THERAPY THROUGH A LENS
There is a lot of debate about what 'works' in therapy and much is made of the therapeutic alliance ie. it is the therapist and not the model of therapy which is effective.
I disagree. Having started my career as a person centred counsellor and then moved into a more solution- focused model I have been very aware of the benefit of having an additional skill set.
That is not to say I am not person centred now. I am. It is my default position and I adhere to the core conditions of congruence, empathy and unconditional positive regard.
However, it is technically interesting to notice the difference in counselling styles, to compare and contrast models.
Here are three case studies. The first illustrates my work using a human givens framework and the second and third were written in a person centred centred model.
COUNSELLING A CLIENT WITH M.E. USING THE HUMAN GIVENS MODEL
David was referred to me by his GP. He had developed ME two years ago at the age of 13, following a severe flu like virus. Depression and chronic pain were now part of the picture.
David came for the first time, in summer 2009 and we spoke about the current situation.
He complained of a feeling of continual tiredness, from the moment he woke up in the morning. He estimated he slept on average 16 hours a day and on a bad day would stay all day in bed.
He had a constant headache (level 8/10), pains and swelling in his left wrist and severe back pain (level 9.5 /10).
Not surprisingly, he had a very low mood (3/10), said he hated being around people because of the noise.
Lately, he had been very down and crying a lot.
He described himself as ‘The boy who doesn’t go to school’.
‘I can’t do anything’, he said, ‘I have no future. Sometimes I think I don’t want to wake up at all’
NO WONDER HE WAS DEPRESSED!
I regard my work as largely psycho educational. The things we do not understand can frighten us very much and I knew that it was important right at the outset, to give David a full explanation of the mind body connection between depression, sleep and pain.
David’s emotional needs audit showed he currently had a life that was just not getting his emotional needs met. He had little control; did not feel safe due to his uncertain health. He scored low on an emotional needs audit questionnaire on status, achievement, emotional connection and fulfilment. In other words, he was tired, bored, and lonely….frightened of the future…..and in constant pain. No wonder he was depressed!
I had so much to tell David, it was difficult to know where to start, so I began by describing the mechanism of emotional hijacking, in other words the ability for the emotional brain to switch off the rational, logical brain. I described also the black and white thinking style of the emotional brain and how it sees things in all or nothing terms such as ‘I will never get better’, ‘my whole life is a mess’ and ‘everything is ruined.’
I also described how, in that emotional state, you could find yourself thinking ‘I can’t carry on like this, so I want to die.’ David was relieved to hear a clear explanation for his frightening suicidal thoughts.
I explained to him how worry and rumination in the day also affects sleep quality, that dreaming is our way of discharging the emotional arousals of the day and that, if he was dreaming a lot at night, he was not benefiting from the deeper, slow wave sleep which repairs and refreshes the body. I told him that, because it was still very unnatural for us to be upright, that we tear and damage our muscles during the day and that these quite naturally repair at night in slow wave sleep.
We also discussed that, in sleeping so long during the daytime, he was disrupting his normal ultradian and circadian rhythms, was probably over dreaming, and that dreaming had been shown to be actually very tiring as it uses motivational energy. In other words his get up and go was getting up and going during excessive sleep….!
DAVID 'GOT IT' STRAIGHT AWAY
I made a suggestion that David try to sleep only at night, that the bedroom was for sleep only, not reading or watching TV and that if he felt like resting during the day, he should relax on the settee downstairs.
I soon realised that David was a very intelligent young man and that he understood these concepts straight away.
On that first session, I taught him how to relax himself very deeply with the seven eleven breathing technique. When we breathe in, we activate the sympathetic nervous system. It is more of an effort to breathe in and so, when we breathe in, we tense.
When we breathe out, we engage the parasympathetic nervous system. We relax. We have a feeling of letting go.
Therefore, if we continue for 5 or 10 minutes to engage a breathing pattern of counting seven on the in breath and eleven on the out breath, we cannot help but start to relax..
I gave him a notebook to record his internal monologue (the background tape we run internally which is often very negative) and I also asked him to write down at the end of the day, three things that had gone well during the day, something he was looking forward to the next day, plus any improvements he noticed as a result of doing the breathing exercise.
I suggested that he asked mum to get a good quality omega 3 supplement as trials have shown that omega 3 is depleted in the modern diet and that it is essential for good brain function. It has also been shown to alleviate depression on its own and, as a side issue, is also very good for eyes, joints, bones, circulation and heart.
By session 2, it became clear that David was practising the seven eleven breathing technique and using it to calm the emotional brain. With David in a calmer frame of mind, we could commence the real psychological work and address the issue of pain.
CLOSING THE PAIN GATES!
We talked about pain and how the body perceives it. When stress is high, the spinal pain gates open and pain feels greater.
Also, if the brain notices a pain and thinks it is significant, in other words something is really wrong, it pays greater attention than to a pain that has been identified as insignificant.
I explained to David the natural filtering system within the brain, the reticular activating system or RAS, which allows subconscious information to filter through to a conscious level.
We only hold around seven pieces of conscious information at one time, but we are processing millions of pieces of information subconsciously.
For example, until I say ‘your left foot’ you are unaware of it. It is simply your left foot doing what your left foot does all the time. But when you direct your conscious attention towards it, you become aware of the level of warmth or cold, the pressure of the foot on the floor or the slight pinch of the shoe on the heel.
And so it is with back pain for instance. That if you think it means something is really wrong with you, you will pay it greater attention. RAS will allow sensations to come to consciousness, which might otherwise drift into the background of awareness. It is not uncommon for people to ‘symptom scan’, in other words, look for evidence of illness.
Our discussions around lifestyle involved the implication of full spectrum light on mood and wellbeing.
Full spectrum light has an impact on mood. It enters the retina and is directed onto the brain where it produces serotonin, out feel good hormone. This has an immediate effect on how you feel.
It’s interesting to know that, indoors we receive around 100 units of light, or lux, per hour,
and outdoors, on an overcast day, we receive 7000 lux per hour.
Outdoors on a sunny day, we receive around 20,000 lux per hour and this has real implications for wellbeing as the first thing we do when we are ill or depressed…is stay indoors. Lower serotonin equals greater pain perception, and so the spiral can continue down ward.
David could see that his current lifestyle and excessive sleep pattern may be implicated in prolonging his pain and illness and he resolved to take action.
His appetite was also poor as he had nausea as part of the picture. We discussed the importance of a diet which would stabilise his blood sugar so that he would have more constant energy levels. He should eat protein at every meal and ensure that he ate something every three hours throughout the day..
By session 3, David stated he was sleeping better, not waking in the night, not crying and felt more positive that he would recover from ME.
David was a talented visualiser, and so we were able to do some very interesting work in guided visualisation which was to have a profound impact on his pain management.
Once he had relaxed very deeply, I suggested that he imagine he had a dial on his back, like the dimmer switch of a light and that he could use that dial to reduce the back pain to a level that was more comfortable for him whenever he needed to. I suggested that he might like to try that every hour for a day or two, noticing that he could get better and better at it and the results could be more effective as she practised.
LAPSE IS NOT A RELAPSE
David felt well enough to go on a school trip to London, but, on his return was very tired and felt he had taken a step back.
‘Lapse is not a relapse’ I told him. It is not uncommon to feel you are taking two steps forward and one step back. We should build that into the model of your recovery.’
At session 4, we started to focus on the future, identifying goals like going to university, being independent.
David said he wanted to get back to football again, which he had missed so much. Between us, we constructed a paced exercise programme which involved daily walks and stretches. David didn’t even know where his football was anymore. It had been put away, along with his identity, somewhere near the outset of his illness as he became David with ME rather than David who loves to play football.
It is essential to disidentify the illness from the person. We worked on who the real David is. The one he was before he got ill; all those old hobbies and interests and activities that had got lost along the way.
In starting to play again, David was reconnecting with his old self. It represented his hope for the future, a life without pain. Also, it is important to realise that inactivity impacts fitness levels, and so gentle and paced exercise would begin to strengthen all those tired and aching muscles.
To help David separate himself from the ME, we began to think of the illness as a bully that must be stood up to. David had some experience of bullying at a previous school and so this analogy fitted very well in enabling him to take a step back from the ME, see it from further away where it was the enemy and he must summon all his forces to weaken it.
STORYTIME....
I wrote a therapeutic tale especially for him…………..about an old, tired king who was too weary to fight the dark prince and who handed rule over to his son, the prince. With his youth, energy and vibrancy, he retrained the army, equipped them with strong, modern defences and fed them well until, at last they were ready to take on the invader and defeat his men with their superior power.
I asked him, if ME had a face, if pain had a face, what it would look like. He thought for a while with her eyes closed and said that ME and the pain were like two ogres, two giants that threatened him and tried to take control . In a visualisation, he imagined them shrinking in size until they were small enough to tie up and dump down a well!
David was improving all the time. He noticed better sleep, appetite, energy and mood. He enjoyed the visualisations and so every session, we tried something new….
…..a cloud over his head that he could allow negative feelings to be absorbed away from him, a walk through a rainbow where every colour represented a level of healing.
As his back pain was receding, we targeted the headache and one visualisation seemed very helpful.
In relaxation, I suggested that David could look up into a corner of his mind and see the level of pain reflected there. He said it was a level 6. I said ‘so the number represents the level of pain and the pain is reflected by the number. If you choose to lower the number in the corner of your mind, the pain will lower in accordance with that number. So you can choose to reduce it to a level 5 and then a level 4 until you are more comfortable.’
THE STOP SYSTEM
I had devised by this time something I referred to as the S.T.O.P system for challenging negative self talk. We had identified at the outset that David’s internal monologue was rather negative such as ‘I’m useless, I wish I wasn’t me, I wish I were dead.’
The psychological and physiological impact of these self statements is very powerful, and so I suggested to David that, whenever he noticed negative thoughts, he should challenge them every time with emotional intelligence, a positive reframe such as ‘actually, some of my life is working very well like family, football, schoolwork. There is lots of evidence now that I am recovering from ME and that the future will be bright for me.
Negative thinking can become a habitual thinking style, but by constantly challenging it, new neuron pathways can form, and new ways of thinking.
I knew David was putting this into practise when, at his next session he said that in a way ME had been a good thing as it had made him stronger. I was pleased to notice that he was starting to refer to ME in the past tense.
The back pain had gone by now and the painful swollen wrist. The headache had receded to a level 2.
I asked him how near he felt he was to recovery. I drew a line representing a road and asked him to draw a car in the place he felt he was at the moment. He was three quarters of the way there!
Interestingly, when mum came to pick him up, I asked her to do the same, to put a car where she thought David was in his journey towards recovery. Mum’s line was only halfway which prompted an interesting discussion around perception, it also firmed up the image that there was a definite end to this journey and that it would not go on forever.
Hope had replaced fear and there was now positive expectation about the future. Mum had been badly affected by her son’s illness and depression and needed to see an end to this also, so that David could benefit from the positive expectation of his family.
Sadly, during this time, David’s Uncle died and he experienced some of the familiar reactions to that; sadness, anger, guilt. I work also as a bereavement counsellor and while we were working through those feelings, David made an observation which was significant and a clear indicator of how he had developed an understanding of the mind/body connection.
He said…..’I’ve noticed that, when I feel down I feel worse physically, I get more pain. That upsets my sleep pattern and then I get more tired and more tearful.’
I was beginning to think that David would make an excellent counsellor!
By now, I was only seeing David once a month. The pains were largely gone, but re emerged on the run up to his GCSE’s, only to recede again when the exam stress was over.
Occasional low energy is his only remaining symptom.
However, he returned from a trip to Spain recently and reported that while he was away, his energy had been near to level ten all the way through.
I asked him why it was so much higher on holiday and his reply was illuminating. He said:
‘I wasn’t bored, I wasn’t depressed and I wasn’t lonely. I didn’t have time to think about me. I didn’t have time to think about M.E.’
David’s focus is very much outward now. He is doing A levels, in school full time, has made new friends. He sleeps 8 hours the same as everyone else and describes himself as confident and sociable. He has his sights set now on being a teacher.
He will make a very good one!
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COUNSELLING IN A CATEGORY A PRISON USING THE PERSON CENTRED MODEL
As part of the counselling team, I work under the umbrella of the probation department, within BACP guidelines. There is an active equal opportunities policy in place and relevant insurance. There is one and a half hours of personal supervision each month and counselling is in the person centred model. Sessions with the client are 1 hour long and restricted to 8 weeks.
It takes around twenty minutes to enter the secure area where solicitors, probation officers and counsellors see their clients. Not surprisingly, boundaries and rules are paramount in this environment. Apart from the BACP recommended framework, there are additional precautions which must be taken.
No personal information can be given to clients apart from first names. Even then, clients will often choose to address me as ‘Miss’ and this can feel incongruous with the person centred approach.
But confidentiality is key and for very good reason. As a category A prison, many of the inmates have histories of violence. For personal safety, one must follow all the guidelines and there is absolutely no room for deviation.
Any intimation of self harm or harm to others must be reported. Any intimation of abuse involving children must be reported.
No items can be brought in for the client and, indeed, nothing must be accepted. In fact counsellors can and have been prosecuted for passing items to an inmate.
No information regarding an inmate can be passed to another inmate or family thereof.
Relationships with clients must be on a professional level only and no contact between client and counsellor is permitted post release. Also there must be no written contact post release as this would be regarded as unprofessional and inappropriate.
Counsellors have to be careful not to collude with inmates in the matter of racial or sexual prejudice or stereotyping, particularly when working with sex offenders who may look for support of deviant behaviour.
Appointments have to be booked two weeks ahead. There is a team of 10 counsellors with limited access to secure rooms.
Very limited records are kept by the counsellor in notepad form. This means they fall outside the data protection act. Any written notes must not contain the client’s name and are destroyed as soon as possible after completion of sessions.
There are good reasons for working in this restricted environment but there are also challenges:
Reasons for…..
There is a need.
Brief therapy concentrates the mind so that clients move forward quicker.
Boundaries are so tight that everyone knows exactly where they stand.
Done well, it definitely helps with the client’s sense of autonomy, self esteem, anxiety, depression.
Challenges…….
The need may be much greater than can be accommodated by 8 sessions.
There is little privacy in the interview rooms, although conversations cannot be overheard.
The prison environment can be intimidating.
Such tight boundaries can feel confining in that ‘the system’ is governing the boundaries and are not being mutually agreed by the client and counsellor.
The client may see the counsellor as part of the prison system and may be more guarded in what they say, an issue of trust.
Endings can be very sudden due to transfers.
My client;
Paul is a 24 years old male, single. He is in prison for aggravated theft and arson.
Prior to this stretch in prison, he lived with a girlfriend and her children by a previous relationship.
His mother and father separated when he was 3 years old. He is the middle child of three boys and lived with his mother until he was 10. One of his few childhood memories is of being put on the front doorstep by his mother, who could not cope with his challenging behaviour, and waiting for his father to pick him up.
He lived with his father until teenage, when early criminal activity, drink and drugs ensured he entered the criminal justice system.
He reports a good relationship with his father and paternal grandmother, but little contact with his mother. He feels ‘disowned’ by her.He has some contact with his brothers.
His father has remarried and he very much dislikes his father’s new partner. It was their home he burgled and tried to burn.
My client has stated ‘relationship issues’ as his reason for requesting counselling and reports low mood and anger management problems.
He hopes, in counselling to make sense of his story, how he came to be in prison and where his life is going.
My client appears well, somewhat pale, cleanly dressed. His manner suggests a certain amount of bravado and he rocks backward and forward on his chair as we talk. His body language is, however quite open and expressive and he gives me good eye contact. He seems very ‘present ’and I am hopeful of good psychological contact.
My client has a history of drink and drug abuse, self harm by cutting, and depression. He is currently taking antidepressants prescribed by the prison service medical team.
He has recently finished an enhanced thinking skills programme run by the prison, which he found beneficial and has tried relaxation classes and acupuncture, also run by the prison.
Boundaries and greeting my new client;
I explain the boundaries to my client. By seeing the limitation of sessions as a boundary imposed by others, not a condition imposed by me, and clearly communicating this to my client, I believe I am very much leaving him in control of how that time is used.
Therefore, it is not a condition of worth imposed by me. This is different to a contract which is reviewed and extended. This is unacceptable from the person centred point of view which I translate as ‘I will see you for x sessions and if you are good I will let you come a bit longer’- clearly a condition of worth and part of the problem rather than part of the solution
I try not to have preconceptions about my clients when they arrive and do not have a treatment plan or goal.
When I greet my client, I welcome him, but try to avoid suggesting what he should talk about, so, in a first session, I might say ‘what brings you to counselling?’. I don’t even want to suggest that they have a ‘problem’, that is a judgement I do not feel able to make.
In later sessions, I will say I do not want to suggest a direction to the client but will try to understand as deeply as possible, and from their frame of reference, whatever they would like me to know.
I do not mind silence and will not try to fill it. I will trust my client to find his own way with my support. He is his own best expert and he is therefore far more likely than me to know what is important for him to talk about.
Similar considerations apply to his drink, drug and self harm. It is very rare these are the real issue, but rather a symptom of a deeper problem. I will therefore ignore these and leave the client to talk about his real problem. To talk about the drink, drug problem is a way of colluding with the client and avoiding the real issues.
Whilst building rapport, I pay particular attention to body language, both his and mine. There is a desk between us which is a barrier, also a panic button and visibly patrolling prison officers, at odds with the core conditions of congruence, empathy and unconditional positive regard.
But as I ‘turn on and tune in’ to this new client I am aware that he seems relaxed and attentive, focused. He says something amusing, I laugh out loud. He laughs, and I feel psychological contact is made.
The first session;
Transcript of part of the session;
He wants to talk about relationships, family relationships and his dependence on women.
He tends to drift from one relationship to another, often moving in with a partner who has children by a previous partner. He temporarily takes on the role of husband and father, enjoying the family environment, before becoming restless and looking for sexual excitement elsewhere.
I ask him what he enjoys about moving in with a woman who has children;
Client. ‘I don’t know. I like helping out… Doing things…. I’m a very loving person. I just enjoy being there.
Cllr.1. ‘you’re a very loving person.’
Client. ‘Yes. I’ve got a lot of love to give. I enjoy doing things for other people and feeling wanted.
Cllr.2. ‘you need to feel wanted….loved?’
Client. ‘Yes. I need to feel loved. That’s it…….it hasn’t always been easy.’
There is silence and my client looks as though he is watching something on a screen.
Client. ‘I haven’t always felt loved.’
Silence.
Cllr.3. ‘When have you not felt loved?’
Client. ‘All through my life….. My mother didn’t want me. The school couldn’t handle me. My father got stuck with me.’
My client looks angry.
Cllr.4. ‘How are you feeling at this moment?’
Client. ‘I’m getting angry again. I always felt different, pushed out, isolated. I just never fitted in.’
Cllr.5. ‘You felt pushed out and that made you angry.
Client. ‘Yes. Being different made me angry and the more angry I got, the less I fitted in. I wasn’t wanted. I could see it in their eyes.’
Cllr.6. ’Whose eyes did you see that in?’
Client. ‘Everyone……Mum……..the way she looked at me. I could see she didn’t want me and it made me feel…..’
Silence.
My client is visibly upset. He rocks on his chair. I notice he is digging his thumbnails into his hands.
Silence
Cllr.7. ‘the way she looked at you made you feel….?
Client. ‘Lonely….. On my own. If your mum doesn’t love you, you must be really bad…… Right?’
Cllr.8.’You felt as though you were a bad person.’
Client. ‘Yes. I felt I was bad from very early on…..’
Cllr.9.’ You felt you were a bad person even when you were so young?’
Client. ‘Yes.’
Cllr.10.’ And yet, earlier on, you referred to yourself as very loving, having a lot of love to give.’
Client. ‘Yes.’
Cllr. 11.’Does that sound like a bad person?’
Silence.
Client. ’No.’
Analysis of interventions.
Intervention 1; I am reflecting back to my client something very positive he has said about himself. I hope to draw his attention to a positive part of his personality. This may be helpful in terms of his self esteem.
I have noticed, understood and mirrored this positive affirmation.
In a sense, I am affirming that he is loving and therefore loveable.
Int. 2; Again reflecting, affirming, reframing ‘wanted’ with ‘loved’.
My client is telling me he needs to give and receive love, one of the basic human needs, a very positive part of personality and the basis of all human relationships.
I have offered him what I hope is an accurate interpretation and empathic understanding.
Int. 3; I wonder where the origins are of this lack of feeling loved.
In person centred terms, unlike the psychodynamic paradigm, childhood is unimportant…..unless the client thinks it is and takes you there.
Int. 4; My client has referred to his relationship with his mother. The evidence is that my client has introjected an external condition of worth, that is ‘I will only love you if you are good’.
In Rogerian terms, the mother has become ‘an external locus of evaluation’ and possibly the beginning of a gap opening between the client’s ‘true self’ and the self he must portray to win his mother’s love and approval.
My client is looking angry and I reflect this to him.
This is what Zimrung (1990) referred to as a ‘hot emotion’.
The memory evokes anger in my client and anger management is a specific issue my client has brought to counselling.
I am reflecting to get my client to explore his underlying feelings. In a sense, I enter into his anger and make an empathic connection. My body language would have reflected his at this moment.
Int. 5; I connect the mother’s rejection of the child with the possible origins of his anger. Whilst maintaining my non directive approach, I am drawing my client’s attention towards his own observations, his own feelings. I allow him to own his feelings. It feels as though my client’s basic physiological needs for safety, belonging, love and esteem or ‘deficiency needs’ (Maslow 1957) were not met at a very early age.
These needs are what Rogers termed ‘the motivational construct for the actualising tendency.’ In other words, these early feelings of emotional abandonment may have restricted my client’s capacity for physiological freedom, growth, development and realisation.
Int.6; I am asking my client to clarify, be specific about whose eyes were so cold and, again, he refers it back to his mother. My client’s anger now embraces another emotion. He looks upset.
I mirror his body language. I notice his distress and reflect it back to him empathically. I hope at this moment he feels ‘held’.
In a counselling sense, I am ‘remothering’ the child, noticing his emotion and being concerned. It is important that I genuinely feel his distress and concern. If I fake it, I become part of the problem, not part of the solution. I need to be very present and real for my client at this moment.
Int.7; Again I try to reconnect my client with his emotion. Anger may be masking a deeper feeling of sadness, rejection, abandonment.
I feel at this moment as though we are communicating at a deeply intimate level.
The client has displayed huge trust by opening to his emotions in this way and I feel privileged. I hope he is feeling heard and understood.
I, as counsellor, need to have the emotional maturity to enter into my client’s feelings, whilst, at the same time, being clear about the distinction with my own.
Family and rejection resonate with me and I am aware of the possibility of counter transference.
I notice it, but am able to ‘set it to one side’ so that it will not interfere with the counselling process. I will take it to supervision.
By observing and reflecting these deeper emotions in my client, I invite him to step into his observing self or what Carl Rogers called ‘the organismic self’, and thereby increase his sense of ‘inner knowing’ in a psychological environment free of conditions of worth.
Ints.8 /9; From an early age, my client has thought of himself as ‘a bad person’. Bad people do bad things. It seems he acted this out as a child and continued into adult life.
I am going to challenge this concept of self.
Ints.10/11; How can a loving person be such a bad person?
This kind of challenge creates dissonance in my clients self concept, his introjection, and is a move towards emotional congruence.
Following sessions; Explicit and Implicit pattern; Endings.
My client was given the ‘bad’ label very early on in life and has acted out his ‘badness’ ever since.
When Carl Rogers referred to ‘unconditional positive regard’, the evidence is he actually meant love but felt this to be an unprofessional term. This unconditional love of client, in counselling terms, offers a healthy psychological environment for ‘remothering’ and renurturing, allowing the ever present actualising tendency to emerge.
Evidence suggests that most psychological movement occurs in the first three or four sessions of therapy and this proved to be so with Paul.
At the start of each session, I offer no direction but open with an invitation to my client to bring whatever has come up for him during the previous week. This non directive approach allows Paul to target the subject most pressing for him at that time and will lead in the direction he wishes to take it. I assume at all times that my client knows best and is his own best expert. He knows what hurts and what needs attention.
Relationships, family and anger were often uppermost in his mind and, although he seemed to have considerable childhood amnesia, he often referred to specific events which had been so painful they had left an imprint on his memory.
For example, on the occasion of his 11 birthday, when he had hoped for a pair of football boots, admiring them in a shop window every day on his way home from school.
Just before his birthday, the boots disappeared from the shop window and he ran home to unwrap his present.
He had, indeed, been given the boots by his mother only to have them passed to his brother because the school had telephoned that day to complain about his behaviour.
After Paul recounted this story to me, I waited for his reaction. He offered none and so I asked.
‘How did that make you feel?’
He replied that he had been ‘a bit upset, suggesting a huge understatement of the emotional distress and hurt this must have caused.
His defence, his bravado, would sometimes slip at these moments as he began to reconnect to his feelings and my purpose at these times was to understand, hold, support.
Paul’s recollections led me to theorise that my client had become estranged from his ‘true self’ in early childhood. Perhaps through scapegoating, distortions of perception, lack of a nurturing environment, he introjected a ‘bad boy’ image.
Babies do not come into the world estranged from themselves. Socialisation and introjected conditions of worth are behind the alienation.
Rogers (1961) found the infant baby to be a model of congruence;‘He is seen as completely genuine and integrated, unified in awareness and communication. Distorted perceptions from conditions of worth cause our departure from this integration.’
I hope that, for Paul, changes in his self concept may occur during his experience of counselling and, as our final session approaches, I do notice more positive affirmations and an emerging ability to ‘own’ his feelings, to go deeper into his experience of self.
The boundary, the end of counselling, found Paul calmer, more introspective and he surprised me when, in the seventh session, he stated his intention to write a book of his life story, how he came to be in prison and the way forward.
At that moment I had to resist an urge to jump from my chair and shout ‘yippee. That is probably the most cathartic thing you will ever do!’
In this instance, I had a good ending with my client. It is not always so, particularly when, frustratingly, inmates are moved to another prison without notice, often leaving me with a feeling of unfinished business. However, Paul had already arranged to be moved to a prison closer to his home town and had stated his intention to seek further counselling when he arrived there.
I do not know what will happen for Paul and, in person centred terms, demonstration of a ‘good outcome’ is unnecessary.
Actualisation is a journey, not a destination and Paul’s story continues, evolves where ever his is.
I feel privileged to have known him.
Conclusion and personal reflection;
When I began counselling at the prison, it was my first encounter with brief therapy.
The restriction to eight sessions, in conjunction with the tight security system, at first felt incongruous with the person centred approach.
We had a good early rapport and Paul was very open with me from early on in our encounter. I felt privileged by the trust he placed in me.
He reminded me, in a way, of my own son. He was a similar age and build and I was aware that, in the counter transference, I should not make comparisons.
It is not uncommon to feel a maternal connection to a client and, in these circumstances, in can be very useful in renurturing the wounded inner child.
However, observing the nature of the relationship and, especially in the prison environment, it is important to disidentify with the emotional connection so that relationship builds on a purely professional and not personal level.
My struggle in counselling Paul centred on not becoming over-involved. Wanting to ‘fix’, wanting to heal are subjects I often take to supervision.
I have a natural inclination to be goal oriented and my constant problem is with the strict adherence to the non directive approach. I am quite cognitive in my own perceptions and, without the confines of the Rogerian paradigm, may have been tempted to use other integrative interventions in my encounter with Paul.
I would have been interested in trying some subpersonality work with him. The introjected ‘bad boy’ image may benefit from disidentification and a sense that ‘he’ is more than that part of his personality.
I was curious about his childhood, much of which he claimed to have forgotten. I wondered whether memories could be retrieved by him in deep relaxation.
Psychodynamically, I hypothesised about the unresolved oedipal nature of the relationship with his mother and how that now impacted on his relationship with women, his patterns of behaviour.
But, at all times, and in the counselling context, I have my own internal supervision, so that I keep the concept of counter transference at a conscious level, constantly aware of the dynamic.
Knowing the client’s boundary, where he stops and I begin, keeping the work safe and integration of theory and personal understanding, all become part of the ‘mosaic’ my counselling practise. It continues to evolve, as do I, and I rely on my internal supervisor to guide me in its development.
Carl Rogers felt the core conditions were ‘essential and sufficient’ and, in Paul, during the eight sessions, I did think I noticed psychological movement. My efforts to perceive the world as it appeared to Paul, free from personal distortions, were based in these core conditions and came from a deep respect for him as an individual.
By mirroring, reflecting, holding and sometimes challenging his introjections, I hoped that changes would occur in his perception of self and his perception of reality so that changes would naturally occur in his behaviour.
Meeting Paul was a deeply enriching experience and, by the eighth session, I had a sense of his internal reorganisation. I do not know how things progressed for him after his move to another prison and a clear conclusion cannot be demonstrated.
However, in Rogerian terms a freedom from tension, a different feeling about and perception of self is, and must be, ‘sufficient’.
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Frances Masters MBACP Accred. UKRCP GHGI.
Copyright (c) 2010 Frances Masters
