Relational Therapy and Ethical Practice

Introduction

In writing my case study it has been crucial for me to be aware of the UKCP code of ethics. As a psychotherapist, I am observing all the ethics related to the work regarding the client, such as, boundaries, confidentiality, diversity and so on. In addition, under the UKCP code of ethics, I will not mention my client’s real name and the place where I work. The client’s confidentiality is very important for me, therefore all the details related to the client and others have been changed. In order to respect my client’s confidentiality I shall call her Miss K. My theoretical approach in working with my clients is one of relational, ‘relational therapy is about self-with-other’ (DeYoung, 2003). I am also leaning towards an integrated approach as this also comes under the same umbrella, conditions such as empathy, congruence and unconditional positive regards (Rogers,1957) are all relevant to my work with my clients along with other approaches.

Setting

I work in a center for women I started working there as I really wanted to work in a setting where I can work with women who have gone through many crises including domestic abuse and so on. Furthermore, I feel comfortable working with women. Why do I feel more comfortable? In my culture women do not have voice, they suffer in silence and also feel ashamed. My upbringing was strict and I was not allowed to mix freely with men and therefore I struggled to raise my voice and express my opinions in a male setting. I feel more relaxed and focused with female clients. I learn hugely in my group supervision, through private supervision I have more time and I can have deeper discussions with my supervisor. This supervision for my clinical progression is crucial as I am a trainee and need to learn more through my experience with client work and the impact of individual clients on me. When I started the supervision group I was overwhelmed by other peers as they had more client work experience then me. As a result, I was struggling with articulating my own reflection on client’s material as I lacked confidence or Winnicot’s term ‘not good enough’ (1965). Over time, I gained more confidence through my work with the clients, supervision at university, personal therapy and also my private supervision.

Miss K is a 29 years old white British woman, she is married and has three children. She has both of her parents, a sister and a brother. Miss K is a part time teacher at the junior school. She got married ten years ago, however, she is now separated from her husband. Miss K’s childhood was not very nurturing and containing. She went through a traumatizing experience when she was thirteen years old. Her parents are strict Christians and she went to a Catholic school where she went through numerous challenges. Miss K, as a late teenager, suffered a lot on her own, she got involved in witch crafting and later developed an eating disorder. Her grandmother died when she was aged eighteen whom she was very attached to. This was a huge loss for her and left her very lonely and heartbroken. After a few relationships, she decided to get married to Mr. A whom she fell in love with as he initially treated her with love and care. Miss K’s present issues were anxiety, depression and low self-esteem. She has been on antidepressants from the last few months. She also went through domestic abuse, both emotional and sexual from her husband. Miss K attended the course ‘My Life’ at the Women Centre before she sought counseling services. So far, we have had twenty-four sessions together. I will later present a few verbatim extracts from different sessions with deeper reflections of the process.

Miss K and I developed a very good relationship through our twenty-four sessions together. I sat aside my personal views and allowed Miss K to express herself with the ability to change. I believe this to be consistent with the concept of unconditional positive regards by Carl Rogers (1957) which is the acceptance and support of a client regardless of what he or she says or does. I will reflect on our work on all the sessions we have had together. Miss K’s lack of confidence, depression, self-blame/not good enough issues are deeply rooted to her childhood experiences and attachment style. Miss K has anger turned inward and suffers acute depression. She also has dissociative state due to her early teenage traumatized experience. She is a people pleaser and does not like to show her true feelings. Miss K is going through a lot at the moment as she has a court case against her husband who sexually abused her. Social workers are also involved as she has young children. She is under huge stress as she looks after her children along with her job. Her parents help her with the children while she works and attends the court hearings. Miss K is going through an existential crisis at the moment and is struggling with her identity as she often asks existential question ‘who I’m I’? (V D, Emmy, 2010)

The Therapy

Miss K was one of my very first clients since I started my clinical work. I had mixed feelings of excitement and anxiety. I was excited as I was keen to work with clients on one hand and on the other hand I was anxious about my feelings of being a ‘good enough’ therapist. This helped me to be with my client and not to think about whether I was right or wrong. Miss K has attended most of the sessions and she is very talkative. Sometimes, I find it challenging to stop her from talking too much as it takes over the focus on her deeper feelings. Miss K almost in every session says, ‘I am not good enough’. Her husband always criticised her the way she looked, talked and so on. Her mother in law also criticised her for not being a good wife and mother. Miss K in the first ten sessions was almost disassociated with her real emotions and she did not talk about her childhood or parents. Her main focus was her current issues with her marital problems. Although it was challenging, I had no major concerns with Miss K talking too much, never at any point did I feel she was trying to block me or fear me in case I would react like her mother in law. Due to my relational approach, I am aware I have to listen to all her current and past stories and not only observe but to participate in them as well. It was important for me to understand and apply the relational therapy framework. As has been summarised by DeYoung (2003), the most important features of relational psychotherapy are firstly the focus on self with other experience and secondly is what hurts and heals as result of applying the first characteristic. By doing this, you encourage the clients to tackle their relationships with others to make themselves feel better.

Miss K’s internal working model (Bowlby,1969) is “I am not good enough”. In addition, she has a traumatic experience from her childhood which I will mention in the verbatim. Her attachment style with her parents is ambivalence and anxious (Howe, 2011). She was more focused on her childhood in the last few sessions and also talked about her trauma in more depth. I felt more confident in these sessions with her as I could challenge her deeper feelings such as anger. I believe the therapy sessions so far have gone well and Miss K has started reflecting on her deeper feelings. She often comments on her appearance as she does not like the way she looks. Her parents were not available while she was growing up, therefore, nobody heard her feelings and she suppressed everything and tried to forget a lot of memories or emotionally dissociated herself. Miss K wants to be heard empathically and I am providing her the secure place to express her deeper feelings. I believe this therapeutic alliance is crucial in order to build the relationship with the client.

Extract 1- session 3

C1 I am ok… but not ok… I just wanna talk about it. [silence]

T1 You said, you want to talk about it?

C2 Yes, I just want to talk about what is going on in my life at the moment.

T2 I am listening.

C3 I have realised that I have been abused in some other ways as well. When I had my elbow operation, I was not able to move my hand, so I decided not to wear my night dress because it is easier to go to the toilet. [silence] and I woke up him doing it [silence] was having sex with me. I did not say that I wanted to do it so I was so confused.

Also there was another occasion, on the Boxing Day night, I had really bad anxiety attack and was a bit drunk. I woke up to him doing it and then I just closed my eyes and just let it be over. I was so confused and again I tried to hide it or ignore it. Later on, the next morning, I said to him that you made me feel like you raped me. And he said oh see, look you are really loosing it now, you always accuse me for no reason. And just thought maybe it is just me, may be this is normal with married couples.

T3 I can understand why it was so hard for you to talk about it and I am so sorry about what happened to you.

C4 yeah, thank you. I am frightened about what people would say, I am frightened that maybe it was me and I deserved it.

T4 Nobody’s deserves to be treated like this.

C5 I just cannot accept this, It is really bad, I am so scared of all, I just think who am I now? I thought he really cared about me, I feel very lonely and I feel like I just want to talk to someone.

T5 You can talk to me, I am here for you and this is your space.

This part of the verbatim is somewhere at the middle of the session. Prior to this extract, Miss K was talking about her husband’s behaviour towards her and she highlighted some of his verbally abusive behaviour. She also talked about her interviews with the police when she was asked about her husband whether he ever physically abused her. I could see her tense body language and her breathing heavily. I sensed that she wanted to tell me something however she seemed anxious. After C1 there was a long silence therefore I paraphrased her words in T1. In C2, through her facial expressions and tone of voice, I felt as if Miss K needed my permission to express her feelings. Therefore, in T2, I made sure that Miss K knew that I am attuned with her and also I leaned forward. It was my attempt of affirmation to her that I am with her and she can feel comfortable. However, it did make me think if Miss K was comfortable with sharing her full experiences and it could be that I missed the opportunity to explore the perspectives of sexual abuse and consent during the session. T3 was my attempt to show empathy towards her, however, at this moment I was overwhelmed with what she said, as I was not expecting something like this, it was huge. Reflecting on my intervention I believe at that point I was shocked to hear something very powerful in the session and I did not know what to say. Her statement made me feel angry at her husband and I could feel the anger in my body. At the same time I was aware of not getting caught up with my anger and tried to focus on Miss K’s emotions. This was my counter-transference (Bateman and Holmes, 1995). I could see the limitations to the relational approach and it did make me question the honesty of the therapist relationship. Why did I feel angry? One possible explanation is that the experience of emotions is different in cultures, what might be perceived as angry might be seen sad or lonely for another culture (Gruber, 2013). In western culture, people strive for emotions is displayed in enthusiasm and excitement whereas, in the eastern culture, it displays signs of calmness and peacefulness.

T4 was my attempt to show empathy and affirmation that she does not deserve such abuse. However, I missed Miss K’s feeling of fear, she said she is frightened about people’s judgments also perhaps my judgement? I failed to explore one of the important element of the session. My intervention T5 was another attempt to reassure her that this is her space and she can trust me. Once again, I unconsciously ignored all the feelings she mentioned, for instance, fear, identity, loneliness and so on. I was trapped in expressing my counter transference, therefore, I could not explore her feelings at a deeper level in this session. When Miss K left after the session, I was so angry at myself for not being ‘good enough’ for her. What should I have done? I had the option to pause and think, I could have used my counter transference indirectly to better understand the client (Evans and Gilbert, 2005). My personal therapy and supervision helped me to process my feelings and carry on working empathically with Miss K.

Extract 2- session 14

C1. They just touched me, and then after that they were so horrible. They spread so many rumours about me but they were not true. Like I was a slag, I was easy and said all sort of really horrible things. I lost a lot of self-respect….[Silence]…. I think maybe that’s why….. I don't know…may be…. I don't know…[silence]

T1.May be that’s why?

C2. I don’t know…..[Silence]…I struggle with that side of things anyway….[Silence]… or maybe that’s why I let my husband to do what he did. May be that’s why I lost sense of like what special and just don't like myself. I blame myself for what happened, I shouldn't have gone to the fields with them. They touched me, took my trousers off….[Silence]……

T2. I am feeling very sad to hear about what happened to you, I am very sorry.

C3. I can still remember their face, I can still remember where we were sitting, what I was wearing, I can still remember the weather, the wind and I remember I just put my cloths back on, I was so drunk and I went to find my friends. I didn't tell anyone. I went home, I remember mum shouting at me because I came back home so late. Nobody knew what had happened to me.

T3. You never told anyone?

C4. No because I thought it was my fault, I was embarrassed, and felt so sick. When I saw them again, they both came to me and whispered in my ears that I was so disgusting.

T4. Was it around that period of time in your life when you started self-harming?

T5. I am just imagining that very lonely 13 years old girl who went through a lot on her own, and it makes me very sad.

C6. I felt disgusting.

T6. I am aware of the time, we have just couple of minutes left. How are you feeling now?

T7. We have to end our session here and we will talk more about this in our next session or sessions, I just want to know if you are ok?

C7. Yes I am ok, I am going to meet my lawyer now so I will be ok.

This part of the session is the second half of our session. The first half of the session was all about her current issues with her marital life and updated me with what went on last week. I went to this session with Miss K with an agenda as she mentioned something really big right at the end of our previous session. We did not have time to explore further in detail, however, it stayed with me throughout the whole week. I wanted to know more about that traumatic event which had happened when she was thirteen years old. Why I was so keen to know about that event? This was our fourteenth session together and she barely mentioned her childhood other than her recent issues in therapy and I was very frustrated. Every time I attempted to say something about her childhood she would take me back to the current issues. I felt angry at her projective identification (xxxx) and also myself for not being able to challenge her more. In her previous session, she said that nobody in her family other than her husband knew what happened to her and this was the first time she has spoken about it in the session. I believe Miss K never told this to anyone before because of the shame. I also believe that she was finding it difficult to tell me because she did not want to face the vulnerability and empathy from me as she was overwhelmed with being heard by someone. This session was very different for me as I felt as if I understood her more now and I could link many of her issues with her traumatic experience. I also felt good about myself that she began to feel secured and that she trusts me. In the supervision group at university, there were very strong responses among my peers. There was an interesting discussion on my client’s self-pity and some responsibility of what happened to her and so on. As she was a young girl and also a drunk, people in my supervision group had different reactions on my verbatim. There was division among gender as this is a very sensitive issue (sexual abuse). Some people were angry and others were saying something about taking responsibility. The content of the verbatim triggered many emotions in the group, and also triggered the social narratives which had been gender driven.

Miss K has a very complicated history as she has been taken advantage of. I was feeling frustrated by the group’s response and wanted to defend Miss K. I brought these two sessions here because I want to reflect on my responses to Miss K’s content of the sessions. Although I felt absolutely sorry for her regarding all the sexual abuse she suffered and I was very empathic in the sessions, however, I cannot ignore my feelings of doubt or question myself after the sessions about how much of what she is telling me is the truth? I feel shame judging and having doubt in Miss K’s very sensitive issues. Some peers in the group said as a therapist we should not have any judgments on client’s material, however, I agree with my supervisor that it is important to have some judgements on the side and be conscious about the judgment coming up in the session and think about why am I having these judgments. I believe it is not about how much truth there is in her sexual abuse stories but it is about taking some responsibility of what can a person do to protect them or carry on staying in the victim’s position.

Miss K’s experience at thirteen years old was shameful for her and she couldn't tell anyone. This was damaging but also there was something deep underneath that she was not touching upon. My supervisor asked me if I was finding it difficult to hear about ‘rape’ as I did not mention the word rape in the session with Miss K or in the supervision. Before the above verbatim extract, Miss K started talking about her parents and what was it like for her as a child. She also talked about not being able to talk to her parents about what was going on with her as a young girl. Therefore, I saw the opportunity to ask her about the traumatic event she mentioned in our previous session. Miss K seemed really anxious and told me about how horrible she feels about that day and blamed herself for going to the fields with those two boys. I empathically asked her if it was fine for her to tell me more about that day. Miss K’s body language was tense and she looked outside the window as if she has gone back to those fields where that horrible event took place. I believe I was also feeling anxious as I did know that she was going to tell me. T6 was my attempt to encourage her that I am listening to her. Miss K glanced at me as if she needed the assurance that I am listening to her. I sensed that this was very difficult for her to talk about and she might feel ashamed. I could have acknowledged her difficulty to express her feelings and could have asked her if she was feeling embarrassed to talk about that day. T2 was my attempt to show empathy and express my genuine feelings as it made me really sad. I also felt angry towards those two boys however I did not express my feelings of anger in front of her. This makes me wonder why it was difficult for me to tell Miss K how angry I felt towards the boys. I talked about this in my therapy and the outcome was that I was once again overwhelmed with her story. Like all cultures, sexual abuse is a taboo and people feel humiliated and ashamed to talk about such events and for me it was more disturbing to hear it first hand as it is a major sin in my religion.

T3 intervention could have been more focused on her feelings such as how difficult it was for her to keep everything to herself and not telling anyone. My intervention T4 was more intellectual rather than emotional as I was linking Miss K’s attempts of self-harm. I could have stayed with her emotions but I tried to help her understand why she was self-harming. She expressed many emotions such as self-blame, embarrassment and so on. However, T5 was a very empathic attempt to show her that I heard her and showed my vulnerability. Being honest with how a therapist feels can help the client to build the connection, hence, I expressed my feelings in front of her. T6 I realised that we only had few minutes left together and did not want to go deeper with her feelings of ‘disgust ’. I wanted to make sure that Miss K was feeling ok before she left the room. Miss K ignored what I said and carried on telling me more about why she couldn't tell anyone. T7 was my attempt to make sure that Miss K leaves the room feeling ok and I had to stop her as I was aware of the time and boundaries.

Conclusion

In our sessions together, one major theme that comes up is powerlessness. I often struggle with powerlessness as I have the desire to ‘fix’ Miss K’s traumatic memories. However, I am aware that by taking the relational approach I cannot fix anything for her and all I can do is to be with her and help her feel better. Further, by being empathetic with her in the form of unconditional positive regard (Rogers, 1957), it does not alone develop a good therapeutic relationship. The above had its limitations and at times, I struggled to have an honest relationship with Miss K, especially when I wanted to express my personal views, I held back at such moments. It felt to me that her transference (McLoughlin, 2006) to me of her feeling powerless, was an attempt on me to get rid of those traumatic memories. It is argued that before trauma, we have assumptions about everything and after the trauma, some of these assumptions may shatter and therefore, one can feel being helpless (Janoff-Bullman, 1992).

How can I help to empower her? In order to help her, I am aware that I have to separate myself from her despair, here, I find my personal therapy to be very helpful. In our more recent sessions Miss K often expressed her fear of introducing another man in her life and that she is not ready for another relationship. She often says she wants to focus on her children and so on. However, she then tells me about her online dating with men and having sex. She also says how guilty she feels afterwards and she says that she would not do this again. However, she does fall into this vicious circle repeatedly. The paradox in client’s theory of sex does not sit with me comfortably. I have to be mindful of her contradictions as this evokes anger in me. I feel angry because she is not helping herself to ‘fix’ her issues. I am aware of my desire to ‘fix’ Miss K’s issues. In addition, I belong to a culture where, having sex with a random person and also outside the marriage are unacceptable. Therefore, I am aware of my biases and prejudices in the sessions and I ‘bracket’ (Spinelli, 2005) my perceptions and views. I focus on Miss K’s existence in the world and attempt to see the world from her eyes. I believe that the contradiction in her behaviour is all part of her confusions. Clients often think that present thoughts and their behaviour are full of contradiction and confusions. Through recognising this, I developed greater empathy towards her. I am there to help her to understand herself better through therapy so she can be in a happier place. I can sense that throughout our sessions together, Miss K developed a secure attachment with me and she is ready to express her struggles and difficulties. As a psychotherapist, I will come across numerous clients with variety of diverse problems, therefore, in order to work with these clients, it is vital to have an integrative framework with variety of theoretical concepts and strategies (Corey, 2001).

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