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There Is No Such Thing As A Therapist: An Introduction to the Therapeutic Process

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This book deals with the link between the purpose of therapy and the boundaries of the therapeutic situation, which - the author argues - derive from the omnipresence of the anxiety surrounding separations and death. The theoretical framework of this book is part of a developmental line from Freud, Klein and Winnicott to Langs, via Sartre and Buber.

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1. Ground rules

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The term “framework” was first proposed by Marion Milner (1952) to describe symbolically the therapeutic setting. It suggests a basic structure that outlines, limits, and defines the therapeutic environment and relationship, thereby distinguishing it from other kinds of environments and relationships.

Psychotherapy in general has viewed the framework or ground rules of therapy as a necessary but relatively peripheral element of therapy, in contrast to the more significant position given to the content. Day and Sparacio (1989) explain: “Although structure is fundamental to counselling, structure is often a neglected dimension of the counselling process” (p. 17). This neglect is evidenced by the absence of literature on this topic.

One of the aims of this book is to attempt to redress this balance and to offer the reader a convincing argument for considering the integral role that the therapist’s framework management has for the ongoing therapeutic relationship.

Donald Winnicott, an analyst who devoted many years to working with children, developed a theory of emotional development which informed his therapeutic practice. He stated: “Spontaneity only makes sense in a controlled setting, content is of no meaning without form” (cited in Davis & Wallbridge, 1981, p. 144).

 

2. Communication and the therapeutic process

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The communicative approach to psychoanalytic psychotherapy views the patient-therapist relationship as a dynamic system. Systems theory emphasizes the close correspondence and interdependence between the elements that constitute the system. Communicative theory and technique is therefore primarily focused on the immediate relationship between the elements that comprise the therapeutic system—that is, the process between the patient and the therapist. However, in order to classify a system it is essential to specify its boundaries. Boundaries are therefore fundamental to a system, as they distinguish it from the wider environment. Without boundaries, the system would lose its form and dissolve. Robinson (1980) states: “Such a system is isolated from its environment and static relative to that environment. It always contains identical elements or parts. Given the same initial conditions, the pathway and end result are always the same. Change the initial conditions and everything changes with it” (p. 185).

 

3. The limits of therapy and existential conflicts

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The creation of a holding environment implies and entails the notion of limits and boundaries. Existential psychotherapy, which is rooted in existential philosophy, emphasizes the crucial role that anxiety plays when human beings are confronted with the ultimate givens of existence. Existentialists are therefore concerned with the fundamental aspects of the human condition and of the individual’s ongoing struggle around his or her inevitable limitations on the one hand, contrasted with his or her ability to make choices. This can also be phrased as the unavoidable conflict that necessarily exists between the awareness of our precarious position in the world counterbalanced by the need for safety and certainty in order to compensate for our extreme vulnerability. The existentialist school of thought is focused primarily at the level of human experience. MacQuarrie (1973) suggests, therefore, that “it is a philosophy of the subject rather than the object” (p. 14). There is some agreement that the term existentialism encompasses a range of ideas and, as such, is therefore not clearly defined. Nevertheless, there are certain themes that appear to encapsulate the basic dilemmas of human existence. The following definition captures the essence of the notion of existentialism:

 

4. Anxiety and the therapeutic process

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Existential anxiety

Anxiety has been defined in general terms as “a state of uneasiness or tension caused by apprehension of possible misfortune, danger etc.” (Collins English Dictionary, 1986, p. 33).

More specifically, existential anxiety (which is derived from the German term Angst, or anguish) is distinguished and described as “The dread occasioned by man’s realisation that his existence is open towards an undetermined future, the emptiness of which must be filled by his freely chosen activity. Anxiety characterises the human state which entails consistent confrontation with possibility and the need for decision with the concomitant burden of responsibility” (Speake, 1979, p. 13).

From an existential point of view, anxiety is considered to be an integral and crucial aspect of the human condition. However, the discomfort and distress that, by definition, accompany anxiety also reinforce the urge to be rid of it. Nevertheless, it is through the experience of anxiety that the existent may be able to mobilize her freedom of choice if she is prepared to face the temporal and unstable quality of the human condition. Existentialists therefore lay stress on the presence—rather than absence—of anxiety, which may activate and enable the individual to confront and acknowledge the dubious and insecure state of her finiteness.

 

5. A sense of the absurd: contradictions and paradoxes

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The communicative approach to psychotherapy concentrates on the moment-to-moment patient-therapist interaction and stresses the adaptive aspects of the relationship. The curative and helpful abilities of the client are therefore considered alongside the harmful and damaged capacities of the therapist. These principles affirm very lucidly the contradictory elements that reside in both individuals in the encounter and underscore the significance of verifying these contradictions as part of the curative process.

These essentially contrasting elements of the human condition that create so much anxiety are particularly exposed in the consulting-room whenever there is a framework deviation. On these particular occasions the therapist has the unique opportunity to sanction the patient’s unconscious therapeutic advice and to communicate her commitment and capacity to allow the patient not only to take the lead, but also to be intrinsically involved in assisting in the curative process.

It is well documented in many schools of thought and theories of human nature just how difficult it is for us to accept, or even acknowledge, these dual elements. However, there is also a great deal of agreement about the relevance and importance of being able to synthesize and come to terms with these primary ambiguities. The term paradox has been defined as “A situation arising when from a number of premises all generally accepted as true, a conclusion is reached by valid deductive argument that is either an outright contradiction or conflicts with other generally held beliefs. Such a result is both perplexing and disturbing because it is not clear which of one’s well entrenched beliefs should be rejected, while it is plain that in the interests of consistency some modification must be made” (Speake, 1979, p. 243), or “A seemingly absurd or self-contradictory statement that is or may be true” (Collins English Dictionary, 1986, p. 611).

 

6. Boundary issues in alternative therapeutic settings

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The institutional setting

The provision of an appropriate and ethical framework for the practice of psychotherapy in institutional settings has been considered to be an incessant problem (Lemma, 1991; Milton, 1993). In more general terms, it has been cited by some researchers that institutions in their wider context supply their staff members with the ideal conditions for managing and maintaining the denial of fundamental existential anxieties that coalesce around issues of life and death. Jaques (1955) was one of the pioneers who explored, from a psychoanalytic perspective, the ways in which the individual within the institutional milieu was able to defend against unconscious infantile processes linked to paranoid and depressive anxiety. Jaques concluded from his germinal investigations that “Taking these conceptions of Freud and Melanie Klein the view has been advanced that one of the primary dynamic forces pulling individuals into institutional human associations is that of defences against paranoid and depressive anxiety; and, conversely, that all institutions are unconsciously

 

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