The therapist role and its contradictions
It’s a funny thing being a therapist. On the one hand we speak about the importance of challenging stigma and discrimination in the lives of those affected by mental health distress and write at length about inclusion, on the other, many of us fear being open about our own mental health distress, use discourses and/or behave in ways that can perpetuate stigma and the fallacious distinction between service users and mental health professionals. Service users are often constructed as though they were a discrete, separate group of human beings. For example, we invite service users to speak to ‘us’ so that we can learn from ‘them’. We argue with much passion that ‘they’ are vulnerable, voiceless and/or oppressed as opposed to ‘us’ who have power on our side. We firmly hold onto professional boundaries in part because we do not want to confuse ‘them’ about ‘us’, about who we are and about our role.
Those service users who get into the realm of the profession are often referred to as ‘service user researchers’, ‘service user consultants’ or as ‘experts by experience’. Equally, those professionals who have gone public and disclosed their use of mental health services are also set apart from the rest of us in various ways. Many view them with adulation, a few with disdain but, whether we agree with their choice to go public or not is immaterial. The point is, one aspect of their history or experience (their use of mental health services) seems to often become an all-encompassing dimension of their being in the manner that we relate to ‘them’ in the same way that past use of mental health services or experience of mental health distress seem to become the key part of the job tittle, role or identity of those constructed as service users.
In my sense these processes; which of course may well be helpful in some respects, can also be problematic. They arguably allow us to distance ourselves from those we view as service users but most importantly, they may also serve to distance ourselves from ourselves within the safety of a ‘them and us’ separation (for some evidence on the pervasiveness of stigma within mental health professions, click here). Of course there is no ‘them and us’. They are us and we are them. Disclosed or not, it is clear that mental health professionals as a group, have/have had their share of mental health distress. There are no official figures (that I am aware of) about the rates of mental health distress amongst clinical psychologists. However, a number of studies have evidenced the higher than expected rates of diagnosable mental ‘disorders’ within mental health professional groups including; that of trainee clinical psychologists.
Facing our vulnerability
The current prevalence of ‘stress related’ or ‘stress induced’ absenteeism within the NHS also seems consistent with the above. Further, career choices and interests are not coincidental and, personal motivations to work and indeed to be with mental health distress can be quite complex. Rarely are they simply academically or financially driven. Jung theorized that as psychotherapists we may be compelled to ‘treat’ patients because we are wounded so that the helping role also enables us to heal our own wounds. The idea of the ‘wounded healer’ appears to have some empirical support as some evidence suggests that a range of traumatic experiences (including mental health crises) influence ‘helping professionals’ decision to train.
There are of course potential safety gains in maintaining some relational distance from the people we see within services particularly when their stories and experiences are very similar to our own. A strategy often employed by therapists to develop empathy for their clients is to find life experiences of their own that evoke the feelings described by the client‘s material. In the context of shared ‘wounds’ such strategies can give rise to over-identification. Over-identification carries risks for both the therapist and the client including: the occurrence of significant blind spots which may adversely affect clinical decisions; re-traumatisation and/or unhelpful tranferencial processes. From this perspective the ‘them and us’ illusion may well have a protective value and be ethically desirable.
Terror management and splitting?
Nonetheless, things are rarely that simple…Indeed, many a times when we are busy constructing service users, we are not acting in a clinical or therapeutic capacity and the above distancing may not be warranted. I have found Terror Management Theory (TMT) a useful framework to make sense of this distancing. In essence TMT posits that as human beings we are motivated and indeed built to defend against the awareness of our vulnerability. To do so, we create belief systems that allow us to escape, if only momentarily; the inevitability of our ultimate vulnerability: our mortality. Of course TMT focuses on our terror of death and I am not aware that the concept has been used to consider our relationship with madness but, it seems to me that the fear of madness or that of going mad are also exclusively human.
Not only do they appears as deeply rooted as the fear of death, interestingly, they often seem to go hand in hand with it. Isn’t it the case that those who are in the process of mourning commonly question their sanity and fear losing their minds? It follows, from a TMT perspective, that separating ourselves from service users may also have the function of managing anxieties we may harbour in relation to our own mental health. Refusing to accept that no qualitative difference exists between ourselves and the people we serve may therefore also help to defend against the fear of our own vulnerability when it comes to insanity. Such distancing may psychoanalytically be conceptualized as ‘splitting’.
A possible inability to integrate our vulnerable mental health and indeed our potential insanity into a cohesive, realistic whole which include both the identity of the service user and that of the therapist. In this sense, having service users that are different from us makes it possible to disown these potentially unacceptable parts of ourselves and to locate them inside them. Can we fully support others to accept all aspects of their experiences and identity without doing so ourselves? I am not sure but, I know from experience that it is often our vulnerability that allows the people we see to connect and engage with us and; for movement to take place within therapy.
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Want to learn more?
Barr, A. (2006). An Investigation into the extent to which Psychological Wounds inspire Counsellors and Psychotherapists to become Wounded Healers, the significance of these Wounds on their Career Choice, the causes of these Wounds and the overall significance of Demographic Factors. The Green Rooms. Retrieved 06 November 2014.
Cushway, D. (1992). Stress in clinical psychology trainees. British Journal of Clinical Psychology, 31, 169-179.
Hubble, M. L., Duncan, B. L., & Miller, S. D. (1999). The heart & soul of change: What Works in Therapy. Washington, DC: American Psychological Association.
Jung, C. G.(1951). Fundamental Questions of Psychotherapy in Read, M., F.; Adler,G. and McGuire, M.(1951). The Collected Work of C.G. Jung, Vol. 16. Ed. Princeton: Princeton UP, 116-25.
Kuyken, W., Peters, E., Power, M.J. and Lavender, T. (2003). Trainee Clinical Psychologists’ Adaptation and Professional Functioning: A Longitudinal Study. Clinical Psychology and Psychotherapy, 10: 41 – 54.
Solomon, S., Greenberg, J. & Pyszczynski, T. (1991). A terror management theory of social behavior: The psychological functions of self-esteem and cultural worldviews. Advances in experimental social psychology, 24(93): 159.
For a personal account of the lived experience of training in clinical psychology when in mental health distress, please see: On being a trainee psychologist with mental health problems, an inspiring and saddening blogpost from a fellow trainee.