A Special Therapeutic Setting - Essay Example

Client Study Number of words count not considering the verbatim 3495 (1698) In order to protect the client anonymity and confidentiality his and any other names in this client study have been changed 1. Therapeutic setting The placement where I am training is a charitable organisation that was established in 1958 for the purpose of providing both low cost and full fee services. A specialist counselling service promoting sexual well-being and healthy sexual relationships, the placement was originally set up to help individuals who had nowhere to turn to for expert professional help on sexual and relationship issues. The organisation has been providing this help for over sixty years and deals with a wide range of issues. These may include problems that cause difficulties either at home or at work. Or, it may be that sex itself, or lack of sex, is having a negative impact on ones relationships or general health. In addition, the organisation offers help with relationships where one or both partners are unhappy or are being hurt. In addition, help can be provided where a relationship has ended badly. Above all, the organisation offers help to anyone with worries about their sexuality.   The placement, which is situated in Wondsworth Borough in London, tends to provide services specific to the local community. The local population comprises many different ethnic groups, most notably Afro-Caribbean, Somali and Polish. Other counselling services share the Victorian terrace house, where the Albany Trust is located; this provides a dynamic and stimulating setting. The practice contains a waiting room with sitting facilities where clients wait to be met by an appointed therapist. Access to the practice is via an entry phone that is placed and accessed by the therapist in the waiting room. The consulting rooms are spacious and provide natural light, resulting in an environment that made me feel very comfortable. However, I realised that the only via starts access prevents us from seeing clients with disabilities or any other kinds of impediments. 2. Referral Conditions The client, Stephen, was self-referred and allocated to me after an assessment was made and a team, which included the practice manager, assessor and my supervisor, discussed my suitability for the case. Having discussed the case with my supervisor before meeting the client gave me the chance to explore my feelings and reactions towards the case. However, looking back on it now I possibly would have preferred not knowing as much about the clients case because in a way it prevented me from having a more open approach to the process with him, especially at the beginning of our therapeutic alliance. Stephen was offered open ending therapy, as he was seeking social benefits, and a low income fee of fifteen pounds. 2a. Client Biographical Stephen is a very articulate tall black gay guy in his early thirties. He is a university graduate with a career in management through a charity organisation. However, he is currently unemployed and has been so for the last four years. He is well-mannered and presented himself as well-groomed. He is currently single, but he had an important relationship for two years; this ended three years ago. Stephen comes from a traditional family and experienced a very religious upbringing, especially through his mother. His family was originally from the West Indies but came to settle in the north of England before moving to London when Stephen was eight years old. His father died in a car accident when he was at university. Stephen has an older brother (two years older) who also lives in London and is married with a young child. They have an adequate relationship. The family knows about his sexuality, and for his mother this is a big issue, especially in view of her strong religious beliefs. When he told her about his sexuality she shouted "abomination, abomination". Stephen is also very religious and used to be very much involved with the church (Pentecostal), so much so that he was one of the speakers and leaders of his congregation. He has now embraced a different church that he defines as inclusive. This is an evangelical church called Oasis and founded by Steve Chalke. However, in his words "there are still some forms of racism in it". When he was fourteen years old, Stephen was sexually abused by a family friend; the abuse has understandably had a profound effect on him as a teenager and now as an adult. Stephen has been suffering from depression, which was the main reason why he could not sustain his job. He has also experienced some suicidal thoughts, which tend to occur if he finds himself either crossing bridges or open spaces. He has been taking medication for depression since he lost his job, while his general health is not great being an overweight individual. 2b. Reasons for the client to come to therapy Stephens main concern is that his anxiety has been the reason for losing his job and not being able to find another. Although he has applied for many jobs and done some interviews, he cannot pass the final stage due to a high level of anxiety that he experiences during the interview. He is also trying to overcome and manage depression. He feels that this is somehow "trapped" in his sexuality and the abuse he suffered as a child. Stephen wants to be able to find a space where he can feel safe enough to explore and express his thoughts and concerns. He ultimately wants to be able to manage his life, as at present he does not feel he has control of it. Stephen believes that depression has also been the cause of his lack of confidence, low self-esteem and an introvert attitude to the world around him. He has had therapy before, within his religious congregation, for over one year, but he found it unsuccessful due to the fact that he felt that the therapist wanted to change his sexual orientation. 3. Orientation of the therapist Although both the placement and my supervisor encouraged a psychodynamic approach with the client, I found it difficult to embrace this as a solo framework, as I am also informed in the way I am with the client by the existential–phenomenological and humanistic approaches. I am also informed by the principles of the attachment theory, especially by the ideas of Winnicott, which considers the influence of the environment and the idea of holding the client as a "form of love" (1965, p. 65), the love where reliability and empathy are both crucial and sincere. The work and theories of Gendling also had an impact on my way of being with the client. The phenomenological method sits with me because I like to adopt an attitude of openness and understanding of what the client brings while trying to avoid applying a fixed explanation of the problem. I like to work with the phenomena that the clients brings and explore the meaning of it together, even if at times this means to stay with the unknown ;The idea of un-knowing suggests the therapist’s willingness to explore the world of the client in a fashion that seeks not only to remain accessible to and respectful of the client’s unique way of being-in-the-world but also to be receptive to the challenges and therapist’s own biases and assumptions (be they personal, professional or both) that the exploration may well provoke (Spinelli, 1997, p. 8). I found the method of phenomenology both liberating and empowering for myself and the client, allowing an unfolding the client’s lived experiences of the problems presented. 4. Working with the client: The therapeutic relationship Session 1 While waiting for Stephen to arrive, I had a sense of anxiety and began to think about if I would be able to take on such a complex case. I had already formulated some ideas about the client and was somehow aware that I was entering this new therapeutic relationship with some readymade pre-concepts and assumptions that were mainly influenced by what I already ‘knew’ about Stephen from the assessment. On further reflection, I wondered what it would have been like to just meet Stephen and his world without knowing anything about it beforehand. As I went to pick him up from the waiting room, Stephens large presence, both in height and body size, were something that one could not take note of. As I asked Stephen to follow me to the room, it took him a little while to get up from the chair he sat on in the waiting room area. A similarly slow pace was something that I also experienced when he followed me to therapy room. I wondered if that slow motion was a resistance to entering the process or just the way he was in the world and his way of moving in it. Once in the room, I introduced myself and went through the confidentiality aspects of the contract, while I left other parts of the contract, like payment for missing sessions, holidays and payments for the end of our first session. I also did this because I was not sure if I would be able to work with him and indeed if he also was open to me. T1: So Stephen what brings you to therapy? C1: mmmm I guess I have been going to an anxiety group for the last 5 months and I feel that is not always the place where I can say everything that I would like to say….so I thought that one to one therapy would be better T2: What do you feel you cannot say in the anxiety group? C2: Well I would like to talk more about personal things but I realise that is not really the right place T3: The right place? It took a little while for Stephen to respond C3: I mean a place where I would probably feel more comfortable I wanted to ask if he felt comfortable here T4: What would that place be like? C4: Well….first of all I would like to be a place where I can talk to one person and not share my stuff to eight other people ….plus I think it should be a place where I can be myself and people do not want to change me T5: Could you expand more ? C5: Well I mainly refer to my previous therapy…….my therapist , although was good, he was trying to readdress my sexual orientation. I told him that I was gay and him being a Christian therapist had some difficulties in understand that I was happy as I was ….. so we spent may months discussing my sexual preference …. Stephen went on talking however at one point during his conversation he started to move his legs sideways and eventually he took off his shoes and socks and start to scratch his feet. It lasted about a minute, but it felt much longer. It took him a while for him to speak. C6: I’m so sorry, the same happened when I went for an interview last time …and of course I did not get the job, I was so so anxious during the interview and I had to take my shoes off I just could not cope with it… T6: You could not cope with what ? C7: I feel so ashamed I noticed that the client did not really respond to my question. T7: Ashamed ? C8: Yes, in taking off my shoes, but I could not keep them…. T8: What did you feel ? C9: I was burning , my feet were burning I needed to remove everything and I need to scratch my feet. I felt anxious so anxious. T10: What were you anxious about ? C10: I do not know After a brief silence Stephen looked at me and very quickly looked down, he engaged with me in this way a couple of times , and the he smiled. Like if nothing had happened he changed the subject. C11: I was a church leader in my twenties and I had many responsibilities at the time I embraced God and I was very involved with all the activities of the congregation. I came from a very religious family especially my mum so God has been always very predominant in my life…. The client went on to talk about his involvement with the church in the meantime I noticed that his posture changed he was now sat much more straight, more over his eyes were sustaining my gaze……while talking Stephen also put back his socks. T11: I noticed that you put your socks back on C12: Ho, yes …..I feel a bit better, I’m less anxious maybe what happened is to do with me not being taking medications lately. T12: What medications are you taking? C13: ……….. The doctor wanted to prescribe me also some antipsychotic medications but I refuse to take them. T13: How come you are refusing to take them? C14: Well there is a very important aspect about antipsychotic medications and I have done a lot of research into it and I found out that those sort of medications have not been tasted on black people so there is no much evidence that are working for me. There are some fundamental differences and not everything that has been tested on the white population will have the same result to black people. T14: What are the fundamental differences that you talking about ? C15: Well there are some biological differences to start which is one of the reason why not everything works for us black people. T15: I am wondering about our different race which is important to talk about it especially if we are going to be in a therapeutic relationship. if you do have any concern about being able to work with me or with a white therapist I think is important that you are communicating it to me so we can look at other alternatives. C16: I do not have a problem with you, What I feel so far is that you understand me Reflections from the Session 1 This first session was very difficult for me. I came out from it with many feelings to deal with. First of all, there was a great sense of insecurity about my ability as a therapist while trying to contain Stephens very high anxious state expressed through his actions, not to mention the race issue that he brought up quite early in the session. Reflecting on the session, I could see how from the start I was looking for some sort of reassurance from Stephen. He felt comfortable with my presence (C3), and although I did not explicitly ask the question, the feeling of wanting to know or the temptation of asking was great (T4). While I set out the confidentiality aspect of the session, it felt like Stephen was taking care of other parts of our therapeutic relationship by informing me of the kind of therapy he wanted (C4) (C5). He expressed something that I had never experienced before. Witnessing that reaction generated a state of anxiety in me. I felt powerless to stop it. I was present in the unfolding process of him, shaking and stretching his bare feet, and I did not really know what to do. It was as if his powerless control of his body also made me also powerless. I noticed that in the action of scratching there was some form of rhythmic movement. Stephen seemed immersed in that repetition of the movement in which he seemed to find some sort of relief. While I was trying to contain the situation, I had a sense of witnessing some sort of ‘primitive’ dance in which the frantic but yet rhythmical movements brought the dancer to a cathartic state. Once it stopped, I felt I wanted to acknowledge what had happened as well as wanting to re-engage with the client and not leave him to bear alone that sense of shame that he felt (C7). In supervision, both my colleagues and supervisor made me aware of the many narratives that the client was possibly communicating; however, the one that resonated with me was that his dramatic display could have been a test for me as to whether or not I would also reject him, as had indeed happened after his job interview (C6). The latter made me reflect about the dynamics that sometimes can come into play, especially at the beginning of a therapeutic alliance, when the exchange between the therapist and client can shape the rest of the interview. I felt uncomfortable when Stephen introduced the biological differences between black and white people (C14-C15). One reason why I felt uncomfortable was due to the fact that I did not agree with his comment, and somehow I felt he was dividing us into separate worlds. At a cognition level, this did not resonate with the way I view the world. The uncomfortable feeling was possibly also present due to the fact that he was my first client from an ethnic background. As such, that feeling was a translation of my insecurities of working with differences. Although in the earlier part of the session Stephen had been very anxious, and the last thing I wanted to do was to increase his anxiety level, it was also true that I could not ignore his comment about racial differences and had to acknowledge it. He was a black client and I a white therapist, and this was an obvious fact. Acknowledging that difference (T15) was for me very important to state and share because if Stephen did not feel comfortable with me being a white therapist it would have been better for both of us to look at a more suitable alternative for him. Reflecting back and sharing my feelings in supervision, I have come to understand that some of my doubts and concerns about possibly not sharing my feelings about our different races for fear of increasing the clients anxiety was possibly something to do with the fear to increase my own anxiety, as I was tackling a topic which was not present anymore once I managed to voice it to the client. 5. Development of the therapeutic relationship Overview of the work with the client from the 2nd to the 10th sessions Much of the initial work with Stephen was based on keeping a very secure space where a therapeutic relationship could take place while trying to contain Stephen’s anxiety. Donald Winncott (1971) was influential in the way I related to Stephen and the importance that I gave to the setting over interpretations: by being on time, being there and being real we could create a secure space that would facilitate a sense of basic trust. However, containing the client was at times very challenging for me because it was painful to witness his struggle. The temptation to either fix or rescue him was present for me at times. Leaping ahead rather than leaping in (Heidegger, 1962) was what Stephen wanted. The client unfolded his story and sometimes managed to express his feelings about his sexual abuse and how it had an impact on his experiences with himself and others. Moreover, Stephen identified the sexual abuse as a possible reason for his anger, both towards himself, for allowing the abuse to take place, as well as towards his parents and family, who did not protect him from the abuse. This was especially true when he learned that abuse was endemic in his family. Stephen, in an emotional session, also told me about his father, who had been abused by the same person who abused him. Session 11 We carried on the work started the previous week, which saw us trying to explore what was not expressible in words, his anger and where it was placed in his body and also his anxiety. Ten minutes after the start of the session, Stephen said: 1T: Last time we said that we were going to talk about the experience of the anger in your body do you still want to do that? 1C: Yes I thought about it and it will be probably helpful because I do not really know how to explain that sense of anger that I have 2T: You seem to talk about your anger quite a lot lately but I have not felt or hear you to express it in any way, neither in here or in you 2C: I think I’m afraid to express that anger 3T: what are you afraid of? 3C: I’m afraid that the anger will become uncontrollable and I do not know what I will be able to do 4T: uncontrollable? 4C: Yes, I really do not know… I sometimes think that that anger is so powerful that I could do anything and that frightens me a lot I do know… I’m so confused about it ... Stephen went silence for a short time. 5C: I really do not know … 5T: If you close your eyes now can you fell your anger somewhere in your body? Stephen closed his eyes and we stayed silent for a little while, I was a bit anxious about this experience. 6C: Well, I can feel it, it is difficult and somehow painful to connect to … I think my anger is always there 6T: Where ? With his eyes still closed we stayed silent again for a little while 7C: I do not know, where I am … which dimension… I’m confused….is somewhere in my stomach I think… I feel that is also in my groin . I feel is there. The client had opened his eyes and looked at me 8C: I am afraid that the abused will be the abuser 8T: what do you mean ? 9C: What I’m saying is that I could become an abuser 9T: Have you ever thought about abusing anyone? 10C: No, never …. I never even contemplate about it but the fear is there 10T: So you are fearful of something that you never contemplate to do 11C: well what I can say is that the fear is there, and it seems is something that my family has been living through Stephen carried on talking about the sexual abuse that he knew had happened in his family, in which two of his cousins had been victims of and reiterated the abuse that his father allegedly had suffered by the same abuser. However, the session ended with him feeling more confused and starting to doubt about what really happened with his abuse. In his words, the latter feeling made him very "fragile". I had been aware since the first session with the client to leave always a few minutes before the end of the session to allow Stephen to take care of himself and be ‘ready’ to engage with the world outside the therapeutic relationship. Reflections from the session 11 During my training I found out that integrating some of the work from Eugene Gendlin (1982) on his ideas of ‘the felt sense’ has been very useful. Although I was anxious at first (5T), Stephen engaged with this process well by bringing into the session his experience of both the relationship with his body (7C) and how he also related through the body in the therapeutic relationship, especially when the vagueness of his feelings could not be voiced. I believed very much that through our bodies we had the ability to communicate the words we could not explain or were emotionally so overwhelming and indeed traumatic. At some level, it had also been my very personal experience with epilepsy, in which my body made me aware that there was something that I needed to acknowledge and take care of. During the session I felt close to the client when he was able to explore and witness his struggle through his body process and that sense of undefined and vague "dimension" he was in (6C-7C). I also realise that by not exploring further his ‘felt sense’, the client disengaged with that process and somehow brought it into the light of a more cognitive world (8C). The exchange that followed was very much of that kind, although in supervision I was also made aware of some further explorations that I could take with regards his sexual practice and what kind of abuse he could potentially inflict. It was also very useful to think about how much media coverage influenced the client to formulate his own ideas about abuse and what that kind of public exposure meant to him. I also agreed with my supervisor and colleagues this was an important part of the work in trying to understand how much those ideas were coming from within him or were permeating in his world from the outside and then Stephen made them his own fantasies. 5a. Development of the therapeutic relationship Overview of the work with the client from the 12 to the 16th sessions Some of Stephens ‘rituals’ disappeared. For instance, his bus journey to therapy was no longer part of his introductive narrative that had been present in the previous sessions in addition to his positioning of his jacket and bag and bottle of water was placed in more random places. I felt that the client did not need to bring into the room his own frame, as he started to feel safe enough without it. In addition, the race issue that had been voiced many times during the previous sessions had not been brought into the therapy. I had also noticed that the anxiety that was predominant in the early part of our therapeutic alliance was somehow better managed, as his body, which was for me a main indicator of that anxiety, seemed to have found some sort of relief. However, Stephen brought to therapy his relationship with his mother, which he described as “not an easy one”. Although he was sure about her love for him, he also felt as though she did not accept his sexuality. The latter made me wonder if, in the therapeutic relationship, Stephen was looking for some sort acceptance from me. According to his mother, his difficult life was as a result of him not following "Gods path". I wondered and explored with Stephen if he thought that by not following "Gods path" it had resulted in him not having a job, not living in his own house or being abused. He dismissed this at once and took responsibility of what happened in his life, although his anxiety and depression had been along with God and his relationship with faith also present in the sessions. Stephens ideas about faith and religion were not my own, and sometimes I had great difficulty being open to his ideas and "bracketing" my assumptions and personal beliefs. Session 17 1T: How are you today? 1C: I’m not in great shape…things are not too good…especially my financial situation is not getting any better, today I had an appointment at the job center and I did not go. 2T: How come you did not go? 2C: Well I overslept and by the time I got ready to go it was too late 3T: I seem to remember that it happened before 3C: Yes it did, that time I had forgotten about it, they give out appointments after so many weeks later that one forgets. 4T: Do you tend to forget appointments? I was thinking about that he did not miss any of our sessions 4C: well no really , but …. it happened 5T: I am wondering what happened for you to forget about it 5C: Not sure it has been some weeks ago 6T: I was thinking more about if you did really wanted to go to the appointment 6C: mmmmm I do not know…but I needed to go as I need to work 7T: I understand that but what is not clear to me is the fact that you been given two appointments and somehow you did not go to any of them 7C: It’s true , I am not sure what happened there. I feel some how stuck . 8T:Stuck? 8C: Yes , I feel I cannot find a job hence my financial situation is not great at all and I am very very worried about it, plus I do not really know if I have to go away from my cousin flat as she is acting a bit strange lately and I ‘m afraid that she will tell me to go. It ‘s a mess and I’m stuck in it. 9T: I feel that more than being stuck there is some a kind of choices that for some reason you are not embrace. 9C: I do not know …maybe, is like that. I just feel that things are not happening for me and not getting any better. 10T: What I sense is that changes and choice can be fearful , like not wanting to ask your cousin about how long you got left or how she feels about you staying. Stephen body moved to one side of the chair and he was not looking at me. 10C: Maybe it is true I do not want to make those decision or choice…. ( he looked back at me ) maybe there is a fear in going for an interview again and being not accepted for the job or having an anxiety attack like last time. We carried on through the session to explore at the idea and Stephen ‘s meaning of choice and fear . Reflection from session 17 In this session I felt I could be more challenging (6T) with Stephen, possibly because through the work that we did so far I noticed in him engaging much more with the therapeutic process. Moreover, his dramatic initial signs of anxiety that he manifested through his body and later voiced were managed in a much better way. Stephen brought to the session his difficulties of being productive and a feeling of being "stuck" (7C). He talked about his financial situation and not being able to get a job. His concerns were also to do with how long he could stay at his cousins house; however, he did not want to talk to her about it for fear that she would have told him to go. His sense of being "stuck" did not quite resonate with me, as I felt it was more a case of him not wanting to make some choices. I felt that I needed to express my genuine thoughts and feelings to Stephen (9T). I was glad that I was able to express my view, as that authentic sharing allowed us to connect and also for the client to look at himself possibly in a much more genuine way (10C). Acknowledging the status quo that he had set for himself was possibly the safest option for him but not the most rewarding. 5b. Development of the therapeutic relationship Overview of the work with the client from the 18th to the 20th sessions As the weeks progressed, I felt that we were moving in a more genuine direction, where our mutual feelings were expressed more freely although still keeping the important frame and boundaries. The work was much more concentrated in the intersubjectivity, and in trying to look into what was happening in our therapeutic relationship to better understand what was happening in ourselves. Heidegger wrote in Being and Time: "a subject is never given without a world and without others. Thus . . . it is within the context of (every human being’s) being-in-the-world that he comes across intersubjectivity (p. 124). For example, in one of the sessions there was a sad mood permeating the room. I reflected this to Stephen by asking if he was aware of this sudden change. He responded that he was feeling sad and somehow wanted me to reach out and rescue him from that sense of sadness. I felt somewhat frozen at this rescue request, as it was something that I was very much trying to avoid, being one of my propensities. In contraposition with the latter way of being, I found that exploring the phenomenon with him rather than rescuing him was a much better way to understand his experience. 6. Critical Overview My own anxiety when I accepted to take such a complex case is still present today. With time I found that the former is easier to deal with and has become not just a way to be with Stephen but also a way to understand his world. The not knowing part and personal challenges that Stephen presented to me, such as religion and race, have pushed my own assumptions and beliefs, which at times left me feeling frustrated and questioning my own capabilities as a therapist. Working with a client with suicidal thoughts, I had to be extra cautious of any possible risks. This vigilant state, especially at the beginning of our therapeutic alliance, possibly did not gave much space for a more relaxed approached; however, thanks to my supervision I was able to discuss my concerns and felt constantly supported. The work with Stephen has been a crescendo, both in the way he feels about himself and in the way he relates to me. Making him more aware of his body and connecting and integrating it to his feelings has been a challenging yet rewarding experience. Although dealing with his abuse is still an ongoing project, I feel that Stephen has made progress through the sessions. Bibliography E. T. Gendlin. Focusing-Oriented Psychotherapy: A Manual of the Experiential Method. Guilford Publications, 1996. E. T. Gendlin. Focusing: Second edition, Bantam Books, 1982 Heidegger, M. (1996) Being and Time. Trans. Joan Stambaugh. Albany, NY: Sate , Unversity of New York Press Read More