Jesús Hernández Valdivia

As has already been shown, the literature on therapists’ experiences and processes in their work with psychosis remains scarce, particularly within the phenomenological and counselling psychology literature. In this section, I provide a

brief description of some studies that have dealt with this issue that are predominantly derived from the psychoanalytic and early E-P schools of thought.

The psychotherapy of psychosis does not regularly appear in the CoP literature. There is a significant scarcity of research in exploring how CoPts construct, make sense of and work with psychosis and psychiatric diagnoses in general. Some recent and interesting publications are important to mention here. Larsson (2010) interviewed CoPts working with a diagnosis of ‘schizophrenia’ with an interest in exploring their general work and found that they had a tendency to negotiate their relationship with their clients, their professional identity and the organizations they worked for. In addition, he found that there were a number of complexities in their relation to the diagnosis of ‘schizophrenia’, for instance how to negotiate the balance between phenomenology and empiricism. Additionally, Lamproukou (2014) interviewed CoPts working within the NHS and found that while they expressed the experience of a plethora of tensions in their working environment, they also developed a variety of coping strategies to deal with these tensions, such as holding a pluralistic stance, assimilating the medical model with their own value base system and prioritising the clients’ needs over the NHS guidelines. What was particularly significant is that all participants had a strong therapeutic identity and reported practicing in accordance with CoP values which mainly prioritise a relational approach and a tendency towards the deconstruction of pathological conceptions. Along similar lines, Davies (2013) interviewed CoPts who worked with clients who had been given a psychiatric diagnosis and found that many participants expressed feelings of uncertainty when working with this diagnosis. The positions the participants adopted in order to deal with uncertainty included a combination of uncritically adopting the diagnosis, challenging the diagnosis, and compromising and avoiding the diagnosis in their efforts to deals with feelings of uncertainty. The researcher concluded that overall the participants lacked confidence in working with diagnosis and struggled to adapt to medical model contexts. Lastly, Larsson, Loewenthal, & Brooks (2012) explored how CoPts working with ‘schizophrenia’ experienced the work and found that they constructed their experiences of working with these individuals in a ‘relational’ way by relating to the person’s experience and normalizing the experience while there was a particular emphasis on the therapeutic

relationship rather than technique. However, the authors also stressed that the dangers of pathologizing language are always present. What the literature therefore seems to suggest, is that CoPts working with a diagnosis in medical settings such as the NHS, seem to express a certain level of uncertainty, anxiety and ambivalence relating to issues of diagnosis.

What the in-depth exploration of the literature on the psychotherapy for psychosis has demonstrated is that earlier publications are more attentive and explicit on issues concerning the psychotherapist’s experience, with early psychoanalytic work (e.g. Fromm-Reichmann, 1954; Searles, 1965; Sullivan, 1962) and early E-P work (e.g. Minkowski, 1933/1970; Rumke, 1941/1990; Binswanger, 1963/1993; Laing, 1965) more keen to engage with this dimension. This lack perhaps reflects Buber’s assertion of the incongruity of the relationship in psychotherapy due to a power imbalance between client and therapist. He suggested that there is an asymmetry within the therapeutic encounter in the sense that both the client’s and therapist’s gazes are usually directed towards the client’s condition and not at the therapist’s (Friedman, 2002). Even though recent contemporary psychoanalytic literature deals with the countertransference, this body of knowledge is considered to be relatively small (Horowitz, 2002). Traditionally, psychoanalysis employs the notions of transference and countertransference to deal with the therapeutic relationship. However, the epistemological and ontological position this project endorses instead takes a phenomenological and intersubjective position on the relational view of the therapeutic situation and understands it as real. As Cohn (1997) has stressed, the E-P perspective suggests that a person cannot be a screen for the projections of another and does not encourage an impersonal stance from the therapist. Even though a critical appraisal of countertransference from an E-P perspective will not be discussed in this project, some early and later psychoanalytic work regarding the therapists’ processes and experiences in the psychotherapy for psychosis (which come close to a phenomenological understanding) are briefly considered.

Interpersonal psychoanalytic accounts on countertransference often report that working with psychosis elicits intense feelings of sadness, despair, terror,

hopelessness, anger, frustration and anguish (e.g. Horowitz, 2002; Baranger & Baranger, 2008; Grinberg, 1962; Heimann, 1950; Langs, 1978; Little, 1951; Kernberg; 1965; Sullivan, 1962). Searles (1965) wrote lengthily on the experience of these feelings and the use of the self in the psychotherapy of psychosis. He strongly recommended that the potential for recovery, which takes place in the therapeutic relationship, concerns both therapist and client. He suggested that the therapist is involved in a dynamic process which entails her personal healing as well and demonstrated through an abundance of case studies how the difficulties of engagement from the therapist side are mainly due to the retrospection and recognition of less healthy parts of herself. However, he demonstrated clearly that this is the condition upon which a therapeutic bond can form. Sullivan (1962) with his interpersonal approach to people with psychosis also demonstrated the therapist-as- person approach to psychotherapy with personal involvement, vigorous questioning, and rigorous listening by making use of his own emotional responses. He too believed that the psychological disturbance in psychosis echoes something inherent in everyone. Moreover, Benedetti (1992) a renowned psychoanalytic psychiatrist who worked extensively with psychosis suggested that the suffering a person with psychosis goes through consists of the most severe issues the human mind encounters. “Tackling them means illuminating the human being with signification and sense, gaining a better understanding of the human being in general, not only of the psychotic person” (Benedetti, 1992, p. 15). Fromm-Reichmann (1954) talked extensively along similar lines of the therapist’s processes/difficulties and stated that “Psychiatrists can take it for granted now that in principle a workable doctor-patient relationship can be established with the schizophrenic patient. If and when this seems impossible, it is due to the doctor’s personality difficulties, not to the patient’s psychopathology” (p.91).

Additionally, therapists’ understanding of the meaningfulness of their therapeutic interventions and relationships with people with psychosis has been often reported as shaken (Horowitz, 2008). Horowitz (2006) stressed that the therapists’ difficulty in creating meaning out of their clients’ experiences is of a common feature in work with psychosis: “(…) no therapist immersed in work with the long-term mentally ill is spared the agonising search for a common thread in the swirl of chaos”

(Horowitz, 2006, p. 177). Moreover, therapists’ empathic attunement to clients has been described as severely restricted when confronted with experiences within the therapeutic relationships that elicit strong emotions in therapists (Wilson & Lindy, 1994). Apart from the compromises in therapists’ empathic and reflective capacities, therapists working with psychosis come across difficulties that relate to a sense of fear in working with this client group even before encountering the client. The common discrimination against people diagnosed with schizophrenia and other psychotic disorders that seems to be common among mental health professionals as well (Thompson et al., 2002), generates a negative climate even before the professional starts working with a client. The generated social stigma towards psychosis according to Benedetti (1987) creates a sense of fear, which in turn creates a form of a generalised social aggression towards the person diagnosed with psychosis with related resistances from the therapists’ side and resultant complications in the therapeutic process.

Another noteworthy observation comes from Searles (1961) who has written extensively about the therapist’s anxious need to provide ‘antidotes’ for the clients and rescue them from their circumstances and experiences, particularly in the cases where these experiences provoke extreme amounts of anxiety and terror for the therapist. This experience of terror was also stressed by Fromm-Reichmann (1959) who suggested that persons diagnosed with psychosis embody fundamental elements that the rest of us manage to suppress in order to avoid the experience of the terror they generate; however, by so doing, we miss the opportunity to gain awareness into our own processes. Along these lines, Brody and Farber (1996) explored therapists’ attitudes towards their therapeutic relationships and found that despite the excitement and lack of boredom inherent in their work, therapists expressed intense emotions of anxiety, frustration and hopelessness. A multifaceted combination of countertransference responses was also reported, while at times a strong wish to abandon the work and refer clients elsewhere predominated. Additionally, in exploring the beneficial aspects of psychoanalytic psychotherapists’ experiences of their work with psychosis, Laufer (2010) proposed that therapists reported transformational and learning experiences in their work. The author highlighted that the majority of her participants shared that their clients taught them something

essential about the human condition. She particularly commented that their experience “(…) reveals our vulnerability, our dependency on each other, and that’s very threatening for people. They’re just a reminder of how fragile we all are, and that’s scary for people” (p. 170).

From the early E-P tradition, some inspirational work includes the work of Minkowski (1933/1970) and Rumke (1941/1990). Rumke introduced the term praecox feeling to demonstrate the therapist’s difficulty in connecting with people with psychosis, by explaining that it mainly consists of feelings of bodily unease, echoing the detachment and alienation of the client. He placed significant emphasis on embodied intersubjectivity and strongly suggested that the diagnosis of psychosis should be grounded not on individual symptoms but on the difficulties experienced by the therapist with regards to the affective exchange and the bodily feelings arising because of that. As Rumke (1941) has suggested: “As interpersonal relations are not one-sided, the investigator examining a sufferer from schizophrenia notices something out of the order within himself” (p.336). Rumke implied that the therapist’s self-relation changes and the experience of rupture in the therapeutic relationship also results due to a failing of engagement from the therapist’s side.

Minkowski (1933/1970) in a similar fashion with Searles and Fromm-Reichmann suggested that both therapist and client change in the therapeutic relationship. He aspired towards a better understanding of a person’s situatedness by immersing himself in his clients’ life and sharing their experience and considered that the therapist’s own emotional reactions could be used as a precious exploratory and therapeutic ‘instrument’.

The revival of phenomenological and intersubjective conceptualisations of psychosis appears to influence diverse psychotherapeutic modalities including the cognitive-behavioural, humanistic, psychoanalytic/psychodynamic and the narrative/dialogical (Lysaker et al., 2011). This has been one of the essential motivations in recruiting psychologists and psychotherapists from diverse modalities for the purposes of this project. As Markin (2014) has pointed out, “It’s our relational stance which bridges theoretical differences. It’s our concern for the quality of therapeutic relationship which binds our diverse orientations” (p.329). However, I

consider that the contemporary literature on intersubjective approaches to psychosis lacks a detailed examination of the psychotherapist’s role and lived experience of psychotherapeutic processes. Even though the majority of contemporary phenomenological literature exhibits a ‘two person psychology’ it still employs an ‘egocentric’ position, in the sense that it mainly focuses on the person who receives therapy and considerably ignores the therapist’s experience. In the cases where the therapist’s experience is considered, more emphasis is placed on her interventions and other-experience rather than the inclusion of a detailed exploration of her lived self- experience as situated in the betweenness of the therapeutic process and how her experience of therapy intersects with the manifestation of psychotic phenomena. Taking into consideration the preceding exploration of intersubjectivity, I suggest that this tendency is to a certain extent anti-intersubjective and calls for reconsideration.

In conclusion, these approaches not only suggest that psychotherapy for psychosis and its recovery are possible but also consider in detail the therapist’s involvement and difficulties in the therapeutic process as an inextricable aspect of the psychotherapy of psychosis. They also demonstrate that in order to intersubjectively and meaningfully approach clients’ experiences, we must authentically come to grips with aspects of our own selves that we usually tend to avoid because they connect us with painful facts about our vulnerable human condition. Moreover, these approaches suggest that an attentive engagement with clients allows us to rediscover aspects of ourselves, obliterate the separation between ‘madness’ and ‘sanity’ and learn about being human and being transformed. Strongly espousing these views and based on my lived experiences, I consider that a deeper understanding of the psychotic state provides the opportunity to rediscover and re-evaluate our notions of self and otherness. As Friedman (2002) has suggested: “(...) the abyss in the patient calls for the abyss, the real, unprotected self in the therapist” (p.190).