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The Gossamer Thread

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This book is a memoir of the author's professional life as a psychologist and psychotherapist. It shows his progression from a hard-nosed behaviour therapist with a strong commitment to science to a psychodynamic therapist with an interest in narrative. Along the way he shows the way the main schools of psychotherapy (behavioural, cognitive, psychodynamic) work, drawing on case material from his professional practice. He shows the mistakes he made and the lessons he eventually learned from his patients. His focus on clinical cases enables readers to see psychotherapy in operation and get drawn into the ups and downs of trying to help some fascinating and often tricky people who rarely conform to what is expected of them.The book is free of jargon and can be enjoyed without any prior knowledge of psychology or psychotherapy. It is designed to entertain and inform the general readership about the mysterious world of psychotherapy, what goes on behind the consulting room door. It will be of particular interest to the increasing number of people who encounter psychotherapy either through their own experience of seeking help or the experiences of family and friends or through reading of popular books such as those of Oliver James and Irving Yalom.It should also prove invaluable for those interested in training as a clinical psychologist, counsellor or psychotherapist.

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Chapter One: Beginnings

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CHAPTER ONE

Beginnings

A blond, curly-haired, slightly chubby 17-year-old boy sits by a squat, black telephone staring out of the top-floor latticed window of a grand house on the Berkshire/Surrey borders. The telephone is the old-fashioned sort with a circular chrome dial that has letters on it as well as numbers and requires a hard tug to make it move. The phone does not ring and the boy appears not to be interested in it. In fact, the vacancy of his gaze, his casual, slumped posture, the occasional, irregular drumming of his fingers on the window-seat, suggest that he is entirely caught up with his internal world and that the external world is, for the moment, lost to him. Were he to take in what is in his immediate vision, he would see a square, gravel forecourt below, temporarily empty of cars, leading to a drive that bifurcates in front of what, in the summer, is a sumptuous rose-garden but is now a long parcel of dark earth. There is a small cottage beyond and, everywhere to his left and right, stands the gaunt tracery of trees and bushes that make up the extensive grounds. If he were to open the window, lean out and look to his left, he would just see the top of a tennis court. And if he were to look to the right, he might catch a glimpse of Rosie, his brother's foul-tempered horse, in the field beyond the hedge. And if he had been looking out of a window on the other side of the house, he would see manicured lawns, neat, cultivated flower-beds, a rectangular swimming pool dormant under a grey plastic cover, and an expansive view across fields and woods unimpeded by another house or building. It would remind him, if he needed reminding, that he was a privileged child, the son of rich and successful parents, on the brink of what he hopes will be a glittering career.

 

Chapter Two: A Suitable Case for Treatment

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CHAPTER TWO

A suitable case for treatment

I am sitting at one of the long tables in the Institute of Psychiatry canteen along with my fellow students on the Maudsley course. It is a coffee break between lectures. I am struggling to understand why I am here, why I want to be a clinical psychologist. For the most part the lectures are about psychometric tests, tests of intelligence, personality, aptitude, attainments. Intelligence tests like the Wechsler Adult Intelligence Scale (WAIS). Tests of reading and spelling. Tests of fine and gross motor skills. Tests that supposedly give rise to personality profiles and tests that somehow suggest what jobs suit people best. This is what clinical psychologists do, what I am being trained for, and I am seriously wondering if I should have done something different. Perhaps I should have gone into advertising after all.

We are being lectured about the scientific basis of these tests. Our lecturers are searingly critical of almost everything to do with them, their construction, their standardization, their theoretical basis, their fairness. It seems the tests are of uncertain reliability, doubtful validity, and limited utility. Oddly enough, we still have to give them to the patients and, more to the point, pass out on their administration rather like passing a driving test. This disparity between theory and practice is one I am destined to come across many times in my career.

 

Chapter Three: Getting My Hands Dirty

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CHAPTER THREE

Getting my hands dirty

Gary and I are sitting on the uneven grass that passes for lawn in the Maudsley Hospital. Just in front of us is a flower-bed, a long thin rectangle of earth to which some straggly rose bushes cling hopefully. We are about 30 metres from the Villa, the euphemistically named locked ward in the Maudsley Hospital complex. It is July 1969 and the sun is shining, the beginning of a long warm spell. The patients in the Villa—the mad, the bad, and the very dangerous to know—are not allowed out of their “sanctuary” except under vigilant supervision. But they can see us from the windows of the patients' sitting room. What Gary and I are doing out there must have been very puzzling to these onlookers and, to some, must have appeared as mad as anything they had ever done themselves.

Gary is staring moodily at the ground while I prattle on. He is 26 years old and comes from a solid and supportive working-class family in Chipping Norton. He is an inpatient with a diagnosis of obsessive-compulsive disorder or OCD. Those with OCD fall into two categories: washers and checkers. Gary is a washer. His whole life is governed by the necessity of ensuring everything and everybody around him is free from contamination. He likes to wash his hands a lot. A lot means more than 30 times a day, scrubbing them with detergent repeatedly until he is satisfied they are properly clean. His hands—if you could see them for he is holding them across his chest and under his armpits—are red and raw.

 

Chapter Four: How many Psychologists does it Take to Change a Light Bulb?

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CHAPTER FOUR

How many psychologists does it take to change a light bulb?

After just over a year's training I qualified as a clinical psychologist. I registered with Dr. Rachman for a research PhD intending to demonstrate in a scientific study how successful behaviour therapy was. A half-time clinical lectureship at the Institute came up. I was offered it and, this being the Maudsley, without so much as an interview. My main duties were to provide a clinical service to one of the wards and to do the odd lecture. The other half of my time I would do my doctorate. I had hoped to work on an adult ward and carry on my behaviour therapy work. But there was in fact only one job available and that was working on the psychogeriatric ward at the Bethlem Royal Hospital in Beckenham, Kent. I knew nothing about psychogeriatrics. I had never worked with elderly people. And, I thought gloomily, what prospects would there be for behaviour therapy? Were they not, well, too old for therapy? Such was my unabashed arrogance.

 

Chapter Five: Fail Again. Fail Better

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CHAPTER FIVE

Fail again. Fail better

In the early 1970s the randomized controlled trial (RCT) had just become the gold standard of psychotherapy outcome research. Patients were randomly allocated, usually to one of three groups, the treatment of choice, an alternative or placebo therapy, and a no treatment control. Pre- and post-measures were taken. A straightforward statistical comparison would show if the new treatment was better than both the alternative and the no treatment condition. A follow-up assessment—six months and/or a year later—would show if the changes lasted. To me it seemed simple. Already there were several published studies of behaviour therapy using the RCT model and in all of them behaviour therapy was proved the winner. I would join the select band.

One decision I had to make was what patient group to focus on. While research was already underway on specific phobics, agoraphobics and obsessionals, I noticed there was one group of patients no one had yet done a proper outcome study on: social phobics. There were just a few case reports in the behaviour therapy literature. Mainly, they showed that Wolpe's systematic desensitization or a version of it seemed to work. But no substantial research trial had yet been done. In the psychiatric literature social phobics were defined as people who felt excessively anxious in the company of others. Someone who blushed easily perhaps, who felt tongue-tied and shy, avoiding the company of others. In personality assessments they would score high on the dimensions of introversion and neuroticism. Many psychology theorists—my boss H.J. Eysenck was a leading figure in this regard—thought this was a basic temperamental difference with a strong genetic basis. Behavioural theory on the other hand pointed to a learned component just as in any other phobia. People could become conditioned by anxious experiences in social events, it was argued. Certainly when I began seeing social phobics, they recounted tales of humiliating and embarrassing experiences that had been burned into their memory. Being picked on at school because of a slight stammer and then mercilessly bullied. Asked to read in class and being laughed at for blushing. Trying to sign a cheque in a shop and trembling so much they couldn't do it. Of course these incidents did not prove that the learning theory explanation was necessarily right. People could start with a temperamental sensitivity that made them more vulnerable to experiencing anxiety in social situations. An interaction between temperament and learning seemed the most sensible explanation.

 

Chapter Six: “Whatever Happened to Flaming June?”

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CHAPTER SIX

“Whatever happened to flaming June?”

In 1975 I finally completed my doctorate. The findings on the effectiveness of the two treatments may have been negative but I needed to write up the study paying careful attention to the theoretical and methodological matters that had led me to it in the first place. I had added another research project, one that was not to do with evaluating treatments, but was drawn from the data I had obtained from the pre- and post-treatment videotaped assessments of patients in conversation with a confederate, that is, someone neutral whom I trained for the task. Painstakingly, I analysed these into categories of verbal and non-verbal social behaviour and examined how much they correlated with each other and with my more general measures such as self-ratings of social anxiety and self-confidence. I was keen to see whether some behaviours might be indicative of the sorts of problems my patients had. This proved fascinating though, as the mass of data accumulated and the correlations reached their hundreds, the picture became highly complicated. Fortunately, a friend who happened to be a biometrician suggested a new statistical technique called multiple regression that somehow simplified the many correlations into a few key ones, thereby extracting meaning from the confused and confusing picture. As I waited for my viva, my worry was that my external examiner, Michael Argyle, would ask me penetrating questions about it and I would flounder horribly. But Michael cheerfully confessed he had never heard of multiple regression. So I was able to explain it to him with an airy confidence that belied my tenuous grasp of how it worked. I was awarded my doctorate subject to some minor changes. Hooray! But getting my doctorate did not feel like a great achievement. In truth, I felt a bit of a sham. I gave up science in the third form at school and now I had somehow obtained both a master's and doctorate in science. How could that be except by some sort of sleight of hand?1

 

Chapter Seven: Speaking Prose

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CHAPTER SEVEN

Speaking prose

I sometimes wonder,” says Angie, speaking very carefully as though the exact words were crucial, “if I could get taken over by the Devil. Like in The Exorcist.” She looks at me and there are tears coursing down her cheeks. I feel moved by her evident distress. “Do you believe in the Devil?” she asks.

“No. But you do. Is that what you're saying?”

“No. I don't know. I don't know what I believe any more.”

Angie continues to cry. I do not know what to say. We are in a small side room of a GP surgery in Harborne, Birmingham. I have been invited to work here by one of the doctors as their visiting psychologist and behaviour therapist. It has been four months and I am beginning to build up a caseload of patients. Angie is one. This is our second session.

Angie is 30, married with two very young children. She had worked as a dental receptionist but now stays at home to look after the children. Keith, her husband, works on the North Sea oil rigs. He is away from home for long stretches of time, as he is now. The GP referred Angie to me because she had become depressed a few months after the birth of her second child. He had diagnosed post-natal depression and suggested antidepressants. But Angie had refused medication. He had been seeing her supportively when she told him about the horrific fantasies that had first appeared after the birth of her second child. Angie confessed that she had awful thoughts about killing her children.

 

Chapter Eight: “I Think I'm Wasting your Time”

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CHAPTER EIGHT

“I think I'm wasting your time”

The essence of cognitive therapy is summarized in a much quoted remark of the Greek philosopher, Epictetus, “People are not disturbed by things, but by the view they take of them.”1 If, for example, someone experienced a severe and unexpected pain and thought it signalled a major illness, he would be likely to be anxious. If he dismissed it as a minor muscle twinge, he would not. The perception determines the feeling, not just the experience on its own. In 1976, Beck's book, Cognitive Therapy and the Emotional Disorders, was published, launching cognitive therapy as the successor to behaviour therapy. Beck's psychoanalytic training had alerted him to the need to attend to what goes on in the patient's mind. However, psychoanalysis, still very much under the influence of Freud's ideas about the unconscious, focussed on interpreting behaviours as signs of deeper disturbances with their origins in the patient's past. The method was a slow, painstaking analysis of potential meaning using the analyst-patient relationship as the cauldron in which that meaning eventually emerged. Beck became aware that there was another aspect of thinking that had been largely ignored. He noticed that patients often experienced a continuous train of thought that ran parallel to the thoughts they expressed in therapy. One patient, angry at Beck, reported feeling guilt at his anger, which made sense as, psychoanalytically, anger is thought to lead to guilt. But he experienced another train of thought which he described as continual self-critical thoughts, a disturbing commentary in his head about his shortcomings that he had not reported until now. Working with other patients Beck discovered that they too were experiencing similar streams of thought, usually negative and critical of the self. Moreover, when these thoughts were brought out in the open, they bore a direct relationship with the feelings that brought the person to therapy in the first place. A woman's anxiety turned out to be provoked by her doubts about her ability to express herself in therapy and a belief that she appeared foolish. A man's depression was deepened by his sense of being a failure as a patient, believing that his therapist saw what an inadequate person he was. Beck labelled these as negative automatic thoughts (or NATs). He decided that instead of delving into the past, it was more valuable to bring these immediate thoughts out into the open and to work with them therapeutically. The thoughts were always extreme and often irrational yet had a powerful grip on the patient's thinking. Beck began to experiment with ways of changing the thoughts so that they became more realistic, less extreme and, most importantly, ceased to have such powerful emotional effects. Cognitive therapy was born.

 

Chapter Nine: Going Cognitive

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CHAPTER NINE

Going cognitive

I left Birmingham to become the Oxford Regional Tutor in Clinical Psychology, a much grander sounding post than it actually was. My job was to re-start clinical psychology training in the Oxford region after the university's MSc course had ground to a halt for typically academic reasons (squabbling over which group of neuropsychologists should be invited to lecture the students). Although I was back in the NHS I had no formal clinical commitment. I established myself as a therapist in a GP practice in a small market town in Oxfordshire, working in the same way as I had in Birmingham, seeing the patients the GPs referred me. Here I adopted the more cognitive approach I had tried out on patients like Angie and Naomi. In Philadelphia, Beck and his colleagues had set up a Cognitive Therapy Center, which served both as a centre for research and a base for training others in the new approach. Several UK psychologists went over to learn at the master's feet. As it happened, two of them, John Teasdale and Melanie Fennell, were in Oxford, working in the university department of psychiatry. I knew them both well. John was a colleague from my Maudsley days and Melanie had been a student of mine at Birmingham. One day John stopped me in the corridor and told me he was starting a cognitive therapy training course in Oxford. Would I like to be in the first group of trainees? I did not have to think twice. This was exactly what I was looking for, a chance to formalize what I was already putting into practice, to become a proper cognitive therapist.

 

Chapter Ten: Microbes in the Vast Universe

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CHAPTER TEN

Microbes in the vast universe

I have a confession to make. The cognitive therapy supervision is the first formal training I received in any form of psychotherapy. My training in behaviour therapy consisted of observing Jack Rachman and a few other pioneers, reading books, and attending workshops. Mostly I made it up as I went along. Almost all the early behaviour therapists did this for there were no training courses then. Nowadays every new therapy has to have a formal training programme. Often these are lengthy and almost always costly. In 2007 a professional training in cognitive therapy can last between one and two years (one day per week) and can cost as much as £6,000 per annum. Even very simple techniques become formalized into a therapeutic school that is zealously guarded by the acolytes. Training with John and Melanie is informal, so much so that it hardly feels like training at all. We follow the recommendations in Beck's books, adapting the methods to the patient's needs. My fellow trainees are all experienced therapists, committed to becoming cognitive therapists, eager to learn. Our tutors have only just learned the approach themselves. The feeling generated is that we are all in this together, working it out as we go along.

 

Chapter Eleven: “The Heart has Reasons that Reason Cannot Know”

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CHAPTER ELEVEN

“The heart has reasons that reason cannot know”

In my view life is meaningless.” Stan throws this comment diffidently, almost languidly, into the discussion. The supervision group has been grappling with my difficulty in getting beyond Frances's core belief. We have not got much further than it is part of her depression, a debilitating hopelessness that needs to be challenged immediately if the therapy is going to work. Stan, normally on the periphery of the group, has said nothing until this bald comment.

“But isn't the belief that life is meaningless a sort of meaning in itself?” says Ruth. She is a perceptive and sensitive therapist who was later to co-edit a book on “wounded healers”, therapists who themselves had been psychiatrically ill.

“Perhaps,” says John, our tutor. “But the point is not whether or not the belief is true but that it encapsulates the central core of Frances's depression. She's held this belief for a long time. When she's well, it lies dormant and doesn't have the impact it has now. Why has it become active now?”

 

Chapter Twelve: The Power of Negative Thinking

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CHAPTER TWELVE

The power of negative thinking

The inspiration provided by Dorothy Rowe's talk led me to her other writings, in particular her book, The Construction of Life and Death, a theoretical analysis of the beliefs human beings hold about the world. Fundamental beliefs such as those about the meaning of life and death are, according to Rowe, metaphysical not rational. A belief in God for example is a statement of faith; no amount of evidence will shake it. This was brought home to me vividly a few years ago when I was on a visit to Egypt with my family. We were shown around the Valley of the Kings by an urbane and cultured guide, Rifaat, who had previously worked in Egypt's Office of Antiquities. The indefatigable Rifaat was immensely knowledgeable about Egyptian culture. An intelligent and excellent teacher, he even taught us the basics of hieroglyphics. When we were there, a tsunami devastated Thailand and other Asian countries. More than 200,000 people died. Innocent people going about their daily business. How, I thought, is this compatible with a just god? I asked Rifaat what he thought. Why had this happened? Was it God's will? Yes, he said simply. They must have done something to deserve to be punished. His belief in God was not shaken by natural disasters or evidence of other awful events that had no apparent purpose. It was central, a given, an axiom from which everything else flowed. As believers are wont to say, God works in mysterious ways. We mere humans cannot always fathom His purpose.

 

Chapter Thirteen: Crossing the Rubicon

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CHAPTER THIRTEEN

Crossing the Rubicon

Some years ago one of my daughters gave me a book called Shrink Rap featuring jokey cartoons about psychologists and psychotherapists. A recurring cartoon was of a defenceless patient lying on a couch being listened to (or not) by a small, bearded, middle-aged man who, if there was dialogue, is shown speaking with a heavy Viennese accent. This popular image of psychotherapy is one of the many legacies that Freud has left us. Even today, some 70 years after Freud's death, most people see psychotherapy as Freudian psychoanalysis, the patient lying on a couch, the therapist a silent, inscrutable, European-looking, older man who seems excessively interested in his patient's early sex life.

Simple, stereotyped, negative, and highly distorted views can be remarkably persistent even among those who should know better. In the late 1980s the vast majority of academic psychologists, with a few rare exceptions, regarded psychoanalysis as at best an old-fashioned, outmoded therapy and at worst a form of deception. Their view was no different from that of the cartoonists: the sadly deluded patient lies on a couch, day in, day out, year after year, while the hidden analyst makes portentous, ridiculous interpretations about entirely hypothetical and unverifiable psychic processes. No benefit could come from this approach, it was believed. This view was bolstered by various critiques of psychoanalytical psychotherapy claiming to show it was no better than placebo. But for academic psychologists their major objection was theoretical. Freud's ideas about the workings of the mind were, in the dispassionate language of modern science, arrant nonsense. His “hydraulic model”, for example, in which unconscious sexual drives build up until they somehow overflowed into the psyche, causing neurotic symptoms, was pseudo-scientific, 19th century thinking at its worst. The division of the mind into the holy trinity of id, ego and superego could not be sustained given what we knew of the workings of the brain. The idea that there were stages of development, oral, anal, pre-genital and genital, and that adults can get neurotically fixated at a certain stage, did not fit with modern research into child development. The various psychic processes that Freud had elaborated—repression, resistance, denial, displacement, projection, introjection—were regarded as little better than mumbo jumbo. In other words, academic psychologists saw psychoanalysis as fundamentally unscientific. Its theoretical concepts did not meet the Popperian criterion of falsifiability, namely that scientific hypotheses should be capable of being disproved by evidence. Hypothetical mental processes that acted unconsciously on the person are difficult, many thought impossible, to put to experimental test. Take psychological defences. Freud had suggested that when a significant intrapsychic conflict is exposed, say, in a therapy session, the patient will unconsciously defend against acknowledging it because it is too frightening to do so. They may staunchly deny that they have any such feeling (anger, lust, jealousy, love, whatever it might be). This defence is known, appropriately enough, as denial. The analyst however knows better. But how then, the academic psychologist asked, can one test out the truth of the analyst's assertion? If the analyst's hypothesis is true about the unconscious feeling, the patient denies it. If it is false, it is also denied. Heads the analyst wins; tails the patient loses. The concept of denial, as with many other psychoanalytic concepts that are unconscious, is incapable of being scientifically disconfirmed for this reason.1

 

Chapter Fourteen: Dipping my Toe in the Water

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CHAPTER FOURTEEN

Dipping my toe in the water

How could I set about being a psychodynamic psychotherapist when I knew so little and had had no training? Had I a right to do this? And if I did try it out, how do I explain this to whichever patient I selected as my guinea pig? Do I tell him or her I am trying out a new approach? That I am under supervision? That I was a complete novice? That there was no guarantee of success or even what success would look like? Would any sensible patient not run a mile? On a training course these ethical matters would be worked out in advance. All novices in any new therapy had to confront them after all. I had told my two cognitive therapy patients, Frances and Brian, that the therapy I was trying out was new to me and that I was under supervision. That had not presented any problems. Yet I was not in the same situation. I was not training as a psychodynamic psychotherapist but trying out some of the methods. Anthony Storr was acting more as a mentor than a supervisor. He would see me from time to time and I would talk about what I was doing and present whatever problems might have arisen. He carried no responsibility for what I did, which is very different from a supervisor on a training course who can be held to account if things go wrong. The obvious solution would be to apply for a proper training in psychodynamic psychotherapy, get on an accredited course and spend however long it would take to become a psychodynamic psychotherapist. I did not want to do this. At least, not yet.

 

Chapter Fifteen: “I'm So Grateful for all your Help”

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CHAPTER FIFTEEN

“I'm so grateful for all your help”

I don't know what to say.” Jeremy looks at me expectantly. It is the start of what I have called “our exploratory work together”. Normally I begin the session by asking him how he is. But not this time.

“Just say whatever's on your mind.”

A frown appears on Jeremy's face. He puffs his cheeks and sighs. “I just keep thinking about the conference and the lie that I told to get out of it.”

He stops, looks at me. I say nothing, holding his gaze. He looks away and stares out of the window.

“You know,” he says after a short while, “what comes into my head is the story about George Washington and the cherry tree. How he told his father he could never tell a lie.”

I seize on the word “father”. My plan, inasmuch as I had formulated a plan other than to get Jeremy to do most of the talking, was to focus on his relationship with his parents. “How do you think your father would have reacted if he'd known?”

Jeremy gives me a sharp glance but looks away immediately. “He'd have been disappointed,” he says, flatly without emotion.

 

Chapter Sixteen: “I've Told you all I Know”

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CHAPTER SIXTEEN

“I've told you all I know”

First days are always difficult. I tell myself this as I sit amongst a group of strangers. I have been accepted on the Oxford psychodynamic psychotherapy course and I am at the beginning of the training, one of a small group of highly selected students about to embark on a two-year, part-time course. We are seated in the group room in the Warneford Hospital's Psychotherapy Department. So many disturbed psychiatric patients have passed through this room, I fancy I can sense their distress, the feelings that suddenly erupt, the stormings out, the tears, the hopes raised and dashed. But it is really my own anxiety I am feeling. Now that it has come to it and I am about to start on this journey, doubts assail me. Do I really want to be a student again? I head up my own training course after all and have done for years. I am normally on the other side of the fence, cheerfully giving out reference lists and course programmes to my own quaking bunch of novices. It is a strange, dislocated feeling to be seated this side.

 

Chapter Seventeen: Not Waving but Drowning

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CHAPTER SEVENTEEN

Not waving but drowning

Over the following months Matthew attended every session. He was always on time. As before, he refused to lie on the couch, which I put down to his fear of being vulnerable, and sat, or rather lounged, in the chair opposite me. The Rubik cube never returned though I was aware of its symbolic presence. Could we solve the puzzle and bring Matthew's fragmented parts into a solid whole? But at least he talked. Quite often this was in the same jokey, superficial vein as in the first session. He tested me, making jibes at the stuffiness and stupidity of psychotherapy. He made dark references to secrets that he couldn't possibly share. He entertained me with witty stories about friends and family. He portrayed himself as a sort of cross between Oscar Wilde and Jarvis Cocker of the pop group, Pulp. I sat tight, waiting for the moments when I could make an interpretation or draw his attention to his defences or try to bring him to contemplate what I saw as his truer, deeper feelings. It was not easy. Matthew was adept at deflecting my attempts to breach the walls. If he did not care for what I had said, he disparaged it or simply ignored it. I felt frustrated yet I always looked forward to the sessions. I enjoyed his company and relished the battle of wits. I wondered if this was what should happen in psychodynamic psychotherapy. It did not seem to be how other therapists described what they did. That was altogether more serious, measured and reflective. Was I being unconsciously drawn into Matthew's way of relating as though everything were a game? Perhaps, but I wanted to establish a good relationship with him, a therapeutic alliance. After that, I told myself, we would get down to the real work.

 

Chapter Eighteen: Getting Personal

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CHAPTER EIGHTEEN

Getting personal

Matthew's lack of discernible improvement might have made me question the value of the psychodynamic approach. But it did not. By now I was experienced enough as a therapist to recognize that he would not have been easy to help whatever therapy I had tried. The sort of problems Matthew presented were categorized then, as they are now, under the diagnosis of personality disorder. I disliked the label not least because it conflated two incompatible ideas, the psychological term personality with reference to the general characteristics that people show to some degree, and the medical notion of disorder implying an illness or abnormality. This made no sense to me psychologically. I did not see how a personality could be anything other than a collection of general characteristics. To label some personalities as disordered was a value judgment and in the clinical case an example of medical hegemony, giving doctors (and others) unwarranted powers of control and influence. This is not to say that Matthew did not have serious problems; he clearly did. Nor that it is necessarily unhelpful to try to categorize his problems in order to understand them better. But the medical perspective implied in the word disorder took therapists down the wrong path. It implied a normality. There is no such thing as a normal personality although in people like Matthew various behaviours and attributes could coalesce to make life pretty difficult. The psychodynamic approach offered an explanation, or more accurately, a number of explanations for how Matthew came to his present state. These were encapsulated under the term narcissism and focussed on failures of early parenting, on the sexualization of relationships, and on Matthew's difficulties in identity and self-esteem. The year I spent with Matthew enabled me to understand him better. Or so I thought. I had hoped to use that understanding to guide him to a more adaptive and adult way of relating to the world. That had not happened. If there had been some change in Matthew, it was the merest glimmer, a spark of recognition that I worried would be all too easily snuffed out by events in his chaotic life.

 

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