Tony White

As the all day workshop on the therapeutic relationship appraoches I have sought to add to my previous blog posts on terminating the therapeutic relationship.

In those situations where the client is the one to make the decision to end the treatment relationship a number of scenarios are possible it would seem as this transaction shows.



This demonstrates some of the difficulties that a therapist can have when the therapuetic relationship comes to a halt.

1. I want to cease therapy (Social transaction from client).
2. Are you sure that is wise at this point? or Is this a way of you avoiding significant issues coming up now? or Perhaps you should make a No Run contract? (Social transaction from therapist)
3. Covert transaction from therapist’s Parent to Child. “Explain yourself” or “Don’t you dare get out of my control”
4. Covert Child to Child transaction. “Please don’t reject me” or “Show me I am a good counsellor”.

Of course the termination of therapy in this instance is not going to be harmonious due to the therapist’s own difficulties. Other therapist’s can of course avoid such difficulties and end the relationship with the client in such a way as to benefit the clinet and them self such as in the transaction below.



1. I want to cease therapy (Social transaction from client).
2. I feel some sadness at the end and I am proud of what you had done. (FC social transaction from therapist)


Of course the client can terminate the therapy in a way which advances their life script or in a way that will promote their health and growth. If the relationship ends in an argumentative way then it would seem safe to say that the client did use the termination of this relationship to advance their script. If there is some kind of an abrupt end or disjointed end or an end that feels wrong then it is possible that the client has used it to advance their script from their AC.



1. I want to cease therapy (Social transaction from client).
2. I will use this relationship end to advance my script. (AC covert transaction)
3. I need you less. The dependency is needed no more. Your style of therapy no longer fits for me. (FC transaction from client)

If the client has a FC motivation accompanying the Adult social transaction then the relationship end is not advancing the script but promoting their health. When this happens there is usually a stepwise and slower end to the therapy. They stop coming once a week and it becomes once a fortnight and so forth. There is less contact over time.


The way to really tell if script advancement has occured is to ask self at the end of all the transactions if you feel like saying inside your head,
“It just goes to show you that...”
you can’t really trust people.
they always abandon you in the end.
I can never seem to get it right.
I never liked him anyway.
and so on endlessly



The most important factor in the termination phase of counselling, is that the client does not leave the therapeutic relationship in the same old self defeating relationship patterns that they have done so before.

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In the previous post myalterego talks about what is bad with a no-dependency life?

Jacob Bronowski of book fame, “The ascent of man” refers to humans as social solitaries. I have found this a good descriptive term. Humans like their solitude, independence and individuality. At the same time they are communal beings and have a need to be in relationship and belonging with another person and having a sense of belonging to a group of people. So in this sense they are dependent on that other person and group to be there to fulfil their need for belonging.

If I ever present the idea of the dependency hump inevitably there will be comment by someone that once they get over the hump then they can be independent and thus wont need to depend on anyone. Indeed many psychotherapies promote such an ethos - the healthy state is not a state of dependency but a state of independence. Self reliance is highly regarded in some counselling systems.


Belonging



My response is - dependency for life is a healthy state. Without a doubt self reliance, independence and the like are very good qualities to possess in life. I would encourage people to seek those personality qualities and use them in their daily lives.

Just one problem - they are not enough on their own. We need other people to be psychologically strong ourselves. When we depend on a dependable person/group then we are much more psychologically robust than the person who does not have such dependence in their life. So one needs a person(s) on which to be dependent their entire lives until the day they die.

Let’s take a transactional analysis explanation of this.



Person A has a problem in that they feel sad. However they go and use their own internal resources and use internal nurturing to assist their sadness and after time the Child is soothed and the problem is solved. A clear example of a person being self reliant and independent. A most desirable state to have for anyone I think it is safe to say. Some times however it is not enough and consider person B.



Person B feels sad and uses their own internal NP to assist in soothing the Child. However they also ask another person for help and that person offers their caring and kindness. So the Child is self soothed and soothed by others as well. Person B in the long run is going to be much better off than person A because of their willingness to engage others in their time of need. This person is not being self reliant and independent at this point, which I am suggesting is a healthy state.

However person B has one extra problem. As soon as person B transacts with the other, all sorts of very difficult and thorny psychological issues come rushing to the surface. Issues of trust, reliance, need, importance, closeness, dependence and so forth all come rapidly to the fore. As we know these are major issues of psychological importance that sometimes are not easily dealt with. If you get soothing from others then you have to also deal with these issues.


Trust



For some they are simply too difficult and they choose to rarely seek soothing from others. They will never allow themselves to be in that dependent position and thus they will live an emotionally crippled life.

I suggest that the healthy state is where one allows self to have some kind of life coach, mentor, confidant, therapist for the rest of their days. They allow self at times to be the dependent like party in such a relationship and this is a much more psychologically healthy position than the person who is completely self reliant and independent.

Graffiti

There is often conjecture over the relationship between self harm behaviour and attention seeking. It gets all mixed up with how people want it to be, politics and how it actually is. I have mentioned before that there are 8 alternative reasons why people can self harm:

1. Gang behaviour tattooing type of self harm
2. To make self feel real. Dissociation, detached from reality. Cutting closes the gap.
3. To make self feel something. No feelings at all just numb
4. Tension relief and pressure stress build up
5. Physical expression of emotional pain. Cutting provides concrete evidence of pain
6. Cutting as self nurturing. Allows caring of self. Munchausen Syndrome
7. Self punishment and self hate
8. Manipulation and to get attention

Of course these are not all mutually exclusive. People can be driven by varying combinations of the different motivations. But as mentioned before attention seeking behaviour (ASB) is a particularly difficult one.



So what is the problem? It is well stated by Kahless who says:

I think people react to self harm being called ASB when it is presented as the sole reason and given that most people associate the term ASB as being selfish, self asorbed, etc etc.
(End quote)

I think she has identified one of the problems well. I understand that politically the self harm support groups want to deny people self harm as an ASB because it can reflect badly on all self harmers for reasons like Kahless says.

My view is that some people do self harm as an ASB. I have worked with self harmers and when you build up a good relationship some have told me to my face that they do self harm to get attention or to manipulate circumstances. Clearly some do not and keep their cutting well hidden for long periods of time.

This picture below took me three minutes to find on the net.



I went to my Flickr, went to search all photostreams, typed in “self harm” and then hit search. I was then given thousands of hits of photographs titled - “self harm”. I simply clicked on one of these and went into that person’s pohotostream. There were other photographs with her face displayed for all the world to see along with her cuts. In her profile there is the name of the city she lives in, a bit about what she does and who she is. There are thousands and thousands of people doing the same and this was only in Flickr, imagine how many there are on the entire web. Why would a person do such a thing and display their cuts and their face on the web? ASB?

When a loved one dies at some point many of those left behind will at times reflect on their own mortality. As I have mentioned before people are very good at lying to themselves. Whilst we all know intellectually that we are going to die sometimes our Child ego states manage to some how trick us into believing that it kind of, really wont, somehow happen to me.

At the funeral we are slapped in the face with a reminder of our own mortality. So some do things like thinking about their priorities in life and for a while some stop the pursuit of the almighty dollar in favour of spending more time with family. However it usually is only temporary as the Child ego state sets about getting the person to lie to them self again. The point is, that when a close loved one dies were are slapped in the face with a reminder of our own finiteness.



Consider a hypothetical client. A nurse who works in a local hospital comes to a session with me and reports how two days ago she had to deal with a teenage girl who had ‘slashed up’ on her arms. The client reports that when she saw this girl she felt a surge of anger and treated her with disdain. One of the first things I would do is search for her own self destructive and self injurious urges. It is quite possible that seeing the girl had slapped the nurse in the face with a reminder of her own self injurious feelings.

So back to the reason given by Kahless as to why those who do ASB are viewed poorly - because they are seen as self absorbed and selfish. With self harm there maybe another reason why some react particularly negatively to them - they are reminded of their own self destructive urges. The teenage self harmer scared the nurse and she dealt with that scare by getting angry at the source of the scare.

Finally, assuming I am correct and there are some people who self harm as an ASB, at least in part, then these people have a very big problem. Not only does some of society view them negatively the self harm support groups further damage them.

Its like going to the doctor and saying I have a pain in my back to which the doctor replies no you don’t really its just that your hungry. Such a patient would leave feeling confused.

If a self harmer discloses to her support group that sometimes she slashes up to get attention only to be told that she does not really do it for that reason then she is also going to be left confused. She will walk out thinking that she does not cut self to get attention but in the back of her mind she knows she does, because she in fact does. She is now worse off because of the political agenda of the self harm support group.


Self harm

In addition to this she is also left untreated. The treatment goal of some one who cuts self to get attention is clear. For the Child ego state to learn how to get attention by others means than damaging self. Much easier said than done but the gaol of treatment is defined. If one is told they do not self harm for attention then of course it can never be treated.

Like all self harmers those who do it as an ASB are struggling in life and doing the best they can with the psychological resources they currently have. No different than the person who reports depression or panic attacks. No more or less valid and human. They just need to be treated for a different condition.

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Humans have what is known as an attachment hunger . That is we all have a biological, psychological and social hunger for an attachment to a mother [father] figure. Without it in infancy there is a swift decline in our mental and physical health eventually leading to a state of marasmus or 'hospitalism'. This hunger persists throughout our entire lives.



However from adolescence onwards, peer attachments allow the childhood need for a parental attachment to decrease. Thus there is more variety in the type of attachments in adolescence and adulthood. However without at least one firm and secure attachment in adulthood there is also mental and physical decline. This is primarily exhibited by withdrawal behaviour and the various problems associated with that. Most notably the schizoid personality type demonstrates these difficulties. In addition, it is noted that the psychopathic personality is also typified by the lack of the formation of social bonds.
Attachment hunger comes into play at about 5 to 7 months of age. Prior to that time there are indiscriminant attachments. The infant does not discriminate between who is feeding her, changing her or holding her. As a result some call this phase the stage of primary narcissism. At about 6 to 8 months the child develops specific attachments - the object period. The child will develop an attachment to one primary person, most often mother. At this time the child shows a fear of strangers and of being left by the primary object.


With narcissism one does not realize others are missing



If the specific attachment phase proceeds well, after a few more months the child will show a broadening of attachments. First to one other person and then to several others. By 18 months most children have an attachment to several people, with some research showing that only 13 percent of 18 month old children are still exclusively attached to one figure.

It should be noted that these two phases: of the attachment to one figure only, followed by the broadening of attachments to a variety of others may be culture specific. In monomatric families there is a tendency for the child to initially form a single all exclusive attachment to one figure. However in polymatric families, where the care of the child is shared around, this initial single all exclusive attachment is less observable. Whatever the specifics are the child will begin forming attachments around 5 to 8 months of age and there will be a broadening of them over time.


Supermario wallpaper



This is not meant to discard the notion of stimulation hunger or the craving for strokes, recognition and sensory stimulation. The research clearly the human need for stimulation. Stimulation and attachment are in many respects necessary for each others existence. For example it seems impossible that two people could become attached without any stimulation. That is physical and/or non-physical strokes, occurring between them.
Stimulation hunger in part allows the attachment hunger to be satisfied. For attachment to occur there must be stimulation or strokes occurring between the two parties. However that is not enough in itself for attachment to occur. There needs to be other conditions met. First there needs to be a consistency of the person providing the strokes. The few primary parent figures need to be there consistently and stimulating consistently. Second the person providing the strokes needs to be giving something of their own Child ego state to the relationship. A parent who mechanically and disinterestedly gave physical strokes to a child would of course hamper the attachment process. Attachment is a two way process.



The literature notes that one of the most important features for attachment to occur is the, "...readiness with which an individual is prepared to respond to the infant's signals and his general willingness to engage in playful interaction". In transactional analysis terms the parenting figure must be willing to invest his own Child ego state into the interactions with the infant. Both sides need to attach.

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