Diploma in Therapeutic Counselling
WAES April 07

The Case Study

Introduction The purpose of this case study is to show process during the time I saw this client at Southwark Bereavement Care. In it I intend to focus on how the psychodynamic approach that I used with my client was effective and helped my client to have an understanding of the way he relates to people and to himself. For this I will cover the first 3 sessions and explore my thoughts on the process. The setting Southwark Bereavement Care is a short term, free counselling service offered to people living in the London borough of Southwark who have been bereaved.
It offers weekly one to one sessions up to twelve weeks. This can be extended for a few more weeks in individual cases where both counsellor and supervisor agree it would be beneficial for client. Group supervision is provided by the agency fortnightly. The agency is based on the first floor of an office building in a residential area of south London. Clients are seen in a room towards the back of the house, which is quiet and dimly lit, with 2 sofas and a little table where there is a water filter and a box of tissues.
There isn’t a waiting area and part of the contract that counsellors discuss with clients and request them not to turn up for session earlier than their allocated time. This has proven to be challenging at times when clients arrive early and counsellors have to let them in and use the waiting area that belongs to the company that occupies the ground floor. This can be perceived as lack of consistency in what a counsellor says and what he does. I have had a conflict with a client that was consistently arriving early although I had mentioned in the contract this fact, and his pushing the boundaries was having an effect on the way I felt towards him and also how I started to worry towards the end of the session with my previous client that they would turn up and interrupt my time, so I had to address this with this client which has proven to have an amazing effect on the therapeutic relationship as my client said he perceived my honesty and openness as a sign that he could also be open and trusting with me in the relationship. I see my clients in the evening at a time when I am the only one in the building and because the director leaves the office in the afternoon, I have no access to the phone and when a client is late or does not turn up for session I do not know if they have contacted the agency or not, until the following Tuesday when staff comes back to the office. This also makes it difficult to follow the non-attendance procedures as by Tuesday it becomes late to write a letter in time so client receives it before next session. So, in order to follow the agency procedures, after discussing it with my supervisor and the other counsellors in my team we decided to give out our mobile numbers to our clients for emergency use only when clients cannot attend sessions and the office is closed. This has proven to lessen the anxiety I felt around this attendance issue and made it more comfortable to be part of the agency.

The Client My client, who I shall call Ben here, is a 43 years old, white British single male, who lives alone in London. He has a job as a CCTV camera operator.

He came to counselling because his mother had died earlier in the year and he felt he needed some support in going through this event. During the assessment Ben identified himself as a carer for most of his life and now that his mother had died he felt empty. Ben has a difficult relationship with his sister and brother whom he contacts regularly. Hi sister has bipolar disorder and Ben feels he has to take care of her. His father died when Ben was 8 years old. This has had a profound impact on Ben. He has been married twice and has an 18 years old daughter who lives with her mother. Ben feels isolated and has no contact with friends due to the shift work he does at his job. The first time I saw Ben he was outside the agency as I was coming in, and when I come downstairs to let him in I felt his curiosity about me. In the room I asked him to fill out a monitoring form for beginning of therapy and he seemed a bit annoyed with that and said that this should have been done during the assessment, adding that he thought the guy who assessed him was quite nice and professional. I felt that maybe he was telling me not to make mistakes and be nice too or he would be disappointed with me. He looked well presented and I noticed he had a walking stick. I asked if it would be difficult for him to climb 2 sets of stairs and he reassured me he was fine with it. He told me of his physical health issues and how difficult they are sometimes. He seemed friendly towards me although I was aware of feelings of superiority and condescendence in me. We went through the contract and Ben smiling said he knew all from previous counselling experiences and he could relate to my position as he had been listening to people all his life. When I asked how he felt to be in the room with me and how was it for him to be to the one who is now doing the talking he said it was strange and he thought that I seemed a good person to be doing that job as he knew how demanding it could be. I felt my client was giving me a compliment to prove how good and generous he was. I felt somehow unreal in that exchange. The Assessment My client was self-referred and another counsellor at the agency did the assessment. It was clear from the notes that my client was in distress and needed some support through a difficult time after his mother had died. The presenting problem In supervision we agreed that there weren’t any risks or any other issue that seemed not appropriate for the type of service the agency provides. From the assessment notes it seemed that my client was willing to engage with a counsellor and make full use of the time in therapy. However, after reading about his personal history my supervisor pointed out to the fact that other issues of loss would certainly came out like the fact that my client’s father died when my client was 8 years old and also been through 2 divorces. We agreed that a psychodynamic approach would be beneficial but were also aware of the constraints of the short-term nature of the agency, and discussed the need to maybe be focused on the bereavement of his mother and how I could help him going through that, rather than trying to deal with all the other issues of loss in a scattered way, so that by the time the counselling would finish my client would have at least dealt with one issue. This was very helpful for me to have an understanding of how important it is to keep the focus on one issue at the time so my client would have a sense of solving something in his life. The client story During the first session, Ben talked of how he had taken care of his father through his father’s illness and how Ben heard his father always talking about his pain and how he wanted to be dead. That Ben felt like the roles were inverted as he felt like a father to his father. He also mentioned that they used to visit his granddad who was also ill and again Ben would hear they talking about their illness and how Ben felt scared and that he wanted to prevent his dear father to die. Although Ben seemed to be open about his past, I noticed that he would say things like “but that’s life” or “that’s just the way things were” and I wondered if he was defending against very powerful feelings that were being covered by this rationalisation. I was aware of feelings of division towards what I thought my client was feeling and what he was saying. I asked:
-“I wonder how it must have been for you to be a child that was taking care of your father?” and he said. “ I felt pulled in different direction between my father and mother”. I was now feeling confused and wondered if I was experiencing countertranference. I wondered if my client confused because he felt divided and torn between the 2 most important people in his life.
-“ I wonder what was your relationship with your mother like?” Ben said: “ I was always in the middle trying to avoid conflict between my mother and father. My father was always dragging me everywhere and I felt that my mother and siblings were resenting this”. That his father never showed any emotions in the presence of his mother who was constantly trying to find out how he was feeling. I then realised that I was just acting in the transference like my client’s mother by been curious about how my client was feeling and that he, like his father, was showing no emotions and was defending against my probing. I understand that by being aware of the transference and countertranference issues that were coming up in this first session, I was able to have a sense of what it felt like to be my client, and this insight into his inner world gave me an understanding of the therapeutic relationship and how may my client have felt towards me. I was also aware of the unconscious defences that my client was showing through his body language as he was sitting with his legs crossed and his arms folded across his chest.
I then asked my client how did he feel with me in the room. He said: “ you have to ask questions, that’s your job” I felt that again my client was being rational about the process and defending against feelings, so I reflected back: “ that’s my job to probe and ask questions”, Ben said: “ you need to probe to find out how I feel”. So I asked: “ I wonder how you feel about me asking questions?”, “Fine” he said. I then decided to take a risk although I felt it may have been early in the process and our relationship may not have been strong. I said: “ I wonder if you are just saying fine to protect me from how you really feel?” Here Ben smiled and said that he knew how difficult it is to be listening to people’s problems.
I could sense how the fact that Ben was caring for his father who was constantly mentioning his pain and desire to die, had stopped him from being in touch with his own feelings so he could be there for his father. So I asked: “ how difficult it was for you to be listening to other people’s problems I wonder?” Ben said it was a burden for him and he felt confused and at the same time special for having that kind of attention. At this point I became aware of feeling fragile and vulnerable and could relate to my client’s fear of showing his feelings. I too have been burden by somebody else’s feelings and felt I could not be real or I would hurt them. And I could also sense that my client was afraid of getting in touch with those feelings, almost as if they were too powerful and would destroy him, or maybe me… In this session I was able to understand my client’s defences and how he was put in a role of carer in his early relationship with his father and how that had had an effect on how he behaved in most of his relationships. Also that he was trying to do the same with me in the counselling room. I was also aware that I had to be gentle as I could sense that although my client seemed able to use therapy as he presented during the assessment, I sensed a deep fragility that I was not sure he would be able to cope in been in touch with. And how his mother’s death had open a deep wound in my client’s inner world. I took this session to my supervisor who agreed that my client was defending against very powerful feelings and when I explore my opinion that in the transference relationship he was also trying to protect me and care for me, we were able to discuss how I would not act on this and collude with him and also how could I use the transference to unable my client to move on. During this supervision I was able to realise why I felt I needed to be gentle with my client. Maybe this was what he was feeling, that he wanted me to be gentle and take care of him like he felt when he was a child and wanted to be taken care of. His wishes to be loved and cared for were very present in me. My supervisor and I were able to identify this as me experiencing countertranference feelings.
We were also able to identify these feelings as a result of his bereavement and how my client have been left open and vulnerable without a person to look after in consequence of his mother passing away. During this supervision I was able to identify that I too have been looking after my carer’s feelings when I was growing up. My mother used to say that she was ashamed of gay people, maybe sending a clear and open message to me. I felt I had to hide my real me in order to spare her from pain and disappointment. So I explicitly have been afraid of telling people who I really am and what I think. Reverting this has been a painful and difficult process that I have been able to achieve in my own therapy. Being aware of this helped me to relate to my client’s history and his inner world that would be beneficial for my own understanding of how we were in the therapeutic relationship. On the second session, Ben told me how he felt relieved to have somebody to talk to and how helpful the previous session had been. He told me that the fact that his mother had died had left a void in him that he could not fulfil and was resigned to the fact that he would spend the rest of his life alone because no one could love him. He said his parents knew he was gay since a very early age but he felt he could not be real with them and come out or he would damage them. Ben told he had to pretend to be somebody else the whole of his life and had to put others in front of him. Here I was aware of feelings of rage in the room and asked: “ I am wondering how does that makes you feel Brian?” As soon as I said it I realised the terrible mistake! I just had called my client by another client’s name when he was telling me that he had spent his life putting others in front of him. Ben smiled and asked: “do I look like a Brian?” I felt really embarrassed and in shock. I apologised and asked how he felt with my mistake. He continued very calm and said maybe I know some Brian and was thinking of him. What I could not admit then was that that was the case, that the client I seen before Ben was called Brian and I was having a bit of a difficult time with him, however I was not aware of thinking about Brian on that moment. Ben carried on and I found it difficult to follow after this “incident”. I was quite sure that I acted on the countertransference. That Ben “made” me put him in second place just there in the therapeutic setting where he was meant to be cared for. I felt amazed by this powerful force that drove me to act on something that I have been trying not to. In his book “on learning from the patient” Patrick Casement explores a similar example where a therapist was trying not to fail the client and ended up oversleeping one morning leaving her client waiting and not knowing what had happened. Casement goes on to say” it is uncanny how this therapist unconsciously reproduced a real failure in the therapy which was so close to the experience of her patient’s own childhood trauma. How is it, then, that we sometimes fail a patient even when we are so carefully trying not to? When this happen it can threaten the whole therapeutic relationship. And yet, when a patient is confronted by a real issue like this, about which he or she can be genuinely angry with the therapist in the present, it can equally become a pivotal experience in the therapy.” Patrick Casement, “ on learning from the patient” page 91-92. I again felt angry in the room and was aware that Ben was being polite and not expressing his anger at my mistake. I was aware of my own feelings of anger towards my failure in the relationship. I thought that it would trigger his real feelings in the room and that would help him to move on in his therapy. Ben insisted that he was fine with it. I realise the unconscious communication that was going on in the room. Ben was telling me how he really felt through the feelings I was experiencing. I think this was a way of defending that my client was using. It was too painful for him to admit that what he thought of himself has been confirmed in the counselling room, just in the same session that he told me that he found helpful to have somebody he could talk to. Like it was too painful for him to come out as a gay man and go through the process of hurting his mother. I decided to risk and to ask him if that was the case: “ I wonder if it would be too painful to tell me that you are angry with me, like you were when you were growing up hiding your real feelings from your father, and then from your mother? Maybe you think that I may reject you or that your anger would be so destructive that it could almost destroy me”. Ben said: “when I was a child and heard my father talking about wanting to die, I thought I had to protect him from pain, and I knew that if I told him how I really felt it would make him very sad and could kill him faster, and I didn’t want him to die.” Ben told me he feared abandonment from his mother and then his 2 wives if he was to tell them he was gay. That he had to keep the farce for their sake. He was then able to understand that maybe he was doing just the same in the room with me. Here I felt that maybe it would be beneficial to self disclose my sexual identity to support my client. I was also aware that during the first session I felt his curiosity and that maybe it was a searching, maybe Ben was looking for clues that he would be safe with me, that I would be able to love his real person…However I decided to wait as this was only our second session and I was not sure how my self disclosure would interfere with Ben’s real issues. I was aware that it maybe could be used as another way to defend against his painful feelings and difficult inner reality. Conclusion In conclusion, I would like to point out some aspects of my work with this client that are relevant to my learning as a psychodynamic trainee counsellor. In the first 2 sessions with my client Ben, I was able to managed the beginning of the therapeutic relationship by taking the lead from my client and exploring his childhood and how that had had an impact on the way he behaved in relationships in general and in the counselling room in particular. By using counselling skills like open questions and applying a psychodynamic approach exploring how his past relationships had an effect on his inner world I was able to support my client in understanding why he behaved in certain manners. In the beginning I felt that my client was not ready to go into deeper grounds of his personality, but I then became aware that maybe I was acting in the countertransference, that in the transference relationship my client was seeing me as someone that would also reject his real self and I had to be spared of his real feelings. At one point I made a “mistake” and called my client by another person’s name. Then although I felt embarrassed I realised that he had set me off to fail him. I now think that it was an important moment of our relationship and that my readiness to be open and use immediacy had an effect on my client in that he was also able to explore difficult feelings in the room. In my work with this client, I was able to use my internal supervisor as a way to understand what was going on in the therapeutic relationship as I felt there was a lot of powerful feelings and at times I felt entangled and that my client was acting out in his issues with me in the room. By being aware of my own feelings and the ones I considered countertransference I was able to listen to what really my client was telling me and the best way to continue my interaction with him. My clients was using a lot of defences in our relationship, and by being aware of them and explore them in my supervision, I was able to deal with them and not let them stop the process. I consider that the work I done with this client have been excellent in that I was able to learn and understand some of the aspects of theory I have been learning like acting out in the countertransference, issues of transference, defences and unconscious communication. I was able to take some of my own issues that came up during the time I saw this client and explored them in my own therapy. And by being aware of them I was better able to support my client as I had a good insight of how my client seemed to be feeling. In using all this tools and applying psychodynamic theory to my practice work, my client was able to go from an external frame where he have been taking care of others and not being in touch with his own feelings, to a place where he felt safe to begin to explore these in the counselling room.

References: Casement, Patrick (1988) On learning from the patient, London: Routledge pag91-92

Word count: 3972 words

C M
April 2007