Freedom and Oppression in Therapeutic Space.
“Max Ernst’s “Two children threatened by a nightingale.” symbolises how traumatised people struggle to reclaim an inner world as a thing of beauty not a threat. “It is about the inability to see beauty…To be threatened by something you can’t have, so… you turn it into something else”.
Comments by research therapist ‘Toni’, who also quoted the Tao Te Ching below.
Tao Te Ching
In loving your people and governing your state
Are you able to dispense with cleverness?
In the opening and shutting of heaven’s gate
Are you able to play the feminine part?
Enlightened and seeing far into all directions
Can you at the same time remain detached and non active?
Rear your people, feed your people
Rear them without claiming them for your own
Do your work without setting any store by it
Be a leader not a butcher
This is called hidden virtue.
An exploratory workshop with Jessica Woolliscroft at the
UKAHPP AGM 14th April 2012.
This is the full transcript of a lecture delivered at the UKAHPP’s (UK Association of Humanistic Psychology Practitioners) Annual Gathering of Members. My intention in setting up this workshop was that participants would leave with some knowledge that had real practical value. That they would get some ideas about how to protect themselves and their clients from a range of oppressive forces that compromise therapeutic space and that the participants would feel empowered to use the freedoms that they still have.
The workshop was in three parts.
In part one we looked at theory – the different ideologies as to what the ‘therapeutic position’ should be and how I had tried to resolve this dilemma for myself by conducting humanistic research with a group of trauma therapists, trying to work therapeutically in settings that were multiply intruded upon.
In part two we had the opportunity to reflect on our own experiences of safe therapeutic space being threatened and protected.
And in part three, I shared the findings from my research study which revealed how trauma therapists protect safe therapeutic space, what it costs them and the implications for all therapists in practice.
Effective, sensitive therapy is careful not to take the client beyond their zone of tolerance. A therapeutic frame is held - marking boundaries of time, place and ethical behaviour that all contribute to this sense of safety.
A large part of a therapist’s work involves defending these boundaries from interpersonal and intrapersonal attacks. Traumatic material does not stay conveniently located in our client’s pasts, but continues to disrupt their lives in the present in all sorts of ways.
Chu (1998) describes the kind of intrapsychic and interpersonal intrusions into therapy that can result.
“repeated unpredictable reexperiences of traumatic events accompanied by despair and panic”; “intense impulses, often of a destructive nature, that feel compelling and overwhelming”; crises that lead the clients “to seek increasing amounts of reassurance and time from their therapists”; and tendencies to “re-enact abuse related interpersonal dynamics in the therapeutic relationship” (Chu 1998 p.132-133).
Most psychotherapists are trained to work with this sort of material that routinely threatens therapeutic space. The kinds of oppressive intrusion I wanted to look at in this workshop were not so much these interpersonal and intrapsychic intrusions, but what have been called ‘meta intrusions’.
Meta intrusions were described by Dick Blackwell (2007) as the social, economic, religious and cultural forces that seem to have the power to undermine and sabotage therapy completely.
Dick Blackwell worked at the Medical Foundation for the Treatment of Victims of Torture. Many of his clients were asylum seekers waiting to see if their refugee status would be approved. If it were not, then they faced the real possibility of being returned to the countries where they had already been tortured. Blackwell movingly describes how he struggled in working therapeutically with this client group…what on earth could he offer them as a therapist?
Even more extreme pressures exist for therapists who work in the same traumatic settings as their clients, such as Vucho (2002) who worked in the former Yugoslavia at the time of the Bosnian war.
“ Sometimes sitting and talking with patients about their problems struck me as completely useless and insane while nearby…people were disappearing or being killed simply because they belonged to another nation…However, the fact that my patients had endured the bombing and other misfortunes better than ‘normal’ people helped me to continue with my work.” (Vucho 2002: 70)
My own professional dilemmas as a psychotherapist and supervisor in the NHS were embarrassingly mild compared to these examples, and yet from about 2007 onwards, I still found my therapeutic and supervision practice increasingly intruded upon by social, economic and political forces…strong enough to make me wonder how I could protect clients and supervisees from their sabotaging effects.
Here are some examples:
Lengths of therapy in the NHS for complex trauma cut from 2 years to 20 weeks and for counselling and CBT 12 sessions to 6 sessions.
NICE recommended therapies narrowing the range of therapeutic options.
Stepped Care IAPT services impacting upon teams, use of rooms, supervision arrangements, and reflective space
The introduction of minimum data sets requiring patients to fill in questionnaires at every session.
Computer databases replacing paper files, computer notes being shared across services, threatening confidentiality.
The possibility of Statutory Regulation and protected titles limiting who could call themselves a psychotherapist.
Confidentiality diluted due to litigation and medico legal concerns.
The introduction of the 30 minute therapy session.
New GP Commissioning laws leading to a focus on short term, lower level and cheaper interventions provided by trainee and junior staff and phasing out of longer term, complex treatments offered by more experienced and more qualified staff.
The traditional therapeutic space seemed to be coming under sustained attack from a variety of sources. So I decided to turn my dilemma into a research question:
At first I formed the question provocatively as follows:
…Is psychotherapy possible in an immoral environment?
I think from this one can deduce how I felt about the situation. However, my research question gradually changed into the much more constructive:
…How do trauma therapists protect the therapeutic milieu?
Most therapy trainings are squeamish about admitting that therapists as well as their clients may be oppressed in their work settings. Advice is usually limited to guidance on work-life balance and self care and maintaining training. But some environments see self care regimes as ‘precious’ and have no budgets for training, and expect their therapists to carry heavy caseloads with little reflective supervision.
I found that the literature on this area was split ideologically over whether therapists should maintain a neutral position or take a stance when experiencing oppression.
The classical position is that of neutrality, offering interpretations so that the client can reflect on and deeply understand their situation. However, many researchers and therapists believe that therapeutic neutrality is impossible and that therapists as well as clients are overwhelmed by the dominant discourses of society (Portuges 2009). Others, like Prillelltesky (2008) believe the best we can offer is a reflective practice, acknowledging our positions. This was a position held by Blackwell, the therapist working with refugees, who saw both therapist and client positioned historically, politically, and culturally but engaged in a dialectic in which one was trying to heal the other. Blackwell described the need to enter and understand the client’s world whilst being able to live in one’s own world and reflect upon and critique both.
At the other extreme, there were the Testimony Therapists like Cienfuegos and Monelli (1982) in South America who advocated on behalf of their patients, recording witness statements of torture and making them available to Human Rights Courts or adapting them to a healing form of community theatre.
Judith Herman (1997) who has claimed that both sexual and combat trauma are the outcomes of the same socio-political dynamics, clearly stated that:
“…moral neutrality in the conflict between victim and perpetrator is not an option. Like all other bystanders, therapists are sometimes forced to take sides” (Herman 1997 p 247).
But is that really true? Are we as therapists really like all other bystanders? Or do we have an importantly different job to do?
I also discovered that the term ‘Therapeutic space’ was not as straight forward as I had thought. It is usually used to denote a ‘psychic envelope’ which can have an inside and an outside and contains psychic objects. Social geographers had discovered that most therapists agreed on what they meant by the term, but the term itself was paradoxical because safe therapeutic space evoked the idea of a boundary being held but also a place where taboos, secrets and other boundaries might be challenged.
In the course of my research I also explored such concepts as
The ‘deviant frame,’
The therapeutic relationship and the core conditions,
Whistleblowing and resilience.
Lastly I read everything I could by trauma therapists working in extreme situations to find out how they protected the therapeutic space.
What did I discover?
I learnt to appreciate the almost magical value of reframing, that process of taking a situation and exploring it to find new angles, opportunities and resources hidden within it.
I learnt about the importance of
establishing a focus for the work, when time is short.
The importance of reflective time so as to be able to keep one’s clients in mind, if we are able to keep our clients in mind then they too can learn to keep themselves in mind, to care about themselves.
Regular training keeps one not only up to date but challenged and stimulated.
Regular supervision ensures again that we are gently nudged if our work becomes lazy or drifts into areas that verge on collusion with the client, or indeed intrusive forces that jeopardise the client’s safety.
Lastly, the importance of a meaningful life of one’s own in addition to the therapeutic practice.
All of these were revealed as helpful in empowering therapists.
Why Humanistic Research?
I would now like to say a few words about why I used the humanistic research methodology known as Heuristics.
As I was studying issues of freedom and oppression it would be important that the methodology was sensitive to the issues, as non oppressive and encouraging as much freedom in the responses as possible. I wanted to use a reflexive approach that would produce a deep and universal depiction of the phenomenon of safe therapeutic space, it being threatened and protected. I chose heuristic enquiry because it allows all kinds of data to be included in the analysis, and its approach is deeply respectful of the individual experiences and narratives of the research participants, or as they are known in heuristic research, co researchers.
Sometimes we know something is important, without being able to explain why, just as we can recognise a face, but cannot say how. This is described by Polanyi as tacit knowledge of the essence of things (Polanyi, 1983 P.4). The phenomenological approach to psychological research invites us to drop preconceptions and return to this tacit knowledge of things so that we may understand their nature more deeply and Heuristics offers a way of making tacit knowledge more explicit.
“The root meaning of heuristic comes from the Greek word heuriskein meaning to discover or to find. It refers to a process of internal search through which one discovers the nature and meaning of experience and develops methods and procedures for further investigation and analysis. The self of the researcher is present throughout the process and, while understanding the phenomenon in increasing depth, the researcher also experiences growing self awareness and self knowledge. “
(Moustakas, 1994, p.17).
This is why beginning heuristic analysis of the ‘preoccupying question’ is like swimming into an unknown current (Moustakas 1990, p.13) as there is no way of predicting the outcome.
In order to research this area I needed to recruit some very experienced trauma therapists. 6 trauma therapists were recruited for the study; one had to withdraw due to boundary issues. 5 women and one man. Approaches included gestalt, psychoanalytic Jungian and Discursive, EMDR, EFT, CBT, Integrative, humanistic, psycho synthesis and biodynamic. The therapists worked with adults and children. In settings including private practice, NHS, prisons, day centres, drug treatment centres, child protection teams and crisis teams. Some worked in the UK some on the continent, 5 were UK nationals and one Eastern European.
The interviews with the therapists were texturally and structurally analysed before being combined into a composite synthesis of the phenomenon of protecting safe therapeutic space. .
Textural analysis presents images, thoughts, feelings and struggles in a way that is as true to the original voices as possible. All relevant nonrepetitive and non overlapping statements are listed. These are the meaning units. They are clustered into themes and used to create the texture of the experience.
The resulting textural description is then analysed for its invisible and implicit dynamics. This produces structure (Moustakas 1990).
The endpoint of heuristic research should be a detailed composite depiction, faithful to the original descriptions (Moustakas 1994p. 18) and conveying the universality and deep essence (Polanyi 1964) of the phenomenon, with essence defined by Husserl as “the condition or quality without which a thing would not be what it is” (Husserl, 1931 p.43).
(These composite syntheses were reproduced and pinned up on flip charts at various points in the room. The workshop then invited participants to reflect upon their own experiences of these things and to write or draw representations of their reflections on sticky notes that were put up around the room for all to read and ponder upon).
How do Trauma Therapists protect the safe therapeutic space?
The following texts in blue are the composite synthesis of all the researched therapists’ replies. They make up a description which aims to represent the essence of the experience of safe therapeutic space being protected.
Experience of safe space
Truth emerges as a vital element allowing freedom to be oneself. Any emotion is possible and one is not punished for speaking the truth. One feels listened to, wanted, valued and validated. This makes one feel ‘calm and warm in one’s heart’, and the body feels relaxed and aligned, ’true’. It is a relief to be heard and challenged gently. There is warmth of connection, rapport and compassion. Sometimes this experience is tinged with sadness because it feels so rare.
Effects of intrusions on therapeutic space
Intrusions may feel like an invasion, a conflict in which therapists feel pulled in many directions or they may be a spur to creativity. Internal intrusions such as emotions, body or spiritual experiences may be viewed as threats when they are a normal part of life. External intrusions that distort the frame are experienced as oppressive, and alter the ethic of empowerment that exists in authentic therapy. This situation is like ‘therapist and client working in a cage.’ Unsafe space results from a loss of connection between client and therapist, the therapist’s attention being distracted and the therapeutic intention wavering. Overwhelming intrusions distort the task, ethics, space and time boundaries. This alienates therapist and client and the protective membrane is pierced.
Experience of unsafe space
Unsafe space feels contaminated and profane. A chaotic environment of abuse and neglect, resonating with memories of past abuse. Unsafe space feels malevolent. People describe feeling inhuman, machine like and mechanical. There is a constant sense of hurry. Rooms are cold, noisy, exposed and poorly maintained. Therapists feel incongruent and guilty for engaging in processes that oppress others. Therapists feel spread thin in their attempts to protect the space. Clients are mute or chatter about nothing. Clients feel unwanted, unheard, misunderstood and excluded. Clients feel trapped and want to escape, or try to hide themselves. Unsafe space evokes anxiety, fear, stomach knotting around the navel, experiences of dark alien objects intruding into the body, and the body feeling out of alignment, out of true. Life feels pointless. One has to hide oneself or lose one’s soul.
Protecting safe therapeutic space
Protecting the therapeutic milieu is a normal part of therapy. ‘Holding the frame’ is a discipline requiring constant vigilance. It is like ‘tilling the soil and enriching it with nutrients, so it becomes a place where someone can develop and grow.’
Protecting the therapeutic milieu entails working to values and ethics. These are expressed by how we treat people. Ethical practice ensures therapists work to the best interests of the client. Therapist’s values are tested when resisting external threats is risky. Therapists might be required to fight for what matters, making full use of their free will and courage.
If a space can be loved and taken care of then so might a person. Safe spaces are consistently described as quiet, private, warm, comfortable, relaxing, pleasant, with objects of beauty, well maintained and clean. Chairs are firm, supporting and positioned to respect personal space. Working in larger rooms in reputable locations reinforces the trustworthy message. Through rituals of care, safe space is created and maintained.
It is possible to do trauma therapy in the most compromised of therapeutic milieu. However, sustaining a therapeutic connection becomes increasingly demanding of the therapist’s resources, the more they have to adjust for intrusions. This can lead to burn out. Safe therapeutic space is not only healing for clients but also protects therapists.
The findings of the research
Safe therapeutic space is protected by three main factors under which all the other protections can be subsumed.
The Therapist’s Knowledge of the work
The Therapist’s Knowledge of self
The Therapist’s ethical standards and willingness to hold the frame
These three factors provide the frame for the work of psychotherapy and whether the space is safe or not depends upon how this frame is held and maintained by the therapist.
The therapist has to be willing to defend the frame from intrusions and from forces that seek to sabotage it.
The forces that are particularly intrusive are those oppressive forces that behave unethically. For example, putting profit before patient care or the reputation of an institution before authenticity and honesty towards clients. (Eg. labelling patients who do not respond to inappropriate short term therapies ‘treatment resistant’ as happens in some IAPT services, is not only psychologically damaging to the patient, it is a lie).
When therapists defend the frame against oppressive forces they must expect to be attacked, scapegoated and demonised. This research revealed that some therapists, in order to protect the safe therapeutic space, have had to go underground.
One way therapists can protect themselves is to ensure that their professional organisations set optimum and minimum ethical standards. That we support our colleagues who try to maintain those standards, and that we build our own ethical resilience by training ourselves in what constitutes ethical practice… always reflecting on our work, admit ting our mistakes and being willing to learn.
My own position is that if the frame of psychotherapy is not protected, then it actually becomes something else. You can call it psychotherapy but the clients know deep down if it is really a safe therapeutic space or not, and if it is not they will vote with their feet or hide until it is safe for their true selves to emerge.
Implications of the research and effects on co researchers.
This research concluded that whilst therapists can protect safe space up to a point, there are some settings where therapy is impossible either because there are too many intrusions or because the nature of the intrusions corrupts the frame too much to make it safe, and the therapist is overwhelmed in those settings. These findings corroborate those of Forster (2004) who concluded that for example, real psychotherapy within the NHS was impossible because clinicians had already compromised too much. Price and Paley (2008) concluded that therapists had to be assertive to protect their space and this was easier for more senior clinicians.
Studies of whistleblowing and corporate organisational psychology reveal that assertive staff will come under attack. So they need protection from their professional associations and colleagues. One way of protecting those who try to hold the frame is to encourage organisations to sign up to meaningful ethical standards. One example is set by Sandra Bloom in USA who developed the Sanctuary Model. This sets out a code for nonviolent and nonoppressive practice and institutions including hospitals can sign up to these values. Bloom’s research (2005) has revealed that hospital wards that work to the sanctuary model have lower incidents of self harming and violence than wards that do not.
Strong ethical standards also prevent reframing a situation from becoming ‘spin’. For example, a patient may be referred for trauma therapy but can only receive very short term interventions due to lack of funding. An ethical assessment would make it clear that short term therapy can offer a formulation and perhaps some skills in self soothing and modulating arousal. It will not be able to process the trauma memories or support the patient to consolidate new patterns. It is important to be honest about what treatments can achieve; this honesty keeps the therapeutic space safe.
How did the research affect me? In many ways, these are just a few…
1. Strengthening boundaries of therapy with clients and recontracting where boundaries were unclear.
2. Rebooking rooms, altering times and organising refreshments to protect peer supervision from intrusions.
3. Deepened commitment to a reflective practice group where these and other issues were discussed.
4. Revised agenda for reflective practice group ensuring that it would not be minuted or become a business forum.
5. Reduced working hours in a highly ‘threatened’ setting in order to increase hours in a more ‘boundaried’ setting.
6. Renegotiated brief work and what could reasonably be achieved in the time.
7. Turned down work that could not be renegotiated within ethical boundaries.
8. Clearer sense of professional identity.
I noticed after the research that I was a lot more confident with my supervisees about clarifying the focus of their work with patients and I felt more comfortable about drawing lines between what I could support and what I could not. Paradoxically, my strict approach to boundaries has actually led to me getting more, not less work, as supervisees have sought me out. Because I have set out very clear boundaries at the beginning of supervision I have also been spared the stress of working with clinicians who are not able or willing to protect the therapeutic frame as they find my approach too challenging.
Lastly, learning about how protecting the ethical frame inevitably leads to conflict with vested interests, this helped me to put my own struggles into perspective and has been very useful in therapy with trauma patients experiencing oppression. I have been able to share this knowledge with patients - how these powerful socioeconomic and political forces operate and this has helped to empower them, to feel less of a victim and to understand their position within these powerful cultural patterns.
The co researchers generally reported that they found the research process thought provoking and empowering. Toni found that the research confirmed her in her practice and she was able as a result of the research involvement to tackle some difficult boundary issues coming up in her own rural practice, by doing this she felt she made her practice much safer for herself and her patients. Mathilde in particular found herself questioning how she was working and soon after the research finished, she changed her job.
This is the email she sent ……I think it illustrates really well what ‘freedom’ feels like…
Hi Jessica 26 October 2010
I am sorry I haven’t replied earlier, it has been a rather busy few weeks!
I hope all is well with your dissertation – thanks for the summary, very interesting!
I just wanted to comment that the interview with you has helped me to better clarify my own therapeutic values and my personal ethos of therapy, and has contributed to my decision to ditch my …….job – which I joyfully did in September - I now work part time for …………… as a therapist with their staff support team – it is a safe, healing and peaceful; environment (in comparison to the ‘police state’ of my last job) , my line manager is a gentle angel (an experienced therapist and also a trained shaman!) and I absolutely love the job – I feel safe , valued, appreciated and hope that this reflects on my clients too. Thanks very much for including me in your work!
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