“A Rock & A Hard Place: Counter-transference Captivity ”

A Discussion Of A Piece Of Recent Therapeutic Practice, Showing How My Art Therapy Experience

Helps Us Learn About An Aspect Of The Theory & Practice Of Psychodynamic Psychotherapy

Presentation

Emma AllenHCPC Registered Art Psychotherapist

Rampton Hospital, High Secure Hospital

“A Rock & A Hard Place: Counter-transference Captivity ”

Aims & Objectives

•Providing case study material from forensic mental health setting.

•Drawing upon clinical applications of attachment theory, pathological, violent attachments.

•Looking at the potency of the first image made in a group setting.

•Considering counter-transference expression & “captivity” counter-transference.

•The importance of holding & containing & the centrality of the therapeutic relationship (patient- image-therapist).

Joe•Joe witnessed domestic violence from an early age – violent & abusive father.

•Left school at 15 to live in a hostel / Illicit drugs & alcohol misuse.

•Challenging & threatening behaviour at school / hospital admissions / bipolar affective disorder.

•Barricaded himself in an attic – admitted to psychiatric hospital, drug induced psychosis.

•IO: Murdered girlfriend after days of torture – keeping her hostage for a number of days, causing significant injuries.

•Violent in prison, deteriorating mental state/ months in his cell at a time. Delusions, acute paranoia – believes he is a prophet.

•Threatening & abusive behaviour at Rampton.

•Hostile when challenged / defensive. Relationship difficulties – Controlling, domineering & possessive of Art Therapist in a group setting.

•Therapist relates to victim.

•Drawing on attachment theory when thinking about the offence, presentation, transference & counter-transference.

•Experiences from first relationships continue to influence throughout the life span - experiences include pre & non-verbal interactions (Sobey and Woodcock).

•Patterns of relating that took root in early relationships (& make up the pt’s internal world) are likely to surface quickly & strongly within the pt-therapist dyad in pt-led psychotherapeutic work.

•Mary Ainsworth (1976): Securely attached, Insecure-avoidant, Insecure ambivalent.

•In cases where experiences have been destructive, the Art Therapist provides a different experience of relating – working to create an environment that will promote a less polarised & more secure attachment – consistency & reliability.

•It is thought that insecure attachment patterns play a significant role within many emotional, behavioural & psychiatric disorders.

•Chronic emotional detachment in psychopaths (Bowlby, 1944) (Reid, Door, Walker & Banner, 1986).

Violent Attachments•John Bowlby (1907-1990) ‘father’ of attachment theory identified that abuse & neglect as factors in adult psychological problems.

•‘A Secure Base’ (1988) Violence of parents a major contributory cause of a number of ‘distressing & puzzling psychiatric syndromes’.

• ‘Violence breeds violence’; perpetuating itself from one generation to the next. Violent fathers – what has Joe learnt from how others attach/relate to each other? Fears of being abandoned?

•Anger is often functional. Sado-masochistic projections/ relating reflect the way the offenders internal model for relationships is organised & may be a way to master trauma.

•Many violent offenders have rarely had any experience of containment or boundaries.

•Maternal deprivation prevents containment.

•“This lack of emotional containment along with enduring trauma that later in life the forensic patient adopts very complex, often dangerous defence mechanisms simply to survive their unbearable emotional states”(p.109, Aiyegbusi, 2009).

“Many inmates have experienced & perpetrated damage & abuse with recurring detrimental effect.

A poor sense of belonging, an inability to trust, fears of invasion or rejection,

theft or assault can all overrule the inmate’s capacity to engage in meaningful relationships.”

(Guidelines for Arts Therapists Working in Prisons, 2002).

Attachment & Psychotherapy

• Bowlby believed that attachment theory was central to both normative & psychopathological development – relevance for psychotherapy.

•The therapist functions to “provide the patient with a secure base from which to explore both himself & also his relations with all those with whom he has made or might make, an affectional bond” (Bowlby, 1977 p.421).

•Providing a ‘temporary attachment figure’.

•Helping the pt examine the relationship with the therapist, & how this relates to (past) relationships or experiences outside of therapy (Adshead,1998).

•Transference & counter-transference dynamics provide the opportunity to negotiate multiple contradictory internal working models, helping pts to feel, think, & act in new ways.

•The internalization of the bond with the therapist becomes a representational safe haven the pt can turn internally in times of distress (Levy, K.N et al, 2012).

Possessive Containment•The therapist is ‘held’ & contained in therapy: Feeling stuck, trapped, ‘possessed’ by the pt.•Art expression can reveal aspects of unconscious communication & offence-paralleling behaviour.

•“Art is recognised as a process of spontaneous imagery, released from the unconscious, using the mechanisms of repression, projection, identification, sublimation, & condensation” (Daley, p.xvi).

•For avoidant individuals holding is perhaps the key ingredient in therapy. Only when they feel securely held can these pts begin to confront their inner world & put emotions into words.

•Domineering / Ownership “Since when have you become Emma? since when do you now speak for Emma? Since when do you now start acting as if 'she's all mine not yours’?”

•Therapists need to contain not only the pt’s affects but also their countertransference responses (Therapists can be possessive too).

•Therapist acts as a containing function if can tolerate the clients feelings & emotions through transference & CT. Melanie Klein ( 1943, 1952).

•Central dilemma in the image: to hold or to let go?

Counter-transference Captivity•“Moments of fear & suspense in the therapeutic relationship where the therapist may feel pinned to the spot & alert to some unknown danger” (p.57 Greenwood, Wood, 2010).

•Like in the image, I identified with the victim.

•Therapist expected to hear about the offence – sometimes this can be frightening.

•“The attempted integration of subjective & objective ways of thinking in the pt or the bringing together of empathic understanding & intellectual comprehension by the analyst that is believed to cause a catastrophe” (R.Britton, 1998:43).

•Attempts to distance – intimacy threat to autonomy (Schaverien, 2006)

•Containment parallels with the experience of a developing therapeutic relationship with a pt. Detoxifying (Bion, 1962). CT as key to the pt’s unconscious (Heimann, 1950, Aiyegbusi & Clarke-Moore, 2009).

•Help as weakening / Envy / Growth of therapeutic relationship is defended against; feelings of need, want & vulnerability are all intolerable (Greenwood, Rosenfeld, 1987).•Fear is often a projection in the transference & counter-transference.

Fear in the countertransference (CT)

•The psychotic aspect of a pt cannot tolerate awareness of their vulnerabilities or dependency, & wish to attack & kill off awareness of this reality by attacking the perception, or the source of awareness of reality (Bion, 1957).

• Fear of an eruption of violence.

•This fear is justified: pt’s wish to kill off reality is real - have actually killed or attacked the source of awareness of reality – their victims. (Aiyegbusi & Clarke-Moore, 2009).

•Did he feel fear from violent father? Frozen with fear?

•Re-enactments: Victim, persecutor, rescuer (Karpman‘s Drama Triangle, 1968) psychological roles playing out in the therapeutic alliance.

•The therapeutic alliance in forensic mental health is often complicated by potential & actual risks the pt presents to others.

•Container paralysis. Feel hostage to pt (Greenwood, 2000).

•Managing CT in supervision & multidisciplinary working.

Klein (1975) described how the infant will want to get rid of unwanted parts of himself and will not want to experience his mother in a way that leaves him with negative feelings about her, as this will cause him anxiety & distress.

The infant gets rid of intolerable feelings by projecting them into his mother. The infant does this in order to dominate & control her, take over her capacities & make them his own, & invade & destroy her.

The powerful defence mechanisms of projection & projective identification afford the infant the ability of avoiding any awareness of his own feelings of separateness, dependence, admiration, feelings of envy, loss or anger & acute anxieties of fearing death through annihilation. In ‘normal’ development, these projections lessen as the infant learns to tolerate the ambivalent feelings of love, hate & dependence for his mother.

•Forensic Art Therapy, as part of a multi-disciplinary approach, can contribute towards the assessment of risk of further offending or the understanding & treatment of an individual’s offending behaviour.

•Behaviour observance – symbolic offence paralleling behaviour

•The unspeakable can be externalised, visualised, expressed, communicated, shared & symbolised.

•Vehicle for catharsis.

•Containment is fundamental: offender patients can develop a symbolic container inside themselves through the medium of art-making.

•The combination of ‘The Scream’ & ‘The Kiss’ makes for a very powerful, first image.

•The potential significance of the transference is embodied / held & contained in the artwork.

•The image reveals his attachment difficulties; suffocating, intoxicating.

•Conflict & resolution: Holding & Letting go.

•Bridging affective states & memories.

•“Pictures offer a medium for relating, first to the self and then to another person” (p.140, Schaverien, 1995).

•Self-awareness & insight into their impact on others, ways of relating & attachment patterns.

•The image & Therapist as container.

•Wanting to capture you!

“A Rock & A Hard Place: Counter-transference Captivity ”

Conclusion

•“Working with the Counter-transference” (Captivity), projections. ‘Pinned to the spot’ in fear, may be the pt’s fear.

•Attachment Theory, Violent Attachments; Early attachment experiences help explain emotional distress, personality disturbances, anxiety & anger (Bowlby) & helps us understand the pt.

•Attachment needs exist throughout the lifecycle putting separation & loss central to psychiatric disturbance/Relationships & Survival/ appropriate dependency.

•Impact /potency of the first image -“charged material” holding significant information. Conflict & Resolution / Early (pre-verbal) experiences made visible & relevant to present day.

•Importance of holding & containing, safe therapeutic relationship – trusting & collaborative. Supervision.