with either positive reinforcement (strokes), negative reinforcement (strokes) or with no reinforcement (strokes) and that will influence how they behave in the future.

This remarkably simple discovery lead to the entire field of behaviour modification which has lead to probably millions of pieces of research on this very simple premise and has produced libraries full of books on the topic. 

It is a huge area that is based on the premise, as I said, that how we respond to someone influences how they will behave in the future. Remarkably simple and yet remarkably powerful and of course the therapeutic implications are clearly evident. 

If how I respond to a person can influence their future behaviour, this means as a therapist, I can respond to a client in a way which will influence how they behave in the future. Obviously a useful therapeutic approach to have.

Indeed this leads us to the basis of relational therapy. In therapy I will respond to a client with either a positive stroke, negative stroke, or no stroke. This then will influence their future behavior. The client will then respond back to me with either a positive stroke, negative stroke, or no stroke which in turn influences my future behaviour. The basis of relational therapy. It seems the psychotherapy of behaviour modification has been using a relational approach to therapy all along and it began in the 1950s.

Furthermore as the research on behaviour modification has shown you can’t avoid it. We are effected by the strokes we get from others. We can’t avoid being influenced by the strokes we get from others and often it is unconscious.

A most useful discovery so we set about refining the therapeutic applications of this discovery. In transactional analysis we discover that strokes can be conditional and unconditional and these effect the future behaviour of others in different ways. For instance with stroke power, negative strokes are more influential than positive strokes. 

As negative strokes are more powerful then as therapists we should give clients Critical Parent negative strokes and that will help them to stop a behaviour like panic attacks. But it is not that simple. First the side effects of negative strokes damage the psychology of the person whereas positive stroke do not. Second, negative strokes may help a person to stop the neurotic behaviour in the short term but in the longer term it may actually get worse. As so often happens with human psychology, as soon as you start looking a bit deeper it gets more complicated.

But the basic premise remains. Sometimes we forget how important strokes are in therapy. People have different levels of stroke needs. Some require a lot day to day and others require less. However the important point is, when taking a client history how many of us ask about any level of stroke deprivation. From what I have seen not many. Are they getting enough strokes to meet their daily needs? If not, that is important as stroke deprivation can have a devastating effect on the personality. 

An obvious example of this is depression. Some people are depressed because they are stroke deprived. Try this yourself. When you next have the chance spend as much of a day as you can getting no (or very few) strokes from others. You get no attention from others. Spend one day, two days, three days doing this and you will quickly discover how stroke deprivation leads to psychological collapse such as depression. Some people live in a state of stroke deprivation for years!

From what I have seen when a client presents with depression it would be uncommon for a therapist to look at stroke deprivation. Instead they start to look at internalized anger, high internal critic, changing internal self talk, history of depression in mother and father, potential suicidality, insomnia, eating problems, low self esteem and so forth?

In the DSM-5 the diagnostic criteria for major depression does not even mention stroke deprivation or psychological isolation. Hence my thesis that stroke deprivation is a significantly important aspect of psychological dysfunction and at the moment it is the forgotten relative and given little credence when the research clearly shows it is of significant psychological importance.

Of course therapy in itself is a big stroke. The client is getting a full hour of attention and can repeatedly do so on many occasions. If the client is reporting generally feeling better it could be partially due to the fact that the therapy is reducing their stroke deprivation.

One can use other techniques like the encounter exercise of stroke bombardment. To see that done is quite a moving experience and one again sees the value in simply reducing a person’s level of stroke deprivation which usually is not all that hard to do.

One can also separate strokes out into physical strokes and verbal strokes (both positive and negative)

Physical strokes have much more potency than verbal strokes. This chart would seem to suggest that to modify behaviour one would obviously use a negative physical stroke. If parents want a child to behave a particular way a negative physical stroke is most likely to achieve it. But as I said before the the problem with negative strokes (especially negative physical strokes) is they have unwanted side effects on the overall personality and they will also cause ruptures in the relationship between the parent and child. Positive strokes also modify behaviour and also produce side effects but these are wanted ones. But the unfortunate fact remains, negative strokes are more powerful in modifying human behaviour than positive strokes. This is why some parents use them - they work (at least in the short term). They get the short term result the parent wants.

With a stroke deprived person the best thing one can do is give positive physical strokes. But as we know professional organizations discourage therapists from touching their clients. So they actually cause the clients more problems. All therapists are left with is positive verbal strokes, which as we can see is the least powerful of all four.

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Fantasy and meditative anger work

Anger work or the cathartic release of anger in therapy is a contentious issue. Some actively support it and others see it is a retrograde step that will just lead to more anger and violence. There are many ways to release anger in therapy ranging from the quite mild to restrained rage work on a mat.

Fantasy anger work is an interesting procedure and somewhat of a contradiction. In terms of cathartic release it is the mildest of all in that the person writes down or draws pictures of them self being angry. On the other hand it can be of a very violent and aggressive quality unlike any other type of anger work. Indeed it is limitless in its aggression and violence and people can do this type of anger work and think of things that are murderous and so forth. So on the one hand it is a very mild cathartic release of anger but at the same time it can be highly aggressive and violent.

Below is a statement of this type of anger work. After that is a paper sent to me recently by a friend. It uses a meditative or guided fantasy type of anger work. I have not seen this before in this way and adds an interesting addition to the area of anger work in psychotherapy.

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Drug and alcohol use history of the therapist

In my book I discuss a situation that all drug and alcohol counsellors fear. It lurks in the back of the mind and can surface at any time. The client can raise it at anytime and leave a conundrum for the counsellor. The client can ask, 

“What is your drug and alcohol use history?”

In my experience I have not been asked this question often but it does happen from time to time. How does one answer? There are two schools of thought on this.

Should I choose the red or the blue?

First the counsellor can in essence refuse to answer the question and say that it is not relevant and move onto another topic. Others may use the distraction technique and answer the question with another question:
Client:  “What is your drug and alcohol use history?”
Therapist: “Why is that important to you?”
Sooner or later however the client will realize the therapist is not going to answer the question.

Second the counsellor answers the question and does some self disclosure about their history of alcohol and drug use.

I think the first response is not a wise one to take. It in my view builds intrigue you do not want. The client is left wondering why you ‘really’ refused to answer. Is there something you are ashamed of or maybe your drug and alcohol use history has been extensive. Also you are asking the client to disclose many things, some of them quite intimate and then you refuse to disclose something to the client. This may leave them feeling problematic emotions about your refusal.

If you take the second option and answer that you have had little or no history in this way then some clients will feel you are somewhat ignorant about such matters. To most it probably make little difference but there is a group to which it is quite important and it can damage your potency as a therapist in the eyes of the client.

If you answer that you have used drugs and alcohol at times in the past then that can leave some clients feeling that you do know what they are talking about. However it is also permission giving to the client to take drugs. If you are a strong transference figure to the client this can be particularly so. If you stopped using drugs when you were 30 and the client is only 25 some could take this as permission to keep using for 5 more years. Other clients may view you as hypocritical. You are suggesting a client do something that you did not do yourself. 

Then of course there is the situation of the counsellor who is currently using significant amounts of illicit drugs or abusing alcohol. That can also provide permission to the client and is a more delicate clinical scenario.

On the positive side it can engender trust in the client towards the therapist. If the therapist reports a history of drug and alcohol use the client may respect the therapist for being honest with them by reporting previous ‘bad’ and ‘unprofessional’ behaviour. If you say you don’t have any significant drug and alcohol use history the client is going to wonder if that is true or are you lying to them. To tell such a truth can build respect of you in this way.

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Terminating counselling with a client.

Introduction

When one employs a counsellor it is different to employing a plumber because you have to take the relationship into account as well. Indeed it is unique when compared to others in the ‘helping’ professions. When one goes to a doctor, surgeon, dentist or physiotherapist the relationship is clear. One goes for a specific goal and when that goal is achieved the relationship ends. Both parties know this from the beginning of the contact between them. Counselling is not like this. Firstly because the goals are usually less clear and the relationship between the client and counsellor is just as important (if not more important) than any treatment techniques applied.

Ending a relationship (attachment) is not an easy task. It does not matter what that relationship is be it siblings, spouses, friends and of course client and counsellor. It can be quite difficult for both parties no matter what the relationship.

Obligations between client and therapist

At this point it seems cogent to remember the underlying principles on which the relationship between the client and therapist are based. My thoughts are that the relationship is largely obligation free. (It should be noted that there would certainly be other counsellors who are of a different view on this matter). There is one out of four obligations required.

1. The client has no obligation to see a particular therapist

2. The therapist has no obligation to see a particular client

3. A client has no obligation to explain to a therapist why they wish to end therapy.

4. If the client requests it, a therapist has an obligation to explain to the client why they wish to end therapy.

The exit consultation

Sometimes a therapist will ask the client to contract to make an exit consultation. To agree to not just suddenly cancel an appointment or simply not show up and never contact the therapist again. They contract to make one final (exit) consultation should they choose to end therapy. The usual reasons for this are:

For a sense of completion of the gestalt for both the client and the therapist

To make sure the client is not leaving in a bad place

Counter transference and the exit consultation

These reasons seem reasonable and valid and if the client does agree to an exit consultation then this seems like a therapeutic thing to do. However there can be other motives why the therapist may make such a request and these can be due to counter transference issues in the therapist.

As mentioned before ending a relationship can be difficult and that is no different for a counsellor who may have developed some level of attachment to a client. It is hoped the counsellor would have some kind of supervision available should a difficult termination arise. The therapist may feel such thing like:

“I will use the exit consultation to try and talk the client out of it because I am insecure about my abilities and I take it as a personal rejection”.

The therapist may even be unaware they are feeling such things.

The counter transference termination transaction

Transaction 1 is the overt Adult to Adult transaction that the therapist and client make with the exit consultation contract. 

In conjunction with this the therapist can also have ulterior, covert and (probably) unconscious motives. 

Transaction 2. The covert Parent to Child transaction: “Explain yourself”, “I don’t like ti when my influence is reduced”.

Transaction 3. The covert Child to Child transaction: “Please don’t reject me”, “Show me I am a good counsellor”.

Normal counter transference reactions

It seems safe to say that with some clients there will always be some kind of counter transference reaction when treatment ends. Especially if there has been quite a long period of treatment and if the therapist has developed some degree of psychological attachment to the client. When the relationship ends the therapist will have some level of a grief reaction. Hopefully the therapist is aware of this and may even communicate it to the client and then the termination can proceed relatively easily. The Free Child of the therapist will feel the pain of grief and bereavement in varying degrees.

Some therapists view this as a negative aspect of therapy and seek to avoid this normal counter transference by ‘keeping it clinical’. Some therapists become clinical in their view of the client and therapy and thus the attachment from the therapist to the client is kept to a minimum. The down side of this is you loose the therapeutic power of the client - therapist relationship. If the therapist is going to allow himself to develop some attachment to the client then one gains the advantages of the therapeutic relationship. However they also need to be aware of their tendency to get into their old self defeating relationship patterns that can interfere in the therapy process and make the outcome worse for the client.

Life script and terminating therapy

People tend to behave in patterns which means their relationships will tend to have patterns as well. In their relationships they will tend to do the same thing over and over again. The most important factor in the termination phase of counselling, is the client does not leave the therapeutic relationship in the same old self defeating relationship patterns. If this happens the client is using the ending of this relationship as a way to further their life script. They are ending the therapeutic relationship in a script bound way. It is most wise for the counsellor to raise this issue if they suspect it may be heading that way. Indeed some counsellors raise the issue with every client early on in the therapy.

For example if a client has a history of being rejected they may start to do a few things that will get the therapist angry or tired of them. They may start to not pay bills, they may consistently keep attacking the therapist personally, they may all of a sudden appear at the therapist’s home one night because they just have to see them then and there. It’s up to the therapist to identify and anticipate these relationship game maneuvers by the client so that the therapeutic relationship does not end up in the same old way for the client.

The No run contract

A “No run” contract is similar to an exit consultation but the reasons for it are different. The client contracts to make at least one more appointment before ending treatment. The motive behind it is that for some reason you want to lock the client into the therapeutic relationship. That may be to close the escape hatch of running from a relationship when the client feels reliance developing which may be their life script pattern. The counsellor is seeking to increase the clients distress by not allowing them to ‘run’ and then use those feelings in a therapeutic way. Or indeed it may heighten a sense of security for the client. There can be a whole range of motives for a therapist to suggest such a contract.

For the person who uses flight (compared to fight or freeze) as a basic coping mechanism such as the schizoid personality, it can be advantageous to introduce the idea of a no run contract quite early on, but it depends on how they do their flight. Some schizoids can 'flight' with physical relocation and hence the no run contract can be quite useful. Others don't have to move anywhere and will simply 'flight' in their mind and feel distance when they are sitting in the same room as the therapist. It is possible to have a psychological no run contract but that is harder to create and manage.

When the client terminates therapy without discussion

Sometimes a client will leave a message canceling an appointment and not making another one. Other times they simply do not turn up for the appointment and you do not hear from them again. The therapist is not given a chance to speak with the client when they terminate the therapy.

What therapists do in these circumstances varies greatly. Some will do nothing at all and others will actively pursue the client to talk with them directly. My own view is to take it on a case by case basis. Sometimes I do nothing and other times I will try and contact the client to speak with them.

This comes from CARMHA (2007) who are discussing working with suicidal clients.

“A client’s lack of follow-through with treatment may reflect hopelessness, pessimism, and cynicism regarding the value and benefit of treatment, and may be affected by the stigma of mental illness and suicide... Clients who reject help and withdraw prematurely from treatment tend to view interpersonal situations as risky and ripe for potential humiliation and emotional hurt”... (p10)

Speaking generically and not just about suicidal clients my view is that one needs to be careful not to harass or pressure a client. If that happens the client will either move into Conforming Child ego state and approach therapy from a conforming stand point which means the therapeutic process is significantly compromised. Or they shift into Rebellious Child and you never see them again.

This pressuring can happen particularly with the treatment of the suicidal where the therapist becomes a bit scared of a possible suicide attempt. This results in a change in the therapist’s behaviour such as how they deal with a client who drops out of therapy. The unusual behaviour of the therapist can result in outcomes one does not want. The therapist panics and ends up doing ‘poor’ quality therapy. When working with the suicidal one needs to often ask the question:

“If this client was not suicidal would I be doing what I am doing?”

Unlike the quote above I would suggest a significant number of clients stop attending because they are not ready to deal with what they are working with. Whenever I take a history of a new client I always ask if they have been been to counselling before and if they have, what happened and why did they stop. Not uncommonly they will say  things like:

“I just was not in the right frame of mind.” 

“I just wasn’t ready to do what was required at the time.” 

“I had had enough by that time and needed a break.”

“I felt I was not getting what I wanted.”

I would say that rarely would a client report it was because they were afraid of interpersonal risk, because of stigma or because of the potential for humiliation. The examples I provide above I would say are much more common reasons.

Over the years I have had clients cancel appointments or just not turn up. Some I never see again and others come back later on. Indeed when a client ‘drops out’ that can be a used for therapeutic gain later on when they re-engage. One can use No run contracts, No engagement contracts, Phratry contracts and the like to create a variety of therapeutic scenarios for the gain of the client.

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Reference:

Centre for Applied Research in Mental Health and Addiction. (CARMHA)

2007. “Working with the client who is suicidal : a tool for adult mental health and addiction services”. Simon Fraser University: British Columbia

The anatomy of human self destructiveness

It has been postulated by many over the years, none less so than Freud, that we all have a life instinct (Eros) and a death instinct (Thanatos). These two interact in our lives effecting it in various ways at various times. It can be expressed in a wide variety of ways. 

Physically people will do things like exercise and set about eating a good diet. These are of course heath promoting and could be seen as an expression of the eros force within the individual. However for most there will be times, sometimes many times where the person will not exercise in such a way that is best for them, eat foods that are physically damaging to them, drink excessive alcohol, smoke cigarettes and so forth. The person will do these things repeatedly whist clearly knowing it is bad for them. This it could be said is an expression of the destructive forces in them, known as thanatos. Many people will spend their lives doing these contradictory set of behaviors over and over again. This strongly suggests there are two contradictory motivations inside them.

Psychologically people will do the same, perhaps even more so. Entering into a relationship can be very life giving and a positive thing for oneself. It can provide a sense of connection, fulfillment and strokes that are life giving in a powerful way for both the individual and the relationship. However thanatos can also be active in the way we relate to others. People can get into repetitively destructive relationships, some women can fall repetitively for unavailable men and then we have the idea of psychological games as was presented by Eric Berne.

A psychological game can be defined as a repetitive series of self destructive behaviors and games form part of almost all relationships in varying degrees. One reason for this may be due to the force of thanatos, inside each and every one of us. For such large numbers of people to repeatedly do things which they clearly and consciously know are damaging for their relationships, strongly suggests there is something at play that is central to human nature. The idea of thanatos could be an explanation for this.

Many psychology and psychotherapy approaches over the years have tried to deal with these two forces in a similar way. Essentially it is to rid self of the thanatos and to encourage the the eros.

For example in transactional analysis one talks about being ‘game free’. That is, the goal of treatment is to become game free and no longer play any psychological games in ones relationships. Relationship counselling is usually the same, about identifying the destructive behaviors in the relationship and making contracts not to do them. On an individual level the same tends to happen. Carl Rogers with client centered therapy had this at the core of his approach. It was assumed that if you provided the client with unconditional positive regard then their natural life force would be stimulated resulting in a natural growth towards health and any neuroses would diminish. The gaol was to increase the life force (eros) and diminish as much as possible the thanatos within the client.

This is common in a wide variety of psychotherapies and psychological theories. They use techniques to increase eros and diminish or extinguish thanatos within the psyche of the individual.

In my workshop on the psychology of human destructiveness I present a new approach. Like many other therapies one encourages the development of eros in the client’s psyche. Regarding thanatos, we all have it, we are all born with it and we can never get rid of it. It will be with us each and every day from birth to death. One does not try and get rid of it as so many other approaches attempt. 

Key to this approach is one does not deal with the behavioral or emotional consequences of thanatos. For example a psychological game is a behavioral consequence of thanatos, it is not the thanatos force in itself. One can use various techniques to access thanatos in the personality directly. One then has the opportunity to build relational contact with it. I cannot stress enough the importance of doing this. To be able to have direct contact with the core of the client’s self destructiveness is a most valuable therapeutic task indeed.

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The machinations of developmental psychological theory

This comes from a book on developmental psychology. 

“Although many people cope with old age gracefully and meet death with dignity, this is not always so.”

Developmental psychologists often present human development as a series of tasks that have to be dealt with or mastered at the various stages in life. This is no better illustrated than with the developmental theory of Erik Erikson and the 8 ages of man as it has become to be known.

The diagram shows the various conflicts and tasks each person tries to resolve at each stage. For example as a child reaches adolescence he has to master the stage of leaving home. That means psychologically breaking away from the parents and developing his own social world. At the same time the parents have to master the task of letting the child go and restructuring their life as necessary as their parenting of children comes to an end.

People who complete the different developmental tasks are said to be developing normally. Those who don’t would be seen to develop a neurosis of some kind and this is where therapy is meant to intervene to assist the person to get through the developmental tasks and to move onto the next stage of human development.

According to the original quote I cited above if one enters old age gracefully and meets death with dignity then they are said to be finally completing their last stage of development. This means of course that the elderly person who is not being graceful or dignified would be neurotic and in need of some counsel to assist them to be so.

I am reminded of a time a few years ago when two sisters came to seek my counsel on a matter just like this. Their mother was in her mid eighties and in reasonably good health physically and mentally. She lived in her house where she had lived the last 50 years of her life and indeed one of the daughters lived with her at that time.

The problem presented was that the mother was being recalcitrant and obstreperous. She was hard at hearing and refused to get a hearing aid, she had no intention of leaving her house for a old people’s home and basically did very little of what the daughter’s suggested she do with her life and circumstances. This had the two daughters fatigued, at a total loss for what to do, exasperated with their mother and hence they came to see me.

According to developmental psychology the mother was neurotic and not successfully adjusting to her final stage of development. She certainly was not being graceful and had no desire at all to meet death with dignity.

After much discussion I presented to the sisters that perhaps it was mother’s rebellious, defiant and hard headed attitude that was keeping her alive at this juncture. Perhaps the mother knew (probably unconsciously) that if she ‘gave in’ to their wishes and became more graceful and dignified she could quickly deteriorate and die. If this was the case then one could understand the mothers gritty determination in that she was scared of dying.

The sisters did not know what to make of my suggestion and did not expect me to make such a determination about their domestic situation. They left some what perplexed and decided to think some more on my proposal before they decided about what path to take with their mother in the future.

Human psychological theory can sometimes be a precarious and malevolent thing. One needs to be clear that such theories of human development are not really a mechanism of social control. The study of human psychology is meant to be about how the human functions psychologically not about how society says they should function psychologically.

If an elderly person is meeting their final time of life with grace and dignity who benefits from that? The children and loved ones of the elderly person are feeling stressed and scared as they know their mother is going to die and that will be a painful event for them all. If mother is graceful and dignified about the ending period of her life that will certainly make it much easier for the children and loved ones than if she is being recalcitrant and obstreperous.

Assuming my proposal to the sisters was accurate then the mother’s own Child ego state was scared of dying and she was coping with that fear in the best way she knew.

A psychological theory which says the last stage of life is meant to be graceful and dignified, is that because it is better for those others around the elderly person than for the elderly person. If it is, then it is no longer a theory of human psychology instead it has become a system of social control of a particular group in the society.

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Ego syntonic and ego dystonic

Something is said to be ego dystonic when the person perceives it to be foreign to them, outside them or not belonging to them. Something is ego syntonic when the person sees it to be part of them, belonging to them or forms part of who they are

These are two important concepts in psychotherapy. Is the problem ego syntonic or ego dystonic for the client?

A client may present with agoraphobia or perhaps insomnia. The therapist needs to ascertain in his own mind does the client see self as

1. A person who can experience agoraphobia, (ego dystonic)

2. An agoraphobic (ego syntonic)

Does the client experience self as  

1. A person who can suffer insomnia, (ego dystonic)

2. An insomniac (ego syntonic)

Unfortunately in most circumstances by the time the client gets to therapy the problem has become ego syntonic.

Ego dystonic I believe

A person sleeps normally and then for some reasons starts to sleep poorly. Initially this will feel abnormal to the person and the problem is seen as ego dystonic. They perceive self as someone who sometimes does not sleep well but not as an insomniac.

Over time if the insomnia continues the person’s view of it changes. It becomes something that they expect to happen because it has happened many times before. They tend to start to view it as part of who they are - an insomniac. When this change occurs the problem then becomes ego syntonic. The insomnia is perceived by the person as part of who they are and how they live.




The shift from ego dystonic to ego syntonic can be seen to have at least three aspects.

1. It becomes habitual

If a person has slept poorly most nights for the past year then the insomnia is partly a habitual way of being for the person regardless of any other causes for it.

2. It becomes part of the persons life style

As it becomes a habitual pattern of being the person will adjust the practicalities of their life style to fit for it. They will tend to do the same things like get up and do such and such and then go back to bed and then wake up again. They develop a routine at night time that incorporates the wake times.

3. It becomes part of the person’s self perception or part of their identity.

Finally it becomes how the person sees self and a sense of who they are as a person. I am an insomniac is part of the person’s sense of identity.

If a person has slept poorly three nights in the last four months then it wont be habitual, they have no routine when being awake and it is not part of who they see they are.


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How long does it take a problem to shift from being ego dystonic to ego syntonic?

In trauma debriefing research indicates that therapy should start within 6 weeks of the trauma. The earlier you start the better. After 6 weeks it is harder to treat the problem (PTSD) as it has become ego syntonic.

Research on the formation of new habits indicates that it takes 66 days for a new habit to fully form. After that the person will behave habitually in the new way. Of course this varies on how often the new behaviour occurs and if there are any relapses along the way.

This suggests that it will take about 1.5 to 2 months for a problem to move from being ego dystonic to ego syntonic if the new problem occurs regularly.

If it is ego syntonic then not only does one have to treat the insomnia, but also the habit of not sleeping and the routine involved, along with the self perception of the client as an insomniac.

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The loneliness of the long distance therapist

I can recall back in high school, in literature, we studied a book called “The loneliness of the long distance runner”. The title always stuck in my mind for some reason and I am not sure why. I always thought it was a good name for a book.

The title here refers not to a therapist who is a long distance from the client but the therapist who goes the long distance, that is, is a therapist for many years. Therapy is an odd profession in a number of ways. A long time ago I wrote an article on psychotherapy and prostitution and some of the similarities between them. Both professions require the person to sell them self.

This is unlike the plumber or an accountant. When they are employed by a client it does not matter what they are like as a person just as long as they do a good job plumbing or accounting, at least that matters the most. When a psychotherapist is employed they are employed for their skills as a therapist but also as a person who the client is going to relate to. Indeed the relationship is a significant part of the therapy along with the therapeutic techniques. You can not really separate them in this way.

This has its down side in some ways. Over the years I have seen various therapists who may be changing profession or moving try and sell their practice. And it never is really successful. A therapist can not sell his practice in the same way a plumber could sell their plumbing business. One reason for this, is it is the therapist as a person who relates to the client that makes the practice successful or not. And obviously you can not sell that along with the business.

The majority of new clients who come to me are referred by someone who knows me in some way. Word of mouth is by far the most effective marketing technique for a therapist doing counselling. I do sometimes get randoms or people who found me by looking on the internet but this is a small group. 




They may say they found my name on LinkedIn or came across my blog or these days even more so they say they found my website. I don’t know if I should let out my trade secrets here, but what the heck! My website is not the usual style of website for a psychologist or a therapist. One particularly odd part is the pictorial history which can be seen here.

I can not recall ever seeing a similar thing on another therapist’s website. If a client reports they have seen my website I will ask them what was their reaction to it and invariably they will talk about the pictorial history. Of course they do, as that is where they can get some insight into me as a person. BTW, that was not the reason why I put it their in the first place. It was just something that felt right when I was constructing it. However it is very unusual for a therapist’s website and now I find that it is a good idea from a marketing point of view. Oh well, these things happen.

So I can never really sell my practice, because most of the clients come to me as a person not to the practice as an entity in its own right.




What about the long distance therapist? Well therapists spend their working days relating to people and often the relating can be quite intense. Every person has relational needs, they need to have a sense of being in relationship with others and those relationships must be lived out first hand at least semi regularly. If this does not happen (and thus the person is isolated) then psychological deterioration will occur quite rapidly and can lead to quite severe consequences. Accordingly then therapists must be well supplied in terms of getting their relational needs met and indeed they are, one could say. That could be seen as a positive of being a therapist over time. 

Does this have an impact on relationships in other areas of their lives?
If their relational needs are met in their work maybe they are less motivated to have relationships in other areas of their lives?

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The young therapist - Part 1

Jay Haley

“When a therapist is young, he should not try to appear wiser than he is. The beginning therapist is often young and even unmarried. Faced with a couple married for 25 years, the beginner may be tempted to act as if he understands that stage of marriage as well as they do. It is not so. Instead, the therapist should find a stance to work from that is acceptable to the older couple. For example, the beginner can say, “Obviously you know more about marriage than I do since you’ve been married for a long time, and certainly you know more about your marriage than I do. But as an outsider, I can offer you an objective view of some of your problems.””

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This has some personal significance for me because I began as a very young therapist. I began running my first therapy groups with a cotherapist when I was 22 years old. Probably about a year later I started seeing clients individually and has done so ever since. My circumstances were unusual in that both my parents were psychologists and they ran one of the first ever private therapy training institutes in the city where I lived.

I started my original psychology degree when I was 20 years old and began in my parents training institute when I was 21. In those days in a university psychology degree you would study psychology for three or four years before you actually got to work directly with any clients. In the private training institute it was very hands on. Starting with being a therapist with another student as a client in the training group with the supervisor there. Then as a cotherapist with ‘real’ clients and then finally in individual therapy, all under supervision of course until one passed the exam and was qualified.

When I began in the private training institute I was the youngest by far and remained the youngest student in it for a number of years. I experienced the situation of an early to mid 20 year old therapist working with adult clients who were at time many years older than me.

My mother with Bob Goulding on workshop - holiday. The person sitting with the long hair in front is myself (early 20s year old at the time)

Obviously I was aware of this and at times I did think of it but not really all that often. I can only recall one situation where a client stated it to me that I was young. It is highly likely that some talked about my age to others in their life when they talked about the therapy they were doing with me. 

However in the early years I always worked in private practice which meant the clients who came to see me, they selected me and paid me money to counsel them. They were not assigned to me which can happen in a counselling agency where the client does not get to choose which therapist they see. This I imagine allowed for some self selection by clients. If they felt my age was a problem they would have never selected me in the first place and this may account for the fact that only one client ever said anything to me.

I can recall talking about it with other trainee therapists and thinking about it my self. This is why I have quoted Haley above. What view can one take of this, as young therapists are not all that uncommon. Haley’s point seems to be quite a good one and what I used to say was a bit similar. My view was:

“I have learnt the basic theory and the basic techniques so I just do what I do. If people get something out of it they will come to see me and if they don’t then they wont.” 

I think this is similar to what Haley says. There is no attempt to justify or explain away the age issue. No attempt to say that age does not matter or some similar kind of thing. It is a statement of I am who I am and the input I can provide. This is available if you want it and if you do not, that is OK.

Young adults.

What is the problem?

Obviously the problem for the young therapist is a lack of life experience. But does this mean anything. As a young therapist I lacked more (at times much more) life experience that almost all of my clients. However people still voluntarily came to see me and obviously got something out of being my client. 

At that age I did not understand what effect lesser life experience would have on me as a therapist. Now as an older person I do understand. This lack of understanding actually helped I think because at that age I had belief in myself. It was not until later that I realized maybe my belief in self was a bit unrealistic. However I had a confidence in what I was doing and most people respond favorably to a person who has confidence and particularly a person who just is who they are which my statement above tends to say. I never tried to show my self as being more experienced than I was and never felt the need to justify myself. I accepted myself as a 22 year old therapist doing what he had been trained to do with the personal and professional resources he had at that time.

Clearly young therapists can and do work effectively, so life experience is by no means a necessity for an effective therapist. Having said that life experience can help. Having been a very young therapist and now an older therapist I am of the view that it can help in the practice of therapy.

All new therapists are technicians, no matter how old they are. They have been taught the basic theory and practical techniques of the therapy they are trained in. When they meet their first clients they apply those techniques were it is appropriate. The practice of therapy can have a mechanical feel in this way. After time as they get life experience as a therapist they can stop being a person who just applies the technique and they can relate more to the client as a person who also does therapy with them. You can’t make that shift without the life experience as a therapist no matter how much other life experience one may have. Thus it is my view that life experience as a therapist is more important than life experience in general.

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Jay Haley on marriage counselling - part 2

This post follows a previous one (July 2, 2012) where I recited some of Jay Haley’s thoughts  on marriage counselling, here.

I have mentioned before how I like some of what he says. He is a family system therapist. My personal view is sometimes the family system is of central importance to a client presenting with some kind of symptom. On other occasions it is of little or no importance. On those occasions when it is, I tend to use the Haley model of systems theory. Or at least I keep it in the back of my mind when working with the couple or family members.

In my early training in couples therapy which was some time ago it was highlighted how the counsellor must be an impartial party and not to be seen as favoring one party over the other. I have tended to follow this over the years but have always felt a bit uncomfortable with it as it seems a bit limiting in what the therapist can do.

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Jay Haley

A good therapist will avoid consistently being in a coalition. At times the therapist will side with the wife and at times with the husband. The art is to avoid consistent coalitions. One should join a spouse against another in a calculated way for a specific purpose. In certain situations the therapist may want to destabilize a marriage to produce change. Sometimes a marriage may be stable but miserable. An effective way to destabilize a marriage is to join one spouse against another and simply hold that position. It will tend to bring out emotions and action in the stable couple.

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I like this idea as it allows for much more flexibility by the couples therapist. It is different than my original training in marital therapy that I mentioned above. Also it rests on another basic premise of Haley. He posits the following

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Jay Haley

In couples therapy it is best for the therapist to consider whatever the partners do in relation to each other they also are doing in relation to the therapist. The therapist views the couples therapy as a triad where the therapist is an active party in the dynamics of what goes on between the couple.

A comment by the therapist is not merely a comment but also a coalition with one spouse in relation to the other or with the unit against a larger group.

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This makes more sense to me. The therapist automatically enters the dynamics of the marital relationship. They cannot be uninvolved, instead it is inevitable and couples therapy is always a triad not a dyad. This clarifies for me what I kind of knew but have never articulated clearly. When doing couples counselling one sees this obviously happening. One is an involved party in the couples relationship.

This however raises another interesting proposal as it provides the beginning of a relational therapy approach to couples counselling. The therapist becomes actively involved in the relationship with the couple and the relationship is used as the agent of change. The therapist is using his relationship with the husband and wife (and their marriage) as the means to facilitate change. 

In this relational approach to psychotherapy, it is the relationship to the client that is seen as the agent of change. This implies that as the client changes the relationship to the therapist, this forces the therapist to react to the changed relationship and this makes the therapist also have personal change.

Jay Haley states, “He usually finds his own marriage undergoes changes in response to his experience with couples.” Here we have Haley stating in 1976 a basic premise of the current ‘new’ relational approach that is currently very in vogue in world psychotherapeutic circles.

Individual and couples therapy

Some therapists have a rule that if you see a person in individual therapy you must not at a latter time see that person and their spouse in couples therapy. This situation not uncommonly arises in counselling, where the partner wants to get involved. Some of the logic behind this rule is that you cannot be unbiased as the couples therapist, because you have a pre existing relationship with one party and not the other.

I have never had that problem or followed that rule. I am quite willing to see a couple where I have had a pre existing therapeutic relationship with one party and not the other. After thirty years of counselling I have come to learn that in marital disharmony there is always two sides to the story. 

What is being proposed here by Haley now makes more sense. In the situation described there is already a coalition formed between the therapist and the client previously seen in individual therapy. It is quite likely the spouse who appears later in counselling will experience such a coalition existing as does the pre existing client. Even before the first couples session has started the dynamics of the husband-wife-therapist triad is occurring. One simply uses the perceived coalitions for the couples gain.

This changes the therapeutic landscape quite considerably. Haley states that counselling one party in individual therapy and not the other will tend to build a coalition between the two with the other spouse being out side that coalition. Thus one can use this method to build coalitions with one spouse as well as reducing existing coalitions by seeing the other spouse in individual therapy.

In this way the distinction between individual therapy and couples therapy becomes meaningless. Individual therapy becomes one technique or one subset of the overall couples therapy.

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