by Eve O’Kelly
I recently came across a reflective piece I was asked to write at the end of my fourth year in training. Reading it over, I realised how many nuggets of wisdom and practical tips I had internalised from my supervisors on the journey from student to therapist.
As a student beginning to work with clients, the gradual learning was how to tune in to what was going on within myself while at the same time tracking what was happening for the client, using “trial identification” as described by Casement (1985: 34-35) to try to understand what was going on in the room. At that stage, many of the concepts and theories I was reading about in textbooks seemed very abstract. Over time, however, I began to experience them ‘live’ in the room, constellated in and through my clients. We learn as much, if not more, from our clients than they learn from us and truly it has been said that that ‘we get the clients we need’ – or as some would say, ‘we get the clients we deserve!’
Among the many new perspectives and possible approaches to the work that I gained over four years in training, and particularly in group supervision, these are some of the pointers that have particularly stayed with me now that I’m ‘out of the nest’.
The work in the room
- Keeping my focus on the contact with the client and tuning into what is happening in the moment rather than being distracted by ‘the story’; asking myself (and also asking the client, where appropriate) ‘How is this relevant to you and me now, at this moment?’
- Really understanding the importance of holding the boundaries and being much more confident in doing so. I realise now how much we learn about how the client is in the world when they try to push the boundaries or act out.
- Looking for glimpses of the part of the client that isn’t their usual ‘public face’ ‒ that isn’t usually in the room – and engaging with that hidden part (and exploring why it is hidden).
- Looking for ‘handles’ as the client talks – a word or a passing reference which, if you can catch the end of the thread and give it a tug, may slow the client down and open up an exploration of underlying feelings. To do this means tuning into the layer below or behind the story and identifying emerging themes.
- Being simpler and more ordinary, not doing the work for the client, not getting ahead of him/her; slowing down, waiting until the time is right, and then bringing in an interpretation and watching to see if it lands.
- Finding a balance between support and appropriate challenge with each client; always difficult, and always fluctuating.
- Remaining aware of the vulnerable, fearful and usually younger parts of the client and supporting those, while at the same time bringing the adult into the room and working with him/her.
- Dreams are always important and always worth exploring as to what they may mean for the client in their lives, and also what they may mean in the context of the therapeutic relationship.
- The idea that therapy is a series of incomplete Gestalts is a helpful one. Then the process of working with the client is often around the stages of finding these and closing them, one by one. This makes it easier to see ‘the parts of the whole’ that lie within the whole client.
- Giving each session a title – a word, or a couple of words, representing the overall theme. This is a useful way of remembering sessions, looking for hidden links between them, and spotting threads and ‘bigger picture stuff’.
Transference and countertransference
- If a client has a strong impact on me for some reason, then that client is ‘someone’ to me – so who is that? And how do I work with the impact in a way that keeps ‘my stuff’ out to the side, yet enables me to use it to give insight into what is going on for the client.
- Having my own emotions triggered in the session and needing to hold them out to the side so that I can use this as information in the work with the client; this is good practice in not acting out of my own emotional response but using it to engage with the client.
- Experiencing projections from clients – emotions that they are unable to be in touch with themselves – and checking in with the client on this. On some occasions, experiencing a projection has enabled me to facilitate the client in making contact with his emotions in the session and experience them with cathartic effect. In other cases, it has led to the client disowning the emotion and staying up in the head – thus offering a different kind of opportunity in the work, i.e., to explore with the client that part that is cut off. In either situation, experiencing a projection is a unique and powerful experience.
- Maintaining an awareness of what I may be missing or unconsciously constellating for the client, that he or she has already experienced in life (whether positive or negative) and working with this in the transference.
- Noticing how clients can ‘deposit’ something at the end of the session, either by dropping in a significant new issue in a ‘doorknob moment’, or by making a more subtle communication via a throwaway remark, perhaps to ensure that I will think about them in between sessions.
My own growth and learning
- I understand now how everything really does come back to ourselves in the work. This is what ‘the use of the self’ means. I didn’t understand this at first and now I’m beginning to see how it can work in practice (this is a lifetime’s work, I’m sure!).
- Tuning into myself and coming down out of the head, developing my internal supervisor and using unfocused listening, again as described in Casement (1985: 38), and paying attention to the contact as it ebbs and flows, are the most important aspects of the work. But this is also very hard because it’s like receiving on several different radio wavelengths simultaneously.
- Combining this with staying back and becoming smaller, being more ordinary and not trying to be ‘the good therapist’ all the time, is probably the biggest learning for me.
- A comment that has stayed with me is that you need to let the client regress to the point where they need to be held, and then hold them – but at the same time you need to let the dilemma bubble up, or they will never work with it. I have realised several times (so far only after the event) that I have unconsciously ‘lowered the temperature’ for the client instead of staying with the emotion, whatever it was, and working with it.
- I have now experienced what Malan refers to as “the inevitability of the patient’s problem manifesting itself in the transference sooner or later” (1995: 91), for instance, when a client’s anger was directed towards me and could then be brought into the room and explored.
- This was another helpful step in understanding the concept of transference. Just as when a client only really makes sense of something when she realises it for herself, it’s the same for me in the therapist’s chair ‒ the theories come to life when I see them mapping in what is happening in the therapeutic relationship.
Minding myself in the work
- Now, as I work through my accreditation hours, I have a greater understanding of the importance of minding myself in the work. If I don’t there is a risk of burnout, particularly given that, like most early stage therapists, I am still working almost fulltime in ‘the day job’.
- Clients are demanding and their emotions can activate stuff of our own. They can leave us with a lot, and self-care is very important to counteract this.
- They can be manipulative, consciously or unconsciously, and leave us feeling used, annoyed, frustrated, angry, etc.
- When a client finishes therapy, whether in a planned or an abrupt way, we can be left with unresolved issues: feelings of inadequacy and not being ‘good enough’; anger because they don’t appear to value us; loss of that relationship, etc. If these feelings come up, we need to work through them in supervision and personal therapy, and we may also have to forgive the client for not persisting with the therapy. They may not be able to do the work and we may have to accept that this is their decision.
- Advice that is really valuable in the work generally is around holding the boundaries and also staying in contact with my own physicality. For instance, I may notice that due to something happening in the session my chin is pushed out or my feet are off the ground, or I am not breathing. It’s important then to make contact with myself physically, e.g. by pulling my chin in, placing my feet more firmly on the ground, taking a breath, momentarily putting my finger on my nose, etc. While it is important to be empathic, I need to stay in my own space.
- If a client is very demanding, I can also pull back and ‘hear without listening’ to extract the threads and themes. “Pushing away with the eyes”, as described by Rothschild (2006: 142-145) may be a useful skill in achieving this.
- A valuable practical tip for me is to visualise drawing a protective sphere or bubble of light around myself at the start of the session. This keeps me in my own chair when a demanding client has the effect of making me feel pulled across to his side of the room.
- Another tip which I always now employ is to devise a ‘closing ceremony’ for each session. After some experimentation, I found what feels right for me. After the client has left the room, I open the door and take three standing breaths, circling my arms in a slow stretch towards the ceiling. This clears the energy before the next client arrives.
If I were to distill one really significant thing I learned in group supervision, it is the importance of ‘keeping it in the moment’; bringing it back all the time to what is going on right here, right now in the room, and working with that. This is the most effective and in fact the only way of working with clients.
With thanks to Janet Murray, Freda Hanley, Annie Sampson and Breda Lilburn – wise women all.
Eve O’Kelly graduated with an Advanced Diploma in Psychotherapy from the Tivoli Institute in October 2015. She is currently developing her own practice in south Dublin.
Casement, P. (1985). On Learning from the Patient. London: Routledge.
Malan, D. H. (1995). Individual Psychotherapy and the Science of Psychodynamics (2nd ed.). Boca Raton (FL): CRC Press.
Rothschild, B. (2006). Help for the Helper. New York: Norton.