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Ceyda Senel Tekin

University of Oxford, Certificate Program In Psychodynamic Studies

I would like to write about a patient, who I observed together with my supervisor when I was doing my training in a university hospital. The therapy room was comfortably furnished with armchairs and a small table. It was situated in a quite area of the building where there were no extra noises, outside the door there was a "Do not disturb " sign. And my supervisor told the department secretary not to connect any calls during the session. There was a box of tissues on the table in case the client became emotionally upset or tearful during the therapy. My job was to observe the session and not to interfere.

Alice was a beautiful girl of sixteen years of age. I first saw her when she entered the therapy room. With her long and clean hair she looked casual in her jeans and a T-shirt. She had no make up on. She seemed quite hesitant and I thought that she tried hard to smile. She was leaning forward, trying to escape eye contact with me and my supervisor. Her body language suggested that she was quite vulnerable. She was living with her parents and her six year old brother. She had two older sisters who were both married. Her mother was a schizophrenic and she could not take care of the house therefore Alice did all the washing and cleaning. In addition to this she was dealing with her younger brother, and going to school as well. Her father was an alcoholic and he worked on and off. When she first came to therapy she was suffering from severe depression and she had suicidal thoughts. She had attempted suicide twice and after that she decided to seek help. When I first saw her and listened to her complaints, I thought she was just stressed because of her workload and her mother's situation [my natural assessment]. But this turned out not to be true. Later in the session, when she was talking about her father she started to cry. She was extremely upset and vulnerable. After she was done crying there was a long silence that lasted fifteen minutes. In my counter transference like response, I was quite moved and saddened by her desperate cry and also anxious to hear what she was going to say. Her silence made me very uncomfortable. I glanced at my supervisor, perhaps hoping that he might intervene and try to ease Alice pain. In sharp contrast to my expectation my supervisor was very calm and seemed untouched by her story and was not about to make a move. She then started to talk about her relationship with her parents.

I

Client: " My father is an alcoholic and when he drinks his behaviours change. I really hate him when he drinks. He does very bad things to my brother and me. He is just six years old." (After a short silence she continues.)

" One day he was drinking again and watching television when I entered the room and sat next to him. And he started to touch my legs. I was very scared and ashamed but I couldn't say anything, I couldn't even move. At first I thought that it was just an innocent touch because I knew that he loved me as his daughter. After I realized that it wasn't an innocent touch, I ran away from the room. It is very shameful to talk about it but I can't stand anymore to keep this secret. But I think I have to finish the entire story. Last year my father and I went to our summer-house to bring some goods to where we live right now. It was getting dark and we decided to spend the night there. He was drunk that night and he wanted me to sleep with him in the same bed where he used to sleep with my mother. I rejected him. But he insisted. And it was the worst experience I have ever had in my life before".

What I had heard from Alice shocked me and it became painful to listen any longer. But on the other hand I felt that she was very brave to tell her story to us. I was desperate to help her but did not know what to do. I found my supervisor nodding his head and I thought that his behaviour was quite helpful in reaching out to Alice and easing her shame.

After a short silence my supervisor the following conversation took place between my supervisor and Alice.

Therapist: I imagine it is very difficult for you to be here and to share your experience with us I wonder what is going on with you right now?

[ I thought that this question was unnecessary because he did not allow sufficient time for her to relax after what she has gone through in conveying her painful story. I also felt quite uncomfortable to be actively included to the picture by my supervisor's use of the word us in his question. In the beginning of the session Alice was asked if she would be comfortable with my presence and she accepted me as an observer. In retrospect I find it quite wrong to sit in a session as an observer but at the time I considered this opportunity invaluable. When my supervisor acknowledged my existence by using the word us I thought that Alice would misinterpret this. It turned out that I was right in my discomfort and in a later session Alice asked if I was the girlfriend of the therapist.]

C: I don't know maybe mixed feelings. Should I trust you? Because I made a mistake once and I don't want to do it again.

T: what do you mean by mistake Alice?

C: "To trust my own father. That night my father had anal intercourse with me. But I could have stopped it" (She was very upset and near to tears she was leaning slightly forward and her head was down). [I felt that she was accusing herself and I barely contained myself to refute her]

T: How did you feel when that happened?

C: LOST! (She screamed.) [ I felt that this question was rather unnecessary and clearly it did not lead to a positive consequence. Alice revealed her story sufficiently clearly and no more explanation from her on how she felt would be needed.

T: Alice you said your sisters are married did I get right?

C: Yes poor them he did the same things to them as well. Do you understand why they got married?

T: How do you know that?

C: Because they told me. But this is not the entire story. Oh. My little love (silence) he didn't survive from his abuse like us. Can you believe he is just six years old? (She was angry and tensed. She closed her eyes to avoid eye contact and was leaning back in her chair. )

After that session my supervisor sent her to another unit in the hospital.

Now I want to talk about what I observed in this case. First I think the most important issue here is her suicidal thoughts. What should I do if I experience a case like this? How can I help the client? As I mentioned before Alice attempted suicide several times. In the beginning of the therapy she was severely depressed and at once she said that " I really don't want to live anymore".

I think suicide is an aggressive act. It is aggressive to the person who takes her own life and it is aggressive towards the person who is left behind. (In this case towards Alice's father). The most important thing, which the counsellor can offer to a suicidal client, is a safe and accepting environment in which she can express her worst fears and concerns. [With regard to Alice's case it seems to me that my supervisor could have been a bit more careful in some if his questions which I thought would create some doubts in Alice about the safety of the environment]. The other important issue here is to remember that clients who feel desperate sometimes talk about suicide in oblique terms which may be difficult to decipher, unless direct questions are clearly asked. (I will talk about questioning later).

If a client attempted suicide previously or has suicidal thoughts the short-term management is more important then the long term. Because he/she needs immediate help to deal with immediate problems. In Alice's case she was deeply distressed and she neglected her own welfare. I think she should have been told to take care of herself, to eat properly and to get more sleep and rest. Because she looked extremely tired and emotionally drained it would have been helpful if the therapist gained control over the situation. I felt that my supervisor did not pay enough attention on her suicidal thoughts. I think Alice felt alone and held a great deal of unexpressed, anger resentment and frustration towards herself and towards her father as well. Presumably those suicide attempts meant -" I will make him see what he has done to me. I will make him sorry". In this situation what should one do as a counsellor? Probably we should be direct and say, " Are you saying that you are having thoughts of killing yourself? "Without trying to change or direct her thoughts about suicide we should try to explore her relationships or the problems she is experiencing Me should be empathetic and we should give the client a sense that what she is revealing is acceptable and that we are able to hear and contain it neither by shock nor overwhelmed by it. In my case Alice was always accusing herself about what has happened to her and to her family. She was angry with herself for "allowing" the injustices to happen to her. I think she has learned first hand those adults and other people are untrustworthy, cruel and unpredictable. I think trust is a very important and a vital issue with most people who have experienced abuse of any kind; especially when the abuse was sexual. Those who have been abused physically, emotionally and sexually are likely to hesitate in trusting those whom they regard as in a role of authority including a counsellor. The victims of abuse especially children and adolescent often have to rely on the people who abuse them to care for them in fundamental ways. Alice was a teenager who had to stay with her parents because she wasn't working and she didn't have any relations or anybody to look after her and her little brother. And the result is a quite confusing dynamic between loving and hating the abuser. (Her father). It would be difficult to trust a warm positive regard from the therapist. The client who has been humiliated and abused can, without discrimination, assume everybody to be untrustworthy.

Now I would like to talk about the importance of listening to the client. Listening is an active process through which we hope to be allowed to see into the other person's world and help her/him explore it. Active listening is very important. If we are not actively listening it is impossible to be helpful. Active listening means paying attention and trying to understand the thoughts, feelings and behaviour of the other person. Sometimes a client who finds it difficult to come for a counselling needs to know that what she will say will be listened with respect and attention. Giving reflection is important, we should give the message to the client that " I'm listening carefully to what you are saying and I'm trying to understand. I will demonstrate this to you now that I heard what you said. Did I get right? " The other important issue here in listening is being non-judgemental. In my case my supervisor dealt with this issue properly. He wasn't just sitting and being silently nonjudgemental, he was somehow letting her know that he was being non-judgemental. I had a very interesting experience while I was listening Alice, I thought how would I respond what she was saying? And at that moment I stopped listening to her and I knew that I shouldn't have done that. But it was an uncontrolled thought.

As a bad example of listening a therapist can be preoccupied with herself and her needs in such a way that she is kept from listening fully to her clients. As therapists, sometimes we may feel sick and tired or there may be social or cultural differences between the client and us and so we might fall to listen carefully. It is also probable that a client's problem will damage our listening ability. Extra noises, interruptions, discomfort, emotions like anger, anxiety and sadness can also obstruct our ability to listening. "Active listening

language our own and our client. As a helper our behaviour and our body language needs to facilitate the helping relationship; we may display signs of non-attention for example looking bored, fidgeting and checking around. Besides, our posture reveals the degree of interest we have in the client. My supervisor and I were sitting next to each other and the client was facing us. My supervisor was very relaxed and attentive. But I was a bit uncomfortable with the situation because it was very hard for me to hear her story, I was sitting back and my legs were crossed: later I realized that I was sending I negative signals towards her (Alice). And she might have thought that I was less open to her and in some way I was protecting myself. On the other hand if we look at her posture from beginning of the therapy she was avoiding eye contact because she was experiencing feelings of shame and guilt. Facial expressions are also quite important. Our faces can convey our innermost thoughts and feelings. The first impressions we get of other people are usually based on observations on their face. We can understand what the client is experiencing in therapeutic relationship through her facial expressions, which may register anger, sadness, and vulnerability.

Besides all these non-verbal communications, silence plays a vital role in therapeutic relations, because during these periods, important connections are made mentally. As counsellors we should respect that client may need silence, and we should stay with the client and we should resist breaking it. In the therapy session with Alice bearing her silence was really very difficult for me. We are not used to silence in our everyday life. Sound is all around us. On the other hand emotions experienced during a period of silence, for example anger, may help the client to access the material which they are avoiding or are unaware of. Transferential material may come to surface and we (as therapists) may 'become' the abusive parent and the client distances herself emotionally from the offender by means of silence. What Alice experienced was extremely awful. If we put ourselves in her shoes we can understand her better. This brings us to the other important of issue being empathetic. It means to make effort to see the world of another person through his/here eyes to sense their experience, to feel their pain. No matter how different from our own we should try to understand the client's reality. It is quite difficult but it is vital part of helping. But we

should not lose ourselves in our client's material. It is important that we retain our own sense of self. Carl Rogers describes empathy as the ability to sense the clients world as if it were our own without loosing the as if quality. [2]

We cannot actually put ourselves into the client's world. We can never experience the same the thing as client even if we have a similar experience. We will not feel exactly the same about it. But we should be able to understand him/her. In order to sustain a proper balance of the relationship we can not let ourselves to be overwhelmed by the client's emotions. The client needs to believe that the therapist is strong enough to bear and hear what he/she will bring to the therapy. A capable therapist as well as a supporting and accepting one will be able to construct a healthy relationship with the client. In 1946 Rogers expressed his findings that helping is more effective when " the more completely the counsellor concentrates upon trying to understand the client as the client sees himself. If we can provide understanding of the way the client seems to himself at this moment he can do the rest. The therapist must concentrate on one purpose only; that of providing understanding and acceptance of the attitudes consciously hold at this moment by the client as he explores step by step into the dangerous area that he has been denying to consciousness."

Empathy is not just listening or sensing what is going on in the client's world. In order to be effective in a therapeutic relationship empathy has to be communicated to the client. There are two stages to of empathy; in the first stage the world of the client should be sensed and understood and in the second stage this understanding should be reflected to the client, making sure that what she described /experienced is well perceived.

It is worth noting that there is a difference between empathy and sympathy; the latter being more superficial. In the case of Alice one can say that " Poor girl! She has a lot of problems to deal with". This might show sympathy but a more helpful expression would be " I understand that it is hard for you to cope with all your problems by yourself. But we will go through this together." Empathy requires effort and a genuine desire to understand. However sympathy involves feeling sorry for the client.

Finally to summarize empathy, we should attend carefully both physically and psychologically and listen to the clients points of view. We have to listen both verbally and non-verbally. And we should be careful with our response. We should response fairly frequently but briefly to the client's message. We should move gradually to the exploration of sensitive topics. In the case of Alice my supervisor asked some warm and empathic questions like " I imagine it is very difficult for you to be here and to share your experience.

Transference is one of the most important issues in psychotherapy. The displacement of patterns of feelings, thoughts and behaviour originally experienced in relation to significant figures during childhood onto a person involved in a current relationship. The therapist can represent a significant figure from the client's past; particularly a parental figure. My supervisor was a male therapist and it was very difficult for Alice to talk about her intimate feelings and experiences. Alice suffered sexual abuse from her father. She might have transferred her anger, guilt and fear towards the therapist. I infer this from her aggressive way of answering the therapist's questions and from her non-verbal communication. She hesitated in trusting the therapist. [After the end of a therapy session I had chat with Alice and found out that she loved the movie "Leon". This movie is about teenager girl ( Matilda ) whose family is killed by corrupt police officers who deal with narcotics. Matilda does not care much about the death of her father, mother and older sister but is shattered by the death of her younger brother. From being killed by the police she is saved by a professional assassin named Leon who happens to be living in a near by apartment. Matilda and Leon start to live together. Matilda than thinks that she has fallen in love with Leon who is a middle aged man. Alice, I thought identified herself with Matilda. When I told her that I also enjoyed the movie and also purchased the sound-track she wanted to borrow the sound-track from me. Even though anymore interaction between Alice and myself seemed rather inappropriate , I could not help fearing that she would feel unaccepted or rejected. [She quite easily might have fantasized me as a mother figure who could not provide warm feelings towards her if I failed to do she wanted.]

When the client experiences anxiety in the presence of the therapist with whom they are now involved in the transference, the therapist must discuss this with them. The therapist should help the client to learn the source of the experienced conflicts. On the other hand what are our feelings and attitudes relationship. Although like transference they are initially unconscious, we may notice shifts in our emotions and inner responses with regard to the client. Counter-transference may be very helpful it provides insight to us into the problems of the client that perhaps otherwise go unrecognized. We, should ask ourselves "Why do I feel like that?" It gives us to opportunity to explore these feelings further.

Now I would like to speak about defenses, which Alice used in the session. The one, which is quite obvious, was resistance. This can be demonstrated in several ways for example by being late for sessions, by missing sessions and by denial when the counsellor made observations and interpretations. Alice showed us resistance by being silent in first sight. Defenses are mentally armouring that protect the individual threatening feelings. Alice needed reasons to let her defense down; she needed to feel safe, accepted and understood and to be able to trust the counsellor to explore painful issues with him. What I observed as an other defense mechanism, which she used, was Rationalization, "He loves me because I'm his daughter ". To put simply Rationalization is a process by which undesirable or disturbing facts about the self or the behaviour is concealed by superficially logical sounding explanations. The reasons, which are given, not the real reasons but is, designed to protect the individual from painful reality.

To summarize, I have presented my experience of a case from which I have learned quite a number of things with regard to therapy. Even though I was not allowed to ask any questions and interfere the session, I would like to think that I got the flavour of what goes on in a therapy session. I should admit that it is quite a difficult job to pay constant attention to the client and not to be overwhelmed by what she had experienced. During the session I found myself full of anger towards Alice's father and had hard time to keep quite about it. And quite often my sadness aroused to a level that I had to resist not hugging her and comforting her. Now that I am learning the details of a balanced relationship in a therapy, I can see that these behaviours would have been quite unprofessional. As we can see from the case of Alice that the clients who seek help can be quite vulnerable and in the hands of a therapist who is less than understanding, emphatic, patient and capable, very delicate balances of therapeutic relationship cannot be maintained. The consequences of this on the client would be traumatic. Especially in the case of teenager clients with suicidal thoughts, like Alice, any wrongdoing, e.g. an ill-timed question or aggressive behaviour of the therapist, might render the therapy useless and bring more emotional damage to the client.

To conclude, counter-t ran sference, which I alluded to above, is at the heart of a healthy Therapeutic relationship. The client's problems can induce a large spectrum of feelings for the counsellor. The counsellor should make sure that these feelings do not contaminate the relationship and obstruct her from reaching out to her client to be used positively. To resolve potential problems of this kind the counsellor might need supervision, self- development and personal counselling.

REFERENCES

I)Egan, G. (1990) The -skilled helper. Monterey, Cole/Brookes

2)Rogers, C.R. (1957) The necessary and sufficient conditions of therapeutic personality change. Journal of consulting Psychology.

3)Milne, A. (1999) Teach yourself counselling. Contemporary Publishing.

4)Hough M. (1996) Counselling skills. London, Longman.

5)Sanders, P. (1994) First step in counselling. Manchester, PCCS Books .

6)Frankland, A. and Sanders P. (1995) Next step in counselling.

Manchester, PCCS Books.

INCEST CASE