The Client’s Impact in the Context of Clinical Psychology Training

by Mary Fell

The ideas here were initially alluded to within a thesis in part-fulfilment of a Diploma in Integrative Psychotherapy (Fell, 2006). I was reminded of them when exploring, as part of a team, how we might facilitate Personal and Professional Development (PPD) in a more enduring way on a clinical psychology training course. In doing so, I was brought back to the very fundamentals of clinical psychology and psychotherapy work – who we are, how we relate to others, others’ impact on us and how we might move with or resist this. These are relevant regardless of stage of professional development, but are easily lost sight of. In training, they are even more relevant as the trainee encounters client work, supervision, contact with peers, training staff and work colleagues in an evaluative context. We also expect trainees to reflect on themselves, on their part in the co-creation of a therapeutic alliance, on how they might manage the impact of clients’ distress or style. Yet the task faced in exploring PPD was a reminder that trainers can also lose sight of these crucial elements because of the busy-ness of a course, as well as the climate of achieving, ‘doing’ and ticking boxes. We almost need to be reminded that such elements are present and to be expected. It was also a reminder that these potentially influential therapeutic encounters occur in a climate hopefully of support but also of evaluation. Evaluation can bring us back to earlier relationships and experiences of comparison, of authority, of feeling ‘less than’, and of shame – old and possibly familiar scripts.

In considering the client’s impact, it is useful to begin with Bollas’ (1999) assertion that clients touch us, “reaching the deepest recesses of (our) lives” (11), if we allow it and allow awareness of it. Clients can push us towards self-reflection, towards curiosity about ourselves, but firstly, we must allow that touch to be felt. Are there aspects of the work that create a context where such impact happens? It is as if, as clinicians and trainers, we consider psychological touch as possible rather than seeing it as inevitable. Have we concerns about this in general and in the context of training?

There is “wear and tear” (Kottler, 1993: 21) in encounters with clients, clients’ impact on us. For our own wellbeing and survival in the work, we need to attend to this, or at least acknowledge it. In clinical psychology training, we encourage trainees to consider what clients elicit in them. We ask trainees to bring this to supervision (and to personal therapy if appropriate) in an effort to make sense of what is happening, then often we move to wonder about the client in this, exploring what information it might yield about the client. In supervision, we also emphasise the boundary between personal and client-related information (Scaife, 2009), especially important in the context of training and evaluation. It may be that supervision is not always the appropriate space to wonder about the detail of this, yet in marking this boundary, there is a possibility that we close the personal down too quickly. It can be difficult to hold onto this in the role of clinical psychologist with its many demands and expectations. It can be even more difficult to do so in the context of training, where trainees are and feel evaluated, where many demands move trainees away from their internal worlds, where the personal can seem insufficient as evidence within the dominant theoretical framework. Also, trainers and trainees alike can strive to maintain a semblance of control and intactness in the work.

When we talk of the client’s impact on us, it is located in the language of countertransference. While many examples and definitions of countertransference exist, increasingly the term is used to denote all the therapist’s feelings and attitudes towards the client, regardless of its source or form (Kahn, 1997). From Freud’s caution that the limits of the analyst’s own internal resistances were important, countertransference has been incorporated over time into psychodynamic and integrative perspectives. It has been referred to as the “heart of the matter” (Bollas, 1999: 21) in therapeutic work. Considering the part of this that is uniquely the therapist’s, Casement (1985) has spoken simply of personal countertransference as distinct (in so far as it can be) from a diagnostic response. While there is an inevitable interplay between different aspects of countertransference, we ask and expect trainees to be aware of their historical selves andtheir hopes. At certain times in our careers, such as when we are in training, we may feel more vulnerable and our resonance to our internal worlds may be heightened (Wosket, 1999). This in turn can deepen personal responses to client material and make it even more important that we attend to this possibility in training.

The role of helper, of therapist, has itself been suggested to move one to explore one’s own issues. Kottler (1993) speaks of the “inevitable growth and self-awareness” (xii) that comes from being in a client’s presence, as we participate in a client’s changing world. There is no doubt that the therapist’s motivation, the client’s changing processes, feedback from the client, and relating and speaking in internally focussed ways (Wosket, 1999) can contribute to the possibility of reflection and growth for the therapist. However, this is by no means inevitable; we can stay in that safe space afforded to us by the role as it can provide emotional protection and minimal risk. In training, it may be that emphasis on technique while learning can make a stay in a less risky place even more likely. Thus, the role of therapist, in offering such ‘safety’, may not in itself be sufficient to move one to awareness of personal issues and may be insufficient at times in accounting for the impact clients may have.

That which draws each of us to work with clients may make us more vulnerable to that impact. For whatever reason, as psychologists and psychotherapists, we are drawn to others’ internal worlds and experiences. It may be that this provides an opportunity to explore our own inner worlds and experiences, responding to a wish to, and providing a chance to, connect to those. Kottler (1993) commented that the decision to be a therapist is a commitment to our own growth, whatever shape that growth may take. Such commitment to our own growth is also taken up by Bollas (1987) at another level, who holds that we all as adults continue to seek a transformational object, another who promises change and transformation of self, echoing the first experience of transformation with mother. Could we, as therapists, seek out clients to be this for us, clients whose difficulties echo our own inner dilemmas, and even lead clients towards issues that are ours too, or ours only? Using the mother-infant analogy of therapy slightly differently to the usual narrative, we may be drawn towards certain difficulties or clients, as our younger selves seeking transformation. If this is so, it makes a client’s impact more likely. We may also enter the work as an adult, a ‘mother’ in the therapy. Just as the mother, in one of Bollas’ (1987) examples, hopes for transformation and perhaps an altered inner world through the infant/growing child moving out into the world, we may do so too. Our wish for transformation as infant, as mother, as both, is present.

Indeed, as we search for the transformational object or experience, it may be that the therapeutic process itself, as well as the other, holds the promise of change. Searles (1973) commented that those whose childhoods were largely devoted to other family members, for whom this “therapist-functioning proved both complex and absorbing and fundamental to their sense of personal identity” (380) may take such activity as adult work, the therapeutic process seeming very familiar and holding the promise of change. If we, as therapists, bring our pasts into the room, as we cannot but do, we thereby enact earlier relationships in our wish for transformation (thus bringing our presents and hoped-for futures as well). Therefore it is inevitable that one’s own personal idiom and process is caught and connected – how we move or not with this is another question. Either way, the transformational object being client or process, the stage is set for our clients to impact on us as they move through their stories.

Linked to this, Searles (1975) spoke of the notion of psychotherapeutic striving, an innate striving towards “therapeutic devotion” (104) that all humans share, a striving towards curing the other (given expression by those who engaged in such work). He argued that the therapist could, and does, receive therapy from the client. Central to this was his observation that “we do not project into the sky” (105), that there is an element of reality in all clients’ transferences. If a client perceives me in a certain way, then there is a strong possibility that at least some of that characteristic is present in me. This is echoed by Symington (1986) who cautions that the clients’ transferential responses include a response to reality in the therapist. In this way, each client challenges the therapist to consider his or her own personal development and way of being. This does not necessarily mean the challenge is taken up.

We may resist such challenge, such impact, and “may flee from contact in areas of difficulty” (Symington, 1986: 321). As relationships develop with clients, the therapist is drawn into a deeper sense of intimacy, what Wosket (1999) refers to as being “revealed and laid bare” (38). Technique can often be a way to move away from, to protect from, this very intimacy or sense of knowing and being known (Kottler, 1993). When transferential issues become more prevalent in the work, we can move from discussing or wondering about these. There may be times when clients can see us in a more negative light, times when work with clients can feel chaotic and intense. We can ignore such issues, leading to a stagnation in the work (Bauer, 1993), we can move to reassure, to protect ourselves by invoking positive and helpful responses, ultimately deflecting the issue at hand (Casement, 2002). Symington (1996) summarises the various resistances and concerns we may have as responses to feeling frightened and/or uncertain. Such uncertainty is especially difficult for the clinical psychology profession that has worked for so long from a ‘knowing’ position, and even more difficult for a trainee. This reaching of one’s own feelings in the work is seen by Symington (1996) as a life’s work. In this, whether trainers, trainees and/or clients, we share a common dilemma. We may create a ‘knowing’ environment in training. How can we then expect those in training to allow vulnerability and uncertainty? Added to this is a language of failure that comes with evaluation, which may make such resistance more likely and necessary to survive.

How can we allow such vulnerability and impact so that clients ultimately benefit? Reflective practice has become more spoken about and central to clinical psychology training, with training programs seeking to nurture this in a variety of ways, one of which is by trying to pay more attention to PPD. It seems that a reflective, questioning stance, welcoming the unknown and uncertainty (Bollas, 1987) is central to allowing awareness of clients’ impacts on us. This is not the ‘right’ or only way, but rather an ongoing, interrupted and at times stagnant process. Perhaps it is the desire towards one’s own development, acknowledging a search for transformation, that ensures that this stays as a process rather than becoming stuck and turning away from it. However, it is not that we should become all-consumed with our needs and wonderings, but rather come in and out of such reflections; such tension being what Sedgewick (1994) refers to as a “tightrope” (146).

We also have an ethical responsibility to our clients to attempt to face our own needs, wishes and issues (Maroda, 2004). As the notion of countertransference is increasingly incorporated into therapeutic work from various perspectives, Kahn (1997) argued that this brings increased responsibility to determine whose material is evident here and now, likening it to a “dangerous weapon” (162) if misused. Furthermore, as well as a duty of care to clients, as trainers we also have a duty of care to trainees. We need to especially remember this as we place relationships as central to clinical psychology training, as we invite trainees to consider the relational across a range of settings. As relationships form, deepen and change over the course of training, we need to ensure that we support trainees to expect and attend to the moment and experience of impact of a client.

Attempting to attend to this in the context of exploring personal and professional development of trainees brought the above ideas into sharp focus. While material here may seem obvious or very familiar to trainers and trainees in areas of psychotherapy and counselling, I would suggest that the demands of any formal training can give rise to a movement away from the impact of clients on personal processes. In clinical psychology training, it is important that evidence of such impact should not be seen as signifying less than, less able, or failing in some way on the part of the trainee. Only by remembering that this is inevitable, and why, can we begin to take care of ourselves as individuals and professionals.

Mary Fell is a clinical psychologist, and a humanistic and integrative psychotherapist.

References:

Bauer, G.P. (1993). The Analysis of the Transference in the Here-and-Now. New Jersey: Jason Aronson Inc.

Bollas, C. (1987). The Shadow of the Object. London: Free Association Books.

Bollas, C. (1999). The Mystery of Things. London: Routledge.

Casement, P. (1985). On Learning from the Patient. London: Routledge.

Casement, P. (2002). Learning from our Mistakes: Beyond Dogma in Psychoanalysis and Psychotherapy. Hove: Brunner Routledge.

Fell, M. (2006). Healing for Whom: The Client’s Impact on the Therapist’s Personal Processes. Dissertation in part-fulfilment of requirements for Diploma in Humanistic & Integrative Psychotherapy, Institute of Creative Counselling and Psychotherapy, Dublin.

Kahn, M. (1997). Between Therapist and Client: The New Relationship. New York: Henry Holt & Co.

Kottler, J.A. (1993). On Being a Therapist. San Francisco: Jossey Bass Publishers.

Maroda, K.J. (2004). The Power of Countertransference: Innovations in Analytic Technique. New Jersey: Analytic Press.

Scaife, J. (2009). Supervision in Clinical Practice: A Practitioner’s Guide. Hove: Routledge.

Searles, H.F. (1973). Concerning therapeutic symbiosis. Annual of Psychoanalysis, 1, 247-262.

Searles, H.F. (1975). The patient as therapist to his analyst. In P. Giovacchini (Ed.). Tactics and Techniques in Psychoanalytic Therapy, Vol.II: Countertransference (pp.95-151). New York: Jason Aronson Inc.

Sedgewick, D. (1994). The Wounded Healer: Countertransference from a Jungian Perspective. London: Routledge.

Symington, N. (1986). The Analytic Experience: Lectures from the Tavistock. London: Free Association Books.

Symington, N. (1996). The Making of a Psychotherapist. London: Karnac Books.

Wosket, V. (1999). The Therapeutic Use of Self. Hove: Brunner Routledge.