(c) danielbrezina.com, Flickr

Introduction.

A current problem (2010) is that counselling and psychotherapy is not yet governed by UK law.  Anyone can advertise themselves as a counsellor or therapist without actually having any professional training, appropriate qualifications or any actual experience. Unfortunately, this might suggest that the client seeking therapeutic treatment could be at risk of working with an unqualified therapist.

However, finding a qualified and experienced counsellor can be a straightforward process if you know of some helpful things to look for.

This post describes how to find a suitable therapist – and offers some topics to check out with your potential therapist.  At your first meeting, most – if not all – therapists should not be phased by you asking about the topics (in later sessions, however, some therapists may not answer your questions about them directly, but be interested with you in the purpose of your question – keeping the focus upon you.  This is a legitimate form of therapy (eg psychodynamic / psychoanalytical) – but I include it here just so that you are aware).

Advice for Clients.
Read: “How to get the best out of your therapist”
(c) BACP – 2010

Search a Professional Body

An easy way to find a suitable therapist is to use a professional therapists’ body that offers a “find a therapist” type of service. The therapists listed may have had to pay for an entry, but would also have had their qualifications checked before being allowed to pay for an entry in the list.  It’s a good place to begin searching for a therapist.

• British Association for Counselling and Psychotherapy
  http://www.bacp.co.uk/seeking_therapist
• British Association for Psychotherapy
  http://www.bap-psychotherapy.org/
• The British Psychological Society
  http://www.bps.org.uk/

… however, if you wish to find your own therapist – or you would like some advice on what to check out about your potential therapist – then read on.

Finding your Own Therapist.

Finding your own therapist can be easier when you want to find a counsellor with specific criteria.  Sometimes professional bodies do not include such criteria.  Use search engines such as Google, Yahoo and Bing to begin your search – and then refer to the information below about what you might want to check about each potential therapist.

Qualifications.

Does the counsellor has a recognised qualification in counselling.

Diplomas and Degrees – check that the qualification included actual supervised practice (eg 100 hours counselling practice to achieve the qualification).  Having a qualification in the theory of counselling without any actual practice may be insufficient for your needs.

Certificates in counselling may not include any actual practice to gain the award if they are just certificates of attendance.

Membership of Professional Body.

Is the counsellor a registered member of a professional body?  Do they subscribe to a recognised code of ethics or an ethical framework for their therapeutic work?  Is there anyone to whom you could report your complaint if you needed to?

Special interest/experience.

Does the counsellor have any special interests or special experience in working in particular therapeutic areas?

Theoretical approach.

There are different forms of counselling and psychotherapy – and whilst it’s the relationship between therapist and client that is shown to matter, some approaches might suit you better than others.

See Wikipedia – http://en.wikipedia.org/wiki/List_of_psychotherapies for information on therapy models.

Who does the counsellor work with?

Does the counsellor state what types of person they can work with (eg adults, couples, young people, children, elderly etc).

“This is how I work”.

Does the counsellor give you an idea of how they work therapeutically?

Fees.

Do you understand what the therapy will cost?

Supervision.

Counselling supervision is a formal meeting in which the counsellor meets with a qualified supervisor (or another counsellor) to review their clinical work.  Sometimes their professional development and their personal development is reviewed too – depending on the counsellor’s needs. A supervisor is not a managerial role, but more of a professional service designed to support the counsellor.

Is the counsellor taking regular supervision?  Some therapists’ professional bodies require the therapist a minimum amount of supervision every month (eg 90 minutes).

Continual Professional Development.

Does the therapist make you aware that they attend CPD (a form of contining their training and experience throughout their practice).  Some professional bodies, such as the British Association for Counselling & Psychotherapy, require that the counsellor obtain a specific number of CPD hours per year.

Local Towns & Villages covered by iCounsellor’s Counselling.

(c) seier seier seier, Flickr

It’s not unusual to consider that Dean Richardson at iCounsellor.co.uk works with many people from areas that are around his main practice areas (Portsmouth, Hampshire and Chichester, West Sussex), but what might be surprising is the significant number of Dean’s clients who travel from areas much further away than these local areas.

The furthest client regularly travelled 50 miles to each session; the nearest client walked two miles. Many of his clients regularly travel miles to both his central Portsmouth and central Chichester consultation rooms from such places as Arundel, Guildford, Woking, Winchester, Southampton, Lymington, Brighton, Bournemouth, Worthing and so on.

Dean practices as an individual and couples counsellor – and is experienced to work with many people regardless of presenting issues, gender, sexuality and relationship status. He also specialises in working with LGBT couples and individuals.  So, since expanding into private practice in 2009, it has not been unusual for people who wish to work specifically with Dean’s counselling practice to make a distant weekly journey to and from Portsmouth or Chichester.

To make contact with Dean:  click here.

Hampshire.

Dorset

Isle of Wight

Surrey

West Sussex

(c) armigeress, Flickr

This is not an exhaustive list, but this post lists some of the problems that clients have brought to my psychodynamic counselling/psychotherapy practice over the years:

See also What could Couples Counselling help with.

(c) treesftf, Flickr

Introduction to Short-term, “brief” Psychodynamic Counselling.

In addition to open-ended counselling, Dean Richardson can offer short-term psychodynamic psychotherapeutic counselling to individuals where an assessment & both client & counsellor deem it appropriate to do so.

Short-term psychodynamic psychotherapeutic counselling is where the client and counsellor meet weekly for an agreed set number of sessions.  Each session lasts for fifty minutes, occurs once a week, and the whole therapy is limited to an agreed number of sessions (which may be between four to twelve sessions, to give an example).  The actual number will be agreed by mutual consent between counsellor and client.  The brief-therapy work concentrates upon a specific (and agreed) matter in the life of the client(s) and the therapy aims not to expand into other subject matters.  Expanding into other matters is more in the realm of open-ended counselling.

A Summary of Brief Counselling.

• Short-term psychodynamic counselling takes place within an agreed fixed number of sessions.
• The client and counsellor must agree a focus for the counselling work at the beginning (ie during the assessment).
• Although other matters may come up during counselling, these matters may need to be put aside (at least for now).
• The client must be motivated and focussed to do this form of therapy.
• The relationship between counsellor and client must be good to achieve this focussed work.

Benefits of Brief Counselling.

Some benefits of short-term, brief psychodynamic counselling work can include:-

• …the therapy lasts for a certain “known” amount of time,
• …the end date of the therapy is known at the start (which can be helpful on the focus of the counselling),
• …the client is aware of how much money the counselling will cost,
• …only a specific matter is worked with,
• …it can be useful to be able to measure the outcome of the counselling, although this is in no way essential or compulsory,
• …the rapport between client and counsellor is good, and therapeutically reliable (the client having had at least one beneficial relationship in their life)
• …uses client’s own insight into their problem,
• …works if the area of conflict can be agreed upon.

This approach (and, possibly, these limitations) can be beneficial to some clients. It is important, however, to realise that this approach is not suitable for everyone, and an initial assessment will be helpful in evaluating if this form of therapy could be helpful and in the client’s best interests.

Counter-indications for Brief Counselling.

The counsellor is responsible for judging during the assessment if the client is suitable for brief therapy or if such therapy may cause harm to the client (eg based upon the client’s level of functioning) when, instead, the counsellor may offer other forms of therapy (such as open-ended counselling).

Other counter-indications for brief counselling may include:

• The client is unable to focus adequately on one matter, instead requiring the time and space to make use of free association.
• The client is unmotivated to focus on a particular matter within the limited amount of time.
• It is felt by the client and/or counsellor that the client’s needs would not be adequately met by focussing upon just one matter.
• When setting a deadline to a psychological or emotional matter would be inappropriate (eg the client is motivated to select short-term work only because of costs or due to an EAP offering only of a fixed number of sessions, when the client’s needs are greater than that offered & beyond the therapeutic interventions available).
• The client’s ability or potential for insight is limited (insight = a kind of self-realization or self-knowledge).
• The client may be dependant on the counsellor for providing solutions, rather than be motivated to be an active participant  in their own therapy.
• From a psychodynamic point of view, the client’s defense mechanisms and resistance are too high/too ingrained to invite self-change during brief therapy.

The  assessment session will allow client and counsellor to discuss what is and what is not possible, and to reach a decision together as to whether short-term, brief therapy would be suitable as opposed to open-ended therapy.

See also “How long can counselling take”.

Introduction.

This post discusses how the use of a survey containing 34 questions (called “CORE-OM”) allows me to demonstrate that counselling can improve your distress; specifically your well being, symptoms, functioning and risk states (eg self-harm). Further, that these changes can become more permanent than simply temporary relief due to, say, simply talking through matters as you might with a friend or family member.

What is CORE?

The CORE Outcome Measure (CORE-OM) is a client self-report questionnaire designed to be administered before and after therapy. The client is asked to respond to 34 questions about how they have been feeling over the last week, using a 5-point scale ranging from ‘not at all’ to ‘most or all of the time’. The 34 items of the measure cover four dimensions: subjective well-being; problems/symptoms; life functioning; and risk/harm. The responses are designed to be averaged by the practitioner to produce a mean score to indicate the level of current psychological global distress (from ‘healthy’ to ‘severe’). The questionnaire is repeated after the last session of treatment; comparison of the pre- and post-therapy scores offers a measure of ‘outcome’ (i.e. whether or not the client’s level of distress has changed, and by how much).

For further information on CORE, including downloadable CORE forms, see the CORE-OM website.

How you and I can use CORE together.

CORE is an optional part of my counselling procedures – you do not have to participate if you do not wish to.  We can use CORE as part of our “tool-kit” to complement not only my training and experience, but also your own opinion of yourself, your life and your experiences of the counselling process. CORE is not a tool for a complete diagnosis. Rather, you might think of it a little like a room-thermometer – which might indicate if the room could benefit from the central heating being turned on … but, in reality, it’s the people within the room who will decide if they require more warmth.

The CORE survey takes about five minutes to complete, and is done in the counselling room.  When completed, I summarise the most important details and discuss with you what the survey reveals to us.  This can often be a useful source of topics to discuss in counselling.

Near to the end of our counselling work, another survey allows us to compare how you were then … with how you are now, and what has changed for you.  Of course, simply feeling better, recognising that your problems are much better and being able to get on with life is sufficient evidence for counselling, but having the CORE data can be useful too to compare levels of distress.

What CORE demonstrates about Counselling.

By using CORE, a client and I are able to demonstrate statistically that the counselling process is able to improve a person’s psychological well-being, symptoms, life-functioning and states of harm or risk.

For practitioners to assess meaningful improvement over the course of therapy, two measures are essential: reliable change and clinically significant change.

• Reliable change is change that exceeds that which might be expected by chance alone or measurement error, it is represented by a change of 5 or more in the clinical score.
• Clinically significant change is indicated when a client’s CORE score moves from the clinical to the non-clinical population (eg a CORE score of around 10 or below).

This page will be updated periodically with further anonymised statistics as they become available.

(c) a_kep (Flickr)

This section discusses common questions asked about counselling.

To ask a question that is not answered here, either use the comments section (below) or contact me directly.

How do I know that counselling will benefit me?

By using a survey called CORE-OM, counselling can be demonstrated to benefit a majority of people. My own CORE-OM statistics show that every client who has chosen to take the CORE-OM survey has benefited from counselling.

This data suggests that counselling could benefit you too, although meeting with your counsellor for a proper assessment session is always a wise & necessary procedure to make sure that counselling is a suitable treatment for you.

However, we cannot know if counselling will benefit you, and so an ethical counsellor will be paying attention to the counselling work, and discussing in his/her supervision, if the counsellor has concerns that the therapy work seems not to be helping you … and discussing this with you if it is felt it would be helpful to do so.  It’s not in the counsellor’s client’s interest to keep a client attending therapy that is not being beneficial.  Plus, as the client, you too can discuss with your counsellor any concerns that you’re having at any time.

Read more about my CORE-OM Statistics…

How do I find and evaluate a counsellor?

See my separate post on this topic.

Download this free pamphlet on “How to get the Best out of your Therapist.”

(c) BACP – 2010

How do I start counselling?

1. Make contact with me to arrange an appointment for an assessment.
2. Following the assessment, we will both be in a position to discuss if counselling could be beneficial for you.
3. If we proceed into counselling we will arrange a weekly appointment (usually same day, same time, same location each week).
4. If we decide not to proceed into counselling I can either make a referral for you to a colleague, or you are free to find your own counselling.
5. If we proceed into counselling, we will continue to meet together either until a fixed number of sessions is up, or until the issues you came into counselling for are worked through sufficiently for you to feel that counselling can come to an end.

See individual assessments &/or couple assessments.

What Counselling Services are Available?

I offer counselling for the following main services in both my Portsmouth & Southsea (Hampshire) and Chichester (West Sussex) practices:-

• Counselling for Individuals (read more).
• Counselling for Couples (read more).

LGBT Counselling Specialities.

I also practice counselling for on lesbian, gay, bisexual and transgender clients’ specific needs in the areas of Portsmouth & Southsea (Hampshire) and Chichester (West Sussex).

• Counselling for Gay, Lesbian, transgender & Bisexual Individuals (read more).
• Counselling for Gay, Lesbian, transgender & Bisexual Couples (read more).

Is Couples Counselling different from Individuals Counselling?

Counselling for couples is similar to individuals, but with some obvious (and not so obvious) differences.

Primarily, in couple counselling my “client” is the couple’s relationship - I am not working with two individual peoples’ seperate problems. I assist the couple in finding their own solutions to their relationship issue. I work systemically and psychodynamically, meaning that I help the couple to peturb their relationship system sufficiently to gain new information that helps the couple take different approaches to their relationship problems, and I use some of their history to help them understand what each person may be bringing to the table that is helping and hindering the couple’s relationship.

Individual counselling my client is the individual him/herself.  I work psychodynamically with individuals, helping them gain insight into their problem and assisting them in working through the issues to a more satisfactory state.

Which counselling to choose?

An individual coming to counselling for her/her own issues is suitable for an assessment for individual counselling.

A couple coming to counselling for issues with their relationship are suitable for an assessment for couples counselling.

An individual coming to counselling to try and change relationship problems is likely better coming to counselling with her/her partner to work in couples counselling together.

A couple coming to counselling in the hope that one individual is going to be changed sufficiently to suit the other partner is possible unsuitable for couples counselling.

See also Couple Counselling & Individual Counselling.

What can I talk about in counselling?

Advice for Clients.
Read: “How to get the best out of your therapist”
(c) BACP – 2010

You can talk about anything that you think you need assistance with. I have written a separate page for this topic – click here to read.

There are some matters that would come under the law – for example if you wished to talk about your part in terrorism, intended harm to self or others, or criminal activity, then I would be obligated to break confidentiality in serious matters such as these. I will always advise you beforehand about confidentiality, and advise you before I take these matters elsewhere.

How long does a session last?

Counselling sessions with Dean last for 50 minutes. The time is there for you to do with what you need. Because every client’s time is reserved exclusively for them, if you arrive late the time cannot be made up later (eg adding an extra 10 minutes onto the end of the session). Similarly, if you arrive early the session will still begin at your appointment time.

How often do I need to come for counselling?

You will come once a week (on the same day, same time & same location) and attend one fifty minute session.

We will meet as many times as either we have initially agreed up front (eg brief counselling) or until we feel that the work has been done.

What is an assessment?

This is where you and I meet for a session (sometimes more, as required) and discuss what you need from counselling. I may also offer you a CORE survey (which is a questionnaire that helps us identify how things have been for you during the past week). I will offer you a number of tentative thoughts about what I hear from you, and maybe offer an interpretation or two based on how I might understand how matters link together. This is all part of seeing if we can work together.

This is a mutual assessment – you are seeing if you can work we me too.

If I have any concerns then I will discuss these openly with you – and you are welcome to discuss any concerns with me too.

Read more about:-

individual assessments &

couple assessments.

Do I have to pass (or fail?) a test to be allowed counselling?

No.

Unlike some newer IPT services in the NHS, where you only get to the next level of therapy by first being unsuccessful with the previous level of therapy, with me I don’t offer one level of therapy first, followed by other levels later. What you receive from me is my full service from the beginning (although, of course, I will always take matters at a pace that works for you).

Do I need to get my doctor to refer me to you?

No – I am a fully qualified and experienced counsellor/psychotherapist supervised according to BACP recommended standards. I am able to make my own judgements on suitability for counselling, can discuss matters with you directly, and you can make an appointment with me independently of your doctor.

Will you inform my doctor?

I will not inform your doctor that you are receiving therapy from me (unless, of course, you wish me to do so) as my service is confidential and independent of primary care services.

How do I decide between brief or open ended counselling?

When we have our assessment together, I will be paying attention to the problems that you are bringing, seeing how you respond to what I say, and considering if brief of open ended counselling would suit you best. Later in the session I will discuss with you what I think and ask you for your opinion. If we disagree with each other we can talk about this too.

Brief counselling: a set number of sessions, negotiated, usually six or twelve.

Open ended counselling: unlimited number of sessions, but working towards an agreed goal or improved emotional state.

Sometimes, we can also begin counselling in a form of a trial: which is open-ended counselling but starting with four or five sessions. Then we can discuss if we both think counselling is benefiting you after these sessions. If not, we can agree how and when we would like to end the trail.

What happens in a session?

After counselling has been going on for several sessions to establish itself, I usually greet you in reception, accompany you to the counselling room and then wait quietly whilst you consider what it is you want to talk about (you will lead the session).

Read more…

Do you have a particular style of counselling?

I am qualified in psychodynamic counselling for individual work, and am a qualified systemic & psychodynamic counsellor for couples. With careful consideration, I may also incorporate other therapeutic techniques that I believe may be useful to you, provided that I have had previous training and experience in these matters. I do not practice therapy models for which I have received no training nor experience.

Read more about psychodynamic and systemic models…

Are you a Christian Counsellor?

Christian counsellors (http://www.acc-uk.org/) are a form of support that follows religious beliefs at their core.  The following description is quoted from http://www.walking-wounded.net/html/christian_counselling.html :-

[the] approach is a Christian one, that is that Christian beliefs about human suffering and its causes – for example the role of sin in causing suffering, and the need for the presence of forgiveness in people in order for them to be spiritually (and also emotionally) free, is taken fully into account.

My form of therapy respects all form of religious and secular beliefs but is not based upon them.

How does counselling come to an end?

If we have agreed on brief counselling, then both you and I know when the sessions will end.

Open ended counselling is a little different, and more flexible. Usually, you or I or sometimes both of us will begin to notice that the reasons you came to counselling are no longer so prevalent. It is around that time that we can begin talking about if counselling has done its job, and if we are ready to begin an ending process. When we both agree that counselling can end, we will agree how we would like to end. For example: we might agree to end counselling in six sessions time, using those sessions to review where we’ve been, what it’s been like in counselling, and what it will be like to no longer come to counselling in the future. Then we end after the last session is complete.

What if I don’t like my counsellor?

Some clients find it very difficult to tell their counsellor what they do not like. Whether it something about the person themselves, their style, something they said in a previous session and so on.

All counsellors intend to be as open as they can to their clients, and thus we would very much like to hear when you are not very happy about something. Afterall, although this “something” might be happening between you and the counsellor, it might also be an example of something that, if we were able to work through together, might benefit you in your every day life.

And sometimes clashes cannot be resolved – no matter what good intentions both client and counsellor would like to have.

Sometimes a client simply stops coming to counselling, leaving no word why this is. Sometimes a client is able to find the courage to bring up what is bothering them with the counsellor themselves. Sometimes, moving to another counsellor is an option.

As your counsellor, I try to be attune to your needs, and as a human being sometimes I might be mistaken or I might miss something that is important to you. If I spot that something seems amiss, I will try and bring both our attentions to the matter (delicately, of course, because I might be mistaken in what I thought I spotted). Discussing with me what is bothering you about me can be helpful to us both.

Will what I say be told to anyone else?

Confidentiality.

I practice confidentiality. This means that you can speak with me knowing that your friends, your family, your work colleagues and so on will not get to learn what you have said in a counselling session.

I abide by and adhere to the British Association of Counsellors and Psychotherapy’s Ethical Framework.

As a BACP accredited therapist I am supervised to a minimum of 90 minutes per month. This is where I meet with a qualified counselling supervisor to discuss my practice and my case load. I will, from time to time and with your permission, discuss your case with my supervisor – but I will have first made sure that my supervisor does not know you, or is likely to come in contact with you (say, for example, though the workplace) and I will refer to you only by your first name (or another name if you prefer). If I cannot assure your confidentiality in this manner – for example if my supervisor knows you in the work place or socially – then I will seek supervision from another supervisor for your particular case.

Confidentiality will be broken if you disclose intent of harming yourself or others (including children) or if you disclose intent of committing a serious criminal offence. I intend to inform you of my intent to break confidentiality with you before I do so.

See also Ethical Framework.

What if I miss a session?

Missed sessions happen from time to time. Please try and let me know as soon as know that you are not going to be able to attend a future session. If you miss a session without notice, I will still be available for you at the same time and same day the following week (excluding any vacation or planned absences that either you or I have discussed).

The session fee is still payable if you cancel the session within two business-days ahead of the appointment time, if you do not attend your session without having given any prior notice of your absence.

What if I want to change our arrangements?

From time to time changes may come up. Please discuss these with me.

For example, the appointment time may become difficult or you may have heard of a treatment that you would like to try. All of these matters are worth having a conversation about because sometimes what seems to be an obvious resolution (eg changing the appointment time) can look quite different having discussed what’s going on around the potential change.

I need some paperwork completing by you.

Confidentiality is vital to this work – even when, sometimes, it’s not recognised that discussing the contents of the session outside of therapeutic containment would break this confidentiality. Therefore, I operate with some boundaries in this matter:

• Solicitors letter – I will make a charge for this. I will state you are in counselling but I will not reveal the contents of our work. I may also seek advice before agreeing to write a letter.
• Attendance forms (e.g. student placement) – I will co-sign a form that you have completed showing that you have attended counselling, but I will not reveal the contents of our work.
• Attendance forms that I am required to complete on your behalf – I will make a charge for this also.
• Most other letters that you ask of me will require a discussion, as I will not break confidentiality by discussing your counselling.

How much does private counselling cost?

See my Fees page for a description about my standard fees and sliding scale.

Could I see an example of a counselling session?

Counselling, of course, is confidential and therefore I will not demonstrate a real session with a real client.

However, as part of a university project with Pete Allen-Worth I took part in a recording of a role-played counselling session – click to see the video.

If I wished to raise a complaint.

Firstly, please try to discuss your complaint with me first. We will try to address your concerns and put things right.

However, if we cannot attend to your complaint together you are welcome to take your complaint to my professional body – the British Association for Counselling & Psychotherapy.  This will be make your complaint formal and the BACP have procedures in place to handle formal complaints.

See also BACP’s Making a Complaint page.

British Association for Counselling & Psychotherapy,
BACP House,
15 St John’s Business Park,
Lutterworth,
LE17 4HB.

Tel: 01455 883300,
Fax: 01455 550243,
Minicom: 01455 550307,
Text: 01455 560606

http://www.bacp.co.uk/

I have another question?

Please use the comments section, below, to ask your question – or contact me directly.

Patrick Casement: “Mourning and Failure to Morn”, fort da, 6(2) 20-32, (2000).

Introduction.

John Bowlby’s theories of attachment and loss are split into three categories.

• Volume 1: Attachment. 1969/82.
  
• Volume 2: Separation: Anxiety And Anger. 1973.
  
• Volume 3: Loss: Sadness And Depression. 1980.
  

Bowlby claimed that a strong attachment to a mother figure was essential for a child’s psychological health, both in infancy & in later life. That separation from mother had profound adverse affects on the infant, and he disputed Anna Freud’s contention that infants cannot mourn loss because of an insufficient ego development, and Klein’s claim that loss of the breast through weaning was the infant’s greatest loss.

Instead, Bowlby advanced the view that grief and mourning appear whenever any attachment behaviours are activated but the mother continues to be unavailable

‘The young child’s hunger for his mother’s love and presence is as great as his hunger for food. This love and presence are as essential for healthy psychological development as vitamins & minerals are for physical development’ (Bowlby, 1973)

Grief work.

Grief is a highly individual, although universal, process. Grief work describes bereaved individuals’ efforts to accept reality of loss (with or without assistance through counselling).

As attachment, separation and loss are normal experiences of life, grief work in counselling comes into play when a person has experienced a loss but has not been able to work through it through a mourning process.

I define “loss” to include:

• Death of someone – natural causes, murder, suicide.
• Loss of someone (although person is still alive somewhere).
• Loss such as a job or retirement, theft.
• Loss of the body: a woman’s loss of her breast though cancer, a man’s loss of erection through impotence.
• Loss that has not yet occurred, but is about to.
• Loss of ability to manage life (and hence a need to come to counselling).

Grieving for loss is a normal process whereby the person undoes the bonds that bound him or her to the thing that was lost (Raphael, 1984). It’s a healing process that allows a person to move from experiencing the loss as pain and denial and life being worthless, towards a state whereby the loss is accepted and life is seen as worthy of participation again.

Not all mourning is recognisable by others – for example experiencing a hysterectomy, miscarriage or even moving house for some can lead to mourning reactions.

Some may be assumed to have completed mourning when in fact the mourning process still goes on unresolved and done quietly within. To continue living – or giving a pretence of doing so – when a part of us (physically or psychologically) has died.

So, problems begin when there is a failure to mourn, failure to grieve and the person may become stuck either not entering the grieving process, or persistently stuck within the process.

Indications of Failure to Mourn.

Quotation from Anonymous on Bowlby newsgroup:

“My mother died when I was eight, and I had one of the classic states of confusion which is chronic mourning. But I didn’t know it as a state of confusion, I just oscillated between two mental states (“I know she’s dead” vs. “she’s around here somewhere if I just keep searching.”)

It is therapeutic, in a small way, just to know that one’s state of “chronic mourning” or “disorganisation” itself is part of nature… is related to the behaviour of primates in the wild… it relieves somewhat the bubble of isolation which the chronic griever is stuck in.”

(Dr Juan Carlos Garelli – http://attachment.edu.ar/loss.html)

One’s own identity can be affected by a death. The experience can be so painful and so individual that we as counsellors may need to understand that the client’s pain is beyond any description … and that there is the real fear that the pain may never end. It is no wonder that some find ways to avoid the grieving process.

Attempts at replacement.

Casement (2000) – paraphrased: Death of a child is perhaps the most common experience I have encountered. In a particular case the parents had never quite recovered from the experience in the family there had remained a sense of a dead child somewhere. Often attempted is replacing the dead child with another one, in seeking comfort to fill the unbearable gap left by the other child. Too often, however, it is the replacement child that absorbs the family’s distress and never really succeeds in being the replacement.

Mourning is about eventually letting go – and replacement is a form of resistance to letting go. Setting up shrines to the dead also resists letting go as with one family who not only sought a burial plot for their dead child but sought a family grave so that all the family could be buried together one day.

Splitting and Idealising, magic thinking.

Casement (2000) – paraphrased: A woman and her husband came for couple counselling and saw individual counsellors, wife to one counsellor and husband to another. The wife spent a long time complaining of her husband’s faults. During the counselling the husband died of a heart attack. The wife arranged for an elaborate funeral and in counselling spoke of her husband with praise. She became profoundly depressed and developed a skin irritation that drove her to distraction. The doctors could not find any cause for the irritation.

Casement considered that the skin irritation may have been somatising the husband’s irritation; effectively “getting under her skin.” The splitting off of the original irritation (her complaining about it) was now replaced by her words of praise. By “magic thinking”, unconsciously the wife had come to consider that her despising words had killed her husband and her unconscious guilt lead her to idealise him in his absence.

Working with Mourning…

… or with failure to work through mourning.

Casement suggests that the counsellor needs to learn from each new person afresh what helps and what doesn’t help. That waiting to go through the unbearable pain and then to stay with it during the client’s mourning is important:-

With a patient who had lost several babies through miscarriage I spent a long time listening to her in silence as she poured out her pain. I knew she needed me to be able to bear being in touch with her pain and distress. After a long time I said:

“I know there is nothing I can say to make any of this feel less devastating for you. The only thing I feel I can do is to be here for you in your distress and to go through it with you for as long as may be necessary”.

She said: “I know you can’t take this away from me, in fact I would not want you to take it away. But it helps that you are there. And it helps that I can see in your face that you are prepared to feel my pain along with me”. A bit later she added: “Your eyes have said to me all that matters.

I had not tried to hide from her the fact that there were tears in my eyes while she had been crying so desperately. Casement (2000).

Models.

Being aware of different models of grief and mourning may be useful for the counsellor in understanding stages their client is going through during grief work.

John Bowlby developed a four stage model of grief:

• Phase of numbing that usually lasts from a few hours to a week and may be interrupted by outbursts of extremely intense distress and/or anger.
• Phase of yearning and searching for the lost figure lasting some months or sometimes for years.
• Phase of disorganisation and despair.
• Phase of greater or less degree of organisation.

Elizabeth Kübler-Ross took this model further and developed a five stage model that she holds a dying person goes through when they are told that they have a terminal illness. The five stages go in progression:

• Denial,
• Anger,
• Bargaining,
• Depression,
• Acceptance.

This model has, claims the author is useful many other situations where someone suffers a loss or change in social identity.

Closing.

Mourning has to do with experiencing the pain of loss and learning to let go of that which can no longer be retrieved or replaced. It is assisting the client in understanding their grief in real terms and highlighting where phantasies are working to keep the person stuck within the mourning process.

In part it is the re-finding an internal relationship of the person or object that has gone and gaining a sense of support from within where originally the support had come from the external relationship or object.

Bibliography.

” … by the pricking of my thumbs,
something wicked this way comes.”

(William Shakespear’s “MacBeth”).

Introduction.

When I first chose this topic, I thought that I understood what projective identification was about; it was a feeling that the counsellor experienced whilst working with a client, sometimes a weird one and perhaps seeming unconnected the client work. I was remembering only half of the process. What I was not remembering was the client’s own part in this and why they might be doing it as the one that initiates the process. Yet also the client can remain totally oblivious to this unconscious impact on the counsellor.

This paper demonstrates my further understanding of projective identification as part of a counselling relationship.

A definition of projective identification.

I was surprised to find that Penguin’s “A Critical Dictionary of Psychoanalysis” (Rycroft, 1995) does not have a separate entry for Projective Identification. Searching deeper into the book I found an entry under “Identification” (p. 76) indicating that projective identification is a part of Identification:-

“Identification is the process by which a person either (a) extends his identity into someone else, (b) borrows his identity from someone else, or (c) fuses or confuses his identity with someone else.”

There are four types of identification:

1) Primary Identification: the individual has yet to distinguish his identity from that of his objects – it is presumed that this happens in infancy. The distinction between “I” and “you” does not yet exist. (This is seen as normal development and not a defence).

2) Secondary Identification: the process of identifying with an object that has been identified as a separate thing. (This is seen as a defence as it reduces anxiety between the self and the object and enables separation to begin).

3) Projective identification: the process by which a person imagines himself to be inside some external object (again, seen as a defence as it creates illusion of control over the object and to deny the self’s powerlessness over the object ).

4) Introjective identification: the process whereby the object is imagined to be inside and part of the self

– Summarised from “Critical Dictionary of Psychoanalysis”, (Rycroft 1995 p76).

Projective Identification also has a relationship with projection:

Projection: Viewing a mental image as objective reality (…) the process by which specific impulse, wishes, aspects of the self are imagined to be located in some object external to oneself.

– Critical Dictionary of Psychoanalysis, (Rycroft, 1995 p139).

Quoting Michael Jacobs: “Projection and projective identification are reckoned in psychodynamic theory to be early (or “primitive”) defences, although in the early weeks of life they are through to be natural defences against overwhelming pain or terror, occurring as feelings and experiences pass almost without barriers between mother and baby” (Jacobs, 1998).

My understanding of Klein’s early infant development theories suggests to me that descriptions of early paranoid-schizoid position (ego is split into good and bad and destructive impulses are projected into a bad object, then feeling persecuted by that object) are very like descriptions of secondary and projective identification.

To take a description from “Introduction to the work of Melanie Klein” (Segal, 1973), Segal quotes Klein saying:-

“When the mechanisms of projection, introjection, splitting, idealization, denial and projective & introjective identification fail to master anxiety, and the ego is invaded by it, then disintegration of the ego may occur as a defensive measure, The ego fragments and splits itself into little bits in order to avoid the experience of anxiety, This mechanism, grossly damaging to the ego, usually appears combined with projective identification, the fragmented part of the ego being immediately projected.

Now, although the definitions and description above give an idea on what projective identification is about, they don’t seem to me to really describe the feelings or experiences around projective identification. I found an example from Klein’s work (Segal 1973, p 77) that seems to explain the process in more vivid terms and I have summarised it here:-

Analysis of a little girl of four (“Ann”).

Ann would find the approaching holidays traumatic as they represented a break in her treatment. In sessions nearer the break, Ann began behaving like a mother towards Klein. Ann had been poorly at an earlier time, but in recent sessions she treated Klein as though Klein was the poorly little girl. Ann was going to look after her (like “mother”). However, instead of being a good mother, Ann was a bad mother: she treated Klein with presents that Klein was not supposed to want, and refused to feed Klein when Klein was hungry. During the session Ann would pretend to go “out to a show” which would leave Klein alone.

Klein’s interpretation was that Ann herself was being “put into” Klein (the projection) i.e. the poorly little girl, and Ann’s behaviour towards the poorly little girl (the identification part) was a communication of Ann’s experience of her own mother’s treatment when she had been poorly.

If I imagine Klein initially not knowing the details or interpretation behind Ann’s behaviour at the start, I might imagine Klein feeling something of the following:-

• Klein was feeling like a very bad little girl for getting poorly.
  
• She was not supposed to like any gifts (goodness) given to her.
  
• She was to experience hunger and not know when she might be fed.
  
• She was to feel isolated.
  
• She would not know why she was feeling so bad; she might wonder why “mother” was treating her so badly. She had done nothing “wrong” except to fall ill.
  

It is at times when we get these feelings that don’t seem belong to us. This suggests that something from the client is being communicated unconsciously to us and projective identification is one of those mechanisms of communication.

Purpose of projective identification.

Diagram from "Toddler Time" at http://www.toddlertime.com/

According to Klein and others, there are a number of purposes for projective identification:-

• When directed towards an idea object, projective identification is there as a defence to avoid separation from the object.
  
• When directed towards a bad object, projective identification is there to gain control over the source of danger.
  

Different parts of the self may be split off and projected:-

• Bad parts of the self are projected to get rid of them as well as to attack and destroy the object.
  
• Good parts of the self may be split off and projected to avoid separation or to keep them safe from a bad inside thing … “or to improve the external object via a kind of primitive projective reparation “(Segal , 1973)
  

Anxieties of being persecuted might suggest that the client is seeing his or her own “badness” but being experienced as the persecuting person’s own badness, not the self’s. Paranoia can be healthy, to quote Freud:

“The purpose of paranoia is (…) to ward off an idea that is incompatible with the ego, by projecting its substance into the external world.”

- Freud, 1895, ‘Draft H. Paranoia’

Projective Identification can produce two main anxieties:

• Fear that the attacked object will retaliate (Persecution, attacking).
  
• Anxiety of having parts of oneself imprisoned and controlled by the object.
  

Working with projective identification.

Illustrative Examples of client’s PI alive in the counsellor.

1) When working with a client you find that you very much like the client, you feel your ego is stroked positively and you feel like one of the best and most affective counsellors in the world. This could be a form of projective identification in that the client is projecting his or her split-off good self into you. Perhaps for the purpose of making you less scary, or to avoid the anxieties of separation; fear you might abandon the client.

2) Working with a female client in 2001, I found myself feeling quite sick (vomit) after most sessions. The sessions’ content appeared to me unrelated or having no ability to make me feel so sick. It wasn’t until some months of this repeating that my client let slip: “There are things I can’t tell you … bad things … they are unpalatable” which suggested to me that I may have been experiencing her “unpalatable-ness” through projective identification. In supervision we discussed how perhaps this might have been her splitting-off the bad and putting it into me, perhaps to see how well (and for how long) I might cope with her bad-ness

Projective identification in itself doesn’t give you reasons why it is taking place. The “staying with not knowing” rule still applies until understanding reveals itself in an opportunity for interpretation to the client.

Allowing for any possible leaning towards ideal examples from the authors of the material in the bibliography, I have observed one common working practice in the material quoted:-

Interpreting the projective identification lessens the client’s anxieties around the projection experience.

It has to be repeated that the client’s projective experience is very real, even though the experience may have little bearings on reality. The counsellor is seen by the client to contain the nasty or good parts of the client’s self even though it is the client’s self that the client is experiencing. So when projective identification is encountered, a counsellor’s responsibility will include:-

Holding on to the projection – practicing containment. As a defence, the projective identification is something that doesn’t need to be forced back into the client the moment it is encountered.

Over time as the counsellor gains understanding through reviewing his or her feelings and behaviour, considers information offered by the client and discusses it in supervision. There becomes room to make interpretations to the client as the therapeutic alliance and perhaps trial-identification may allow. We are advised in the psychodynamic model that this is best done without actually revealing any specific experiences of what the counsellor experienced in the projective identification (and maybe other material from the client’s sessions). Sometimes the client will not pick up the interpretation immediately. Yet, over time, the client becomes able to take back the projection of his or her own accord.

Summary.

Projective Identification is an unconscious defence that communicates parts of the self into a separate object. These split off parts are experienced as coming from inside the separate object, not from the self. The experience may be good / rewarding, or may be bad / persecuting. As counsellors we will experience feelings and behaviour of projective identification in forms of counter-transference. Containing these experiences and coming to understand what they may mean assists the counsellor in offering back the projections in an interpretative form which aim to promote the client’s understanding of themselves, to promote the client’s well being and to diminish anxiety.

Bibliography

Introduction

This paper uses as its base Feldman’s paper: “Marital Conflict and Marital Intimacy: An Integrative psychodynamic-behavioral-systemic model” (1979)

Also references:

Harriet Lerner: The Dance of Intimacy (1989, ISBN: 0-06-097646-X)

Robert Firestone: Fear of Intimacy (1999, ISBN: 1-55798-720-3)

Experiential Exercise.

Description.

• All participants are to be standing.
  
• Each participant selects two people from the group, yet the selection remains secret.
  
• The main aim during this exercise is to place yourself equal distance between the two people. As everyone will be moving at the same time, it’s likely that your selected two people will move also. As they move, you will need to keep yourself at an equal distance between the other two people. You may ignore everyone else’s activity within the group.
  
• Movement: when the exercise begins, you may move quickly or you may move slowly. You can move quite deliberately (possibly revealing which two people you have chosen; which is quite alright) or you may move cautiously (possibly keeping secret which people you have chosen; which is also alright).
  
• Start the exercise.
  

Exercise Observations.

• What happened?
  
• What did it feel like?
  
• Did the exercise end on its own or did it time out?
  

Associating “Intimacy Extremes” / Purpose of Exercise.

From the exercise, imagine that the two people you elected were extremes of intimacy in a relationship. One person represented: “not enough intimacy; need more. Therefore move towards the intimacy/person”, the other person represented “too much intimacy; need less; conflict. Therefore move away from the intimacy/person”.

Sometimes the exercise ends itself and all participants find themselves equally distanced between their chosen people. This might represent a static, most-perfect state between too much and too little intimacy.

More usually, the exercise goes on for a long time until all participants agree to stop. This might represent the dynamics of relationships; constantly ebbing and flowing between too much and too little intimacy.

• Consider: how might the exercise have been different if people had spoken to each other during the task?
• Consider: what if there had been an external observer giving feedback during this event?
  
• (Further consider: what if these two aspects: too much/too little intimacy were aspects within a single person, e.g. perhaps due to narcissistic disturbance?)
  

Marital Conflict and Marital Intimacy.

Feldman uses his 1979 paper to describe experiences within marital relationships that stimulate and maintain repetitive, non-productive marital conflict behaviour.

To clarify what this means, I have summarise my understanding here:

Starting from a point in the cycle, a person requires intimacy in order to satisfy basic needs as a human being. The need for intimacy drives the individual into seeking for it, and then basking in it once found. However, unconscious anxieties can experience the intimacy attained as something that is dangerous and anxiety provoking and something that needs to be moved away from. This creates unconscious conflict which requires we step away from the intimacy in order to avoid the anxieties and conflict. However, in stepping away, the need for intimacy goes unsatisfied and at some point during the “stepping away” we find we have moved too far from the intimacy and need to begin seeking it again.

The cycle starts afresh.

This is just for one “dynamic” partner in the relationship, assuming the other partner is more “static”. Yet either or both partners maybe participating in this cycle with their own individual angles on the cycle.

The main points that Feldman includes within his model are:-

• This cycle is deliberate (albeit mostly unconscious). There is a powerful need for intimacy and yet there is also a powerful need to avoid anxieties around the intimacies; this is caused by unconscious conflict. These are two seemingly mutual states.
  
• When unconscious anxieties are in force (the “trigger”), destructive acts reduce the intimacy and the anxieties, such as verbal abuse and/or physical abuse.
  
• When the destructive acts have reduced intimacy to a level below that which the unconscious can tolerate the associated anxieties, conciliatory behaviour tries to repair any damage and to attempt to build up intimacy again.

I believe these things are not only prevalent in marital relationships but I can also see aspects in the following:-

• The pre-marital relationship such as boyfriend / girlfriend, girlfriend / girlfriend and boyfriend / boyfriend.
  
• The Parent / Child relationship.
  
• Platonic Friend/Friend relationship within and across genders.
  
• Employer / Employee relationship.
  
• Kidnapper / Hostage (perhaps).
  
• Counsellor / Client.
  
• One’s self / one’s self.

Feldman categorise some (all?!) of the reasons why intimacy may unconsciously hook into ones anxieties. He comes up with five categories.

Five Components of Intimacy.

Fear of Merger.

Intimacy can result in a weakening of self-boundaries i.e. whilst a temporary sense of “we two are one” grows, there may be an unconscious threat that the “self” maybe lost.

If the individual’s sense of self does not weaken then the merger sense satisfies the individual.

However, if the sense of self is weak then whilst intimate-merger is sought it also can be experienced as dangerous and taps into unconscious fears.

Fear of Exposure.

To some individuals, deep privacy is essential to their psyche’s safety. Within an intimate experience the “merging” aspects, described above, may also threaten to reveal the things one keeps hidden (e.g. one’s shadow side, the part of us we don’t want others to see).

A person who accepts himself or herself will not be so threatened by the intimate merger, but the weaker self may fear experiencing shame and – according to Feldman – may attempt to end the relationship rather than seek to reduce the intimacy. This suggests to me that the unconscious fear may be in the region of a threat of death, as to terminate the relationship sounds like an attempt to survive the conflict by destroying the other as an unconscious projection of the self.

Fear of Attack.

Feldman associates this fear with Freud’s Oedipal and basic trust-mistrust period of development.

I understand the trust-mistrust period to be around “testing” the other to ascertain of the other is a threat, if the other might attack us, if the other can be trusted. For example, can baby trust the breast always to give milk upon demand and if the breast is unavailable upon demand will the breast eventually return (hence baby’s life will be sustained) or will it never return (hence baby will die). This is akin to Klein’s paranoid schizoid anxieties that, say, the breast will not behave at our whim – it may even be perceived as being persecutory.

The Oedipal period is where the mother-infant dyad comes under threat when an “other” is recognised in the relationship. The new triad produces conflict due to:

• Sexual impulses towards the opposite-sex parent.
  
• Aggressive impulses towards the same-sex parent.
  
• The same-sex parent is a threat to us, but successful resolution is actually finding a way to lose to the same-sex parent and share the opposite-sex parent with the same-sex parent.
  

So, fear of attack means that the intimacy may raise fears of persecution or fears of being attacked and harmed.

Fear of Abandonment.

In abandonment, Feldman references Freud in talking about “loss of the love-object”. We’re talking here about separation anxiety, that we may have become so dependant upon the partner, that should the partner leave (abandon) us we may then not survive.

Oedipal – threat that same-sex parent and opposite-sex parent may decide to “go off” together and leave the child behind. Or if the same-sex parent is successfully killed off (as a rival) then later this parent’s love and support will have been lost. I take this to mean that a heterosexual relationship may impact upon a person where the partner may represent, in transference, the parent of the opposite-gender that may have been successfully “won” by destroying the parent of the same-gender. Additionally, a homosexual relationship may impact upon a person where the partner may represent, in transference, the parent of the same-0gender that may have been successfully disposed of (in phantasy).

Fear of ones own destructive impulses.

Klenian theory:

• Splitting– a person can be perceived as only good or bad.
  
• Projection – it is actually aspects of ourselves that we perceive in the “other”.
  
• Fear that the bad may be too overwhelming when placed next to the good implies that the bad may destroy the good.
  

To experience an intimate merging with an other may mean that the bad, destructive sides of one’s self come close to being revealed, and come close to destroying the other “good” person in the intimacy.

The Conflict and the Response.

So, intimacy was sought and intimacy was found. The intimacy is tapping upon one or more of the unconscious fears described above. Anxiety is being generated and defences must come into play to protect the hidden feelings.

Feldman describes this defensive behaviour as attempts to destroy the intimacy in order to move away from it. This can be in forms of attack such as verbal: shouting, abuse, denigration, physical: hitting, withdrawal of touch.

There is an Initiator and a Responder, and whilst these roles may be fixed in some relationships, and may fluctuate in other relationships …

…the “dance” is always lead by the person with lowest threshold (Esau, classroom, 2003).

The initiator may start an argument with the responder or may hit the responder.

The purpose of this is to reduce and destroy the intimacy to a level that no longer provokes anxiety.

Rapprochement.

Yet, the confliction behaviour may be more than just successful; it may reduce the anxiety so successfully that there is now less intimacy than the self needs. So, some form of “making up” has to be initiated in order to repair the relationship and allow intimacy to build up again.

Working in a counselling environment.

Main purpose: to diminish the anxieties and reduce the need to enact the conflict behaviour.

Examine transference: Taking the two families of origin.

Dreams – interpretation inform the nature of the transference.

Individual become more aware of their wishes, fears and defences, and become more away of the wishes, fears and defences of the other partner.

Process of change, individuals become less destructive, promote empathy and trust, intimate behaviour becomes more frequent and longer-lasting and conflict behaviour becomes less frequent and less destructive.

Bibliography

BACP Ethical Framework.

I am an accredited member of the British Association for Counselling and Psychotherapy (BACP).  The accreditation means that the BACP have authenticated my substantial level of training and experience to be working as a counsellor / psychotherapist.  Appropriately, my counselling work adheres to the BACP’s Ethical Framework (click to read BACP’s statement on Ethics for Counselling and Psychotherapy).

The BACP can suspend, deregister or remove accreditation from counsellors who fail to perform their work to the highest professional standards.

If you have a complaint or dissatisfaction about the counselling service I am providing for you, your first place to raise your concerns is with me and if we cannot resolve the matter together then the BACP will provide help and assistance to you if you wish to take the complaint further.

BACP Address.

British Association for Counselling & Psychotherapy,
BACP House,
15 St John’s Business Park,
Lutterworth,
LE17 4HB,
Tel: 01455 883300,
Fax: 01455 550243,
Minicom: 01455 550307,
Text: 01455 560606

http://www.bacp.co.uk/