An interview with Michael in preparation of this CPD workshop "Sustainable practice in the 'impossible profession'?" organised by the Wimbledon Guild

Your workshop "Sustainable practice in the ‘impossible profession’?" is unique in its concept, what led you to its creation?

There are two separate but linked recognitions which inspired the workshop, and the 2017 article which it is based upon:

1) the essential impossibility at the heart of the therapeutic profession, and

2) the consequent difficulty in sustaining its practice.

Practising therapy has its inherent strains, but what links the two issues is how so much more exhausting and unsustainable the task becomes unless we accept that underlying impossibility.

How can we relax into the impossibility and stay rooted and grounded in it, rather than implicitly fighting against it or trying to escape the feelings of shame, failure and helplessness that are necessarily part and parcel of the impossibility?

After working for about 15 years following my qualification, I came to a point where I questioned a key underlying assumption of my training that I had taken for granted as self-evident: that if only I thoroughly understood and followed the theories and technique I had been taught, and applied them diligently with good intention, warmth and compassion, therapy could be made to work in the majority of cases. My assumption had been that therapy was do-able through applying ‘correct’ theory and technique.

I began to realise that - in spite of my humanistic principles of authentic relating - the application of theories and techniques to the person in front of me implied a 'treatment' paradigm, not unlike the stance that a doctor would take. Although I was using humanistic theories and techniques, and favouring existential values, implicitly I was taking a medical model stance alongside - and confusingly: in conflict with - my humanistic-authentic-dialogical stance.

On the one hand I was trying to create a space for human intersubjective encounter, on the other hand I wanted the therapy to be effective in taking the client - in fairly linear treatment fashion - from an undesirable dysfunctional state towards what I implicitly assumed was a better, more functional state, of wholeness or self-actualisation.

All the precious knowledge, understanding and skills that I had acquired were meant to enable me to effect that desired treatment outcome, but supposedly without taking a superior or objectifying or pathologising doctor position and without having an agenda. That ongoing conflict not only did my head in, it was exhausting and wearing.

In any case, this idea of the competent practitioner, fairly nonchalantly applying theories and techniques, did not match at all my internal reality within the therapeutic position: I was constantly feeling conflicted, torn between different therapeutic impulses, ideas and agendas; I felt caught in endless dilemmas, between conflicting perceptions, contradictory models and sometimes mutually exclusive interventions. I was torn between pressure to make things happen, often quite desperately, on the one hand and on the other hand equally strong inclinations to let things be, based on a reluctance to impose things or force change. It seemed obvious that – if I wanted to earn my fee - some desperately urgent change or shift in the client needed to to be effected by me, but the idea that nothing had to happen (or be made to happen) seemed equally valid, strengthened by the paradoxical principle of change: change happens when we accept what is.

Much of my experience within the therapeutic position was conflicted and uncertain, but I was equally convinced that a competent practitioner would surely be conflict-free – it seemed obvious that that was the criterion for competence. I was assuming that with increasing experience I would increasingly become single-minded, certain, and sure of my impact and effectiveness, altogether more non-chalant and confident. I was judging myself harshly for failing to live up to that competent doctor position which was spooking around as an ideal in the back of my mind.

Over time, though, I realised that each and every of the linear assumptions I was judging myself by, every notion of what I should do as a therapist, was in conflict with an equally valid opposite truth, and that I was trying to do justice to both of them at the same time. No wonder being a therapist was a fairly effortful, exhausting vocation – like driving a car with one foot each simultaneously on the brake and on the accelerator.

During those years, the movement towards psychotherapy integration was immensely valuable to me, helping me embrace the profound and often irreconcilable contradictions pervading the therapeutic field. There did not seem to be unquestionable and self-evident ‘truths’, as I had initially assumed – on the contrary: there did not seem to be any consensual principle that was not contradicted by some other therapist or some other approach. The more I could accept the paradoxical nature of my most cherished therapeutic principles, the less compelled and haunted I felt by ideas of the linear do-ability of therapy.

I had heard people quip about therapy as the 'impossible profession', and I found that Freud had made reference to it already in 1937. But eventually I began to take that notion seriously, as an essential feature of the therapeutic endeavour, and wrote a blog post on the topic. It then became apparent to me that most counselling and psychotherapy training, especially with its increasingly academic focus, was implicitly fighting against the paradoxical essence of the profession, rather than helping students embrace and relax into the impossibility of the profession.

This also had a big impact on my stance as a supervisor, and what I considered helpful to my supervisees. Rather than adding to their shame for experiencing the impossibility of the profession, for failing to achieve its idealised linear promises, for succumbing to the 'intersubjective mess' (the technical term I started using in order to call a spade a spade), I started to validate their feelings and intuitions of failure (due to therapeutic stuckness and impasse, getting entangled in supposedly countertherapeutic enactments, etc, etc), as accurate manifestations of the underlying impossibility. Rather than redoubling their professional efforts to overcome their sense of failure - through more reading, more CPD, further training, more work on their own process - by embracing and inhabiting the impossibility of their position, paradoxically their work deepened and became more effective and more transformational, as well as more enjoyable and satisfying (at least some of the time).

It was through many years of practicing as a supervisor from this perspective, supporting supervisees in deconstructing the persecutory ideas of their traditions and trainings, that I began to link the impossibility of the profession with the sustainability of therapeutic practice.

The more we have recognised the dangers of vicarious traumatisation, the more prevalent advice has become how therapists should protect themselves, should take responsibility for their self-care, strengthen their boundaries and counteract the damaging effects of the therapeutic position. But the therapeutic position requires a kind of vulnerability and sensitivity which is at odds with protecting oneself.

In contrast to that kind of advice oriented towards self-protection, I'm trying to find ways of processing the therapist’s experience of the impossibility more deeply, more effectively and in a more embodied way (as most of the sense of impossibility is communicated and engendered nonverbally and pre-reflexively). Rather than closing ourselves off more deliberately, or strengthening our professional boundaries more impenetrably, or creating professional distance more coherently, I have found that therapists can learn to sustain their practice the more they can succumb to the impossibility, and then get curious about that experience in a way that benefits the deepening of the therapeutic process and therefore the client.

Apart from the practical and business aspects of making a living from working as a therapist, I have suggested that there are three underlying psychological issues which affect how many clients a therapist can 'hold' in their practice/case load:

1. the therapist’s capacity to digest and compost the emotional impact of the therapeutic relationship as bodymind process;
2. the therapist’s capacity to embrace/inhabit ‘enactment’ as the central paradox of therapy – implying the impossibility of the profession
3. how entrenched or flexible the therapist can be in their ‘habitual position’, i.e. their own unconscious relational ‘construction of therapeutic space’;

Each of these is a one-line condensed formulation of what I consider a complex neglected and under-theorised issue in the profession.

The first one relates to the neglected bodymind process of client and therapist in the 'talking therapies' - this imposes limitations on therapy's effectiveness (which - as Allan Schore has insisted - depends mainly on right-brain-to-right-brain attunement, and beyond that on access to the dissociated implicit patterns laid down in the brain stem). But it also leads to obliviousness and underestimation of how much emotional load the therapist's body ends up carrying and somatising. Without attention to the relational bodymind process we are sitting ducks for overwhelm, vicarious traumatisation and burn-out, or we succumb to implicit distancing manoeuvres which help reduce the impact on the therapist, but at the expense of engagement and effectiveness.

The second issue relates to the decades-old denial of the aforementioned impossibility of the therapeutic profession. Traditionally psychotherapy as a discipline, both in practice and in the training of its students, has been importing an objectifying, linear and academic paradigm from the physical sciences and particularly the medical model, as I described above for myself.

As long as we are not aware of and do not embrace the very impossibility we should be experiencing in the therapeutic position, we are adding a whole other unmanageable surplus load of stress and distress into our practice. The heart of the impossibility lies in the paradox of enactment – that the healing of the client’s wounding in and through therapy becomes fully available only in the enactment of that wounding in and through therapy.

The third issue relates to the notion of the 'wounded healer', and how our own wounded subjectivity is necessarily the instrument we are working with. Since the 1950s, the 'countertransference revolution' has given us the basic principles for understanding how the therapist's experience contains information about the client's inner world and unconscious dynamics – I summarise this in the more jargon-free statement: the client’s conflict becomes the therapist’s conflict. However, unless we manage to translate those principles into an everyday application to practice, we are left with an unprocessed and unmetabolised double whammy: we are both empathic to and absorbing the client's conflict and on top of that we are necessarily having our own conflicts triggered and exacerbated.

In your workshop synopsis you discuss the therapist’s ‘habitual position’ - could you explain more about this and how this impacts the work with clients?

The idea of the ‘habitual position’ is just a consequent application - to ourselves as therapists - of the kind of ideas, concepts and models which we use to understand any client's habitual patterns.

Whatever therapeutic language we use, there is some concept or term we have to describe fixed patterns of experiencing, feeling, thinking and behaving - what we call 'schemas' in CBT, or scripts in TA. A model of such fixed patterns and defensive structures that includes awareness of bodymind processes is Wilhelm Reich's 'character structures', updated into a comprehensive modern integrative developmental theory by Stephen Johnson through his work on 'character styles', integrating humanistic and psychoanalytic traditions.

A character style is like a protective shield which we have developed as children in response to developmental injury or wounding, designed to protect us both externally from being injured again by others, and internally from experiencing the unresolved left-overs from childhood.

If we apply that kind of thinking to ourselves as therapists, what kind of habitual routines and mechanisms are in place to shield and guard us? How does our habitual therapeutic position dfend and protect us? The question then is how all the precious knowledge and skills we have gained in therapy training may be feeding into and exacerbating our defensive structures? To what extent has our training challenged and helped us work through our habitual position; and to what extent has it fortified and entrenched it further?

Our habitual position as a therapist is therefore an amalgamation of our original character style as a person which we bring to therapy training in the first place, plus whatever habits we have acquired through training in terms of our stance as a therapist and our default thinking and behaving as a therapist, i.e. our preferred theories and techniques.

Just as any habitual structure offers protective advantages whilst limiting our responsiveness and engagement with life, our habitual position as a therapist offers both the advantages of a reliable structure and therapeutic identity as well as generating taken-for-granted autopilot limitations to the kind of therapeutic space we are able to offer.

On an abstract level, our habitual position manifests as certain theoretical dogmatisms, or as an avoidance of contradictory theories; or as an attachment to linear ideas which protect us from paradoxical experience and the impossibility of the profession. On a relational level, it manifests as a habitual stance or fixed therapeutic position we take, rather than experiencing fluidly and flexibly a variety of relational modalities, which we are able to inhabit in response to a particular client and the resulting dynamic we are engaged with.

These are the disadvantages of a too partial, limiting and fixed habitual position for the client and their process. But on a deeper level, our habitual position as a therapist has detrimental effects on ourselves, too. Our habitual position is, of course, rooted in our own childhood wounds, which are being triggered – by each client in their own idiosyncratic ways - regardless whether our reflective awareness takes care of them or not.

For many of us, training and working as a therapist replicates our position in our original family, where we were the sensitive receptacles of the unacknowledged or repressed emotional dynamics in the family system. For many of us, whatever counselling or therapy training we engage in as adults constitutes our second training - our first occurred in our original families, and we carry both the skills as well as the scars of that training into adulthood.

Working as therapists we then find ourselves back in the position of being exquisitely attuned and susceptible to unconscious and unspoken dynamics, often without being given the permission or power to name them, address them or challenge them. Within the therapeutic position, we find ourselves experiencing helplessness and uncertainty, alongside all the client’s evacuated and unwanted feelings. In deep psychotherapy, the client’s regression evokes and triggers our own. Many therapists suffer from being willing sponges for toxic material which clients evacuate into them, whilst exhorting themselves and redoubling their efforts to be empathically present for their clients.

So should being a therapist carry a health warning?

It goes without saying that these dynamics are not conducive to the therapist well-being as a professional, nor as a person. So, yes, the therapeutic position should carry a health warning.

Nearly all therapists I meet as students or supervisees are well-intentioned, dedicated practitioners - but sometimes I am reminded of soldiers being sent into the battlefield with insufficient equipment.

Corresponding to the three issues I mentioned above, across the profession we could make efforts to strengthen and update that equipment:

- bringing more awareness to the bodymind process of inhabiting the therapeutic position

- formulating the therapeutic position as inherently conflicted and paradoxical, by embracing the sense of its underlying impossibility, rather than chasing our tail with linear expectations which are inimical to our discipline

- learning to pay attention to how the client's conflicts become the therapist's, and how to process the embodied countertransference experience of the impossibility, in the service of the deepening process

What do you hope that delegates will be able to take away from your CPD day with us?

From past experience, I find that most practising therapists experience relief from understanding that deep engagement with the client inevitably takes us into conflicted unconscious realms of the psyche - most therapists know this in their bones, anyway, but the feedback I often receive is that people leave with more clarity around the 'inevitable' bit.

To appreciate our internal experience of conflict, uncertainty, failure and helplessness in the therapeutic position as a parallel process which carries profound information about the client and the co-created process between us, opens the door to embracing the impossibility at the heart of our work. Many therapists find that a permission-giving and liberating experience, which puts their practice on its paradoxical feet, rather than puts their heads in the idealised clouds. That does not immediately make things easier, but at least it offers a graspable end of that string which is the tangled ball of our confused and fragmented profession, full of transgenerational conflicts we have inherited all the way down from Freud.

In bullet-point summary, here are some of the things that participants might take away:

• a cross-modality formulation of the client's internal conflict as the starting point for the therapeutic relationship and how that impacts the therapist
• a generic formulation and appreciation of how the client's conflict necessarily becomes the therapist's conflict
• some consequent articulation and embracing of the impossibility of the therapeutic position
• some reflection on the many ways in which we deny, defend ourselves and react against that impossibility
• some glimpse of our habitual positions as therapists and communities of practitioners and some curiosity about them
• the beginnings of a bodymind procedure of processing our individual experience of the impossibility in the service of the client's process
• a sense of the kind of fluidity and flexibility between relational modalities, as well as between theories and techniques, which is required as one foundation of a sustainable practice

What are the emotional/psychological factors that limit a thriving practice for therapists (and helping professionals generally)?

• If you're interested, enrol now for my experiential workshop in London (Wimbledon) on December 7 - places are still available: bit.ly/2VUVxkI
• Most CPD workshops on this topic focus on the actual business skills needed, or your own ambivalence about charging money (self-worth).
• The decisive factor for making a living as therapist: what’s the EMOTIONAL cost of the therapeutic position in an ‘impossible profession’?
• How do relational dilemmas inherent in therapy affect therapists’ well-being? How do we absorb, process and compost emotional material?
• How does the particular intricacy of each client-therapist relationship hook into the therapist’s ‘habitual position’ and become exhausting?
• Therapy as impossible profession is potentially exhausting ALL the time, but this becomes most obvious around frame and money negotiations
• The impossibility of therapy manifests in meta-level struggles: whether, how, why therapy works (or doesn't) and its frame and boundaries.
• How to answer the question whether the client’s investment into therapy will be useful & worth it? Somewhere between priceless and useless
• How to then work out the level of fees? How to you present that to clients (esp. those who expect to pay by the minute, as for a lawyer)?
• How do you respond to clients’ challenges to your sincerity: “You only care about me because of the money I pay you?” – and is it true?
• How to respond to clients who accuse you of ‘emotional prostitution’? Or protest against their dependency on a professional ‘selling love’?
• How do you deal with clients’ requests for reductions in fees or changes to weekly frequency of sessions which are inconvenient to you?
• When clients think about terminating, to what extent do you think about their process or the income you stand to lose (it does happen!)?
• How to handle clients ‘getting worse’ as necessary part of the process - how do you communicate that to them, and negotiate the fall-out?
• How to respond to breaks in the working alliance& thresholds in the process which manifest as ambivalence in the client&their commitment?
• When clients complain, how to deeply understand THEIR perception and experience of therapy-what unconscious constructions may be involved?
• How to negotiate arrangements that are safe, consistent and reliable AND doing justice to the client’s needs, requirements and situation?
• How to get beyond simplistic frames/business models borrowed from other professions? Find a practice that suits you & the work of therapy?
• How to process the subliminal bodymind impact of the therapeutic relationship on yourself, including vicarious traumatisation?
• How to inhabit your own wounds when they get touched upon by the client’s process? What if being a therapist IS part of your wounding?
• Harold Searles suggested 70 years ago: one of the most difficult issues of therapy is the therapist’s mother transference onto the client.
• The bodymind process of therapist’s ‘habitual position’ (how they inhabit ther. position) is most critical factor in sustainable practice
• How therapists ‘construct’ therapy un/consciously through lens of their own childhood scenario affects sustainability of their practice
• The therapist’s ‘habitual position’ is a mixture of their character style, relational patterns, own therapy & training & supervision/CPD.
• The therapist’s ‘habitual position’: how fully can I engage the inevitable and necessary conflicts of therapy, and how do I process these?
• As a therapist I need to fully & openly engage the client's conflicts intersubjectively; my mirror neurons ensure that I will absorb these
• Processing the conflicts I engage & absorb depends on ‘implicit relational knowing’ = my bodymind process = my embodiment as a therapist
• How can I generate spontaneous AND reflective, embodied AND imaginative space to maximise the processing of intersubjective conflict?
• The more aware I can be of subliminal communications & reactions, the more likely I can process them more comprehensively & consciously
• How can an understanding of the paradoxical nature of therapeutic enactments create more space within the therapeutic position?

The post Sustainable practice in the ‘impossible profession’? – Interview with Michael Soth appeared first on INTEGRA CPD.

Unique Trauma Therapy Training - CPD Days with Morit Heitzler

Do you experience these obstacles with your clients?

If some of your trauma clients show resistance, manifest stuckness or get caught in hidden dissociation or re-traumatisation dynamics, or you encounter unexpected ruptures, impasses or enactments, these workshops are for you.

If some of your trauma clients do not respond well or only very slowly to the kind of approach that you know works well with other clients, what are the factors that can account for these differences?

If some of your trauma clients are having negative reactions against you or the treatment, or you detect that an atmosphere of mistrust, shame or scepticism interferes with the work, how can we tackle these obstacles?

If you regularly work with traumatised clients, these training days are for you. These workshops are designed for practising counsellors and therapists who are currently engaged in trauma work, and/or have some previous training or experience with trauma. If you have completed basic training in one of the modern trauma therapies: Somatic Trauma Therapy (Babette Rothschild), Somatic Experiencing (Peter Levine), Sensorimotor Therapy (Pat Ogden), EMDR, EFT etc, then you will definitely be eligible. Otherwise we ask you to contact us, to discuss whether the course will be suitable for you.

Are these workshops for me?

These workshops are designed for practising counsellors and therapists who are engaged in trauma work, and/or have some previous training or experience with trauma. If you have completed basic training in one of the modern trauma therapies: Somatic Trauma Therapy (Babette Rothschild), Somatic Experiencing (Peter Levine), Sensorimotor Therapy (Pat Ogden), EMDR, EFT etc, then you will definitely be eligible. Otherwise we ask you to contact us, to discuss whether the course will be suitable for you.

If you have trained and have been practising such trauma therapies for a while, you are likely to have encountered clients with varying degrees of receptivity, producing a mixture of results and creating a variety of problems. You may also have questions regarding the application of theory to practice.

Many of these problems and questions can usefully be addressed through an integration of trauma therapies, each of which have their special strengths and weaknesses.

These CPD workshops will support you in taking the next step and help you to deepen, diversify and enhance your existing practice. For the last 20 years Morit has been developing an integrative approach to trauma work that draws on most the various trauma approaches within an overall relational perspective. She will use her knowledge and experience in demonstrating and role-modeling an embodied-relational engagement with the challenges presented by the traumatised client.

Format of these workshops

These workshops will be oriented towards practice and provide opportunities for you to bring the problems and dilemmas of your actual clinical work. In the workshops you will find support, reflective practice, supervision, diverse new ideas and techniques from other approaches within a group of like-minded practitioners. Morit will provide a sequence of theoretical inputs, to help the group develop a shared language, especially regarding the relational complications you encounter with clients. Participants are invited to bring their particular questions and clinical issues to the group, and the theory will flow from that.

Previous participants have appreciated the mixture of theory, practice and experiential work of Morit’s workshops. In these workshops, in addition to discussing relevant issues and challenges, Morit will suggest various experiential and observational exercises, that will help to bring clinical vignettes alive.

Workshop 1: Trauma Therapy – Treatment and Relationship

The relational subtleties underpinning the working alliance

Although many of these modern therapies claim to be comprehensive, often presenting themselves as applicable to all kinds of trauma, this is not what we find in practice. Human beings present complexities that no protocol or manual can legislate for, especially when it comes to the – often unconscious - internal web of trauma reactions and associations in the psyche. It is in these very individual responses to the therapy and to the therapist that complications arise which are not catered for by theory and technique.

The client reads – or mis-reads – the therapist’s facial expressions, their speed, timing and intonation, their gestures and postures, and scans these for the warmth, professionalism, acceptance, knowledge or encouragement they might contain, or conversely for the coldness, lack of care, judgement, shame or impatience which the client may have come to expect from others.

It is the client’s subliminal reading of such cues and messages which infuses the therapeutic interaction with relational dimensions that can make or break the treatment, but that are not necessarily part of the manual. It is these all-too-human subtleties which either provide a foundation for a productive working alliance, or create doubt and ambivalence, or lead to outright ruptures, regardless of how competent the practitioner, or how appropriate the treatment procedure in and of itself.

Why do we need an integration of trauma therapies?

Trauma therapies tend to fall into a few recogniseable categories along a spectrum of the therapist’s relational position, in terms of they define themselves and their public presentation:

• some of the new trauma therapies define themselves as treatments, with clear protocols and procedures, administered by a knowledgeable expert; here the therapist is understood - by both parties - as an authoritative and directive doctor figure, requiring cooperation;
• in some other therapies the atmosphere is more oriented towards healing and recovery through the therapist’s nurturing presence; here the therapist is positioned in a more motherly role, still an expert or an authority, but with an emphasis on feeling and support.

Because trauma makes us feel helpless and regressed, the therapist taking a motherly or fatherly re-parenting role can be very helpful and often this is necessary to establish a working alliance at all. However, developmental trauma makes any kind of re-parenting task more complicated, as the psychoanalytic tradition teaches us. Even in single event trauma, the internalised drama triangle of victim, persecutor, rescuer can become constellated in the therapy, and complicates what might otherwise be a more straightforward helping or healing relationship.

We cannot take it for granted that the client will experience the therapist’s authority as benign. This has serious implications for the working alliance and for the success of the treatment. When the therapist’s authoritative interventions and directions are received by the client through the lens of transferential complications, the methods and techniques of the various trauma therapies cannot be expected to work in the same way that in principle we know they can. Then the same techniques that we can usually so powerfully rely on are not sufficient to overcome stuckness, resistance, dissociation and avoidance.

It is then that a relational integration of different therapeutic approaches and perspectives becomes increasingly necessary and helpful. The different traditions and perspectives, and their different relational underpinnings, complement and cross-fertilise each other in a way which gives us as therapists more flexibility, robustness and resilience. This can make a big difference to the effectiveness of our work.

Are the new somatic trauma and energy therapies suitable for complex and developmental trauma?

Over recent years, the new somatic trauma therapies and the energy therapies have been extending their reach beyond clearly defined single-event trauma later in life to include early and developmental trauma. This extension has been driven forward on the assumption that the same principles apply to all trauma and to all trauma therapy. However, increasingly we find that this is a flawed assumption: it hinges on the question whether the client has a healthy, non-traumatised personality structure in the first place that will allow them to form a trusting attachment to a therapist. Without that bond, we cannot assume the client’s readiness and willingness to receive the therapist’s interventions, however competent and effective these are in principle.

In complex trauma, the issue of transference becomes unavoidable, as the client is likely to interact with the therapist via their traumatising early blueprint for relating. The client then perceives and experiences the therapist through the lens of that blueprint. This tends to complicate the working alliance and can undermine the therapeutic process in a way that is not sufficiently attended to in the recently developed trauma therapies. Therefore, early developmental trauma constitutes a qualitative difference to single-event trauma. Psychodynamic approaches have, of course, always appreciated the transference dimension, but have not worked sufficiently through the body.

Integrating somatic-embodied and psychodynamic perspectives

Therefore, an integration between somatic and embodied approaches on the one hand and psychodynamic perspectives on the other is becoming crucial in the field of trauma therapy. We increasingly understand how even clearly circumscribed single-event trauma can trigger early developmental trauma unconsciously and complicate and de-rail treatment, even when on the surface it appears fairly straightforward.

Psychodynamic and other ‘talking therapy’ practitioners can benefit from the somatic therapies in situations where clients’ reflective capacities are limited, as language and other cognitive functions are impaired by unconscious or unspoken trauma. The client’s mind is then not fully available for interpretation, collaborative exploration or associative play, as traumatic freezing and dissociation are dominant, and talking therapy doesn’t reach deeply enough into the client’s experience.

Treatment and the Relational Container

If as trauma therapists we can combine powerful methods and somatic techniques on the one hand and an awareness of the working alliance and the client’s reaction against therapeutic authority on the other, our capacity to co-create the kind of relational container necessary for the work takes a quantum leap. To some extent this also depends on the therapist’s awareness of their own body and embodiment, as the relational container depends strongly on ‘right-brain-to-right-brain’ attunement. This is only available to the therapist who is connected with her own subtle and subliminal physical and neurological responses.

In her practice Morit has found that the effectiveness of both EMDR and somatic trauma therapy interventions crucially depends on the timing of pre-reflexive communication, and the synchronisation between the client’s and therapist’s autonomous nervous systems. The difference between an intervention which elicits a relieving release of feeling on the one hand, or a suggestion which triggers in the client a re-traumatising implosion on the other may only be a couple of seconds. The therapist wants to be so attuned to the intensifying arousal in the client’s bodymind that they can offer an expressive and interactively regulating channel for it before it can tip into an internal roller coaster. Intervene too early, and the therapist is seen as anxious and over-controlling; on the other hand, intervene too late and the client’s autonomic process has – lemming-like – taken itself over a cliff into a traumatic pattern. This kind of attunement is only possible if the therapist is sufficiently attuned to her own neurophysiological and vegetative processes that she can micro-track her own arousal and shut-down.

However, many therapists – especially when their initial training was in one of the ‘talking therapies’ - are too habitually disembodied themselves and remain largely unaware of the client’s - and more so their own - subliminal and energetic processes to create that kind of moment-to-moment bond and responsiveness. As a result, treatments tend to lack spontaneity and significant moments are missed, giving the client a sense that they are indeed being ‘treated’, but in a somewhat formulaic fashion. Fortunately, in Morit’s experience, many therapists can learn quite quickly to extend their usual emotional sensitivities into the somatic and energetic realm.

The subjective and relational foundations of ‘treatment’

However appropriate the theoretical models and practical techniques are that we use in trauma work, these are only as effective as the pre- and non-verbal bonds, the reciprocal emotional attunement and the mutual intersubjective understanding which the two human bodyminds in the therapeutic relationship can co-create. It’s the meeting between these two idiosyncratic, unique subjectivities which – for better or for worse – provides the foundation for ‘treatment’. By ignoring – or attempting to remove - the unpredictable subjective human factor from treatment, we destroy the essence of what makes therapy work. Of course, the therapist’s identity is not free from its own wounds and traumas and shadow aspects – how can therapy be made to work when all we have at hand is the frail, imperfect instrument of the therapist’s human self?

The therapist cannot be – in fact, for attunement and mutual identification to work: must not be – invulnerable, ‘all sorted’, plain clinically effective, administering the same uniform treatment to each client, whatever the manual says. However, the therapist’s non-objective subjectivity does engender all kinds of relational vicissitudes which we need to find ways of apprehending: how do we monitor and bring awareness to the intersubjective mess co-created when the arrow of the client’s wounding seeks and finds and hits the therapist’s wounding?

It is here that differentiated bodymind awareness takes us beyond mental speculation into a realm of embodied experience where we have a whole realm of otherwise ignored and neglected information that makes the complex task of tracking ‘right-brain-to-right-brain’ attunement less impossible.

Vicarious traumatisation and the therapist’s own bodymind

The recognition that trauma therapy is hazardous for the practitioner is now widely established, but it is much less clear what we can do about it. Unlike medical practitioners who tend to learn to dissociate from their patients and the pain they encounter, we do not want to lose our relational sensitivity. But unless we can learn to recognise the symptoms, effects and emotional load of the therapeutic position, we cannot effectively process and digest the bodymind impact we experience through exposure to our clients’ trauma. Understanding somatic resonance, projective identification and evacuation of dissociated trauma states helps us become aware of the consequences of unconscious processes in the therapeutic relationship, and the conflicts we are likely to absorb in our work.

Tracking and processing these unconscious dynamics, we gain precious insight into our client’s inner world and their internal relationships, which provide the background context in which recovery and healing occur. This allows us to understand more deeply how current and past trauma interlink and generate protective mechanisms which block and slow down treatment.

About the workshop facilitator:

Morit Heitzler is an experienced therapist, supervisor and trainer with a private practice in Oxford. She offers both short- and long-term work with a wide range of clients from diverse backgrounds. Morit specialises in trauma work, and has developed her own integrative approach, incorporating - within an overall relational perspective - Somatic Trauma Therapy, Body Psychotherapy, attachment theory, sensori-motor, EMDR, modern neuroscience and Family Constellations.

In a wide range of contexts both in the UK and in Israel, including the Traumatic Stress Service of the Maudsley Hospital, London, and at the Oxford Stress and Trauma Centre, Morit has gained a wealth of experience in working with traumatised clients, including refugees and asylum seekers, suffering from a wide variety of PTSD symptoms.

She has been making a contribution to the profession by teaching on various training courses in the UK and in Israel and she regularly leads workshops and groups. More information about her work and publications is available on her website www.heitzler.co.uk.

Morit's articles, papers & publications

Heitzler, M. (2004) My Personal Approach to the Theory and Practice of Integrative Psychotherapy. In: British Journal of Psychotherapy Integration UKAPI, Volume 1, Issue 2

Heitzler, M. (2009) Towards an Integrative Model of Trauma Therapy. In Hartley, L. (Ed.) (2009) Contemporary Body Psychotherapy – The Chiron Approach. Routledge

Heitzler, M. (2010) The Processing Body – Integrating EMDR and Body Psychotherapy. In: The EMDR Practitioner – The Official Journal of The European EMDR Association – published online

Heitzler, M. (2011) Crowded Intimacy – Engaging Multiple Enactments in Complex Trauma Work. In: British Journal for Psychotherapy Integration, Vol 8, Issue 1 (2011), p. 15 – 26.

Heitzler, M. (2011) Using EMDR with Various Types of Developmental Trauma.

Heitzler, M. (2013) Broken Boundaries, Invaded Territories:
The Challenges of Containment in Trauma Work. International Body Psychotherapy Journal, Volume 12, Number 1, spring 2013

Heitzler, M. & Soth, M. (2017) Book Review: William Cornell “Somatic Experience in Psychoanalysis and Psychotherapy”. Journal for Body, Movement and Dance

Heitzler, M. & Soth, M. (2018) Relational complications in current trauma therapy. BACP Journal Therapy Today. May 2018

Heitzler, M. (2018) Working with Sadism: an embodied-relational approach. In: Sadism – Psychoanalytic Developmental Perspectives. Edited by Amita Sehgal. Routledge. London & New York

Dates, Times, Venue, Cost:

Dates:

Workshop 1: 22 September 2018
Workshop 2: 1 December 2018
Workshop 3: 2 February 2019

Venue:

OTS-Oxford Therapy Centre
1st Floor, 142-144 Oxford Road, Temple Cowley, Oxford OX4 2EA

Times:

Times: 10.00 – 17.00

Cost:

Cost per workshop: £100 (£90 for Workshop 1 if booked by 1/8/2018)
£270 for all three days

More information:

Download the leaflet as a PDF

Download the booking form, to email back to us

Download the booking form, to print and post

Email: info@integra-cpd.co.uk

Contact: Michael Soth +44 7929 208 217

The post Integrative Trauma Therapy – CPD Workshops in Oxford with Morit Heitzler 2018 appeared first on INTEGRA CPD.

Starts 5 February 2018 in Karachi, Lahore, Islamabad

The aim of the course is to work towards a comprehensive map of the field and develop a relational meta-position that integrates the whole broad range of approaches. This can help us evolve beyond a merely eclectic stance which picks and chooses pragmatically or randomly from the smorgasboard of traditional approaches, but provides a rhyme and reason for how we navigate the complex and confusing multitude of approaches.

Broad-spectrum integration of approaches (without minimising contradictions)

By aiming at broad-spectrum psychotherapy integration, the aim is to support you in developing a therapeutic position that can draw flexibly from the whole range and diversity of approaches. Usually such an integrative project tends to minimise the significant extent to which the different approachs are not just similar or complementary to each other, but are also confusingly contradictory. However, we will try to work towards an integrative understanding without minimising or circumventing the contradictions between the approaches.

Integration beyond theories and techniques

The basic principle of the course will be a shift away from the attempt to integrate the theories and techniques of traditional approaches and towards an integration of ‘relational modalities’, using a variety of models to clarify what we mean by ‘relational modalities’ (or different kinds of therapeutic relatedness, or simpler: different ‘relational spaces’).

Recognising gifts and shadow aspects of each traditional approach

We are not aiming at an integration that mixes and combines two (or a few) different traditional approaches. In this module we are aiming at a broad-spectrum integration, attempting to draw out of each of the traditional approaches and paradigms its special gifts, wisdoms and sensibilities (whilst recognising also its shadow aspects). Beyond that, we will be working on the assumption that even the contradictions and challenges between the approaches can become valid and meaningful information in the therapeutic position.

Integrating the main branches of the psychological therapies (humanistic vs psychodynamic vs CBT)

On the most basic level, we will want to validate and integrate humanistic, psychodynamic and cognitive-behavioural traditions (as well as those that are more difficult to classify, i.e. systemic, existential, transpersonal and modern hybrid approaches) as the main branches of the therapeutic field, recognising that these traditions are underpinned by paradigm clashes between them (specifically: paradigm clashes that are not reconcilable on the level of theory and technique, nor meta-psychology).

Integration on the basis of diverse relational spaces

This module is based on the recognition that on a level deeper than theory and technique the contradictions between paradigms are rooted in different relational positions or stances and the contradictions and tensions between those.

A significant foundation of the course will be an enquiry into the processes - conscious and unconscious - that shape a therapist's relational position in response to a particular client. In order to investigate these processes, we will be drawing on traditional psychodynamic understandings of transference and countertransference, but we will also have to significantly go beyond this terminology and theoretical framework, by integrating ‘one-person-’ and ‘two-person psychologies’ (using the model by Martha Stark), modern relational perspectives as well as bodymind models of the therapeutic relationship.

Integrating different kinds of therapeutic relatedness (Gomez, Stark & Clarkson)

In reflecting on the therapist’s internal process within and in response to relational dynamics, we will also be distinguishing the therapist’s habitual stance and countertransference from situational countertransference, and will be integrating Petruska Clarkson's model of a multiplicity of relational modalities. Michael has developed the Clarkson model further and integrated it with Gomez’s critique of integration as well as Stark’s model – he calls this integration his ‘diamond model’.

Developing your own style and integration

This ‘diamond model’ is meant to be a comprehensive ‘meta-model’ and should give you a good foundation for integrating a wide range of therapeutic approaches, whatever their particular theories and techniques, helping you develop your own blend of theories and ways of working and your own style of being a therapist.

The post Pakistan: TherapyWorks Level V Diploma – Psychotherapy Integration appeared first on INTEGRA CPD.

The relational subtleties underpinning the working alliance

Although many of these modern therapies claim to be comprehensive, often presenting themselves as applicable to all kinds of trauma, this is not what we find in practice. Human beings present complexities that no protocol or manual can legislate for, especially when it comes to the – often unconscious - internal web of trauma reactions and associations in the psyche. It is in these very individual responses to the therapy and to the therapist that complications arise which are not catered for by theory and technique.

The client reads – or mis-reads – the therapist’s facial expressions, their speed, timing and intonation, their gestures and postures, and scans these for the warmth, professionalism, acceptance, knowledge or encouragement they might contain, or conversely for the coldness, lack of care, judgement, shame or impatience which the client may have come to expect from others.

It is the client’s subliminal reading of such cues and messages which infuses the therapeutic interaction with relational dimensions that can make or break the treatment, but that are not necessarily part of the manual. It is these all-too-human subtleties which either provide a foundation for a productive working alliance, or create doubt and ambivalence, or lead to outright ruptures, regardless of how competent the practitioner, or how appropriate the treatment procedure in and of itself.

Do you experience these obstacles with your clients?

If some of your trauma clients show resistance, manifest stuckness or get caught in hidden dissociation or re-traumatisation dynamics, or you encounter unexpected ruptures, impasses or enactments, these workshops are for you.

If some of your trauma clients do not respond well or only very slowly to the kind of approach that you know works well with other clients, what are the factors that can account for these differences?

If some of your trauma clients are having negative reactions against you or the treatment, or you detect that an atmosphere of mistrust, shame or scepticism interferes with the work, how can we tackle these obstacles?

Why do we need an integration of trauma therapies?

Trauma therapies tend to fall into a few recogniseable categories along a spectrum of the therapist’s relational position, in terms of they define themselves and their public presentation:

• some of the new trauma therapies define themselves as treatments, with clear protocols and procedures, administered by a knowledgeable expert; here the therapist is understood - by both parties - as an authoritative and directive doctor figure, requiring cooperation;
• in some other therapies the atmosphere is more oriented towards healing and recovery through the therapist’s nurturing presence; here the therapist is positioned in a more motherly role, still an expert or an authority, but with an emphasis on feeling and support.

Because trauma makes us feel helpless and regressed, the therapist taking a motherly or fatherly re-parenting role can be very helpful and often this is necessary to establish a working alliance at all. However, developmental trauma makes any kind of re-parenting task more complicated, as the psychoanalytic tradition teaches us. Even in single event trauma, the internalised drama triangle of victim, persecutor, rescuer can become constellated in the therapy, and complicates what might otherwise be a more straightforward helping or healing relationship.

We cannot take it for granted that the client will experience the therapist’s authority as benign. This has serious implications for the working alliance and for the success of the treatment. When the therapist’s authoritative interventions and directions are received by the client through the lens of transferential complications, the methods and techniques of the various trauma therapies cannot be expected to work in the same way that in principle we know they can. Then the same techniques that we can usually so powerfully rely on are not sufficient to overcome stuckness, resistance, dissociation and avoidance.

It is then that a relational integration of different therapeutic approaches and perspectives becomes increasingly necessary and helpful. The different traditions and perspectives, and their different relational underpinnings, complement and cross-fertilise each other in a way which gives us as therapists more flexibility, robustness and resilience. This can make a big difference to the effectiveness of our work.

Are the new somatic trauma and energy therapies suitable for complex and developmental trauma?

Over recent years, the new somatic trauma therapies and the energy therapies have been extending their reach beyond clearly defined single-event trauma later in life to include early and developmental trauma. This extension has been driven forward on the assumption that the same principles apply to all trauma and to all trauma therapy. However, increasingly we find that this is a flawed assumption: it hinges on the question whether the client has a healthy, non-traumatised personality structure in the first place that will allow them to form a trusting attachment to a therapist. Without that bond, we cannot assume the client’s readiness and willingness to receive the therapist’s interventions, however competent and effective these are in principle.

In complex trauma, the issue of transference becomes unavoidable, as the client is likely to interact with the therapist via their traumatising early blueprint for relating. The client then perceives and experiences the therapist through the lens of that blueprint. This tends to complicate the working alliance and can undermine the therapeutic process in a way that is not sufficiently attended to in the recently developed trauma therapies. Therefore, early developmental trauma constitutes a qualitative difference to single-event trauma. Psychodynamic approaches have, of course, always appreciated the transference dimension, but have not worked sufficiently through the body.

Integrating somatic-embodied and psychodynamic perspectives

Therefore, an integration between somatic and embodied approaches on the one hand and psychodynamic perspectives on the other is becoming crucial in the field of trauma therapy. We increasingly understand how even clearly circumscribed single-event trauma can trigger early developmental trauma unconsciously and complicate and de-rail treatment, even when on the surface it appears fairly straightforward.

Psychodynamic and other ‘talking therapy’ practitioners can benefit from the somatic therapies in situations where clients’ reflective capacities are limited, as language and other cognitive functions are impaired by unconscious or unspoken trauma. The client’s mind is then not fully available for interpretation, collaborative exploration or associative play, as traumatic freezing and dissociation are dominant, and talking therapy doesn’t reach deeply enough into the client’s experience.

Treatment and the Relational Container

If as trauma therapists we can combine powerful methods and somatic techniques on the one hand and an awareness of the working alliance and the client’s reaction against therapeutic authority on the other, our capacity to co-create the kind of relational container necessary for the work takes a quantum leap. To some extent this also depends on the therapist’s awareness of their own body and embodiment, as the relational container depends strongly on ‘right-brain-to-right-brain’ attunement. This is only available to the therapist who is connected with her own subtle and subliminal physical and neurological responses.

In her practice Morit has found that the effectiveness of both EMDR and somatic trauma therapy interventions crucially depends on the timing of pre-reflexive communication, and the synchronisation between the client’s and therapist’s autonomous nervous systems. The difference between an intervention which elicits a relieving release of feeling on the one hand, or a suggestion which triggers in the client a re-traumatising implosion on the other may only be a couple of seconds. The therapist wants to be so attuned to the intensifying arousal in the client’s bodymind that they can offer an expressive and interactively regulating channel for it before it can tip into an internal roller coaster. Intervene too early, and the therapist is seen as anxious and over-controlling; on the other hand, intervene too late and the client’s autonomic process has – lemming-like – taken itself over a cliff into a traumatic pattern. This kind of attunement is only possible if the therapist is sufficiently attuned to her own neurophysiological and vegetative processes that she can micro-track her own arousal and shut-down.

However, many therapists – especially when their initial training was in one of the ‘talking therapies’ - are too habitually disembodied themselves and remain largely unaware of the client’s - and more so their own - subliminal and energetic processes to create that kind of moment-to-moment bond and responsiveness. As a result, treatments tend to lack spontaneity and significant moments are missed, giving the client a sense that they are indeed being ‘treated’, but in a somewhat formulaic fashion. Fortunately, in Morit’s experience, many therapists can learn quite quickly to extend their usual emotional sensitivities into the somatic and energetic realm.

The subjective and relational foundations of ‘treatment’

However appropriate the theoretical models and practical techniques are that we use in trauma work, these are only as effective as the pre- and non-verbal bonds, the reciprocal emotional attunement and the mutual intersubjective understanding which the two human bodyminds in the therapeutic relationship can co-create. It’s the meeting between these two idiosyncratic, unique subjectivities which – for better or for worse – provides the foundation for ‘treatment’. By ignoring – or attempting to remove - the unpredictable subjective human factor from treatment, we destroy the essence of what makes therapy work. Of course, the therapist’s identity is not free from its own wounds and traumas and shadow aspects – how can therapy be made to work when all we have at hand is the frail, imperfect instrument of the therapist’s human self?

The therapist cannot be – in fact, for attunement and mutual identification to work: must not be – invulnerable, ‘all sorted’, plain clinically effective, administering the same uniform treatment to each client, whatever the manual says. However, the therapist’s non-objective subjectivity does engender all kinds of relational vicissitudes which we need to find ways of apprehending: how do we monitor and bring awareness to the intersubjective mess co-created when the arrow of the client’s wounding seeks and finds and hits the therapist’s wounding?

It is here that differentiated bodymind awareness takes us beyond mental speculation into a realm of embodied experience where we have a whole realm of otherwise ignored and neglected information that makes the complex task of tracking ‘right-brain-to-right-brain’ attunement less impossible.

Vicarious traumatisation and the therapist’s own bodymind

The recognition that trauma therapy is hazardous for the practitioner is now widely established, but it is much less clear what we can do about it. Unlike medical practitioners who tend to learn to dissociate from their patients and the pain they encounter, we do not want to lose our relational sensitivity. But unless we can learn to recognise the symptoms, effects and emotional load of the therapeutic position, we cannot effectively process and digest the bodymind impact we experience through exposure to our clients’ trauma. Understanding somatic resonance, projective identification and evacuation of dissociated trauma states helps us become aware of the consequences of unconscious processes in the therapeutic relationship, and the conflicts we are likely to absorb in our work.

Tracking and processing these unconscious dynamics, we gain precious insight into our client’s inner world and their internal relationships, which provide the background context in which recovery and healing occur. This allows us to understand more deeply how current and past trauma interlink and generate protective mechanisms which block and slow down treatment.

About the workshop facilitator:

Morit has been developing an integrative, embodied and relational approach to trauma therapy for the last 20 years. She began to encounter these issues in her practice long before they became widely apparent, and engaged with these dilemmas at the root of trauma therapy in a way which has helped her forge a robust integration. Over the years, she has given many presentations which address transference-countertransference dynamics in trauma work, and the dangers and transformative potential of destructive enactments. She is known for using her own body and embodiment as a resource in surviving such enactments and turning them into deeper understanding of her client’s inner world as well as the therapeutic process. This perspective now underpins her supervision of trauma therapists and sheds light on common ruptures, stuckness and failures of treatment, especially cases of inadvertent re-traumatisation.

Dates, Times, Venue, Cost:

Dates:

Workshop 1: Sat. 16 September 2017

Workshop 2: Sat. 18 November 2017

Venue:

Asian Cultural Centre

Manzil Way, Oxford OX4 1GH, UK

Times:

10.00 - 17.00

Cost:

£90 per day (£85 if booked by 31/7/2017)
£170 for both days

More information:

Download the leaflet

Download the booking form, to email back to us

Download the booking form, to print and post

Email: info@integra-cpd.co.uk

Contact: Michael Soth +44 7929 208 217

The post Integrative Trauma Therapy – CPD Workshops in Oxford with Morit Heitzler 2016/17 appeared first on INTEGRA CPD.

This is a much expanded and updated version of an earlier post two years ago -  I have now also added  a resource section at the bottom, with commentaries on useful books.  I've been doing this work in preparation for the CPD weekend “Working at the Edge of Chaos” on 29 & 30 April 2017 in Oxford.

As a therapist, have you ever struggled valiantly, but hopelessly against the entrenched resistance of a client who says they are desperate to change, but are actually digging their heels in at every turn, reacting with “yes, but …” to each and every suggestion?[1]

These kinds of situations can often leave you with the sense that you are much more invested in their self-actualisation than they are, and that your therapeutic efforts on their behalf are somewhat like Sisyphos pushing the boulder uphill.

Here, a crucial feature of human psychology and a central conundrum of therapy become tangible: plainly, just as much as one part of the client’s psyche is indeed desperate to change, another part of their psyche seems equally invested in the status quo, in maintaining their habits and established comfort zones. It’s not uncommon for therapists to get seriously locked into this frustrating battle with what is effectively the client's internal conflict - and whilst we can argue that it's unwise for a therapist to identify principally with just one side of the clients conflict[2], what is the alternative when therapy is apparently committed to helping the client deliver their stated and contracted goals?

Is it any wonder that therapists who have sincerely engaged with the client’s agenda for therapy and been thwarted by the ‘resistance’ throw up their hands in despair and conclude that therapeutic effectiveness is not much to do with the therapist, but essentially dependent on the client's motivation[3]?

This may remind us of well-known joke:“How many therapists does it to change a light bulb?” “Only one, but the light bulb really must want to change!”

Of course, once the client is seriously motivated, therapy becomes an eminently do-able job. Unfortunately, the percentage of clients who are unambiguously motivated is so small, there aren't enough of them to go round to make us all feel effective as therapists. My supervision experience suggests that few therapists can afford to refuse the kind of client who is - already in the initial interview - displaying clear signs of that internal deadlock. And how often do you then say to such clients: "I'm sorry, I cannot take you on - it seems to me you are not motivated enough, and it's going to be ineffective and frustrating for both of us. So let's not bother until you've managed to drum up some more motivation." Which also begs the question: what kind of pre-therapeutic procedure could possibly ever get the client ready for ‘motivated’ therapy? And who would deliver that pre-therapy and how would that work to generate client motivation?

Instead of requiring clients to make our job easier by turning into the right kind of lightbulb, we might become interested in non-linear change.

“What is that?” I hear you ask. In which case presumably you didn’t know that more than one kind of change was on the menu? Well, it depends what universe your restaurant is situated in. If you happen to be entertained in a Newtonian universe, all you get - for breakfast, lunch and dinner - is linear change. Chances are that is precisely the kind of change which the client was both demanding and resisting in the first place.

Linear change in a Newtonian universe

Linear change is what most of our culture - and received therapeutic wisdom – is oriented towards: “I want to go from pain to pleasure, from negative emotion to positive happiness, from pathological dysfunction to well-adapted fulfilment, from existential lostness to self-actualisation - please, in a straight line, ideally the shortest and cheapest distance!” (by-passing the less promising but more achievable route which leads, as Freud cautioned, from neurotic misery to common unhappiness).

Overcoming negative patterns and counteracting negative states is the quite legitimate agenda which many clients bring to therapy – what they don’t realise is that they have already brought an assumption of linear change as part of the package. Unfortunately (for them and for us), their objectives for therapy are formulated within a framework that already presumes and only computes linear change. Unfortunately, their defensive ego (who is doing their best trying to manage the various pressures arising between the reality principle and inner coherence, but has now cracked sufficiently to try therapy and is willing to pay for it) has been educated in a Western tradition in which effortful linear change is the best you can ask and hope for: the whole edifice runs on dualism down the ages in a straight line from Aristotelian logic to Newton and Descartes to CBT.

Because we are culturally steeped in a Newtonian mindset (where every action has a reaction, where for every force there is a counterforce, and the bigger force wins), clients and therapists operate in a universe where everything remains static unless we bring some force to bear. It is assumed that every change has to overcome some inherent inertia and out-manouevre some dastardly resistance. Change is therefore supposedly hard, and requires discipline and consumes energy.

It is a power-over model, fitting to the age of Empire - the late 19^th century when psychotherapy as we know it was initially conceived. The zeitgeist at Freud’s time construed a universe of random deterministic atoms where the bigger billiard ball pushes the smaller one. So we are entitled to wonder whether this a case of the well-known aphorism: “we do not see reality as it is, but the way we are”? Is the universe really organised on Victorian Empire principles, or is that a socially constructed projection into reality, through the lens of a particular point in history?

The limitations of a Newtonian paradigm

Chaos and complexity theory historically emerged out of the shortcomings of the Newtonian paradigm. It’s not so much that the Newtonian paradigm is wrong, it is just that it is quite partial: it doesn’t apply to everything under the sun (even though the paths of the planets revolving around it can be calculated fairly accurately based on Newton’s laws of gravity, which in itself is quite a feat; but even there the limitations become evident quite quickly: just introduce an additional moon and you have the unpredictable chaos of the three-body problem[4]).

For all Newton’s undiminishable genius, there are two problems with his equations: they work pretty well in simple, inanimate controlled systems, with just a few variables. They do not work well in complex, self-organising systems, with many separate but interrelated and connected agents. And they do not work well in evolving, biological living systems, let alone human systems, let alone in psychology and intersubjectivity.

Therefore, linear change via Newton’s equations doesn’t work well in human relationships, especially helping and therapeutic relationships[5].

That’s one of the problems we are bound to encounter when we extrapolate from the physics of inanimate matter to the biology and psychology of human beings: it is easy to forget that these sciences operate by different epistemologies and different laws (which is the key point that postmodern social scientists and philosophers had to struggle to get recognised over the last 70-odd years, e.g. see the work of Jürgen Habermas). As human beings we are not just dealing with supposedly objective facts, but with subjectivities and interpretations.

However, to this day, the logic of physics is being imported into the logic of psyche, ignoring the fundamental point that psycho-logic is different from mental or mathematical logic, and not reducible to it (unless you turn the human being into an abstract idea first). The metaphors of technology – first mechanics and later of computation - shaped the thinking about psychology from Freud’s hydraulic analogies to modern neuroscience.

Non-linear change in dynamic, evolving, complex systems

Complexity theory, and its early precursor chaos theory, precipitated the recognition and slowly growing understanding of non-linear change – change which applies to dynamic, evolving, complex systems. They operate in a universe of impermanence, in a web of self-organising systems.

Contrary to our notion of chaos, these sciences define chaos not as random disorder, but as a deeper, non-linear order - a good image for this are fractals: complex, organic images which are not linear and repetitive, but each fractal does have its own inherent order (a fact which our right brain can visually recognise in an instant, as what’s called self-similarity).

The most famous catchphrase for the paradigm difference between linear change in a Newtonian universe and non-linear change in chaos is the ‘butterfly effect’: the idea that a butterfly flapping its wings at one end of the planet can be implicated in a hurricane at the other.

Whilst this is a catchy image, it is often misunderstood precisely through established linear cause-and-effect assumptions: if we can only track the more subtle and complex non-linear chain of cause and effect, then we might be able to control it. If only we can understand non-linear change within the terms and parameters we are accustomed to in handling linear change, we will be able to control the predicted outcome, avert catastrophes and make even the most resistant client change in a way that their defensive ego idealistically demands.

But that is to misunderstand the radical departure and sacrifice of our Newtonian position which non-linear change invites us into. When it comes to our role in the grand scheme of things, in contrast to the omniscient and omnipotent Newtonian position, chaos theory only offers much less grand and reassuring possibilities for influence: if we can divest ourselves of the ideas of control and predictability and get immersed in uncertainty and interested in the changes that are already always happening, we might be able to involve ourselves in the process and establish the possibility for a more humble contribution. This applies on a global, planetary level, and it also applies in the consulting room.

An established metaphor amongst organisational consultants who draw on complexity theory is the comparison between paddling a boat in a straight line across the pond versus white water rafting. That’s a good image for the paradigm clash between linear and non-linear change.

So what’s the conclusion these consultants draw if we consider the turbulence of the relationships (in an organisation or in our consulting room) as white water rafting? As a facilitator or therapist, I don’t entirely give up the responsibility of involvement in the face of overwhelming complexity; but neither do I fancy myself as in control of the whole process.

In contrast to the celebrity status of the ‘butterfly effect’, the less emotive formulation in chaos theory is ‘dependence on small variations in initial conditions’. In complex systems, a tiny difference in the initial state can lead quite quickly to completely different outcomes (the connection with hurricanes is not entirely fictitious, as this principle was discovered in computer simulations of global meteorology – see James Gleick’s “Chaos”, a very readable introduction to the development of chaos theory, where he introduces the various scientists and disciplines who originated the idea of non-linear change).

Therefore, the rate of change in complex systems is not proportional to the apparent forces exerted (because much bigger forces are always already present in some kind of implicate dynamic equilibrium). Rather than slow and incremental, if these dynamic forces evolve towards a tipping point, change can be sudden and radical, when many apparently innocuous variables conspire to unleash those otherwise balanced energies. A negative feedback loop in a system can escalate quite quickly into unexpected proportions.

Here we are in a non-Newtonian universe of impermanence, where the one certain thing is uncertainty, where things are always already in flux, and dynamic equilibrium is as much stability as we’re going to get - temporarily.

If things are on the move already, it only needs a tiny straw to break the camel’s back, to make the barrel overflow, for the system to go into a chaotic, disorganised state from where it will settle into a new equilibrium.

Non-linear chaotic change between different equilibrium states

Complexity theorists studying many different kinds of systems use the term ‘attractor’ to convey the recognition that each and every system can be attracted to and organise itself into a variety of radically different equilibrium states (because systems evolve through self-organisation, such equilibrium is always dynamic rather than homeostatic - a significant difference to earlier, biologically rooted conceptions of equilibrium, including Freud's).

An apparently stable system can reach a tipping point where the established structure breaks down – we might think of the client’s characterological defences as such an apparently stable system. Intensifying relationships or life crises may have conspired to challenge the established structure of the client’s personality and sense of identity. As in any system that tips into a disorganised chaotic state, this may engender a creative void where everything is up for grabs. In therapy, the breakdown of habitual patterns and identifications may engender a moment of neuro-plasticity.

But we want to be careful not to over-idealise the destructiveness inherent in this process: from the inside, it probably feels unstable, scary and possibly catastrophic: regressive states of abandonment and terror, or spiritual emergencies as the dark night of the soul may be evoked. A chaotic system far from equilibrium is liable to be experienced as overwhelming the resources of the ego, which may crack into psychosis or surrender into transformation. Jung used to say that every monster to the Ego is a God(dess) to the Self, but we only jovially recognise that with hindsight once we have survived the process.

Whether a chaotic state is a good thing or not depends on subtle variations in context and environment. In therapy, that context is significantly constituted by the therapeutic relationship itself. Whether a chaotic state leads to a destructive enactment or re-traumatisation (which destroys the therapeutic container itself), or whether it leads to a transformative enactment which engenders both a deeper sense of self and a deeper connection, is not something that can be guaranteed with certainty or taught via a manual.

In therapy, the outcome of such chaotic processes largely depends on how held the therapist feels ‘held’ within themselves, within their therapeutic position and their professional context (i.e. their own therapy, their supervision, their community of practitioners). That, in turn, is reflected in how attached the therapist is to an exclusively Newtonian universe, or how gracefully they are able to surrender beyond it.

The conundrum of desirable therapeutic outcomes in non-linear change

For our therapeutic purposes and from a human perspective, some equilibrium states seem more desirable than others - we might distinguish between more regressive versus more progressive processes. However, in line with the overall complexity perspective, these notions regarding the outcomes of chaotic re-organisation are fraught with our own habitual assumptions and need to be applied with caution. As therapists we tend to be – understandably - invested in our clients moving towards more integrated and wholesome equilibrium states (by whatever parameters of wholesomeness we conceptualise these).

But we need to be mindful, of course, that such investments on our part may become the very straw that tips the system more towards regression - for many of us as clients, our therapist’s investment in our supposed health replicates parental injunctions which we did not feel seen and met by. Therefore, any sense I might communicate to my client, that I fancy myself as knowing better than they do just what their healthy equilibrium needs to look like, may actually become a counterproductive imposition which propels them in the opposite direction.

I am using this as an example to illustrate the subtle systemic awareness which is engendered by inhabiting the complexity perspective within therapy. Whatever ideas and concepts we formulate and apply via such a perspective, I want to remain mindful that all my internal processes – all my assumptions, thoughts, feelings - are part of the system, feeding back into it, and that I am not operating on it from outside. A complexity perspective is not immune against fuelling destructive enactments, even whilst philosophising about them.

One such trap - which my formulation so far lends itself to - is, of course, to set up a dichotomy between the supposedly outdated dualistic Newtonian paradigm on the one hand, and the supposedly superior non-linear complexity paradigm on the other.

However, this would be to misconstrue and oversimplify the relationship between these paradigms: in the same way as straight lines are only a subcategory of all possible lines, linear change is only a specific instance of a much wider realm of non-linear change. That does not mean straight lines do not exist[6], or that we ignore the reality of Newtonian battles, socially, inter-personally or intra-psychically. What we want to do is to give dualistic reality its home within its wider, more complex, systemic, dynamic context in (relational) space as well as in time.

How are chaos and complexity theory helpful to therapists?

Owing to its origins in the late 19^th century, and its further development throughout the 20^th, counselling and psychotherapy are pervaded by dualistic Newtonian assumptions of linear change. Some therapeutic approaches and traditions may be more wedded to such dualisms than others, with some of the later humanistic developments clearly championing holistic and non-linear intuitions.

However, any deep understanding of the psyche and the therapeutic process tends to lead us beyond the dualistic trap. We can find non-linear intuitions in just about every depth-psychological approach. Across the various traditions, these intuitions have been enhanced in recent years by explicit applications of complexity principles (a selection and summary of the most useful and accessible books can be found in the references below).

But there is a limit to how far theory, reading and thinking can take us in this realm: when faced with the client’s defensive ego, its insistence on linear change and its addiction to dualism, many approaches and many therapists struggle to consequently translate their non-linear intuitions into their actual practice[7]. So a crucial question in practice, addressed by none of the books that I have read on the subject, is: how can we engage and collaborate with the client’s ego in pursuing linear change, whilst maintaining an awareness of the paradoxes and complexities of non-linear change?

Too often the admittedly profound differences between linear and non-linear change are turned into another dualism (which rather defeats the object). So in experimenting with complexity the question that has been rather exercising me over the years (with very nitty-gritty implications in practice), is: how do we avoid falling into the trap of fighting dualism with more dualism?

Chaos implies ‘embodiment’ and bodymind process

One crucial limitation, of course, that traditional therapeutic approaches have in engaging with non-linearity is their bias towards language and the reflective mind. The talking therapies immediately run into a glass ceiling when it comes to the spontaneity of emergent processes. This notion - one of the most basic and immediately helpful distinctions which we derive from complexity theory: between 'established structures' and 'emergent processes' - is not exactly the same as top-down versus bottom-up change, but in many situations it overlaps: often emergent processes announce themselves first through somatic experience[8]: spontaneous sensations, gestures or impulses can thus be the harbingers of an as yet unknown future self.

Following the therapeutic process at this level of attention to bodymind and systemic micro-detail, both internally and interpersonally, requires a therapeutic presence that is equally fluid and solid: anchored and stable as well as nimble and mercurial. We then recognise that on pre-reflexive levels of the interaction in the therapeutic relationship, the attachment – and the working alliance – is indeed a shifting, oscillating complex dance - there are many butterflies flapping their wings all the time, and it needs our own differentiated embodiment and flesh-and-blood presence to notice and pursue them. Left-brain reflection – as important as it is in the therapeutic position – usually happens after the event. In this territory, timing, responsiveness and spontaneity are crucial – therefore, learning about therapy at the edge of chaos cannot happen via a manual, not even a video: you need to be present and embodied in the room, engaging with your own emergent processes and the group around you, and participate.

Nick Totton and Michael Soth are offering a CPD weekend in Oxford on 29 & 30 April 2017, entitled “Working at the Edge of Chaos”. Some places are still available.

They write: “We will turn the fact that complexity cannot be learnt or taught in a book, but needs your whole bodymind, left- and right-brain to be present to ‘get’ complexity, into a feature of the weekend: just as we do not have control over the process in therapy, we cannot and will not set a curriculum for this weekend, and you will become co-responsible for the unfolding of your own and the group’s learning process. The weekend is an opportunity to dance at your own growing edge as a person and a therapist, to deepen your own idiosyncratic therapeutic style and find your own way to inhabit the paradox of risk and stability.”

You can find the full text of the leaflet on Michael’s website.

Resources on Chaos and Complexity Theory

If you want to follow up and get engrossed in the subject in more detail, here are some of the resources you can find, each with a brief commentary:

The most engaging and for psychotherapists probably best and most accessible book (that is also most likely to translate into practice), is:

Psyche’s Veil: Psychotherapy, Fractals & Complexity

By Terry Marks-Tarlow (2002) Routledge

If you don't want to buy the book, many of Terry’s writings can be found - freely available - on her website:

http://www.markstarlow.com/papers-chapters/

Terry uses images and poetry to make the topic come alive, not like some books on complexity that emphasise scientific language or even maths (although the maths is very interesting).

In the field of relational psychoanalysis, probably the foremost writer thinking in terms of field theory and complexity is Donnel Stern. He has now published several books, but I recommend this one:

Relational Freedom: Emergent Properties of the Interpersonal Field

By Donnel Stern (2015) Routledge

The other psychoanalyst who is well-known for his long-term interest in complexity since it first got going decades ago is Robert M. Galatzer-Levy. You can find his paper: "The edge of chaos: A nonlinear view of psychoanalytic technique" online (it's an accessible introduction to complexity from a psychoanalytic point of view), but he also published a book very recently (which I haven't read yet, so cannot comment):

Nonlinear Psychoanalysis - Notes from Forty Years of Chaos and Complexity Theory

By Robert M. Galatzer-Levy (2017) Routledge

Although it is not dedicated exactly to complexity, but to field theory (but many of the ideas overlap, and you can see that Donnel Stern mentioned above is involved), there is now the International Field Theory Association, that offers a blog (published mainly by Montana Katz) and some materials, establishing a rationale and frame for applying these theories to psychoanalysis.

http://www.internationalfieldtheoryassociation.com/about.html

Another fairly recent book I found, but don't know, is:

Psychoanalytic Complexity: Clinical Attitudes for Therapeutic Change

by William J. Coburn (2014) Routledge

My very first reading around chaos and complexity, probably in the early 90s was this book, which has stood the test of time (there is now an anniversary version of it):

Chaos: Making a New Science

James Gleick (1987) London: Abacus.

He is a science journalist who has a knack for making these subjects accessible to the lay person, in an engaging and personal style. The book is a whistlestop tour introducing the originators of chaos theory both as people and scientists, whilst getting the essential ideas across (and their paradigm-shifting significance).

For many reasons I read the following book when it first came out (I was a fan of Deleuze and Guattari in my early 20s and at the time I was trying to turn their 'desire machines' into experiential workshops around the body and its impulses), however all I can remember is feeling vaguely disappointed (and thus not remembering much about it):

Psychoanalysis and Ecology at the Edge of Chaos: Complexity Theory, Deleuze, Guattari and Psychoanalysis for a Climate in Crisis

By Joseph Dodds (2012) Routledge

Chaos and complexity theory have had more significant influence in the fields of organisations, leadership and management than in therapy, so you can find plenty of materials in that realm, and I include a few below. However, the question always is: what's the depth-psychological and facilitative presence and skill of the people applying these theories, in whatever human context? In my opinion, we need more therapists to work towards an integration of theory and intersubjective practice in this regard (otherwise these very promising and paradigm-shifting ideas never quite seem to have the promised effects).

For those of us involved with groups and organisations, Ralph Stacey (from the Business School of the University of Hertfordshire) has been one of the most influential people in the UK applying complexity to businesses and management, by catching onto complexity very early on and seeing its relevance for social organisations (I can remember being on a conference with him in 1996, when his approach was considered fresh and radical, but already well-established):

Complexity and Group Processes: A Radically Social Understanding of Individuals

by Ralph D. Stacey (2014) Routledge

Some of Stacey’s colleagues are providing materials online. One of his early collaborators, Patricia Shaw (who was also involved with Metanoia at some point), wrote a book many years ago which became quite influential:

Changing Conversations in Organizations: A Complexity Approach to Change

By Patricia Shaw (2002) Routledge

In the realm of social organisations, the most well-known complexity celebrity is Meg Wheatley, a management consultant from the US who has turned more into a spiritual teacher now (as you can see on our website):

http://margaretwheatley.com

Somebody gave me her book as a birthday present years ago, and it makes the case for complexity in quite a poetic way - it's more of a coffee table book, but very engaging:

A Simpler Way

by Margaret J. Wheatley and Myron Kellner-Rogers (2012)

IARPP is announcing the publication of a new book coming out soon by an Italian relational psychoanalyst:

Psychoanalysis and Complexity

Gabriele Lenti (Italy)

And if you search on the Internet, I'm sure you can find lots more writing, doctoral dissertations and the like, for example:

From Theory to Clinical Practice: Psychoanalytic Complexity Theory and the Lived Experience of Complexity. In: International Journal of Psychoanalytic Self Psychology Volume 11, 2016 - Issue 4.  By Margy Sperry, The Institute of Contemporary Psychoanalysis, Los Angeles, CA

Footnotes:

[1]           I'm pretty confident you must have come across it, as it is such a common mechanism and dynamic - it was the first 'game' identified by Eric Berne in what eventually became his first book on Transactional Analysis "Games People Play"

[2]           after all, as Fritz Perls said: the underdog always wins

[3]           "Contemporary research indicates that ‘client factors’ are the principal drivers of therapeutic change: e.g. client engagement, participation, hope." – see Mick Cooper's video based on his 2008 book ‘Essential Research Findings in Counselling and Psychotherapy: The Facts are Friendly’, where he quotes Mike Lambert's research with the conclusion that about 70% of what happens in therapy is to do with client factors. Although unarguably true that the quality of the therapeutic relationship is co-created and therefore significantly influenced by the client, this has always seemed a bit of an evasive and disingenuous argument to me - is it not the therapist’s responsibility to gauge the client's lack of engagement by reflecting on their own presence and input by wondering about the unconscious dynamics and implicit ‘therapist factors’ that are putting the client off? It's unfortunate that most outcome research doesn't even consider, let alone factor in unconscious dynamics (understandably in one way because it would really complicate matters - how do you design a questionnaire about somebody's unconscious?). But that then leaves a huge paradigm gulf between research and the (unscientific) principles that most of us need to use as therapists in order to make therapy work in practice every day.

[4]           “An example of a simple linear system that exhibits non-linear feedback effect is the classic ‘three body problem’ of gravitation. Consider a moon orbiting a planet. The path that the moon takes is well known - it was fully described by Sir Isaac Newton's mathematical laws of gravity. But suppose we introduce a second moon of the same size as the first. Would the moons' orbits now be only slightly more difficult to calculate? It turns out that the simple deterministic equations which govern the three-body system are unsolvable. They cannot predict the long-term path of the orbiting moons. The reason why the three-body problem cannot be solved is that gravity is a non-linear force and in a three-body system each body exerts its force on the other two. This produces non-linear feedback and results in chaotic motion of the moon orbits.” from: Introducing Chaos: A Graphic Guide by Ziauddin Sardar, Iwona Abrams p.22

[5]           which hasn't stopped swathes of the psychological field propagating linear change throughout the 20th century, come hell or high water (another little chaotic inconvenience). But a large section of the psychological therapies remains unmoved by these little details, which is why I don’t see much evidence that as a profession we have quite arrived in the 21^st century.

[6]           although, admittedly, in nature they are few and far between, as linearity is mainly at home in the abstractions of the human mind (where arguably it has its uses): the discovery that complex curves could be approximated by calculating large numbers of tiny straight lines via differential equations has contributed to the vast technological progress over the last few hundred years. However, has it got us closer to reality? "Clouds are not spheres, mountains are not cones, coastlines are not circles, and bark is not smooth, nor does lightning travel in a straight line."(Mandelbrot, 1983) – Mandelbrot was one of the originators of chaos theory - see his coastline paradox

[7]           partly because this can become just another enactment of a power struggle regarding the terms of engagement and the construction of the therapeutic space

[8]           or also through spontaneous embodied imagery, as suggested by Arnie Mindell and Process-oriented Psychology which has given us many useful theoretical and practical tools for working at the edge of chaos

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Enactment is when the dynamics of a primary wound become replayed in the dynamics of the therapeutic relationship. This is often understood by the therapist as an error, a mistake made, a transference unseen or poorly contained; but for me that misses the point.

It was once assumed that transference and countertransference were likewise unfortunate intrusions in the analytic process, whereas we now see them both as inevitable and as valuable sources of information regarding the client's relational patterns. Transferential dynamics can take us beyond knowledge of a client's dynamic symptoms into a here-and-now experience of their actual relational presence; including how they construct us through transference into versions of their own primary storylines, how we construct them through countertransference into versions of our own; and, crucially, how it is that our respective stories might collide or merge - enactments usually become apparent when the working-alliance ruptures in some form of collision, or when it remains impassive and undisturbed in some form of collusion.

Enactment dynamics can only be understood as simply a mistake if we assume that we would be better off if the whole disturbance had been avoided, and that a strident stability in the working-alliance is always therapeutically preferable.

If, however, we acknowledge that ‘the mistake’ emanated from a largely unconscious, co-organised relational-psychological field, incorporating the psyches and developmental wounds of both participants, then we might imagine that ‘the mistake’ is significant in their underlying dynamic relationship.

If we now conceptualise that these underlying enactment dynamics are a mimesis of a primary developmental wound, dissociated from awareness, we can see that we have been given an extraordinary access to the wound itself, not in the relative abstraction of past or external relationships, but in the here-and-now of the therapeutic encounter.

It is therefore not mainly the client, but the therapeutic relationship that needs to be experienced and healed; though this can be problematic, as it requires me to step beyond the relative detachment of my therapeutic position into the necessary conflict within me, between my professional persona and my real self.

Martha Stark's 'two-person-psychology’ points us towards this uncertain and challenging territory, whereby it might just be necessary to resolve something within ourselves in order for the therapeutic relationship to resolve something within itself, and thereby for the client to resolve something within himself. If we wish our clients to risk navigating the path that might lead to the razor's edge of transformation, surely we should be willing to do so too.

The more I approach enactment as the vehicle by which dissociated relational dynamics come into the foreground of the therapeutic process, the more accepting I become of the idea that my own flawed being and subjective process are at least as alive in the therapeutic process as any training, knowledge, structures, and capacity for analytic positioning that I might employ; and that this is to be embraced as an exquisite, excruciating potential for mutual growth.

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As we are just planning and thinking about Morit’s forthcoming CPD workshops on integrative trauma therapy, this topic is currently at the forefront of our minds, so I'm sharing it with you.

There is a wide spectrum of opinion as to what role working with the transference plays in trauma work. I believe that the therapist’s awareness of the transferential dynamics is essential. As in all therapeutic work, the question is how my therapeutic awareness might most usefully and appropriately translate into my presence (whether that is silence or an intervention), and in this respect traumatised clients present special difficulties, requirements and conditions.

In simple terms, as traumatised clients have learnt to avoid relational intensity for fear of being invaded or overwhelmed, for the therapist to impose attention to the intensity of transferential dynamics can often be pre-mature and re-traumatising. The fragility of the client’s bodymind system may require that the therapist hold their countertransference reactions internally, frequently for a long time, without ‘letting on’. The therapist, therefore, may need to stay and stick with being aware of and bearing feelings which the client cannot (yet) be expected to engage with.

The client, without necessarily being able to ask for this, needs the therapist to be a protective ally who puts the integrity of the client’s recovering system above their own needs for relating or mutuality. In the meantime, the therapist needs to hold unbearable feelings internally, transmuting them quietly rather then sharing or expressing them, even as a foundation for formulating an interpretation.

However, the fact that the client may need to see and experience the therapist as a wholly good and benign object, does not automatically mean that the therapist has to restrict her own experience to this idealised expectation, or has to positively define and construct her role in terms of precisely that protector figure who was by definition absent in the original trauma. Such an exclusively positive self-understanding on the part of the therapist numbs her to the complexities of the bodymind process involved in addressing the frozen reality of trauma in the here & now of the therapeutic relationship.

Messler-Davies’ work with trauma (Messler Davies, J. & Frawley, M.G. (1994) Treating The Adult Survivor Of Childhood Sexual Abuse: A Psychoanalytic Perspective) reveals how far into the relational dynamics a client and therapist may fruitfully go when both therapist and therapy itself may be experienced as a re-enactment of the abusive object, or when the client’s internalised abuser may be constellated in relation to the therapist.

This degree of working-through may not be required or appropriate (or not yet possible at a given point in time), but the dynamics addressed by such work are ever-present in the relationship with traumatised clients.

In my opinion, therefore, the question is not whether to work with the transference or not – unless we ignore or deny it and override it, the only question is whether to work with it implicitly or explicitly. In either case, the therapist’s handling of her countertransferential responses constitutes the relational container which the client subliminally experiences and which profoundly affects the work and the space she is able to provide for the process of recovery.

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This is a sweet and interesting book, with an obviously attractive title (well - attractive to me!), written as an autobiographical look back over his professional life as a therapist by the 80-year-old George Steinfeld. It is exceptional in its honesty, and it pulls no punches about delivering some uncomfortable home truths about this profession of ours. Many of George’s criticisms I find myself agreeing with, and many of his warnings to clients I wholeheartedly endorse. Here is a collection:

“It has struck me that after about 70 years of practising therapy in this country …  and more than 100 years since Freud’s time, there’s something wrong with clients not getting healthier. Recent work suggests that therapy can make people worse. It’s a useful idea to let clients know of this possibility.”

“Some of the bullshit is therapist driven, but some of it is client driven. Making this distinction is important in our work. Whenever there is money or ego (power)  involved, or some unmet needs of the therapist, we have to be on the lookout for bullshit.”

“One could spend years in therapy, and I’ve heard some have stayed 50 years, till they or their therapist died, with no concern as to whether it was helping. Sure, people changed, but so did people who never were in therapy, and there was and still is no clear relationship between therapy and change.”

“Private practice: now it really gets bullshitty! … As I sit and listen to clients, …  and I do happen to be an excellent listener, if I do say so myself, I often ask myself whether what the client is paying me is worth it. Other times I feel that no matter what the client paid it wouldn’t be enough.”

George’s disenchantment with psychoanalysis

He makes no bones about the fact that - although initially and for many years he was a true believer in psychoanalysis as practised in the US at the time, i.e. the 1960s -  he now thinks of it as one of the key candidates for bullshit. He is especially critical of its search for past origins to current problems and the assumption that insight is sufficient to change behaviour.
“I believed in psychoanalysis for years, in undergraduate and graduate school. And I believed in it when I came to

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The skin-deep apparent consensus around relationality

However, whilst there is quite a lot of agreement that the therapeutic relationship matters, this apparent consensus breaks down at the first hurdle: there is no such level of agreement as to what actually constitutes quality of relationship. On the contrary: there is a tendency for the traditional approaches to define and interpret ‘quality of relationship’ either within their own frame of reference only (taking their own paradigm of relating for granted), or at least restrict themselves to a very limited range of relational stances. Because of this tendency of the traditional approaches to privilege and absolutise their own assumptions as as to what kind of therapeutic relatedness is helpful, it is not generally accepted that 100 years of psychotherapy have given us a diversity of distinct notions what kind of relating is to be considered ‘therapeutic’.
As Petruska Clarkson - in her seminal contribution in the early 1990's - has asserted: there are now in existence different - and quite contradictory - kinds of therapeutic relatedness, or to say it more simply: we find different - and quite divergent - relational spaces across the therapeutic traditions and approaches. Unless we take into account these different notions of relatedness - or in Clarkson’s terms: the different relational modalities championed by the various traditions and perspectives - what we mean by ‘relational’ will remain confused and confusing. It clearly means very different things to different therapists, without - however - these differences being acknowledged or investigated.

Relational as defined by its supposed opposite: what do we mean by 'non-relational'?

As a byproduct of these developments and unacknowledged divergences, and partly due to its own success, the term ‘relational’ has largely lost its meaning. The common ground of ‘relationality’ is a negative distinction from classical one-person psychology and ‘medical model’ non-relationality. So the term ‘relational’ now only retains some substance in contrast to its supposed opposite: the current consensus for what we might mean by ‘non-relational’ would be some quasi-medical treatment - in the current situation in the UK we would be thinking of CBT and associated approaches. However, most CBT therapists would feel sorely misunderstood in being categorised like that, as they tend to emphasise the collaborative nature of the relationship with their clients, which - in their frame of reference - is being relational (and there is now, of course, a new subcategory of CBT being developed, i.e. ‘relational CBT’). This is just one illustration that we do not have a cross-modality shared understanding of the term ‘relational’. Unless we take into account the underlying paradigms and preconceptions and what each of the traditional approaches means by ‘therapeutic relating’, we are talking at cross purposes.

And many medical professionals are rightly riled by being categorised as the supposed antithesis of relationality and by the idea that they are being 'non-relational'. We only have to think of a traditional family doctor and their very strong relatedness to their patients and their families (within an implicitly assumed bio-psycho-social framework, a systemic and trans-generational understanding of the family dynamics and an unbroken relational attachment and involvement with the family system often over decades), to notice that to categorise and construct medical practitioners in opposition to relationality is oversimplifying, misleading and unhelpful.

So we can't even afford to simply and reductively define what is 'relational' by its supposed 'non-relational' medical model opposite. To exclude medical model relating from the field of psychology - as Clarkson herself was doing by default (as she did not include it in her list of relational modalities) - and thus invalidating it as form of psychotherapeutic relatedness, perpetuates the traditional dichotomies and adds to the confusion.

‘One-person psychology’ versus ‘two-person psychology’

A well-established notion that is supposed to bring some clarity to the situation is Martha Stark’s distinction between ‘one-person psychology’ and ‘two-person psychology’ (with a third, somewhat tongue-in-cheek transitional option of ‘one-and-a-half-person psychology’ in between). Whether these distinctions do indeed help to clarify matters depends largely on our underlying attitude in using them:

• when we are using these terms in an antagonistic, polarising way (typically to establish the supposed superiority of the all-new two-person over the ‘old-hat’ classical one-person perspective), they don’t seem to mean much more than ‘relational = modern = good (i.e. better)’ versus ‘non-relational = classical = out of fashion’.
• there is a way of using these terms (and Stark occasionally supports this usage) where all three kinds of therapeutic relatedness (‘one-person’, ‘one-and-a-half-person, and ‘two-person psychology’) can be seen as a valid aspects of what actually happens in the therapeutic relationship. When we can appreciate these notions in such an integrative and embracing way as mutually complementary as well as contradictory, we can use them very productively to enquire into and investigate the relational process.

Expanding Clarkson's model of 'relational modalities' into Michael's 'diamond model'

I have described Stark's ambiguity between these two positions in a detailed critique of her introductory chapter to her seminal 1999 book 'Modes of Therapeutic Action'). As I tried to suggest in that critique, we can develop a more therapeutically useful and detailed idea of relationality by combining Clarkson’s model with Gomez's 'alongside' and 'opposite' positions and Stark’s three kinds of therapeutic relatedness - giving us six relational modalities all operating in the contested force field of the therapeutic relationship. This way of using relational perspectives (summarised in what I call my ‘diamond model’) can become quite fine-grained and helpful in supervision and in reflecting on the therapeutic process generally. It is based upon not only validating a diversity of relational modalities as existing, but upon recognising that each modality can have therapeutic as well as counter-therapeutic effects, depending on context. All therapeutic theories, tools, techniques, ideas as well as relational modalities can become vehicles for enactment: none of them - in and of themselves - are immune against that possibility.

The therapist's internal conflict - processing the countertransference in terms of tensions and pulls between different relational modalities

Understanding how the therapist's internal conflict relates to the client's inner world - in psychoanalytic terms: processing the countertransference and how it interlocks with the transference - can be profoundly helped by understanding how the therapist is being pulled between equally valid, but contradictory and conflicting relational modalities. This understanding, i.e. how the therapist is internally affected by the intersubjective dynamic, turns Petruska Clarkson's theory of relational modalities from an abstract tool of psychotherapy integration into a clinically useful tool moment-to-moment.

This is the essence of Michael's "Diamond Model of the relational therapeutic space": seeing the relational modalities not as some range of helpful stances which the therapist consciously chooses between (one at a time), but considering all the modalities as going on all the time (as a dynamic, systemic whole). The conflicts and pulls between different relational modalities can then be reflected upon and engaged in as manifestations (and enactments) of the unconscious co-constructed dynamic.

Defining relationality through the notion of 'enactment'

The diamond model conceives of Clarkson's modalities not as sequential treatment options, but as all simultaneously present in the intersubjective forcefield of the therapeutic relationship. This forcefield is structured primarily around the rupture-and-repair cycles occurring in the attachment bond between client and therapist, within a fundamental tension between working alliance on the one hand and transference-countertransference enactment on the other (this is based on my suggestion - similar to Stark's - that we can think of the development of the field in terms of 3 relational revolutions, the first being Freud's re-formulation of the transference from an obstacle therapy into the royal road into the depth of the wounding and thus the process; the second being the countertransference revolution which generated a similar re-frame of what was previously considered the therapist's 'stuff' as an obstacle into another royal road; and I am suggesting that the notion of enactment constitutes another quantum leap which re-frames what was previously considered the central danger and obstacle, i.e. countertransference enactment, into a two-person psychology notion of therapeutic action via the transformation of enactment (I have been suggesting this for many years now, but other people are beginning to say more or less the same thing, see Michael Varga: Analysis of Transference as Transformation of Enactment).

Enactment (and its possible transformation) is the key notion capable of capturing the essence of relationality and lending it substance. By recognising enactment as the paradoxical heart of the therapeutic process (when we conceive of its aim as the transformation of unconsciously engrained characterological patterns), a differentiated and sophisticated appreciation of the diversity of relational modalities - always already present in the relational space - becomes possible. Rather than comparing and contrasting ideas about relationality as theories, attitudes, strategies or stances chosen by the therapist intentionally (and then used to play different therapeutic approaches off against each other as better or superior to others), we can use our experience of the relational modalities present in the ‘here and now’ as a perceptive and interpretive tool, as a map of the forces operating within the field, as a meta-process of intersubjective enquiry and reflection, giving us access to the unconscious forces influencing the therapeutic relationship.

The essential conflict: object-relating versus inter(subject)-relating

This day will be an introduction to Michael's diamond model. His starting point will be the perennial and underlying tension (and often: polarisation) between object-relating and inter(subject)-relating in the therapeutic space: the tension between 'using' each other as objects on the one hand (I-it relating, which much of the humanistic field is biased against because of its objectifying and exploitative connotations, but which Winnicott has a lot of positive and developmental things to say about) and subject-subject relating (mutual recognition or I-I relating, as advocated by the humanistic and modern psychoanalytic traditions). When we can validate both as potentially transformative and necessary ingredients in the therapeutic space, and recognise the tension between them as essential to the therapeutic endeavor (a tension not to be reduced, resolved or short-circuited ideologically, but to be entered into in each unique client-therapist relationship), a multiplicity of relational spaces – contradictory and complementary, forming a complex dynamic whole – can be seen to arise from that tension. Michael proposes his ‘diamond model’ as a map that can help therapists process their conflicted (countertransference) experience when involved in layers of multiple enactment.

Here's a list of events currently planned on this topic:

Oxford - OTS: What do we mean by ‘relational’? -  21 April 2018

London - TRS: What do we mean by 'relational'? -  13 May 2018

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Introduction: Clarkson’s seminal contribution

I sometimes get asked why I put such emphasis in my teaching on relational modalities - an idea first formulated in a paper by Petruska Clarkson in 1990. Because it is such a well-known model, that has formed the basic framework for integrative counselling and therapy training courses all over the world, it is often assumed that it is by now well-understood and ‘old hat’. However, based upon what I can gather from CPD teaching and supervision, I'm not left with the impression that it is indeed well-understood, nor often used in a way which is actually as clinically helpful as Petruska intended it to be.

Clarkson’s model and formulation was seminal and revolutionary in the early 1990s - it was one early and major manifestation of the shift towards a relational perspective, which has since been one of the significant influences across the field. During the 1990s Clarkson’s model spread across a wide variety of integrative counselling and therapy training courses, especially in the UK (with the Metanoia Institute being the organisational origin), but also internationally. [1]

Reviewing Clarkson’s model and developing it further

Considering that Clarkson’s model is 25 years old, we are now in a position to review it and update it as well as developing it further. Having worked with this model since its beginnings, and combined it with embodied and other relational perspectives (especially relational psychoanalysis), I have found certain gaps, deficiencies and flaws in the model itself, but especially in how the model is being used in practice, teaching and supervision, including internal supervision.

For the last 15 years I have been suggesting certain extensions and re-formulations of the model, to help update it and keep it current, but most importantly: to make it workable in a practical and experience-near fashion, so that is helpful in my moment-to-moment internal process as a therapist.

For the last 10 years I’ve been calling these adaptations to the traditional Clarkson formulation my ‘Diamond Model’ [2], which currently forms the foundation for my teaching on relational modalities.

Synthesising ideas on relational stances from Lavinia Gomez, Martha Stark & Petruska Clarkson

Some of the issues with Clarkson's model can be explicated by comparing and contrasting it with other well-known ideas on different kinds of therapeutic relatedness: I'm drawing especially on a significant paper by Lavinia Gomez (2004) that challenges the integrative project and proposes a distinction between ‘opposite’ and ‘alongside’ relational positions.

But the most well-known formulation, complementary to Clarkson, comes from the US (which may be one of the reasons why some kind of cross-fertilisation between these models hasn't thoroughly occurred yet): Martha Stark’s (1999) description of a historical arc from classical ‘one-person psychology’ to modern relational ‘two-person psychology’.

These three formulations - Gomez, Stark & Clarkson - overlap and nicely complement each other - by combining them, we can compensate for the limitations of each of these models just by itself. In what follows, I am building towards a synthesis of all of them, which then constitutes the foundation on which I can later present the ‘Diamond Model’.

Relational modalities as a precondition for surviving enactments

At the growing edge of psychotherapy as a discipline at the present time, the key point of distinguishing different relational modalities is that they are, in my view, the foundation and a precondition for recognising and surviving enactments. The different habitual stances we inherit down the generations of therapeutic sub-cultures and approaches effectively blind us to certain enactments, and we need the reference points of the other modalities to help us become aware of these enactments as such, i.e. as repetitions of negative scenarios in the client's experience which undermine our therapeutic alliance with them. So our moment-to-moment awareness of the diversity of relational modalities help us not so much in understanding enactment as a concept in principle, but in actually becoming aware of it when entangled within it, and in being relationally flexible in responding from within it in order to survive it transformatively. This, of course, was not the point 25 years ago when Petruska Clarkson put relational modalities on the map - at the time it was only about psychotherapy integration, and it is, of course, an essential tool for that.
As an illustration of how across the different approaches therapists are struggling with the idea of relationality (and enactment as a key ingredient within it), I was invited to give a response to a paper by the TA therapist Ray Little (Soth 2013 "We are all relational, but are some more relational than others?").

Relational modalities as a foundation for psychotherapy integration

Because the integrative movement has been incredibly successful, especially in the UK, there is less need these days to support psychotherapy integration and justify why it is a good idea in the first place. One of the downsides of its success has been that the notion ‘integrative’ has become diluted: in common usage it is now frequently indistinguishable from ‘eclectic’ - a danger which the early champions of psychotherapy integration were all too aware of [3]. So for the purposes of evolving an integrative perspective beyond its currently dominant eclectic manifestations, towards the possibility eventually of some kind of more coherent pluralistic profession, relational modalities are still an essential concept within the further evolution of psychotherapy integration.

The integrative project: robust flexible (integrative) diversity or headless (eclectic) chicken?

However, my main reason for emphasising relational modalities in my teaching is no longer the integrative project itself. An astonishing majority of therapists now do call themselves 'integrative', and as a result we have moved on to new issues and new struggles. Many integrative therapists are knowledgeable and skillful in drawing from a variety of therapeutic traditions in terms of theories and techniques, but are struggling with issues of containment in the working alliance - issues which were first pointed out as one of the dangers of integrative practice by Lavinia Gomez in 2004. These issues are to do with the therapist - often inadvertently - switching relational stance as a by-product of switching into a different theory or technique. It's that switch in the therapist's relational stance which usually constitutes an unwitting enactment and can have detrimental effects on the working alliance.
The notion of enactment, as we discovered painfully throughout the 1990's and as it has come to be understood in relational psychoanalysis, implies by definition that the unconscious processes constituting enactments are not available in the therapist's awareness and therapeutic reflections - as dissociated dynamics, they manifest through largely non-verbally communicated attitudes and relational positions, on the level of implicit relational knowing. The therapist's rationale and the explicit content of the therapeutic interaction, on the level of the ego-ego alliance between client and therapist, becomes the unwitting vehicle of enactment: enactments occur in spite of the therapist's intention and reflection via theory or technique.
So whilst the therapist is consciously aware of having a very valid therapeutic rationale for switching towards a different therapeutic approach and technique, unconsciously an enactment is taking place on the level of relational position and implicit relational stance. But because the therapist is convinced of their therapeutic intention and rationale, they override their awareness of the intensifying enactment that is escalating in the background.

Challenging the prevalent eclecticism of the integrative project

Lavinia Gomez’s challenge to the integrative project - i.e. that any such switch by the therapist can be experienced by the client as 'breaking the container' (what I would simply call 'a wounding re-enactment') - establishes precisely the significance of the therapist’s underlying and implicit relational stance: Lavinia implies that the therapist's stance is more significant and impactful on the process than their conscious rationale and intention. She offers us a basic distinction into ‘opposite’ and ‘alongside’ relational positions, and associates these with the essence of the psychodynamic and humanistic traditions respectively. These two positions can be readily recognised experientially and observed in practice – during CPD training with integrative groups, therapists find it easy to identify these positions in each other in skills practice or role-play.

The central point of Gomez’s challenge is that ‘opposite’ and ‘alongside’ relational positions cannot just be mixed and matched: “What we are not free to do is encourage a fixation on ourselves [she means inviting the transference] by promoting an ‘opposite’ position, and [then] trying to conduct the therapeutic work through both channels.” She means that once we have allowed the transference to become constellated, we can't just arbitrarily and eclectically switch relational positions from then onwards (well, we can, but it is going to mess up the therapy, or in her language: containment).

It is ultimately an awareness of these relational vicissitudes of therapy which helps us recognise how insufficient - and counter-therapeutic - a fairly pragmatic, utilitarian eclecticism can become. This is because eclectic practitioners, supposedly using whatever 'works' from the various traditions, take their own relational position for granted as self-evident and obvious commonsense, including their associated notions of what actually constitutes ‘therapy working’ in the first place: “I am just intuitively selecting from a variety of techniques and go with whatever seems appropriate.” They thus assume that their own good intention and rationale for a therapeutic response or intervention outweighs and is more important than how the client receives it, consciously and/or unconsciously.

Some of the time that kind of rationale may indeed be appropriate and ‘good enough’ and work very well, but Gomez’s challenge is that when it goes 'wrong', it usually goes wrong spectacularly and disastrously: as this kind of eclectic attitude doesn't take into account the relational implications, let alone attend to unconscious processes and enactments, it tends to gravitate towards a more superficial level of interaction, that takes its cues from the client’s own ideas of being helped and does not take into account the client's internal conflicts (as we will see in more detail below).

In summary: it is attention to relational stances and modalities which is capable of challenging the therapeutic pitfalls of eclecticism as well as helping us transcend these; and Gomez’s distinction of the inherent relational positions underlying the humanistic and psychodynamic traditions is therefore a good starting point.

Beyond an eclectic, pragmatic, commonsense conception of the therapeutic relationship

Gomez’s formulation makes clear that historically both the humanistic - and to a lesser extent - the psychodynamic tradition were conceiving of the therapeutic position in too simplistic terms. Traditional notions of the working alliance framed it as what I call the ‘ego-ego alliance’ only, and were caught in too 'singular' a conception both of the client and the therapist, and therefore the relationship, too (as if both client and therapist could be reduced to their 'singular' ego identity). Even psychoanalysts like Greenson (1967) - when thinking about the working alliance - abandon their conception of the client’s conflicted inner world and unconscious processes, and define it as the supposedly healthy bond between the supposedly rational conscious parts in both client and therapist, that are supposedly capable of co-operating for the sake of creating a helping relationship [4].

Once I have reduced both people to their rational identities, then the working alliance becomes an oversimplified and simplistic idea which is unhelpful in practice. The client is not simply somebody who 'wants help' or 'wants to get better'. The therapist is not just an altruistic ego that wants to 'help' the client.

Due in part to the long-standing polarisation between the humanistic and psychodynamic traditions, their respective conceptualisations - as long as they are deprived of the kernel of validity of the other – thus each end up with a commonsense notion of the therapeutic position which relies too heavily on the public preconception of it as one more helping profession. As long as the general public, and other helping professions, think of the therapist as ‘simply doing their job’, ‘helping’ the client, the therapeutic complexity of actually being a relational other has already been lost or reduced beyond recognition. Whilst we cannot expect the general public to appreciate that complexity of the therapeutic position and its inherent multiple relational stances, for many decades neither have the traditions themselves, in terms of their self-understanding and self-definition.

Gomez’s ‘alongside’ versus ‘opposite’ = reparative versus transferential

Gomez - in order to focus on what therapists actually do, rather than what they think they do or say they do - to some extent bypasses humanistic theory and philosophy, by reducing the humanistic ‘alongside’ stance to an essentially reparative position. Within humanistic terminology itself, we might say that the ‘alongside’ position consists essentially of championing the client’s self-actualising tendency, and many humanistic practitioners would see their task as precisely that. A well-known declaration of this position would, for example, be Alice Miller's (2008) who tries to be an ally to the client’s woundedness as well as their potential for development, focusing especially on the gifted inner child. But this is just one version of a wide variety of ways in which humanistic therapists might frame and justify an ‘alongside’ position.

By placing the psychodynamic ‘opposite’ stance then in opposition to that, Gomez harks back to a long-standing debate within psychoanalysis itself: does therapy work by providing corrective emotional experiences (Alexander 1950), i.e. is the purpose of therapy effectively reparative? Or does it work by the therapist being a transferential relational other, allowing the client’s wounding (their character pattern, script and habitual relational style) to be manifested and repeated in relation to the therapist, so it can be understood, contained, and worked through? In her writing, Gomez does not end up taking sides one way or the other in this psychoanalytic argument. It is, in fact, the inadequacy of this binary opposition which is made explicit by Gomez’s formulation, as clearly both elements are in principle needed - the question is how they can both occur in practice when in theory they appear to be mutually exclusive?

Lavinia does not address or resolve this question. However, the point Lavinia is making is that one cannot just mix and match these positions, i.e. one cannot arbitrarily move between them from moment to moment or session to session in eclectic fashion. In her view, such fickle over-flexibility on the therapist’s part inevitably leads to lack of containment and is therefore counter-therapeutic. She does not quite spell it out like that, but implicitly her reasoning – well-grounded in the psychoanalytic tradition - goes like this: once a negative transference is constellated, to switch away from it into any other position essentially conveys to the client an avoidant message to the effect that the therapist cannot bear the heat of the transferential constellation. Psychoanalysts understand that in order to rationalise an escape away from the intensity of the transference, any kind of therapeutic rationale will do, and are adept at challenging the manouvres therapists resort to in order to minimise, evade and side-step the heat.

What Lavinia does not spell out, either, is her implicit assumption that if any therapist were to switch stance, they would do so unconsciously, i.e. that any switching into another position would not only be perceived by the client’s unconscious as avoidance, but would in fact have to have avoidant functions for the therapist.

In my reply to her at the time (Soth 2004), I was very much agreeing with Gomez’s thinking in principle, but I was questioning whether these assumptions would necessarily have to be the case (i.e. might it be conceivable for the therapist to switch not exactly consciously but with some awareness of the avoidant function of the switch?, or, in enactment terms: recognising that multiple enactments are at stake either way, and that multiple relational stances are present in the field all the time, anyway, the therapist might switch with awareness; ‘working through’ would then become a more complex notion than is assumed in the psychoanalytic tradition where ‘working through’ is seen as depending upon holding to one's position in the transference without wavering).

The missing authentic person-to-person relationship in Gomez’s formulation

Having framed the crux of the ‘alongside’ position as reparative, what is missing from Gomez’s formulation is the essence of many humanistic therapists’ explicit self-understanding: they do see themselves as indeed providing a relational other, just not a transferential one, but an authentic one. In Gestalt, this would be a dialogical other; a similar understanding underpins the existential approaches, drawing on the philosophical history of Buber’s I-Thou and Gadamer’s (1980) conditions for dialogue. The idea that transference-free authentic relating is not only possible, but might provide a fundamental and valid therapeutic stance was anathema to traditional psychoanalysis. However, modern relational psychoanalysis is less categorical on this presumed impossibility.

Extending Gomez’s distinction by Stark’s ‘kinds of therapeutic relatedness’

The more we investigate Gomez’s distinction, the more we recognise that it is a useful broad brush-stroke starting point only and - in and of itself - not fine-grained enough to catch up with the majority of enactments.

The model that helps us push Gomez’s distinction further is Martha Stark’s distinction between ‘one-person’, ‘one-and-a-half-person’ and ‘two-person psychology’. Having been inspired by Stephen Mitchell’s (1988) distinction between the “drive-conflict model, the deficiency-compensation model, and the relational-conflict model”, her formulation from the beginning was always predominantly based upon psychoanalysis, but from a perspective which critiques the ‘one-person’ medical model assumptions of its origins.

The more we think of the client’s inner world as inherently conflicted between different parts (as psychoanalysis has maintained all along, and Mitchell’s model implies, too), the more Gomez’s notions ‘opposite’ and ‘alongside’ break down: the notion of relational stances then becomes a more complex phenomenon, as I may be simultaneously alongside or opposite different parts in the client.

In the most simple classical terms: if the client's ego is defended against an underlying anxiety and impulse, am I opposite or alongside the ego in its repressive project?
Am I alongside the ego, or am I alongside the repressed?
Am I opposite the ego, or am I opposite the repressed?

The client’s conflict becomes the therapist’s conflict

Because the client’s internal conflict is such a crucial and fundamental point when it comes to conceptualising the working alliance, I have tried over the years to present a formulation of that conflict which can resonate with the various therapeutic languages, and can therefore be applied across the approaches. I use the terms ‘habitual mode’ versus ‘emergency’ to describe the client’s internal conflict, and the dilemma it constitutes for the therapist. I will not present this here in detail, as it would take us too far off topic, but for many years I have been using the following hand-out: The Client’s Conflict becomes the Therapist’s Conflict (Soth 1998). An updated version of this hand-out is: The Client’s Conflict across the Window of Tolerance.

As soon as we consequently follow through depth-psychological assumptions about the conflictedness of the client’s inner world, we recognise how complex and paradoxical the therapeutic relational space inherently is and needs to be.

As I hinted above, it is astonishing for how many years psychotherapy has been thinking about the working alliance in singular, simplistic terms which fly in the face of some of its most well-established recognitions: on the one hand psychoanalysts maintained that nothing is outside the transference, on the other hand they conceptualised the working alliance as precisely that; on the one hand we see the client's character conflict as manifesting in each and every department of their life; on the other hand we are positioning ourselves as if coming to therapy and supposedly being helped by a therapist is a simple and straightforward conflict-free procedure.

I am generalising and exaggerating somewhat to make the point, but I'm doing this because this kind of doublethink is still pervasive throughout the field to this day. And it is this kind of doublethink that is a manifestation of unwitting switches in a therapist’s relational stance, leading to confusions and double messages which fuel uncontainable enactments, specifically through therapists inhabiting and communicating simultaneously two contradictory relational positions, without being aware of it. This then makes it impossible for the therapist to notice how their own relational stances are contributing to and feeding enactments.

It would be conceptually clearer to distinguish two relational spaces: one in which the transference/countertransference dynamic is dominant and figural; and one - clearly defined by Clarkson, as we will see later - as transference-free person-to-person relating. Even if in lived reality and in practice these two relational spaces never appear as clearly distinct (as they are in constant dialectic tension with each other), to conceptualise them as discrete allows us to then monitor their occurrence moment-to-moment in a way which makes their conflictedness clinically useful.

The missing authentic person-to-person relationship in Stark’s formulation

Stark, charting the development of relational stances within the psychoanalytic tradition from which she predominantly writes, is not concerned with the similarities and differences with the humanistic tradition. She therefore doesn't emphasise enough that the development of ‘two-person psychology’ had significant roots in humanistic perspectives which long pre-dated the development of intersubjectivity and relationality in modern psychoanalysis.

Stark’s definition of ‘two-person psychology’ does use terms like ‘authentic’, building on ideas of mutuality and Benjamin’s ‘mutual recognition’. However, much of Stark’s actual description of ‘two-person psychology’ stops a long way short of existential or Gestalt notions of dialogue, because she mostly formulates the engagement of the therapist’s authentic self as relevant in terms of the countertransference. So there are significant confusions entailed in squaring Stark's formulation with humanistic terms which she does not explicitly refer to, or mis-represents, or gives new meanings to. Clarkson's distinctions are clearer and more embracing across the humanistic-psychodynamic divide.

The ‘one person-psychology’ medical model as one valid relational modality

However, what we do get from Stark, as a significant addition to Gomez’s distinction, is the role of ‘medical model’ ‘one-person psychology’ in therapy.

Both Gomez - and as we will see later, Petruska Clarkson - excluded the medical model a priori, because they see it for various good reasons as extraneous to the paradigms of psychotherapy. However, with Freud taking it for granted that he was dispensing treatment and having no doubt that he was operating as a doctor, Stark’s formulation makes it explicit that the ‘medical model’ needs to be included as one possible and valid option, albeit challenged and superseded in its erstwhile dominance, in a comprehensive spectrum of therapeutic stances.

Although Stark gives somewhat mixed messages about the validity of ‘one-person psychology’ within a postmodern perspective, she does accord it some validity, rather than excluding it to begin with. To recognise and appreciate the relational aspects of a medical model stance, we want to imagine a traditional family doctor, working holistically within long-standing systemic attachments.

Complementing Gomez and Stark with Petruska Clarkson’s model

Apart from some other misgivings I have about Stark’s formulation which I do not need to detail here (but have spelled out in my commentary to her introductory chapter - Soth 2015), we can see that neither Stark’s nor Gomez’s models are sufficiently differentiated, even if we combine them, to do justice to the multiplicity of relational modalities we actually find in existence across the field. This is why we need to combine both of these models with the diversity of modalities as in Clarkson’s formulation, to give us a more comprehensive phenomenology.

Over recent years, with the relational movement rippling through all the traditional approaches, the idea of relationality has been claimed by just about everybody who values the therapeutic relationship. It has been appropriated and integrated by all kinds of therapeutic orientations, each mostly defining relationality as what they have been doing all along. This flies in the face precisely of what Petruska Clarkson was trying to establish: a differentiated overview that equally validates all relational modalities without fudging them or collapsing them into each other.

So we could ask: does being a therapeutic relational other mean …

1. providing professional collaborative help through clearly negotiated role responsibilities (i.e. a position that monitors the alliance and its effectiveness, e.g. feedback-informed treatment)
2. being therapeutically reparative, i.e. providing corrective emotional experiences
3. being a transferential other who allows themselves to be constructed and used as an object (in Winnicott's terms), including being experienced as a 'bad' object, thus allowing 'working through'
4. being a dialogical, existential other – offering an authentic I-You encounter
5. providing expert treatment in a benign, friendly (and probably collaborative) fashion like a family doctor would

If we add Clarkson’s transpersonal modality, this gives us six distinct relational spaces, based on six distinct therapeutic stances. At this point, this looks very much like Clarkson's original formulation, with the addition of the ‘medical model’. However, based on some of the above and including especially Gomez’ challenge to the integrative project, we are now in a very good position to take Clarkson's model beyond the way it has largely been taught, into a foundation for thinking about the complexity of the relational space between client and therapist, especially in terms of enactments and how they threaten the working alliance.

Interim conclusion: a comprehensive phenomenology of relational modalities

In terms of establishing the principle that several distinct relational modalities do in fact exist across the field of the psychological therapies, Clarkson's original impulse still seems to me as valid as ever. None of the other formulations come near the degree of differentiation that she proposes. I have indicated that Clarkson's a priory exclusion of the medical relationship has serious disadvantages, so, following Stark, I would (re-)include the ‘one-person psychology’ medical model as one valid modality in a comprehensive spectrum.

On the other hand, as neither Gomez nor Stark fully differentiate the authentic person-to-person relationship (although some of Stark’s ‘two-person psychology’ language seems to be nudging in that direction), I would stick with Clarkson's categories in this respect.

All three writers agree on the significance of the transference / countertransference modality, and all three are committed to some idea of integrating the different categories they distinguish, but it is only Gomez who posits limitations to that integration. This is a crucial challenge for the whole integrative movement, which hasn't really been taken up, let alone answered. As I described above, it is a challenge that is appears in the debate between what Clarkson calls the ‘reparative/developmentally needed’ versus ‘transference/countertransference’ modality. However, the underlying and fundamental tension inherent in the therapeutic position is better formulated as the dialectical polarity between: allowing myself to be constructed and used as an object VERSUS mutual recognition - dialogical relating - authentic I-Thou encounter (The essential relational conflict inherent in the therapeutic position). I would prefer to re-translate Gomez’s ‘alongside’ and ‘opposite’ positions in these terms, but maintain the point of the challenge.

Whilst recognising that Gomez’s association of the ‘alongside’ position with the humanistic and the ‘opposite’ position with the psychodynamic is historically valid (and because it lingers as a polarisation within the field, is therefore still experientially useful to explore and reflect upon, until some more solid integration between humanistic and psychodynamic principles is established), I hope I have also begun to show how her distinction is limiting and can be transcended.

As I suggested earlier, these three formulations by Gomez, Stark and Clarkson overlap and nicely complement each other [5] - by combining them, we can compensate for the limitations of each of these models just by itself. Building on the synthesis between them gives us a good foundation for presenting my ‘Diamond Model’, which is intended to draw on the most precious aspects of each, whilst going further towards the formulation that addresses the crucial paradox at the heart of therapy: how to be fully involved in the relationship and make ourselves available to enactments whilst maximising the chances that these will become transformative, and thus allow increasing possibilities for authentic meeting.

References:

Alexander, F. (1950) Analysis of the therapeutic factors in psychoanalytic treatment. The Psychoanalytic Quarterly, Vol 19, 1950, 482-500.

Benjamin, J. (2007) Intersubjectivity, Thirdness, and Mutual Recognition; accessed online 15/11/2015: http://icpla.edu/wp-content/uploads/2013/03/Benjamin-J.-2007-ICP-Presentation-Thirdness-present-send.pdf

Clarkson, P. (1990) A Multiplicity of Therapeutic Relationships. In: British Journal of Psychotherapy: Volume 7, Issue 2, pages 148–163

Clarkson, P. (1995) The Therapeutic Relationship. Whurr.

Gadamer, H.G. (1980) Dialogue and Dialectic: Eight Hermeneutical Studies on Plato. Trans. and ed. by P. Christopher Smith. New Haven, CT: Yale University Press, 1980.

Gomez, L. (2004) Humanistic or psychodynamic - what is the difference and do we have to make a choice? In: Self & Society Vol. 31 No.6 Feb/Mar 2004

Greenson, R. R. (1967) The Technique and Practice of Psychoanalysis. New York: International Universities Press.

Miller, A. (2008) The Drama of the Gifted Child: The Search for the True Self. Basic Books (3 Rev Upd edition)

Mitchell, S. (1988) Relational Concepts in Psychoanalysis. Harvard University Press.

Stark, M. (1999) Modes of Therapeutic Action. Jason Aronson.

Soth, M. (1998) The Client’s Conflict becomes the Therapist’s Conflict; accessed online 15/11/2015: http://www.integra-cpd.co.uk/cpd-resources/the-clients-conflict-becomes-the-therapists-conflict-1998/

Soth, M. (2004) Integrating humanistic techniques into a transference-countertransference perspective - A Response to ‘Humanistic or psychodynamic - what is the difference and do we have to make a choice ?’ by Lavinia Gomez. In: Self & Society, 32(1), Apr./May 2004, p. 44 - 52

Soth, M. (2013) ‘We are all relational, but are some more relational than others?’ - completing the paradigm shift towards relationality. In: Transactional Analysis Journal April 2013 vol. 43 no. 2 p. 122-137

Soth, M. (2015) Commentary and critique of introductory chapter of Martha Stark’s 1999 “Modes of Therapeutic Action”; accessed online 15/11/2015: http://www.integra-cpd.co.uk/commentary-and-critique-of-introductory-chapter-of-martha-starks-1999-modes-of-therapeutic-action/

To follow:

Part 2: The ‘Diamond Model’: relational modalities as a force field around the central paradox of working alliance versus enactment

Footnotes:

[1] in fact, it spread so widely that Petruska found it necessary to publish an open letter in 2002, reminding people to attribute the model to her because she felt that her authorship was being forgotten

[2] As some people who worked closely with Petruska have pointed out, some of the proposals I offer were already part and parcel of what she taught at the time (which is quite different from how the model was understood, used, applied and taught by many others).

[3] “It may need to be recognised in psychotherapy trainings that experience and supervision are required to distinguish between the different forms of psychotherapeutic relationship and in assessing and evaluating the usefulness of each at different stages of psychotherapy. Equally, different modes may be indicated for individuals with characteristic ways of relating so that there is not a slipshod vacillation due to error or collusive countertransference. Confusion and lack of clarity abound when types of psychotherapeutic relationship are confused with each other or if one is used as if substituting for the other. It is possible that all of these forms of relating are needed some of the time, or for some patients, and that psychotherapists with flexibility and range can become skilful in the appropriate choices.” Clarkson

[4] “the relatively non-neurotic, rational, and realistic attitudes of the patient toward the analyst .... It is this part of the patient-analyst relationship that enables the patient to identify with the analyst's point of view and to work with the analyst despite the neurotic transference reactions.” (Greenson, 1967, p. 29)

[5] a summary hand-out, including references, can be found here: http://www.integra-cpd.co.uk/cpd-resource/the-therapists-relational-stance-200320102015/
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