The current situation of psychotherapeutic practice

Therapeutic work, fascinating without a doubt, exposes us daily to interactions coloured by heavy doses of anxiety, violence, disorganisation, hopelessness and so on, and it is not always possible to give a quick and effective answer to that demand. Part of what has not been resolved goes on operating as a disturbance in the therapist.

This is why one of the practices that seem to us necessary is a return upon ourselves, one that re-examines, among other things, the models that have guided us. Far from turning away from clinical work, this return helps to increase its quality. Care of the therapist is necessary if the therapist is to be able to care; people who care for people must and deserve to be cared for.

Practising psychotherapy raises several fundamental issues for the therapist:

• a) facing severe problems set within an extremely critical socio-cultural and economic context;
• b) a theoretical and clinical training that is not always in step with the problems to be faced; these call for more teamwork, more networks and more inter-institutional collaboration and, in many cases, for socio-environmental measures;
• c) the situations just mentioned demand greater emotional and personal involvement from the therapist at the very moment when he has less instrumental preparation at his disposal;
• d) low levels of income and of job stability, together with scant resources and a lower degree of motivation for continuing training, which brings about a fall in the scale of prestige and social recognition of the professional psychotherapist;
• e) everything just listed determines a certain isomorphism between the professional situation of the average practitioner and that of a good part of the population that consults him.

This is a time of accelerated change and of maladjustments, and it produces unease.

The therapist’s macro-context

In short, the new century finds him with:

• clients who present with increasingly serious problems, and decreasing capacity to pay;
• institutional workplaces that take in severe pathologies and pay low fees, when they pay any at all;
• a lack of personal and institutional means for obtaining containment, supervision and training;
• the obligation to compete with various kinds of “magic”: personal development, flower therapies, and so on;
• a State that does not fully provide the means and the policies needed for the development of mental health and psychological care, on the side of services as much as on the academic and research side;
• his own personal, family and social difficulties;
• the difficulties of the institutions he belongs to, which often fail to adapt their paradigms and their practices to a changing and merciless world.

The therapist’s micro-context

Carl Whitaker (1992) sums up very well the characteristics of the daily working setting in the consulting room.

The therapist thus remains in the uncomfortable position of standing in the middle of the pressures of the macro- and the micro-context.

What nourishes the therapist in his professional life?

The matrices provided by the family of origin, the current family and the socio-economic and cultural community in which he lives. Initial and continuing training, theoretical frameworks, his own psychotherapy, supervisions, training courses, and the professional network he is part of, and so on.

But through what do these supports of his profession reach the patient? Through his person, which is his working instrument. This is why it is very important to take care of it.

The person of the therapist is the receptacle of a great variety of themes:

• life stories and life experiences;
• similarities and resonances with the patients’ problem situations, which he may or may not have resolved;
• feelings that are brought into play in the work;
• his own ideas and beliefs, which may collide with those of the patient;
• personality features;
• theoretical learning;
• mandates from the settings he belongs to concerning the way to work;
• personal working styles;
• the fact that in his work he puts at stake his words, his acts and his attitudes.

It is therefore highly desirable that therapists should have a space in which to:

• explore their personal life in depth;
• draw benefit from relating it to their clinical practice;
• connect their personality, their style, their life experience and so on with the patients in treatment.

This space will have to be distinct from, and complementary to, courses and supervisions.

Workshops on the person of the therapist

What has just been described can be obtained in group workshops where experiences are shared within a framework of understanding and confidentiality. This process of exchange would be intended to:

• a) increase understanding of the complex clinical reality and of its context;
• b) assess the degree of involvement, effort and emotional wear that the work implies or demands;
• c) facilitate a transformative elaboration, so that the psychotherapist does not find himself overloaded;
• d) protect him at the same time from a dangerous exposure, dangerous both for his health and for the effectiveness of his professional work;
• e) facilitate the learning of early detection of difficulties, both in himself and in the course of his clinical work;
• f) increase the knowledge of his person, of his strengths and of his weaknesses.

The working themes of these workshops

Concerning the therapist

• how well the therapist knows himself;
• the difficulties and the anchoring points that may come from his life story;
• which moment of his life cycle he is at; his family of origin and his current family;
• the therapist’s relational capacity; the quality of his social network;
• how he handles conflict (is he an avoider or an amplifier?);
• the therapist’s myths; his culture and his life experience.

Concerning professional practice

• how he handles patients; closeness vs distance; flexibility; the therapeutic alliance; the development of skills;
• the characteristics of his training and its shortcomings;
• the different models that guide his action;
• the keys that make it possible to spot interactional patterns (his own and the patient’s);
• the transformation of the therapist’s weaknesses into tools serving particular ends;
• his condition as observer-participant-self-observer;
• relations and rivalries with other professionals;
• survival techniques in psychotherapy.

Concerning the socio-cultural context

• the social changes that influence therapy and the forms taken by the demand;
• the new pathologies and the challenges they bring;
• life, cinema, theatre and the novel as providers of metaphors;
• ethical questions, and the question of values in psychotherapy.

Conclusions

Taking up the tasks described becomes important at the present time, because of the demand for support coming from many therapists who do not have the economic possibility of access to individual, private psychotherapy. At the same time, they could gain from these workshops something extra with regard to professional practice, something such psychotherapies do not frequently provide.

In this sense, sharing as a team the reflection on the therapeutic function, each person’s three-generational perspectives, the use of resonances, the exchange in a workshop that will function as a reflecting team in the manner of Andersen, T. (1994), can enrich professional practice and make it more effective. All these activities can fertilise one another, in a process where the participating therapists speak about their clinical work while also reviewing personal and family aspects.

The activity we are proposing sets out to fill a gap, one that comes from the absence of a specialised psychotherapy for therapists, because:

• therapists who do not belong to the field of psychoanalysis cannot resort to what is called training analysis or its equivalents;
• of issues arising from the cost of psychotherapy;
• of the economic limitations of the profession and, as a consequence, the fall in the therapist’s commitment to his own growth;
• of certain lines of work that promote the role of therapeutic technician.

We therefore consider that working on the person of the therapist may constitute a way of filling the deficit mentioned, without claiming to replace individual psychotherapies and supervisions.

The therapist’s growth according to Harry Aponte

H. Aponte (1985/86) proposes that psychotherapy should develop not only results and changes, but also “the mental growth of patients”, because such growth will help to sustain and to deepen the former.

In this sense, he points to areas of growth to which therapists must pay attention:

• the need for professional work and one’s own intimate life to be congruent;
• the therapist’s personal growth generates a greater commitment on his part towards his patients and towards his profession.

A large part of what the therapist comes to know has to be deduced from what his person experiences in the relationship with his patients.

The acquisition of knowledge and technique is fundamental, but the therapist’s skill in putting into practice what he has learned does not follow automatically from that acquisition.

The same author classifies therapeutic skills into:

• theoretical and technical skills;
• inner skills, or the therapist’s personal integration;
• availability and capacity for collaborative and interdisciplinary work with other professionals.

This last skill is significant when the therapeutic work has to do with the patient’s network: mediations, psychosomatic problems, school problems, family businesses, therapeutic interfaces, and so on.

As a participant in the therapy process, in order to preserve himself, the therapist has to oscillate between being an observer and being a self-observer. Part of the stress of the profession lies in supporting other people without being duly supported oneself. In training, the focus is professional skill and the side effect is personal change. In work on the self, the focus is personal change (and change in that person’s context), and the side effect will be the growth of professional skill.

Coming out of isolation

C. Whitaker (1991/92) underlines the isolation of therapeutic work and proposes, as a remedy, exchange between professionals, of which he mentions various forms:

• group supervision;
• play therapy;
• co-therapy;
• the shelter group, the name he gives to the permanent supervision group within the clinical institution one belongs to.

And he also points to:

• the permanent need for training, combined with;
• the therapist’s commitment to his own growth.

In short, all of this is summed up by this master in a two-word proposition: