The National Council of Psychotherapists
A disturbing case history – discussion
(Names have been changed and artistic license used to protect confidentiality)
This case study contains some unique characteristics and could also be subtitled ‘a swipe at a certain kind of therapy’
This case concerns Sharon - a 24-year-old in full time employment, who at the time of consultation had already been off work for about 8 weeks due to stress and depression.
She had recently been promoted at her work. Following the promotion she found herself working under a new dept head who in her own words “was a bit of a bully”.
Sharon revealed that she had been bullied at school from between the ages of 12 to 14, one incident involving a serious assault by a mob when she was held down by a group of girls and stripped in front of a group of boys – she was rescued by a passing adult.
Sharon had a history of depression and had previously undergone treatment for anxiety by hypnotherapy, having had twice-weekly sessions for about 4 months, (by my calculations 32 sessions).
I inquired about the process employed and approach adopted by the earlier therapist.
Hypnosis was used (and not very well) as an aid to relaxation and recall but otherwise I would have described the therapy provided as a crude attempt at desensitisation treatment.
The sessions were run along the lines of “think about it and get it all out”.
When asked how the therapy concluded Sharon said it was the therapists decision to bring the sessions to an end because in their view she was ‘cured’ and needed to overcome ‘transference’ in order for it (the cure) to become apparent to her!!!
No attempt was made to explain either what evidence there was of either a ‘cure’ nor was ‘transference’ explained.
I think the manual in this case was probably written circa 1852.
At the initial session Sharon’s presenting symptoms were anxiety and debilitating panic attacks against a history of depressive episodes. It was interesting to note that panic attacks did not feature in the presenting symptoms prior to her earlier ‘treatment’ and ‘cure’. Although taking anti-depressant medication there was no other pathology.
The panic attacks were reported to be at the rate of about one a day in the last 3 weeks, although she also reported that she had, prior to this, began to experience ‘environmental’ panic attacks, if she had to phone work or if she tried to join a crowd of people were the two main examples.
She had been experiencing panic attacks for about 12 months and they began about half way through her earlier course of treatment.
Her earlier therapist had confidently explained that this was an expected development and that she should expect to feel worse before getting better. I was already having concerns about this earlier treatment but this latest revelation raised them to a new level. My concerns were further raised when Sharon confided in me that she felt that she had somehow let down her previous therapist but not getting better ‘as she should’ and that she ‘must have done something wrong’!
After the initial interview there was plenty of evidence to support the view that the combination of the stress surrounding the recent promotion, the new ‘bullying’ dept head and the recent termination (not to mention the ‘treatment’ itself) of an earlier therapeutic relationship were in combination sufficient to trigger the reported increase in anxiety levels which were taking the form of increased panic attacks. Added to that there was now job insecurity due to her extended absence from work.
Decades of experience of working with traumatised individuals have shown that very often a key to helping them manage, then overcome their problems is what I call real knowledge. The role of memory, pattern matching, what really happens during stress, how to predict and prevent panic attacks etc are all explained in a first session.
Following this method I began by providing Sharon with information on stress and depression and in particular traumatic stress, the role of memory and emphasising the difference between an active traumatic memory and an unpleasant memory (which is what a detraumatised memory becomes). By the end of a first session with me most of my clients could hold their own in conversations on the dynamics of traumatic stress with the best of them.
Quite often, before any therapeutic techniques are employed, clients begin to feel empowered by the knowledge which explains to them in easy to understand terms that given their circumstances, what they are experiencing is normal and predictable. Because of this any associated problems that are ongoing can be approached methodically and with confidence that the client will be able to overcome them.
(As an aside during one telephone consultation this year another lady broke down in tears after my explanation because she had up to that point feared that she was going mad! Paradoxically this view had been reinforced by well meaning therapists she had previously spoken to by offering her ‘treatment’ and telling her how many session she should plan for – in other words reinforcing the ‘I’m going mad view’).
In this case knowledge really is power – once people understand the process involved in detraumatising (and I want to emphasise here that I differentiate this from desensitisation simply because of what some other therapists have done with it!) then a way forward opens for them which makes for a win win situation.
The therapist has a co-operative and optimistic (or at least less pessimistic) client and the client begins the work with clear and defined goals. Therapeutic mumbo jumbo is dumped in favour of plain English and a working model that the client can actually understand. There was a twist to this case however, explained in the next paragraphs:
At the end of the first session Sharon was a bit confused that we had not spent much more time taking about the actual feelings associated with the incidents themselves, her expectations of what therapy should be having been shaped by her earlier experiences.
I explained that different therapists had different approaches and that I was confident that another approach would be more beneficial for her at this point. Despite being fairly shock proof by this point what I was told next did make my blood boil just a little bit.
Apparently Sharon had been told by her earlier therapist that the treatment she was being offered by them was ‘standard’ and that there was no point in going somewhere else because ‘everyone works the same way!’
Fortunately this was my last client of the day so we sat in the reception area of the clinic and discussed this further. I had to be careful because I was beginning to detect a certain level of animosity between Sharon and her earlier therapist and did not wish to fan the flames or be drawn into any situation that might develop later (fortunately none did).
However I could not agree with the view that there is a standard treatment and that everyone works in the same way. I was able to explain that some therapists are products of their training and that it is not unusual to find situations where therapists were so married to a particular ‘doctrine’ that they did not seek to expand their horizons beyond that.
Another appointment was arranged for the following week. In the interim I recommended a book, Bully in Sight by Tim Field, which she obtained and had part read by the next session. At this appointment I was pleased to note that Sharon had been applying her knew found knowledge and had experienced two panic attacks in the intervening week, a vast improvement, and no therapeutic techniques having been employed yet! She was also referring to herself as a target for bullying and no longer as a victim! She was really beginning to take to the idea that the bully would be a bully anywhere, and that the problem was not any inherent inadequacies on her part.
During session two I employed the rewind technique to help Sharon in detraumatising the main memory for her, of being forcibly stripped, and this was quite successful. We also discussed her fear that she might be badly hurt or raped by the boys that she was stripped in front of – this was something that she had bottled up ever since and had never felt able to discuss with anyone. This, combined with her awareness of pattern matching together with coaching in calming techniques and anchoring was sufficient to leave her feeling in an upbeat and more confident mood.
I saw Sharon for one more session about 2 weeks later. She was arranging a return to work and had experienced one panic attack in the intervening period since the last session.
Her main remaining complaint was that no-one had ever explained to her in a way that she could understand about how the problems she was facing when she came for therapy develop in the first place – she recognised that she was able to accept that it was something inherently wrong with her over the years and that she somehow deserved it due to the low self-image that she had developed as she grew up.
The promotion that she had achieved where she worked proved to be the straw that broke the camels back – it was the first time that she had really put herself out to get something and once she had it, ran into a problem immediately in the form of the ‘bullying’ dept head. It was more than she could handle, she arrived rather spectacularly at her stress threshold.
She plans to carry on practising her calming techniques.
This case raises certain issues:
Relating to the earlier therapy treatment:
· Inappropriate therapy
· A poorly informed therapist (everyone offers the same treatment)
· Failure of the therapy laid squarely at the feet of the client (transference)
· Failure to explain anything clearly to the client
· Mis-information provided by the earlier therapist
· Mis-conception that therapy has to be prolonged and painful
· Arbitrary discharge of the client with no support structure (although an argument in this case that it was no bad thing could be made)
· Dogma allowed to prevail over empirical evidence
I found this whole episode very disturbing, not least because this therapist is still in practice and is presumably offering pretty much more of the same to their other clients.
If this case illustrates one thing it is that inappropriate therapy can and does cause problems. The counter argument in this case might be, well obviously this therapist needs retraining – which is a bit like saying that therapy does not cause problems, but when it does lets blame the therapist.
And of course this argument would be absolutely spot on. I believe that a well-informed therapist, keeping up with modern research and who is serious about ongoing professional development would never be the cause of a situation like that discussed here.
The good news is that the profession as a whole has advanced in leaps and bounds over the past few years and that therapist’s such as this are being supplanted by a new generation of therapist (of all ages) – armed with modern research and techniques and the kind of inquiring mind that will eventually consign dogma and outdated practices and theories to the dustbin of history where they most surely belong…
Michael O'Sullivan FNCP