This is very important for my case study
Case study (4000) words
Understanding the essential framework for a counselling interaction and show empathy with, and insight into the client’s difficulties
Draw on theory in developing understanding
Show that the dynamic has been understood and used
Identify, in psychodynamic terms, the counselling issues which have emerged or are emerging in the work.
Demonstrate your understanding of psychodynamic principles in relation to such issues.
The counselling / therapeutic alliance
Transference and counter-transference
Shifts in the client’s difficulties, viewed psycho-dynamically
Client history/family history
Early work later work of the counselling process, psycho-dynamically
Alan made tentative contact with the counselling service, but did not feel sure if it would benefit him; and in fact he contacted the service several times to check on appointments, cancel and rearrange them and to reassure the service that he would be attending the counselling sessions. As a result, he was assessed as being unsure about counselling, not really seeing how he would benefit from it. He was found to be articulate and able to express his emotions and experiences fluently and consistently. He claimed to have attempted suicide, when and by what method is unclear. He complained of sleeping badly and suffering nightmares and flashbacks, and although he is being treated for depression and PTSD, he said that he did not find the medication helpful.
The treatment plan was for me to offer him counselling sessions on a weekly basis, as I speak his language, with the aim of building a therapeutic relationship where trust and confidentiality are in place which is important with clients who are torture victims.
Alan is a 44 year old man born in KUD but grew up in Baghdad. He has four siblings; two brothers and two sisters. His mother died in 1991 and his father in 1998 due to possible cardiac arrest. He reported happy memories of his childhood and that as a family they were close knit. The family was relatively wealthy, having land and income, and he remembers many happy celebrations of traditional holidays, birthdays and other events. He became conscious of the political situation in his country as a young man and describes feeling oppressed by the politics of that time, with a pervasive fear of being detained and tortured by the K** security forces just for being a Kurd.
He attended primary and secondary school in Baghdad and went on to gain a tertiary qualification in Mechanics. He claimed he was coerced into working in an ammunitions factory, where he stayed for 12 years. Whilst working in this factory he was falsely accused of wrong doing. When I asked him what he meant by wrong doing he replied, “You should know, you’re a Kurd, you get accused just because you’re a Kurd.” I could instantly identify with him and empathise, which stopped me questioning further.
He was arrested by the K** Security Force and detained in Abu Ghraib prison for over a year. Whilst in prison he was repeatedly tortured mentally and physically and under torture, he disclosed the name of a person that he had social contact with. His disclosure about his imprisonment affected me strongly as a result of my own past experiences and I was struggling to remain in my counsellors’ position. I felt overwhelmed and subsequently took this to my supervisor who supported me and reminded that he was the client, not me, and to stay calm and not to over identify with the client.
Alan named the other person Kawa, who was arrested for a month, released and then shortly after was killed in a motor vehicle accident under suspicious circumstances. Kawa’s, relatives then mounted a vendetta against Alan, seeking retribution for his death; rejecting any offers of material contribution from his family. This was one of the reasons for his seeking refuge in the United Kingdom and he still fears that Kawa’s family are pursuing him and may come to the United Kingdom to find him.
Since his arrival to the United Kingdom, Alan’s mother has died of a respiratory condition and a younger brother was killed by a suicide bomber in Mosel, a city in northern K**, in November 2005. He was very upset that he was unable to return to K** for either of the funerals. He has remained isolated, single and has very few friends. He appears to have gone into ‘survival mode’ as a result of his experiences, subjectively having little sense of life after imprisonment and torture. He is no longer sure if he is religious or not, whether his values and beliefs are still valid. Whilst not actively suicidal, he appeared ambivalent about a future for himself.
In addition Alan is receiving treatment for several medical conditions; whilst in detention and as a result of torture he sustained a spinal/sciatic nerve injury which left him in chronic pain. He attends the pain clinic at Chelsea and Westminster Hospital for regular treatment and follow- ups. He has also been recently diagnosed with Vitiligo.
I have chosen a Freudian framework in which to attempt to understand and interpret the client’s experiences. The reason for this choice is based on the depth of Freuds’ concept of personality and responses to trauma and his concept of the conscious and unconscious, covert and overt, which mirrors much of the client’s experiences and emotions. Freud believed that most of what humans feel and experience is not accessible to them at a conscious level. The conscious part of humans is an awareness of what makes them who they are, and the unconscious part contains all the emotion, experiences and impulses that are unacceptable to that person. The conscious is largely driven by the unconscious.
Mechanisms to deal with anxiety and guilt are termed defence mechanisms. These mechanisms basically defend the individuals’ conscious mind from unconscious drives and conflicts that are unacceptable to him/her. Freud described various, specific defence mechanisms by which the individual; protects him//herself;
· Denial: arguing that an anxiety provoking stimulus does not exist
Displacement: talking out urges on a target that is non-threatening
· Projection: placing unacceptable impulses in oneself onto someone else
· Intellectualisation: avoiding the emotional part of an unacceptable emotion by focusing on the ‘mind’ aspects
· Rationalisation: providing an alternative, supposedly logical reason for behaviour instead of the real reason.
· Regression: returning to a previous stage of development i.e. becoming more infantile
Repression: placing unacceptable experiences into the unconscious, i.e. forgetting them.
· Sublimation: acting out socially unacceptable impulses in a socially acceptable fashion.
· Suppression: the active forgetting of an emotion or experience that creates anxiety.
· Reaction formulation: taking/stating the opposite belief because the true belief creates anxiety.
Interactions in the therapeutic relationship:
The important concepts here are interpretation, transference, counter transference and resistance. Interpretation involves understanding and clarifying of the unspoken need that is presented as a spoken thought, emotion or behaviour. The context of the interpreted statement or behaviour needs to be understood before the counsellor can attempt an interpretation and the aim of interpreting unconscious signals is to try and make the client aware of unconscious impulses and conflicts that may be causing a behaviour or response.
A therapeutic alliance is one formed between a counsellor and a patient, and it often involves a patient winning the trust of the counsellor. In psychoanalysis, therapeutic alliance tends to be more difficult that in any other form of psychotherapy. For this reason, it is important that a counsellor should avoid an instance where by they could reveal to the patient any of their personality aspects. In my case, this almost happened when Allan narrated to me the ordeals he had to undergo in jail. Additionally, his narrations brought back to me sad memories that almost had me overwhelmed.
Freud has postulated that overtime however, the patients freely associates, and this results in carbatic libidal energy release. Such an energy release is often accompanied by what Freud describes as a client’s experience during this kind of discharge. In fact, the exhibition of strong emotions by a patient leads to a strengthened patient-counsellor alliance, and this helps in the bringing out of the next therapeutic phase in psychoanalysis; a patient’s expression of resistance and counter-transference. To understand Transference one needs to remember that the individuals responses are based on unconscious reactions to people that were important in his/her early life. Transference may be negative or positive depending on who the counsellor ‘reminds’ the client of, someone who created a feeling of well being or someone who created a negativity.
The transference concept gets intensified in case of a disaster or illness. Thus, illnesses in adults tend to lead to emotional regression to the levels of a child. As such, a patient will normally react to a doctor or nurse as if they were the parent, or a familiar figure from their childhood. May be being a woman, a reminded Allan of his childhood, and so he rekindled the memories he shared as a child with this mother. Greenson (1967) has defined transference thus; the experiencing of feelings, drives, attitudes, fantasies and defences toward a person in the present, which do not befit that person but are a repetition of reactions originating in regard to significant persons of early childhood, unconsciously displaced onto figures in the present” (Greenson 1967).
Allan had an ego strength that enabled him to appreciate that I was his counsellor, and not the mother. However, I cannot claim to have experienced counter-transference when counselling Allan. I regarded him as my patient and left it at that. I did not try to bring my own problems to contaminate his case, for I was aware of the patient-counsellor boundaries. During counselling sessions, I made use of a patient-centred approach, by shining the spotlight on Allan, so that he did most of the talking while I listened.
Counter transference is those emotions that are triggered by the client in the counsellor and are coloured by the counsellors own unconscious reactions to various relationships in their lives. Resistance basically represents repressed emotions. As the therapeutic relationship progresses emotions that are too difficult to deal with may arise. The client defends him/herself from these by resisting – cancelling appointments, arriving late, attempting to detract from the situation by discussing trivia, demeaning the counsellor. These measures may be conscious or unconscious.
According to Freud, the kind of resistance that he encountered from his clients during therapy sessions indicated signs of progress on the part of the client. Therefore, the more a client resists, the closer a counsellor is to getting to the root cause of the problem. Sometimes, a patient will undergo a resistance unconscious process, during which time a patient tends to believe that the behaviour he/she exhibits is either a voluntary and legitimate action, or is externally caused. Such would include a patient either missing a session, or coming to one late. For a counsellor, the missing of a therapy session is often considered an instance of resistance. In the case of Allan, he did miss on several sessions, and although he later made up for it, he exhibited anxiety, and this could be postulated to have been the reason behind his unconscious resistance.
Freud hypothesised that psychopathology is related to an individual being overwhelmed by internal conflicts and is mostly related to loss, conscious or unconscious.
Psychoanalysis holds that personalities tend to create internal representatives of individuals who have been important players our development. These representatives are referred to as objects. According to Freud, all emotional and mental energies are finite. Consequently, he called the act of attaching emotional significance to such objects cathecting, and a withdrawal of the same decathecting. We can therefore cathect or decathect an object. Thus, Allan had fond memories of his family, and the fact that he could not see them now had led to his becoming withdrawn. The principle of limited quality of emotional energy holds that feelings of a client are normally expressed towards a counsellor during a counselling session.
In this case, Allan wanted to have my phone number, and also wanted me to still be his counsellor even in subsequent sessions. As Freud writes, “it is therefore normal and comprehensible that the libido-cathexes, expectant and in readiness as they are in those who have not adequate gratification, should be turned also towards the person of the physician” (Freud, 1959. pp. 312-314.). Allan was lonely, first for having no friends in the UK, and secondly because of the tribulations that he had gone through, like losing a brother and a mother. Additionally, he was 44 years old and not yet married. it could thus be hypothesized that he had repressed sexual feelings all along, and since I happened to be his counsellor and a female as well, he was unconsciously attracted to me.
To validate this observation, Freud adds, “expectant libidal impulses invariably be aroused, in anyone whose need for love is not being satisfactorily gratified in reality, by each new person coming upon the scene, and it is more than probable that both parts of the libido, the conscious and the unconscious, will participate in this attitude” (Freud 1959). Allan was asking for my phone number, and every time that he had to cancel an appointment with me, he was profusely apologetic.
Alan had been referred by his General Practitioner following treatment for depression and chronic pain and because of his reaction to his forced migration from K**, his suicide attempt, detention and torture in K** for over a year. He was simply overwhelmed. Being overwhelmed indicates a failure of defence mechanisms. The conflict between his conscious and unconscious has become untenable.
He made contact with the counselling services in a tentative and ambivalent manner. He presented as an articulate, coherent man who could verbalise some of his experiences, those that were accessible to him, fairly clearly. His eye contact was noted to be poor and remained poor throughout the following sessions. He verbalised being unsure how counselling would benefit him. He arrived for his initial assessment and was given an appointment date for his first counselling appointment. This ambivalence seems to be a fairly shared experience amongst refugees seeking counselling. They have a sense they need something more to help them, but are often not familiar with counselling and its benefits. This psychological help with refugees can be considered useful as ‘telling one’s story’ inevitably relieves a burden, but culturally it is often unfamiliar and incomprehensible. There is no context for the counselling paradigm; it is a euro-centric intervention. It is also possible to interpret his ambivalence as a defence mechanism, a form of denial. If one is neither one thing nor another, it is easier to deny that they are definitely in emotional trouble or may need help. As a male from his particular cultural background it is also considered unacceptable and a sign of weakness to be emotionally depleted and not coping.
At this stage his ambivalence became more obvious; he attended his first session, arriving half an hour early; despite having received a letter stating he would be counselled in his mother tongue. He was surprised that I was Kurdish and a woman. He also described his relief that I would be with him throughout the sessions.
I was aware that it could be difficult to gain his trust and his confidence in my ability to be his counsellor as we both come from the same male-dominated background. I would also like to be aware of any transference that would occur as a result of my being a woman and my own responses to a male Kurd.
Alan asked for my personal mobile number. When I told him that personal numbers were not given to clients he was disappointed but accepting of the boundaries. This reaction reflects his isolation and relief at someone whom he can identify with. This is a well acknowledged problem amongst refugees. The isolation they face on arriving in a foreign country is compounded if they don’t speak the native language. Added to that is a lack of familiar faces and places and possibly an entirely new and incomprehensible culture, societal norms and values.
He was unable to attend the next two counselling sessions due to medical appointments. He phoned four times to advise the office he would be unable to attend the second session and actually came to the office on a different day, in relation to the next session which he had cancelled. When seen in person again, he brought medical certificates to validate his stated reasons for missing the sessions. Although Alan was consciously committed to counselling, it appears that postponing sessions and the associated anxiety around this, evidenced by his multiple phone calls, may be understood as unconscious resistance. This is an important concept defined by Freud, occurring during the therapeutic process, when the client avoids the potential pain that may be experienced by revealing unacceptable emotions during the therapeutic process. This avoidance may be conscious or unconscious and can take the form of not attending sessions or talking about details during a session. Given that Alan was unsure about counselling anyway, and was clearly overwhelmed by his life experiences, it should not be surprising that he would try and avoid a stimulus that could possibly unleash untold quantities of distress.
Alan attended his next session half an hour early. He was embarrassed that he had had to cancel the two previous sessions and went as far as showing me his dermatological condition and providing medical cards to demonstrate his appointments. It transpired that he received laser treatment for his Vitiligo on the same day, half an hour before his scheduled counselling appointment. I was explored with him his life in the United Kingdom. He revealed that apart from attending medical appointments; laser treatment, physiotherapy and the pain clinic, he had little else to do. He spends the time alone in his room, which serves as a window to the world in which he finds himself. He expressed his unhappiness with his surroundings and his sense of vulnerability in the block of flats in which he lives. He had various practical issues with his flat, including; finding his neighbours rather frightening for several reasons; they are unpleasant towards him, rough in their social skills and it upset him that there was a physical fight over a woman whom he perceived as being somewhat lacking in virtue. On a practical level, he lives on the third floor and there are no lifts. For someone with his physical limitations (he uses a walking stick) this is an arduous task and limits his access to the external world.
Several problems became clear here. Firstly, his worry about medical issues which could be seen in several ways; as a means of attachment and easing his loneliness, as a way for the system to deal with him, a learned behaviour to maintain a sick role for secondary gain, which in this case, could be related to gaining a sense of value and identity, as a patient. This point, in particular, has a historical background in the politics of K** and KUD. He identifies himself as a Kurd, but grew up in Baghdad where Arabic is the more commonly spoken language. Having been coerced into a factory, as a Kurd, he would have been subjected to low level jobs, racist jokes and a general sense of being devalued. By being a patient, he is cared for, and therefore gains in stature, and is accorded a degree of importance. On another level, he had been disempowered by being allocated a counselling time slot. This was of course impractical, as he had another appointment at the same time and couldn’t be in two places at once. This issue was easily solved but highlights the manner in which refugees are often further disempowered by the very agencies that are trying to assist them.
His difficulty with his neighbours reflects a number of societal issues. He feels he is living with ‘inferior’ people. This is another practical issue that is often neglected with refugees: the fact that basic needs such as shelter and food are not formally addressed with a group of people that are insecure in all aspects of their new life, and dependent on governmental agencies to attend to these issues. The fight over a woman caused him great distress. I wondered about his level of distress over a conflict that had little to do with him and about his sexual function and lack of relationships. Culturally it is not considered appropriate for a man of his age to discuss his sexual needs but equally, it is considered inappropriate for a man of his age not to be involved in a relationship. This neglect of sexuality and lack of a relationship contributes to the loneliness and depression of being a refugee. It is considered difficult for newly arrived refugees, such as Alan to engage in western style relationships, but commonly they assimilate on this level with the British population or by connecting with a group belonging to a similar culture. This may reflect inflexibility on his behalf in his inability to engage with what he considers to be immoral practice despite having access to multi media and living in a country where these types of relationships are sanctioned by society. This arena is a good example of ‘culture shock’, the refugee finding the community norms open, offensive and shocking. From a Freudian perspective it is almost as if he has frozen his ‘life force’ instinct and is purely in ‘death force’. There is literally no sex in his life but there is also no joy, prosperity or family. He is in survival mode; merely staying alive by whatever means. Subjectively, he has no sense of life since being detained and tortured. He has existed in a state of trauma since his detention in K**. He shows signs of PTSD, poor sleep, survivor guilt, and nightmares, as a result of the traumatic experiences he was subjected to. These traumas are associated with profound splitting of the ego and fragmentation of defence mechanisms in order to survive. In fact, normal defence mechanisms are inadequate and those that can be considered mad are employed. This is done at a cost to the core of the personality however and it does not appear as if the person recovers fully. The ego is under attack and survival comes at a cost.
Some of the psychoanalysts who came after Freud have argued that trauma can be a direct cause of neurosis. In this case, there would be no unconscious cause to such a neurosis. This would then facilitate a direct addressing such a cause of neurosis. However, these notions have since been rejected by Freud. Freud (1936) has argued, “if anxiety is the reaction of the ego to danger, then it would be the obvious thing to regard the traumatic neurosis, which is often the sequel to exposure to danger to life” (Frued 1936, p. 660). Freud was anxious about his safety in the UK, for he was fearful that the relatives of his former social acquaintance Kawa, who got killed, were blaming him for his murder, and he felt they could pursue him even to the UK.
Freud has further added, ‘neurosis is the result of a conflict between the ego and its id, whereas psychosis is the analogous outcome of a similar disturbance in the relation between the ego and its environment” (Freud, 1959, pp. 250-251). Therefore according to the psychoanalytic theory, a psychotic individual is viewed at as one whose ego is not strong enough as to handle life’s tribulations. Alternatively, a psychotic may also be viewed as a person who despite having an adequate ego, is faced with adversities so severe that it has the potential of causing a total collapse of ego functioning. Allan has had to go a lot of tribulations in his life.
He was imprisoned, had to endure isolation on grounds of his Kurdish roots, has lost a mother and a brother, and has been accused of causing the death of his former acquaintance by his relatives, who are seeking retribution for his death. He has attempted suicide, suffers from nightmares and flashbacks, was a torture victim, and is a refugee seeker.
In addition, he has been shunned by his neighbors in the UK, who loathe his lack of being social. This has led him to withdraw from the society. Add onto that his vitiligo skin disease, and the fact that he is not married at 44 years, and he becomes a perfect candidate of a deflated ego.
Although Freud is widely regarded as a pessimist, he nevertheless believed in the use of psychoanalytical treatment, as a way of relieving psychotic symptoms and causing long-term personality changes. To achieve this, the unconsciously invested psychic energy has to be transferred to the conscious. This is often accomplished through several therapeutic treatments, which is what I was trying to do.
Following this session and after discussions with the team, his scheduled appointment was changed to a suitable day for him. Again, he arrived half an hour early for the session. He expressed his gratitude that the day had been changed to suit him but I remained his counsellor. He explained in much detail his discomfort that he had been subjected to so many different medical doctors and when I asked what he thought was the reason behind this he said this was probably because they were training. He was able to name all his doctors, single out a particular general practitioner he felt bonded with and said that English doctors were kinder than foreign doctors. His preoccupation with medical matters raised its head when he described receiving treatment for lumps on his head, by British doctors, who were very kind.
Most of the earlier sessions were spent with him talking about his medical conditions, and I decided to mainly listen and to give him space to talk repetitively about his medical conditions and treatment as it was important that his defence mechanism wasn’t threatened. It was only when I reflected at a later stage the importance he placed on ‘kindness’ back to him the he started talking about his relationships in K** , in particular with his family where he specifically described good relationships with his sister and his dead mother and brother. He became tearful when describing arguments between his two brothers before one of them was killed. The arguments were around the fact that the dead brother lived in KUD and the remaining brother in Baghdad. KUD is perceived as being safer and the family wanted the living brother to move there which he refused to do. Since the brother was killed in a bomb blast in KUD there is a heightened sense of unsafely for the brother living in Baghdad. On clarification it became apparent that his tearfulness was not only restricted to the dissension between his brothers, but more generally to feeling homesick and missing K**. Of note is that although his brother is allegedly dead, he spoke about him in the present tense and inconsistencies have also become apparent in terms of where his sisters live. I was unable to clarify these issues with the client as he gave conflicting information, changing names. I began to feel overwhelmed at this stage and wondered whether he was telling the truth about his brother. However, I decided to go with what he was presenting as his own fantasy without judging him. This fantasy could perhaps be an effort to give a reality to his sense and experience of loss related to bereavement, loss of his homeland and loss of the potential normality he had at ‘home’, loss of his pre-trauma self, marriage, a family, friends, and employment. The theme of loss is strong in his story and this could be reflected not only in his depression but the fact that it appears to be intractable, his decision in leaving his country.
One of the psychodynamic approach assumptions that Freud postulated is that unconscious motives affects our feelings powerfully. According to Freud, there are different formulations for the origin of anxiety. Freud believed at first that anxiety is a consequence of defense, but later, he was of the thought that anxiety was provoked by defense. It is not in doubt that Allan is depressed, for he is already attending a depression management clinic. How then, is depression tied to his anxiety?
Freud opines that when we are reacting to the threat of loss, this is anxiety. On the other hand, actual loss causes depression. Allan has lost a brother and a mother. Additionally, their family was once rich, but now he has to live as a refuge, and this could have caused his depression. On the other hand he is anxious because by attending therapy sessions, he is admitting to his deflated ego, and this is a loss consequently, his ‘withdrawing’ symptoms could be seen as a form of resistance to facing the truth.
In ‘mourning and melancholia’, Freud (1917) has been able to draw attention to similarities in depression and bereavement, such as despair, sadness, inhibition of activity, and a loss of interest in the outside world. Allan has thus far exhibited these signs. Depressive-induced losses may not always be external, as Pedder (1982) notes, but are more of an internal loss, that will often involve a loss of self esteem.
Melanie Klein offers an insightful explanation of depression; an internalisation of the client’s innate destructive forces and the fear of the consequences of what these forces will do to or have done to those close to him. Apart from loss issues, Alan expressed feeling guilty about the consequences his actions had on his family and the family of the person that he named, whilst under torture.
In the later sessions .Alan begins to feel comfortable with me and trust in me. He feels a familiarity that resonates within; whether it’s in terms of cultural similarity, my manner or a combination of these factors that leads to a sense of trust, affection and comfort. This issue of transference and possible counter transference involves me, as counsellor, bringing ‘expectations, fears and problems transferred from the past’ ( Psycho-analytic Insight and relationships. Kleinian Approach. Icsa Salzberger-Wittenberg) and highlights an issue that does not appear to be well covered in the literature; the fear of a counsellor, of similar demographic origin, over identifying with the client. The fear of over identifying is very real and could potentially create a negative counter transference between the client and the counsellor which was the case in the earlier sessions when I was over identifying with my client and my position as a woman. This is something a counsellor needs to be very aware of and the counsellor should be at pains to recognise possible responses that may relate to counter transference, whether it is positive or negative. Bowlby describes how this phenomenon of counter transference can in fact be useful and positive. He names it congruence. This is defined as; ‘Quality of being congruent: of there being agreement between things… allow a connection between what we feel and how we respond’ (An Introduction to the therapeutic framework. Anne Gray.). These emotions of counter transference can be used therapeutically and positively, if the counsellor is able to recognise them. As I was aware of my responses and took regularly took to supervision, my supervisor encouraged to honestly explore my feelings towards my clients.
With torture victims and PTSD, it is important to allow the client to tell their story as the believe in, and in particularly with refugees who have not only suffered from the traumas of torture but also a sense of loss at having left their home, family and friends behind. The healing is in the relationship itself between client and counsellor. With Alan it is important to build that relationship, for him to regain trust in another human being and have hope in the future.
Brown, D. and Pedder, J. ‘An Outline of Psychodynamic Principles and Practice’. Routledge,
London, 2000. Available: http://www.questia.com/PM.qst?a=o&d=108931205.
Retrieved October 30, 2008.
Freud, A. ‘mourning and melancholia’, in standard edition, vol. 14, 1917.
Freud, A. ‘The ego and the mechanism of defense’. Hogarth press, London, 1936.
Greenson, R. R. ‘The technique and practice of psychoanalysis’. Hogart press, London, 1967.