- The client also spoke of the early death of her son, who lived only nine months following an illness that necessitated hospitalisation throughout his life. She felt anger towards her family who will not speak of him and continued to deny his existence. She was the only family member who bonded with the baby, and following depth reflections of her isolation and intense fear during the pregnancy and his short life, spoke of the blame and guilt she felt for his suffering. She realised she had insisted on a sterilisation years later to ensure she could not bring another child into the world to endure such suffering.
- Her degree of perceived 'contamination' increased following the sterilisation and despite being initially unable to understand why the operation had triggered such intense emotion, reflected on the 'contamination' and felt the intimate gynaecological examinations, may have brought back the 'violation' of her sexual experience. After the sterilisation, her avoidance of the Yellow Pages intensified and she was sectioned under the Mental Health Act to receive one-to-one counselling in a mental health unit. She was not open with the counsellor and did not discuss her experiences with anyone until our counselling sessions began.
THE THERAPEUTIC PROCESS
During the opening session, the client assumed a minimal amount of eye contact. When relating the sexual encounter, she remained focused on the floor, giving factual details. I reflected her shame and humiliation, voicing her self-rejection. I recall complete synchronicity between the content and her way of being. My focus was on understanding, accepting and communicating admiration for her courage in speaking with such honesty.
She had developed a condition of worth in the face of her continuing need for parental approval. Her self-concept held the belief that sex was dirty, which would protect her from negative experiences, i.e. parental disapproval or rejection. The conditioned self-concept was increasingly internalised and she became alienated from her organismic self, with the dichotomy between her self-concept and experiencing leading to an increasingly distorted perception. The client's self-regard became vulnerable following the sexual incident, when she was aware that she would be judged by her parents as less worthy of positive regard. When the experiencing of the organismic self finds itself in confusion with the need for approval, the outcome must be confusion. It is possible the experience was so incongruent with the self-concept that her defence system was unable to prevent it overwhelming the self-concept and the obsessive behaviour was the result. It is also possible that she has cognitively distorted her level of consent to the sexual experience; by remembering less control over her participation, she may preserve and consolidate her self-concept.
The opening session involved a high level of client self-disclosure, which could have resulted in feelings of vulnerability and embarrassment some time after the session, so at the end of the session, we considered how she might feel. I recall feeling optimistic about the potential for our relationship and the client's 'state of readiness' for counselling. She was decisive about improving her level of functioning and showed an admirable willingness to explore her feelings.
Session two brought an opportunity for the growth of trust as the client took the risk of sharing feelings she described as 'pathetic', and received acceptance and understanding. She had arranged for her hairdresser be at her home when she returned from our session. However, that morning she had seen an advertisement for the Yellow Pages and, subsequently, did not want her hair coloured as her feelings of contamination were too high. At a superficial level, the client faced a decision to cancel or keep the appointment, but in terms of her determination to 'fight' her problems, the situation held enormous significance. She worked through the positive and negative consequences of each option and subsequently chose to keep the appointment, despite her concerns about levels of subsequent anxiety. She returned the next week having experienced much less anxiety than expected and I felt this was a distinct victory for her in terms of empowerment and could be seen as a temporary restoration of her trust in the dependability of her organismic self. I remained congruent by offering congratulations on her achievement, but stated that my positive regard was not conditional on her movement towards growth.
Following the first two sessions, I was questionned in university group supervision about my feelings for the client. I was privileged that an individual experiencing such self-rejection, had perceived an environment of sufficient safety to disclose personal material, whilst risking my rejection of her. I believed that the client's experiencing of warmth and unconditional regard was the most important ingredient for the fostering of trust between us, and that my communication of positive regard lessened her feelings of alienation; from self and others. Lietaer (1984) uses the term counter-conditioning to describe the process of the counsellor's unconditional positive regard breaking down the link between meeting conditions of worth and being valued. In session four, the client had described the level of emotional support she received from her husband, and through reflection, became aware that his patience and warmth felt time-limited and conditional. It became apparent that our relationship was the first time she had been freely given the time and space to feel truly understood, and was consequently able to articulate her feelings to her satisfaction.
Through reflection on my feelings, I was aware of a non-possessive warmth and respect, plus an initial desire to protect. My group supervisor questioned how such feelings might impede/facilitate the process, which I needed some time to consider. I feel my ability to communicate warmth and acceptance to be a personal strength, and believe it facilitated the client's feeling of being valued. However, a potential negative implication of feeling protective, would be to 'hold the client back' through the desire to shield from potential failure or painful experience. I would be concerned if my response to the client was of pity, sadness and a desire to rescue her from her immediate experience. The desire to protect has lessened as the client's appearance of anxiety has reduced.
In session four, the client was as low as I had ever witnessed her, experiencing nihilism with regard to her family and job. She did not return to any of the material we had focused on in previous sessions, instead talking about the difficulties with her family and job. On reflection, this could be indicative of her need to gain further strength before moving forward. At the end of session three, she had been contemplating showing her husband her affection by hugging him - if discussing other concerns she avoided potentially disappointing me with her 'failure' to act on this. She had perhaps realised that she was at a point of no return, but to go on would lead to considerable life changes, and session four may have been a pause to gather energy and coherence for the oncoming difficulties. I am aware that clients who drastically improve their self-acceptance may end up being 'a new person in an old life' (Mearns and Thorne, 1990). The client's close relationships may flourish with her personal growth, or they may have relied upon the client being troubled, weak and physically distant. It would be ethical to encourage the client to consider these issues within therapy.
I saw myself as a companion through this phase of regression, and I realised the futility of pre-empting sessional content, as the client will bring whatever is important at that time. It also emphasised the client's belief that I am strong enough to cope with her regression, that I would still value her and not attempt to remove her from her desolation.
She remarked afterwards that it had helped to talk as she felt her general state had improved. She then shook my hand and kissed me on the cheek - a gesture that I have reflected on alone and within the MSc group supervision. Initially my feeling was of unease and a concern that her affection had arisen from her misconception therapy and my role. I felt a mild level of fear, that a previously unidentified feeling of 'emotional protection', had been removed. What it means to be a 'counsellor' is evolving within my self-concept at a rapid pace, constantly refining through a seemingly steep learning curve of education and experience. I believe that the person-centred relationship gives the counsellor room to identify their own way of being with individual clients, and therefore do not feel that the gesture raised ethical considerations. I do not need or want to raise that boundary again, my fear is focused on the next session and my tolerance for working with a degree of uncertainty. I am unlikely to discuss with the client what it meant for her, though this is not a decision set in stone. I feel now that the gesture encompassed a number of feelings and processes operating at many levels within the relationship:
- A moment of intimacy emanating from my willingness to be with her in feelings of hopelessness. The gesture marked a profound sense of sharing and commitment.
- The client has a history of disturbed relationships and weak self-acceptance, to be understood and accepted has been a unique experience for her and a powerful instrument in challenging her feeling of 'contamination' and self-rejection. This gesture was a mark of her fledging belief that she is good enough to receive and show affection.
- Her aim of therapy is to increase her ability to willing show affection to those she cares about and who care about her. We had left the session with the client stating her desire to hug her husband; she wanted to see me in two weeks to allow time to achieve her objective. Her gesture was a mark of beginning this process.
I believe this is more my issue than the client's, and highlights a process where I begin to assess how much of myself I am able to bring to the relationship. At present, the client is taking nourishment from me, but is slowly replacing that with her own self-acceptance as her locus of evaluation is moving away from external sources.
Within the sessions, the client has shown the capacity for processing new insight. An example of this would be her statement in session two that her father's belief that 'boys were trouble', was obviously right, because of the resulting traumatic experience when she defied him. My reflection generalised her core statement, 'A = B, no grey areas'. She appeared uncomfortable with the degree of truth in this statement and we remained silent. Eventually she responded by identifying a grey area; that if the boy had been of her husband's calibre, she may have positive memories of the experience.
Through empathy, I have begun to understand the client's personal language of using humour to defend her vulnerability. This understanding has helped me to see the person behind the behaviour, and I am not deflected by her flippancy. As an example, the client laughingly stated, that I must feel 'down in the doom and gloom' following our sessions. I was aware that if I had not been in her frame of reference, I might have colluded through smiling or sharing the joke. However, I felt that underneath her flippant remark was a need to feel that I was resilient enough to cope with her emotion. This checking may have originated from the conditional support afforded by her husband, who she feels limits the emotion the client can unburden at any one time. My response emphasised that we were both committed to the therapeutic relationship and that my emotional resilience would be taken care of within supervision and my own therapy. This flippancy was more apparent in the earlier sessions, and it is questionable whether the client would believe in the efficacy of our relationship if I had failed to respond to the deeper message
DIFFICULTIES IN THE WORK
During the first three sessions, the client questioned how talking about her problems would help, and I asked her to suggest how she thought it may help. She used her insight to appreciate the potential link between her adolescent experiences and the here-and-now, but I sensed her frustration and discomfort, despite knowing that she is motivated to be in therapy. My understanding of these feelings centres on her pain and discomfort when discussing her experiences, and the question phrases her need for reassurance that this pain is somehow bringing her nearer her therapeutic goal. However, despite this understanding of her discomfort, I was aware of a momentary feeling of pressure due to this reiteration of earlier questions that I felt had been both explained and understood. I focused on our initial contract that we were both responsible for developing and maintaining a therapeutic climate, and that the client's role was not a passive one. Her question voiced a tacit assumption she had brought with her to the therapy setting about therapy and therapists, and I became cast in the role of expert. I was aware of a feeling of disappointment that we had not reached the level of understanding of the nature of our relationship that I had perceived. I was uneasy with this, but during supervision became aware that noting her anxiety had brought me a little closer to understanding her view of herself.
The notion of being a facilitator is attractive to me, as it does not demand I behave as an expert - which I do not feel I am. I am aware that I need to pay attention to the communication of implied questions, as my intonation seemed to suggest a conclusion, which usually resulted in the closure of exploration.
I discussed my perception of 'an effective counsellor' within the broad support of group supervision, and how this connects with the transitory anxiety of breaking new professional ground. By listening to their challenges and not hiding behind defensive
ways of communicating, I am confident that my fears of inadequacy are not of a level which is distracting and hence, counter-productive. I am aware that in the early years of counselling practice, it is normal to focus on 'doing a good job' with a conscientious adherence to core principles. Therefore, in order to minimise pre-session anxiety I have implemented three strategies:
- Utilising time-management by booking fifteen-minute breaks between clients.
- Using supervision as an opportunity for feedback and development. The individual supervision at the surgery has, to date, concentrated mainly on client content. In future sessions I intend to raise process and relationship issues.
- Objectively assessing what harm I could realistically do to the client's situation. This was reaffirmed in session four when, for the first time, the client acknowledged the lack of honest communication with her husband. Having identified her needs, she felt to approach him now would be too much and wanted to return to it in future sessions. I realised that in a relationship of emerging mutuality, clients will exert their own power and pace. I am also aware of the
liability of operating from my own theories of human behaviour i.e. that intra-marriage communication must be improved before a satisfying sexual side can co-exist.
REVIEW
The case study herewith has presented an opportunity for an evaluation of self and of psychotherapeutic practice using person-centred philosophy. Within the text, I have discussed personal and therapeutic strengths, plus areas that may benefit from development.
In relation to the client I have focused on, I am aware of the therapeutic advantages of working with a committed client. A challenge for the future will be to maintain unconditional positive regard in the face of hostility, conflicting values or a client seemingly discrediting person-centred hypotheses by moving away from personal growth. I am aware of the need to accept one's own conditionality, whilst working to understand an individual's valuable experience of their own world.
REFERENCES
Mearns, D and Thorne, B (1990) Person-Centred Counselling in Action. London:Sage
Lietaer, G (1984) Unconditional Positive Regard: A Controversial Basic Attitude in Client-centred Therapy as cited in D. Mearns and B. Thorne Person-Centred Counselling in Action. London:Sage