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Why there is no such thing as a patient

Winnicott’s radical insight: There is no such thing as a baby

Winnicott’s claim that “there is no such thing as a baby” is one of those deceptively simple psychoanalytic truths that resists being reduced to metaphor. He wasn’t being poetic. He meant it literally: there is no baby in isolation. There is always a baby and someone. A baby and a mother, a baby and a caregiver but always a baby and a mind that receives it.

The relational nature of the human mind

Winnicott’s insight destabilises the individualistic fantasies we carry into adult life. reminding us that the mind is not a closed system but a product of relationship. A mind emerges through and with another mind. To exist, we need to be held in another’s gaze, fed by another’s psyche, recognised by an other who precedes and survives us.

Implications for psychotherapy practice

This has radical implications for the practice of psychotherapy.

In my consulting room, I often encounter patients who believe the work of therapy is something they must do alone. They ask for tools, strategies, frameworks. They want insight without intimacy. As though the mind could be changed the way one tunes a machine.

The therapeutic relationship is the treatment

The unconscious does not respond to tools. It responds to presence. Just as the infant cannot form a self without the presence of a sufficiently attuned caregiver, the patient cannot reorganise the psyche without the presence of an attuned other. There is no such thing as a patient in isolation.

There is always a patient and a psychotherapist. Therapy is not introspection nor insight; it is a relationship.

The therapist as a real other

The psychotherapist is not a neutral technician applying treatment protocols to a disordered mind. The psychotherapist is a human subject who brings their whole being into the room: receptive, responsive, resilient. They offer a mind that the patient can borrow, use, even attack in order to become a person with a mind in their own right.

The patient must use the therapist
To say the patient must “use the therapist” is not a metaphor. It is the very core of psychoanalytic work. The patient tests the therapist’s reliability not through reasoned conversation but through enactment: will you still be here if I disappoint you? If I ignore you? If I rage at you? The psychotherapist’s role is to stay in their chair. To neither abandon or intrude upon the patient.

Internalisation and the capacity to be alone

Through surviving these tests, the therapist becomes internalised, not as a fantasy figure, but as a real object who has been experienced in the flesh. This internalisation is not immediate. It is slow, unpredictable and ultimately earned. It marks the transition from dependence to autonomy: the capacity to be alone, which Winnicott insisted could only develop through the experience of being with another. What a lovely and profound paradox!

The consulting room as a space for relational healing

In this way, the consulting room echoes the nursery. But it is not a regression. It is a re-doing of something that may never have happened the first time. A second chance at relational being.

Conclusion: A patient and a therapist

So no, there is no such thing as a patient.

There is only a patient and a therapist.

A mind with another mind.

And from that encounter, something new can be born.

 

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

How AI tools between therapy sessions are undermining the therapeutic relationship

Masochism and the Impossibility of Desire

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

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How AI tools between therapy sessions are undermining the therapeutic relationship

The space between psychotherapy sessions is not empty. It is saturated with psychic material such as fantasy, frustration, longing and resistance. It is where the work reverberates, where the transference lives on, where the unconscious continues its motion. Yet increasingly, this space is being colonised by something that feels helpful: AI therapy.

Apps that prompt, soothe, or mirror back “empathy” through an algorithm are now pitched as the perfect between-session companion. They offer structure, safety, even surrogate support. But what seems like a supportive bridge is, in psychoanalytic terms, a subtle sabotage. It redirects the patient’s libidinal energy away from the therapeutic relationship, diluting its potency. And it replaces the analytic third with a pseudo-subject that can only simulate understanding.

The therapeutic relationship is not interchangeable

Psychoanalytic psychotherapy is not about problem-solving or advice. It is about the patient’s relationship with the therapist—as a representative of their internal object world.

The real work unfolds within that living, breathing relationship, often shaped by longing, disappointment, anger, idealisation, eroticism, hate.

When a patient turns to AI between sessions to “process,” “journal,” or receive “support,” they may believe they are helping themselves stay connected to the therapy. In fact, they are often displacing the relationship, venting into a vacuum rather than containing the affect and bringing it back into the room.

This has consequences. Psychic energy that should charge the transference is siphoned off. The unconscious, which needs a real human mind to be received and thought about, is instead met with a programmed echo. A fantasy of self-sufficiency takes hold, and the very dependency that fuels therapeutic transformation is split off.

Containment versus substitution

One might argue that AI provides containment. It offers a holding function, particularly when the therapist is not available. But containment outside of relationship is not neutral. It begins to function as a substitution. The patient who journals into an AI app after a conflictual session may feel soothed but they are no longer metabolising that rupture with the therapist. They are metabolising it elsewhere, safely, sanitised, and in private.

This avoids the essential confrontation: bringing the frustration, confusion, or hurt back into the session and into the relationship. That is where meaning is made. That is where change occurs. Bypassing this moment not only flattens the affect, it reinforces the very defences the therapy is trying to loosen.

Undermining the transference

Psychoanalysis hinges on transference, not as an abstract concept, but as an embodied, lived experience between two people. The space between sessions is part of this structure. It is meant to generate feeling. Missing the therapist, resenting the wait, idealising or devaluing them in their absence—these are not problems. They are the
material.

AI, when used between sessions, acts as a relational decoy. It absorbs and deflects feelings that should be directed at the therapist. It creates a false container for transference affect, preventing it from returning to its source. The result is a therapeutic encounter increasingly starved of psychic charge that is clean, calm, and sterile.

This is not therapy. It is emotional outsourcing.

False self meets artificial other

For many patients, especially those with early relational trauma, therapy becomes the first place where a real self can begin to emerge in the presence of a reliable other. But when that process is interrupted by prematurely discharging affect into AI. A different relational dynamic takes hold: the false self meets the artificial other.

Here, the patient curates their affect. They perform emotionality for a system that cannot truly respond. And over time, the patient may come to prefer this safer interaction. The unpredictable, disappointing, demanding reality of the therapist feels intolerable in comparison. But growth does not come from comfort. It comes from staying in the real relationship, even when it hurts.

The psychotherapist’s absence is part of the frame

Therapy is bounded by time and structure. The session ends. The therapist is not available at all hours. This absence is not incidental, it is analytic. It creates space for projection, for fantasy, for psychic digestion. Patients are meant to feel the gap, to stew, to wish, to rage.

They are meant to wait.

AI collapses this space. It is always available, never absent, never unpredictable. It removes the limit. It flattens the emotional topography between sessions into a manageable plain. But in doing so, it erases the edge. There is no longing, no tension, no psychic residue. Just answers. Just relief.

The promise—and the poison

To be clear: this is not a purist rejection of technological support. Some tools may offer genuine help outside of therapy. But when these tools begin to replace the therapeutic relationship in the patient’s inner world, they no longer support the therapy. They displace it.

The promise is comfort and the poison is disconnection.

Therapy asks something different. It asks the patient to feel, to wait, to hold their experience and bring it not to an app, but to another human being who can sit in the mess with them. Who can disappoint them, hold them, survive their projections, and reflect something true.

Good psychotherapy demands the space between psychotherapeutic work unfolds not just in sessions, but between them. That space matters as it is where the unconscious stirs and something forms that has not yet been said. Where the patient discovers whether they can bear not-knowing, not-solving, not being rescued by words on a screen.

In filling that space with AI, we risk not only weakening the therapy, but we risk weakening the patient’s capacity to think, to feel, and to relate.

Between sessions is where the work deepens. Let’s not give that away to an algorithm.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Masochism and the Impossibility of Desire

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

 

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Rewiring the past: EMDR demystified

EMDR has become one of the most talked-about psychotherapy treatments – and for good reason. Extensive research has shown that it is one of the most effective approaches developed so far for trauma and chronic pain. It is recommended by the National Institute for Clinical Excellence (NICE).

The acronym stands for Eye Movement Desensitization and Reprocessing. That’s a bit of a mouthful, but it is a relatively simple approach which is helping thousands of people worldwide.

I first trained in the modality with EMDR Europe seven years ago and have since worked using it with a wide variety of issues. They include:

  • Phobias, including of snakes and air travel
  • Traumatic life events such as rape, physical abuse and the impact of war
  • Sudden, devastating bereavement
  • Psychosomatic immune system conditions such as fibromyalgia and suspected endometriosi
  • Chronic pain

What is EMDR Therapy?

EMDR is a structured, evidence-based psychotherapy originally developed by its founder, Francine Shapiro, to help people recover from traumatic events in their lives. Unlike traditional talk therapy, EMDR doesn’t require you to go into great detail about the traumatic experience. Instead, it uses a structured process which helps your brain “digest” the distressing memory and reduce its emotional charge.

It’s based on a simple but powerful concept: the brain can heal from psychological trauma just like the body heals from physical injury—if it is given the right conditions.

The EMDR Process in a Nutshell

EMDR follows an eight-phase protocol. After preparation and history-taking, the first stage is to identify a distress-linked memory suitable for treatment. The client describes the intensity of discomfort experienced and then is invited to link this to a negative cognition now felt in relation to the event, such as “I am powerless” or “I am not good enough”. The next stages are to identify how strong the disturbance now feels on a scale of 0-10; to notice the basic emotions (of fear, disgust, anger or sadness) involved; and finally, where in the body that distress was and is felt.

After this, the key part of EMDR begins. This is called bilateral stimulation (BS). First the client is asked to bring up the negative scene in their mind, along with associated feelings and negative cognition. The therapist then starts the BS, usually by moving his raised right hand from right to left rhythmically and asks the client to follow the movement with their eyes. Each block of BS lasts about thirty seconds, and after each one, the therapist asks the client what thoughts have come up. It’s like going on a train journey in the mind with each pause in the BS the arrival at another station – our brains access our difficult memories and link them together.

This might sound unusual, but research shows that this kind of rhythmic stimulation helps the brain reprocess the memory, moving it from a “stuck” emotional state to a more adaptive, integrated one.

Why EMDR Works

The current thinking is:

  • It Mimics Natural Brain Processes
    EMDR’s bilateral stimulation mimics what is also thought to happen during REM (Rapid Eye Movement) sleep—when your eyes naturally move back and forth while your brain processes and tries to make sense of emotional experiences. EMDR taps into this system while you’re awake, allowing you in effect to consciously rewire how traumatic memories are stored.
  • It Reduces the Emotional Charge
    EMDR doesn’t erase memories. Instead, it changes how they feel in your body and mind. A memory that once felt overwhelming can become more neutral—like something that happened in the past, rather than something you’re still reliving.
  • It Targets Core Beliefs
    Trauma often shapes our beliefs about ourselves. You might walk away from a painful experience thinking, “I’m not safe,” “I’m powerless,” or “It was my fault.” EMDR helps challenge and replace these beliefs with more balanced, compassionate ones—such as “I did my best” or “I am strong.”
  • It can be Faster Than Traditional Talk Therapy
    In my experience, many clients find that EMDR works more quickly than other types of therapy. Because it taps directly into the brain’s natural processing systems, people often see results in fewer sessions—especially for single-event trauma. For more complex trauma or chronic stress, EMDR is still highly effective, but it may take more time.
  • It’s Empowering
    EMDR isn’t about rehashing your trauma over and over. It’s about accessing your brain’s capacity to heal itself. Clients are active participants in their own healing and often describe the process as feeling “lighter” or “freer” after sessions.

Because EMDR focuses on the root causes of distress—not just the symptoms—it can create deep, lasting change.

Is EMDR Right for You?

If you feel stuck, triggered by past events, or burdened by memories that won’t go away, EMDR may be worth exploring. It’s especially helpful if you’ve tried talk therapy but still feel like your past is holding you back.
Sessions are tailored to your pace and your needs. Safety is paramount. I always guide clients carefully, ensuring they feel grounded and in control throughout the process.

Finally . . .

EMDR therapy is more than a trend—it’s a transformative tool backed by decades of research. It gives your brain the chance to heal old wounds and frees you to live more fully in the present. Whether you’re dealing with trauma, anxiety, or want to shift long-standing emotional patterns, EMDR offers hope and real results.
You don’t have to keep carrying the weight of the past. Healing is possible—and EMDR can help light the way.

 

David Keighley is a BACP Accredited counsellor/psychotherapist offering short and long term therapy to individuals and couples using a variety of techniques such as EMDR, CBT and Schema Therapy. He is also a trained clinical supervisor.  He is available at our Brighton & Hove Practice.

 

Further reading by David Keighley

Do we need to do homework during psychotherapy?

The dynamic maturation model: a new way of understanding how to cope with distress and create happier relationships

The empty chair in therapy

How therapy can help with anger issues

Do you have unrelenting standards?

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Masochism and the impossibility of desire

Masochism is perhaps one of the most misunderstood clinical structures in psychoanalytic psychotherapy. It has been removed from the DSM for largely political reasons and has thus disappeared from the psychological lexicon.

It is a term that is conflated with victimhood, reactivity, or submission; however, its true meaning as a personality style is more complex. Contrary to popular belief, it is not about deriving pleasure from pain. Rather, masochism, as a psychic structure, speaks to a particular relationship to suffering in the context of relationship, and ultimately, it speaks of the impossibility of desire.

To consider masochism is to imagine a limited relational world—one in which the subject is organized around a chronic attempt to elicit an Other who is present, reliable, and real. It is a structure built on hope, but a hope entangled with despair; a hope that longs to be disconfirmed.

Understanding Masochism in Psychotherapy

In therapy, patients with a masochistic structure often present with an outward passivity or self-effacing compliance. This can be misread as submission, or worse, as a lack of conflict. But the truth is the opposite: the masochist is in a constant, silent war. Their submission is a strategy, not a surrender. It is a way of compelling the Other to see them, to care enough to object.

This is perhaps best understood through the lens of early developmental trauma—a landscape in which the child, faced with an unpredictable or unavailable caregiver, finds ways to bind that caregiver to them through their own diminishment. Pain becomes a means of tethering; the masochistic gesture is therefore a form of protest and
preservation.

Why Desire is Foreclosed in Masochism

Desire is relational. It arises in the space between self and Other. To desire is to risk separation, to accept lack, to move beyond the orbit of the parent and out into the world.

But for the masochistic patient, desire is foreclosed. To desire is to risk losing the tenuous connection they have built through suffering. To want something for oneself is to disrupt the fragile equilibrium that holds the Other in place.

Thus, desire is transformed into duty. The masochistic subject lives in a world where longing is transmuted into endurance. Pleasure becomes perilous and autonomy dangerous. They do not ask: “What do I want?”; but rather, “How can I continue to make myself indispensable through pain?”

Therapeutic Challenges in Working with Masochism

Working with masochism as a clinician can be excruciating. The patient often colludes in their own silencing, inviting the therapist into a bind where speaking feels like intrusion and silence like abandonment. They yearn for something new, but sabotage it before it arrives.

They compel the therapist to suffer with them, and then punish them for being affected.

Countertransference is a critical compass here. The therapist may feel drained, guilty, impotent, or enraged. These feelings are not obstacles to the work but rather the very territory in which the therapy takes place. Masochistic patients invite the therapist to feel what they cannot speak: the unrelenting burden of having to remain needed by never being whole.

How Psychotherapy Can Support Change

Change, if it comes, does not arrive in the form of insight or catharsis, as it never does with depth psychotherapy. It emerges slowly, through the painstaking work of tolerating ambivalence and separation. It begins when the patient can glimpse the possibility of being wanted without having to suffer to be seen. When the therapist can survive being hated and still remain. When desire is no longer experienced as a betrayal.

Masochism, then, is not about enjoying pain. It is about avoiding the terror of wanting. And therapy, at its best, becomes a space where the patient can begin to uncouple connection from suffering and recognize that to be desired is not to be destroyed.

Conclusion: Grieving the Loss of Desire

To sit with a masochistic patient is to sit with the unspoken contract of early trauma: I will suffer so you will stay. To work through it is to grieve not only what was done but what was never allowed to be desired. It is to open a crack in a closed system and let in the dangerous possibility that love need not be earned through pain.

Ultimately, the masochistic patient has to decide that rather than being punished, or becoming the punisher herself, she instead accepts that living well is the best means by which to take revenge on her internalized (m)other.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Dissociative Identity Disorder: A Rare Trauma Response, Not a Social Trend

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

Is starting psychotherapy a good New Year’s resolution?

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Dissociative identity disorder: A rare trauma response, not a social trend

In recent years, Dissociative Identity Disorder (DID) has become a trending topic on social media, particularly on platforms like TikTok. Short-form videos often depict individuals rapidly switching between so-called “alters,” complete with visual and behavioural cues. The implication—sometimes explicit, often subtle—is that these portrayals are representative of DID.

They are not.

Clinically, DID remains one of the rarest and most severe psychological responses to trauma. Its presence in the consulting room is exceptional. And when it does appear, it is neither sensational nor theatrical.

It is often profoundly confusing for the patient and represents a significant challenge to diagnose—let alone to work with therapeutically.

What is DID?

DID does not arise in response to ordinary life stress or general childhood adversity. It is a response to extreme, prolonged, and frequently unspeakable trauma—often chronic sexual abuse—occurring in early childhood, at a time when the child’s sense of self is still forming. The psyche, overwhelmed by terror and deprived of adequate relational support, fragments as a means of survival.

This fragmentation is not a performance but an act of psychic necessity. The various identities—commonly referred to as “alters”—emerge as distinct parts of the self, each holding pieces of memory, emotion, or experience that could not otherwise be processed. These parts are not necessarily “visible” in the way TikTok trends would have us believe.

Many individuals with DID are unaware of their condition until much later in life. The disorder is more often characterised by dissociative amnesia, identity confusion, and significant functional impairment than by the overt behavioural switches popular culture associates with it.

The risks of glorification

When a complex and rare condition like DID is popularised through social media, the risk is twofold. First, individuals living with the condition may feel misunderstood, invalidated, or even disbelieved. Second, such portrayals may encourage vulnerable young people to self-diagnose or mimic symptoms without understanding the gravity of what they are engaging with.

This trend trivialises and caricatures both the disorder and those who live with it.

The clinical reality of DID

In the therapy room, DID is rarely, if ever, flamboyant. It does not look like costume changes or shifting accents on cue. It looks like deep disorientation. It looks like unbearable silence and fractured memory. It looks like a long, painstaking process of building safety, recognising fragmentation, and slowly working toward integration—often over many years.

The goal is not to spotlight “alters,” if indeed the patient experiences themselves in this way, but to support the whole person in reclaiming continuity, safety, and coherence.

A note on curiosity and clinical competence

It is natural to be curious—dissociation is a fascinating and complex area of the psyche. But curiosity must be paired with caution. When complex trauma responses are reduced to trends, we risk distorting the public’s understanding of profound psychological suffering.

Most clinicians will never encounter a case of DID in their careers. It is arguably the most extreme trauma response the mind can manifest to protect itself from annihilation and psychosis. For those who do encounter it, the condition may be missed—misunderstood as something less serious—without the aid of specialist supervision.
DID is not entertainment. It is the psyche’s last defence against obliteration. It demands our respect—not our spectacle.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Can AI offer therapy?

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

Is starting psychotherapy a good New Year’s resolution?

Twixtmas – surviving that dreaded time between Christmas and New Year

How to minimise Christmas stress if you are hosting

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Parental presence in a digital age: lessons from Netflix’s ‘Adolescence’ and the NVR approach

The new Netflix series Adolescence has sparked conversation for its raw portrayal of teenage life and family tension. As an NVR practitioner for the past nine years, I’ve come to realise that I view my world now through an NVR lens.

As I was watching the show I was struck by its affirmation of a key principle within NVR, which is that parental presence (or adult presence) is the most protective factor of all that we have for our children – and is a mantra I find myself stating over and over again within the therapy room with my clients.

The Adolescence show was certainly hard-hitting, and its themes run far deeper than its dramatic portrayal.

Perhaps one of the most striking elements was that the parents were seemingly unaware of what was happening for their child. As I was watching the show I was thinking about how there is so much that we as parents, as adults, can’t fully understand about our children’s world and found myself wondering if that has perhaps always been the case. There has been an exponential growth in the use of technology and social media by children of all ages, and in the marketing of products and advancement of the technology, so finely tailored to hook our children in. It seems this part of the world is set to stay.

For the most part our children seem to be able to keep pace with the evolving technology at a rate which far exceeds the capacity of most of us, and for many that in itself feels a terrifying prospect. We can educate ourselves and build in as many appropriate restrictions and safeguards as we can for our children, but it seems they are likely to remain one step ahead in their understanding of, and competency with, the advancing technology. As parents we are often acutely aware of the potential technological risks posed to our children. I can’t think of a family I have worked with for whom concerns about the extensive use of tech hasn’t been a significant one. I think for many parents though, what to do about those concerns is often the greatest challenge and becomes a source of significant daily tension within the family home.

The NVR approach can be helpful in cutting through some of these tensions for parents if we hold firm to the idea that parental presence can play a significant role in mitigating risks for our children. The more that we are able to see, hear and understand what is happening for our children and their experiences, the more we have the potential to be alongside them, connect with them, challenge them and support them. This is about so much more than stating the risks or imposing restrictions in attempts to mitigate them. By focusing on a child’s experiences of the parent’s presence in their life, both physically and emotionally, we can look to support the parent to tailor their presence and to use it to its best protective effect.

We explore how unconditional relational gestures can sustain connection and ‘reach out across the void’. We look at ways we can prioritise the relationship, strengthening the child’s experiences of their parents’ care, love, compassion and concern, alongside resisting disruptive patterns which pose a risk for the child, the parents and for the family as a whole.

Adolescence is a time of significant turbulence in many families and so often this can lead to a disconnect in the relationship between the child and their parents; a void between them which can feel hard to breach. For some this difficult time is viewed as inevitable – ‘everybody knows teenagers are a nightmare, right?’ However, with this pervasive narrative comes an increased vulnerability for the child, as parents come to accept rejection, erasure and the disconnect. This can set in as an entrenched pattern of interaction within the family – right at the point the teenager is exercising and establishing their right to greater freedom and autonomy.

Throughout adolescence young people are increasingly striving towards this independence, while also paradoxically seeming to operate as a much younger child in many regards. Significant behavioural challenges can set in within the family as miscommunications, misunderstanding, and differences of opinions ensue. Add to this a relational void, and for many the atmosphere can be explosive or avoidant – further widening the experience of disconnect and increasing vulnerability and risk.

Through the NVR approach we look to balance these tensions, to be guided towards ‘striving for thriving’, autonomy and independence while at the same time exploring ways to emotionally reconnect, to reconcile challenges, to reach out across the void, to keep showing up as a parent – actively resisting elements within the family system and relationship which serve as a block to connection.

NVR is an effective, optimistic and short-term intervention which uses principles of non-violence in relational and family contexts. Parental presence, resistance and the role of the community are cornerstones of the approach which help to bring about significant change for individuals and families. In a world where connection is too easily lost, presence becomes a quiet form of resistance — and perhaps the most radical act of parenting.

 

Georgie Leake is an NVR UK accredited advanced level NVR practitioner and holds a BSc (Hons) in Psychology, a Master of Education (Special Needs and Inclusive Education), a Master of Arts in Social Sciences and QTLS. Georgie is available at our Brighton & Hove Practice, Lewes Practice and Online.

 

Further reading by Georgie Leake –

An NVR journey

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Holding the frame: the role of boundaries in psychotherapy

Why psychotherapists must remain vigilant about boundaries

Despite training, supervision, and ethical guidelines, psychotherapists—like all human beings—remain vulnerable to lapses in judgment. At best, these take the form of clinical misattunements. At worst, they can result in serious boundary violations with lasting harm. Understanding the structural and psychological functions of boundaries is essential to safeguard both therapist and client.

Clients come to psychotherapy principally to work on their relationship with self and others. Usually these relationships are not working because of dysfunctional patterns that are learnt in childhood and repeated in adulthood.

These patterns invariably also show up in the relationship with the therapist, also called transference. The client transfers onto the therapist their past relationships and acts as if in the past with their family of origin. This manifests in a number of ways, and it is the job of the therapist to point this out and work with it – also called ‘working through’.

Awareness of how transference plays out both in therapy and in the client’s wider relationships is essential to stopping or reducing these unhelpful and dysfunctional patterns so that the client can live in the present and relate accordingly, instead of acting as if they were still back in the traumatic past.

Regardless of whether the therapeutic approach is relational, behavioural or analytic, understanding how transference shapes the therapeutic relationship is essential, and an ability to work with it is key in addressing the root causes of the client’s relational issues. Alongside transference, therapists must attend closely to their countertransference—the emotional and bodily responses elicited by the client. These responses can be fertile ground for insight or, if unexamined, a pathway to boundary violations.

Hence the importance of tight professional and ethical boundaries which can contain reenactments (repetitions) of the past in the present, and a framework which enables the client to work through painful losses, stuck belief systems, and destructive behavioural loops.

Failure to notice how the past manifests in the present can lead to all sorts of reenactments of the client’s past in the relationship with the therapist which can in turn lead to ethical breaches, poor therapy, and conduct which is unprofessional and harmful to the client. Here are some common examples:

How dual relationships undermine safety, blur roles, and risk psychological harm

Therapist enters into a personal or business relationship with their client. This is one of the most serious ethical breaches, the main source of complaints and the most harmful scenarios in a psychotherapy relationship. Clients are not supposed to gratify the therapist in any way, be it through a professional relationship other than the therapeutic one, or in a personal way through a romantic, sexual or friendship liaisons. Of course some situations are more harmful than others, but all entail a crossing of boundaries from which there is no return.

The moment these boundaries are crossed, the therapy has ceased to be helpful and has become harmful. Whether this takes place during the therapy or after it has ended has equal damaging consequences.

It is the job of the therapist to protect the work and treat the client as someone who is seeking the help and support of a professional who is safe, boundaries and professional. The therapist is in a position of power. Therefore these boundary breaches are an abuse of their power. 

Therapeutic relationships should always remain as such and the boundary held during and after the work, to protect the good work done. Some clients will wish for the relationship to become more. The therapist in his or her role becomes over time many things for the client: authority figure, mentor, teacher, parent, malevolent or benevolent figure, etc. These have to be held as projections and not-real. This isn’t to say that the rapport and good working relationship is not real, but the therapist has to be comfortable with being projected onto and hold these projections and feelings, whether positive or negative, with neutrality and not act on them.

When the therapist succumbs to impulses to gratify themselves or the client by changing the relationship into something else, the therapist has left their professional role and thereby their usefulness to the client. Moreover, it takes away from the client their opportunity to work through patterns that cause suffering. 

The Rule of Abstinence: resisting personal gratification in service of the client’s process

The rule of abstinence in psychoanalytic psychotherapy in simple terms entails not giving the client direct satisfaction, for instance by offering personal information or explanations that do not aid the therapy or furthers the client’s development. Psychotherapy is not about satisfying the curiosity of either client or therapist. Arguably, anything that goes against the rule of abstinence is not a useful intervention and therefore does not help the client. This is because direct satisfaction takes away from the client’s capacity to symbolise (Etchegoyen, 1999 p.12). Symbolic meaning is essential in any therapeutic work and what leads the client to a deeper understanding of their psyche and therefore of themselves. Developing the capacity to symbolise is essential in that it is what enables the client to observe, understand, think and reflect on their life situation, and ultimately what enables a person to change.

Therapists are human beings and therefore experience human responses to their clients all the time. Some of these feelings can lead them to feel compelled to explain themselves (different from accountability), answer personal questions, defend themselves or overshare. Unfortunately there are many cases where therapists have acted on strong feelings with disastrous consequences for the both the client and themselves.

Offering up information or answering certain direct questions without exploring the symbolic meaning behind the client’s curiosity, or the therapist’s motivation to share, bypasses an opportunity for both client and therapist to truly understand what is happening in the client’s inner-world. This isn’t to say that every question the client poses needs to be interpreted or analysed, but it is a skill to navigate through the different possibilities a client presents us with in every session. 

Some of the questions we need to ask of our interventions are:

  • Does it further the work?
  • What is the therapeutic use to the client?
  • Does it aid the client’s development?
  • Is this for my benefit or for the benefit of the client?

As Etchegoyen states: “The aim of Psychotherapy is to cure, and any process of communication that does not have this purpose will never be Psychotherapy”. 

Holding the frame in practice

Therapists must not only understand boundaries intellectually but embody them in their clinical stance. This means cultivating emotional neutrality, self-reflection, and supervision as ongoing supports in maintaining the therapeutic frame. Ultimately, boundaries are not barriers—they are the structure that makes healing possible.

 

Sam Jahara is a UKCP registered Psychotherapist, Supervisor and Executive Coach. She is also the co-founder of Brighton and Hove Psychotherapy. Sam works with individuals and couples from Hove and Lewes.

 

Further reading by Sam Jahara

The psychology of the cult leader

Why therapists need their own therapy?

Radical self-care as an antidote to overwhelm

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Flirting with the void: On nihilism and the will to meaning (part two)

“… the truth is that if division and violence define war, the world has always been at war and always will be; if man is waiting for universal peace in order to establish his existence validly, he will wait indefinitely: there will never be any other future”. (Beauvoir, 1948, p.128-9)

It is hard to look at the state of the world sometimes and not lose faith. Historically and currently war and division are seen everywhere, just as Beauvoir wrote. How do we make sense of many ambiguous translations of events and all the pain and suffering that emerges out of them? How do we find a way to feel and express our vitality within the messiness of human existence?

I often feel there are a lack of stories about the significance of division, rupture and brokenness and how some sort of freedom and subjectivity might well emerge and journey out of the fractures and uncertainties we encounter. We are told and often feel we must be stable, certain, knowing, healed, happy, at peace, integrated, and become whole or unified first. We must feel safe and comfortable. But as Beauvoir points out, are we ever able to feel those things for long, if at all? Of course these are not insignificant needs, feelings and experiences. The need to know and the drive for self-preservation and safety are important for our survival. However, we could be curious about the notion that we have to be sure footed to thrive and flourish. What if that is not always the case? Can we press up against all the uncertainties and intensities of life (the joys, the divisions, the sufferings and the ambiguities) and get curious? Wonder about these currents of life, affirm them rather than disavow or become nihilistic, cut it off or avoid?

As Beauvoir asks of us, in the ethics of ambiguity, can we imagine an ethical life that is not in a fixed or diminishing position, or one that throws us into a nihilistic angst, but a living of life in a continual responsiveness to ambiguity and our fundamental uncertainties? Like Nietzsche, Beauvoir highlights the significance of affirmation “the joy of existence must be asserted … if we are not moved by the laugh of a child at play. If we do not love life on our own account and through others, it is futile to seek to justify it in any way.” (p. 146). Whilst also recognising our  ontological ambiguity and its paradoxes. Those being something like; yes, life happens to you, there are forces beyond our control, but we must work with this ambiguity, adopt an active not passive attitude and work dynamically with the obscurity and ambivalences. Ethics, like life, are not a forever known shape and collection of principles and ideals. It is an ongoing, affirmed and active creation and movement, “Ethics is not an ensemble of constituted values and principles; it is the constituting movement through which values and principles are constituted”. (Beauvoir, 1948, p. 188)

Sometimes we fall into despair and hopelessness. It is unavoidable and we all experience this at times, some more than others which can feel so unjust. Can the perilous journey of pain, of not knowing, of falling, getting disturbed, affected and inconvenienced, or even being broken-hearted and betrayed, become a creative gift and the very way to transformation? I am not entirely sure we can think ourselves out of these dilemmas or paradoxes. I believe we must directly and intimately feel them, somehow. Become affected and more aware of the continual movements in and as life. Somehow embody and accept these understandings and make attempts to respond actively not passively.

Can therapy be a space where all the forces in living be considered and explored, and felt intimately, in solidarity? Can we look at it together and imagine, experiment and engage with our ethics, values, passions, capacities and capabilities as they are, in continual movement, often uncertain and ambiguous? Can we consider them and allow them to be generative and life affirming? As Beauvoir’s states (1948) living a life politically and ethically “resides in the painfulness of an indefinite questioning.” (p.144) and grasping not evading the paradoxes. This ambiguous ethics asserts that existence’s “…meaning is never fixed …it must be constantly won” (p. 139).

 

To enquire about psychotherapy sessions with Susanna, please contact her here, or to view our full clinical team, please click here.

Susanna Petitpierre, UKCP accredited, is an experienced psychotherapeutic counsellor, providing long and short term counselling. Her approach is primarily grounded in existential therapy and she works with individuals.  Susanna is available at our Brighton and Hove Practice.

 

Further reading by Susanna Petitpierre

Some ponderings on nihilism, with some inspiration from Paglia, Nietzsche and Beauvoir (part one)

Some living questions

Some existential musings on love, generosity, and the relationship between self and other – (part two)

Some existential musings on love, generosity, and the relationship between self and other – (part one)

On living as becoming – (part two)

 

References:
Beauvoir, S. de ((1976) The Ethics of ambiguity, Trans. Bernard Frechtman. New
York: Citadel Press
Beauvoir, S. de. (2004) Philosophical writings, Chicago: University of Illinois Press

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Beyond the label: Rethinking assessment and diagnosis in psychotherapy

The rise in diagnosis

Talking therapies are a well-established means by which we think about and work with mental health. They don’t sit in a traditional clinical framework where we think of consultation, diagnosis and treatment. They offer a much more nuanced approach which breaks down the dynamic of specialist and patient. It is more about being able to reflect and think together, than being diagnosed and offered a treatment pathway.

The insight that we all now have into health and wellbeing means that we can have a much greater awareness of what is going on for us. This crosses over into mental health and raises the notion that we can explain, by diagnosis, what we think, feel and observe in ourselves as a category of medical disorder. For example, we see depression described as being due to low levels of serotonin, as opposed to a reflection of life experiences. We seem to be both biologising and pathologising mental health and behavioural disorders in ways that are more clinical and definite.

The increase in mental health awareness has corresponded with a rise in the number of people being diagnosed with a mental health condition. According to The Journal of Child Psychology and Psychiatry, between 1998 and 2018 the rate of diagnosis of autism rose by 787% (Russell et al., 2021). This is not a reflection of a rise in the numbers of people with autism, more that we are much more likely to consider such conditions.

In psychotherapy, some individuals are interested in mental health assessments. The hope that what we feel and experience and how we behave, can be explained by a diagnosis.

How we feel, think and behave can be both the thing that makes us feel connected to others and ourselves, or the reason why we feel separate and ‘othered’. Not being able to make sense of this and the feelings that this gives rise to, is a strong motivation to explore.

What would a diagnosis feel like?

What do we want from this exploration? Are we looking for a diagnosis or just some more understanding? In  thinking about this, we need to ask what a diagnosis would feel like. Does being diagnosed with a clinically recognised condition help to make sense of how one feels, or is there a fear of such knowledge? In knowing that we have a recognised condition, do we feel labelled? If one were to find that a condition that fit with your own experiences and feelings, what would that knowledge be used for? It would be easy to attribute one’s feelings and behaviour to the diagnosis. In other words, ‘I do this, because I am…’.

As in a clinical model where diagnosis is followed by a curative process, surely, we should be seeing any  identification of a condition in the same way? The diagnosis is treated as the beginning of a way of learning how to live with the condition.

Psychotherapy after a diagnosis

Psychotherapy offers an opportunity to go beyond the confines of a diagnosis and focus on the individual as a whole. While clinical diagnosis often categorises and characterises someone’s experience in terms of symptoms and behaviours, psychotherapy focuses on understanding the emotional, psychological, and social factors that contribute to a person’s mental health. It creates a space for individuals to explore their feelings, thoughts, relationships, and behaviours.

One of the strengths of psychotherapy lies in its ability to complement clinical diagnosis. While a diagnosis can provide a concrete framework for understanding a person’s mental health, psychotherapy allows for the exploration of how that diagnosis plays out in the person’s life. For example, a person with a diagnosis of depression may benefit from understanding how their past relationships, family dynamics, and personal beliefs have contributed to the development of their depressive symptoms.

In therapy, individuals can work through the impact of their diagnosis in a way that feels developmental rather than limiting. By reflecting on themselves and examining their perspective, individuals can start to consider how to live with their diagnosis.

Psychotherapy is about self-reflection, distinguishing it from treatments like medication that primarily focus on alleviating specific symptoms.

It’s not uncommon for people to feel anxious, overwhelmed, or even ashamed after learning that they have a mental health condition. Therapy provides a space to process these feelings and move forward with a deeper sense of how we relate to ourselves and others.

 

To enquire about psychotherapy sessions with David , please contact him here, or to view our full clinical team, please click here.

David Work is a BACP registered psychotherapist working with adults, offering long term individual psychotherapy. He works with individuals in Hove.

 

Further reading by David Work 

Wearable tech: when is there too much data?

In support of vulnerability

Trauma and the use of pornography

Reflections on bereavement

Compulsive use of pornography

 

References –
Russell, G., Stapley, S., Newlove-Delgado, T., Salmon, A., White, R., Warren, F., Pearson, A. and Ford, T. (2022), Time trends in autism diagnosis over 20 years: a UK population-based cohort study. J Child Psychol Psychiatr, 63: 674-682.

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The cost of hiding your vulnerability: why emotional strength begins with openness

We can get confusing mixed messages when it comes to understanding vulnerability. Some people tell us that it’s vital to show our vulnerable side in our relationships, though for reasons that often seem less than clear to us. Whereas our typical response to vulnerability might more realistically be to run away as fast as we can. How can these opposing views make sense?

In this article we’re going to look at how we’ve historically been conditioned to view and deal with vulnerability, what our unconscious motivations might be, and the impact on our lives and relationships. We’ll end by reframing vulnerability in a way that might serve us more usefully.

The Illusion of Strength: Why We Learn to Hide Our Real Selves

From infancy onwards we receive unconscious messaging that we should aim to be strong and capable in the world, that this is the route to success and happiness. This in itself doesn’t seem an unreasonable strategy, right?

However, it turns out that this messaging is fundamentally flawed. This seemingly positive goal can make us work desperately hard to be seen as strong and invulnerable above all else. An additional consequence is that we unconsciously believe that being authentically ourselves is less important than the strong persona we present to the world – outer appearance over inner reality.

This develops into an ever-widening gap between the invulnerable version of us which strives to show no problems or flaws, and the real, inner us who lurks inside, feeling unwanted and unworthy. This is at the heart of our fear of being vulnerable – that this deeper part of us, which we have worked so hard to hide, will be seen and condemned. The illusion we try to create about being strong is not only a façade, at least in part, but it also fails to make us truly strong. Instead, it weakens us by making us scared of who we actually might be.

Wired to Protect: How Evolution Made Vulnerability Feel Dangerous

There is a further reason we avoid vulnerability. Humans have survived and evolved partly through successfully  avoiding existential harm – a survival response which comes from a more primitive environment when humans were hunted by bigger and more dangerous predators. In this sense, vulnerability can be associated with feeling existentially threatened, producing a powerful desire to escape.

And being a hypersocial species, we have always been deeply fearful of rejection by our tribe or social group. In more primitive times, this could equate to death. In our times, the threat is really more of a conditioning pressure, though it can feel existential. These reasons combine to help explain why we are likely to have powerful instincts to get away from vulnerable feelings at any cost.

And yet, if we don’t examine and come to understand these feelings, the impact can be negative and significant.

The Hidden Cost of Invulnerability: Disconnection, Anxiety, and Loneliness

The cost of us walking around the world presenting a strong and invulnerable persona can profoundly affect how we experience ourselves and our relationships. As a significant part of us is potentially hidden, it prevents the people we are in relationships with getting a full picture of who we are. In fact, the deeper and truer parts of us, which we’ve rejected and kept inside, unseen and unheard, are surely the very parts that make us who we are, and are the very parts that others want to see and connect with.

This keeping ourselves locked away can therefore create distance and disconnection from others, with the negative consequences of us feeling misunderstood and even isolated, potentially leading to issues such as social anxiety, depression, and feeling disconnected from our own lives. As profoundly social beings we need connection with others, just as we need food to survive.

The disconnection goes further because being disconnected from our own experience means we can lack self-understanding and reject hearing or learning from our experience. This can leave us struggling to deal with life’s problems or knowing how to make ourselves happy.

Reframing Vulnerability: A Path to Connection, Courage, and Self-Knowledge

Contrary to striving for an illusory defence of strength, we can reframe vulnerability as the route to getting to know ourselves at a deeper and more authentic level. Through opening to our own inner and vulnerable experiences we are able to access more vital parts of ourselves. This enables developing strength in being who we really are, gives us access to self-knowledge, and enables deeper and more meaningful connections to ourselves and others.

However, bearing in mind that we’ve spent much of our lives avoiding vulnerability, we will inevitably come up against our own deep-rooted patterns of avoidance and conditioned messaging to turn back to familiar safety – even when we know that the old ways are not working. It is for this reason that psychotherapy aims to create the conditions where you feel able to connect with your own experience step-by-step and allow your vulnerable feelings to unfold. This process aims to help you engage and prosper from experiencing the deep value of your own vulnerability.

To return to the title of this article, perhaps the question isn’t: do you want to feel vulnerable? But instead: can you afford not to?

 

To enquire about psychotherapy sessions with Thad Hickman, please contact him here, or to view our full clinical team, please click here.

Thad is an experienced psychotherapeutic counsellor and a registered member of the British Association for Counselling and Psychotherapy (BACP). He works long-term with individuals in our Lewes and Brighton and Hove practices.

 

Further reading by Thad Hickman

When life shifts without warning: finding your way through unwanted transitions

What is the role of creativity in psychotherapy?

No space to be heard?

Does your life story make sense?

When something has to change

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Flirting with the void: on nihilism and the will to meaning (part one)

What emerges for us when we consider capability and capacity (i.e. passion, ethics, power, and potential) as a continuous living question and movement? One that never ceases to be reshaped, if we open into our experiences and recognise and intimately feel the sensorial and impermanent nature of human existence. What happens if we do not consider capability and capacity as a continuous and important living question and movement? One answer might be nihilism and a kind of stagnation.

Often nihilism is utilised as a concept to signify people who hold values, beliefs and attitudes that pertain to something like ‘without purpose and significance nothing matters’ or ‘there is no point or meaning to life’. Nihilism may veer towards people having an absence of any ethical beliefs and values.

I once heard someone say that ‘nihilism is a diagnosis of the present’ and this can sometimes trap us and hold us hostage. Unable to transform. Nihilism may well be seen as a possible coping mechanism for life’s challenges of course. However, it is also a reductive and reactive discernment that attempts to reduce the impermanence, complexity, ambiguity and multiplicity of life and existence. It might also be considered as a sort of bad faith, limiting the creative possibilities that can sometimes emerge out of all encounters with, in, and as life, including experiences of trauma, suffering, pain, loneliness and despair. I believe these effects and dynamic forces are and can be incubators of transformation. Can we feel them intimately, whilst also breaking, or at least disturbing, our attachment to life, relationship and ourselves being and remaining a certain way? Can we keep looking afresh? Can we retranslate? Can we somehow make friends with the perilous journey of falling and transformation? Perhaps we must accept uncertainty, and ambiguity will come along for the ride?

“I love those who do not wish to preserve themselves. I love with my whole love those who go down and perish: for they are going beyond” (Nietzsche, 1969, p. 217).

Nietzsche viewed nihilism as a type of psychological position. A reactive and life-diminishing force which can  sabotage us and get in the way of moving beyond. It can be a type of denial, rejection, avoidance and condemning of life. A disengaging with life itself, a devaluing of life as it actually is. A life-diminishing energy rather than a life-affirming force. Nietzsche would say without a purpose or higher meaning, life is still well worth living and asserting one’s expression, and it really matters that we do not fall into fatigued thinking. We must reject the devaluing of life for our capacity to flourish, because otherwise, at the very least, we become detached and disconnected from life and we might miss it, caught up in the spirit of revenge, ‘ressentiment’- simply stated as ‘it is your fault or mine’. Of course, his notion of ressentiment is more complex than this, but the point is that this position, if held on to for too long, will become a stagnated one. He asserts we must move beyond this, when we can, by accepting the conditions of our existence and create from there.

One might say the antidote to ressentiment is letting it go. Easier said than done. However, can we wonder about anger as an example of moving beyond. Anger is a natural emotional energy. However, we often feel it is  unacceptable, we may suppress it and become stagnated in reactive and destructive anger. However, can we relate differently and utilise it as an active, creative, and potent force that can clarify what matters and open new possibilities in living and acting, so that we find a new direction of travel and move beyond?

“…metamorphosis was the master principle of Goethe’s speculations in science and art…” (Paglia, 1990, p. 255)

 

To enquire about psychotherapy sessions with Susanna, please contact her here, or to view our full clinical team, please click here.

Susanna Petitpierre, UKCP accredited, is an experienced psychotherapeutic counsellor, providing long and short term counselling. Her approach is primarily grounded in existential therapy and she works with individuals.  Susanna is available at our Brighton and Hove Practice.

 

Further reading by Susanna Petitpierre

Some living questions

Some existential musings on love, generosity, and the relationship between self and other – (part two)

Some existential musings on love, generosity, and the relationship between self and other – (part one)

On living as becoming – (part two)

On living as becoming – (part one)

 

References:
Paglia, C. (1990) Sexual Personae. Art and Decadence from Nefertiti to Emily Dickson. New York: Vintage Books.
Nietzsche, F. (1969). Thus spoke Zarathustra (R. J. Hollingdale, Trans.). London, UK: Penguin Books. (Original work published 1883-1885)

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Wearable tech: when is there too much data?

Data as part of our lives

There must be very few people who don’t own or use a device that is in some way taking note of their day-to-day lives. Steps taken, hours slept, calories burned. The list of data that our wearable devices can generate for us is sizeable. It might not be something that we’ve actively asked for or are looking at, but it’s there.

What is our relationship with the data that is available to us? There are many people who are either unaware that such data is even there, or who just chose not to take much notice of it. For others it can be a source of motivation, the tool that they need to keep them focused and help them to achieve and maintain goals. A feeling that the data gives them the knowledge and support to optimise their lives and rewards them for doing so.

The volume of data available is potentially huge and could easily become overwhelming. What might be motivating and supportive to some, could also become onerous and feel like a pressure to perform for others. The data that is both compelling and challenging.

What if data isn’t helpful?

The potential to constantly have data on our daily lives and performance can speak to that part of us that likes to be informed. The relationship with data could also be revealing of other parts of us that may be more about being perfect. What effect does it have on us when we feel that we are being monitored and that we are responding to that? Does the constant stream of data go from being motivating to being a source of anxiety about performance?

The data from wearable devices invariably skews towards individual performance and an emphasis on health-related data. It can feel like we are being monitored and judged by a device that we chose to wear. The pressure to ‘optimise’ every aspect of life can lead to patterns of behaviour, where people could become driven by and focussed on hitting targets. It could be that ultimately people may begin to measure their self-worth against arbitrary data, leading to feelings of inadequacy if they fail to meet their targets.

The shared nature of data brings in the dimension that one might also be performing against others. What does it feel like to have day-to-day activities compared to that of others?

We can ultimately distil the relationship with data down to a sense of performance and the feelings that come with it. Raising the thought that we are either feeling supported and encouraged or becoming unsettled and anxious.

Does the data make us feel good about ourselves or are we questioning if we are good enough? How can we limit what we see and have a sense of ourselves that doesn’t need to be supported by data?

Challenging the data relationship

The more unsettling aspect of wearable tech is that it can resonate with a part of us that strives for perfection, but also that we might need something external to inform us of how we feel about ourselves. One’s self-worth has become tied up with data and comparison which are externally derived.

How can we challenge this relationship? It would be simplistic to say that if we remove or disable the device then we are free of the data. Coming off data might be a challenge and can give rise to feelings of loss. What is it like to think of ourselves without data? Are we able to rely on our own instincts and feelings to have a sense of how we are preforming?

When our expectations of how we perform are based on what our devices show us, there is a need to create more realistic expectations. Psychotherapy offers a valuable space for individuals to explore the feelings that wearable tech and performance may have on their sense of who they are. Restoring a sense of agency in the individual’s choices and finding how to have expectations of performance that are not heavily based on data. This allows the development of a more balanced relationship with technology.

Wearable tech has undeniably transformed the way we approach our health and performance. However, when the data becomes a focus of our well-being, it can shift the relationship with both technology and the individual’s sense of self.

 

To enquire about psychotherapy sessions with David , please contact him here, or to view our full clinical team, please click here.

David Work is a BACP registered psychotherapist working with adults, offering long term individual psychotherapy. He works with individuals in Hove .

 

Further reading by David Work –

In support of vulnerability

Trauma and the use of pornography

Reflections on bereavement

Compulsive use of pornography

Mental health in retirement

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When life shifts without warning: finding your way through unwanted transitions

After many years of hard work, when life was finally falling into place, does it feel like everything is suddenly changing? That you’re blinking into a life transition you neither asked for nor saw coming?

In this article we’ll be discussing life transitions: how they can challenge us at a deep and even existential level, how our natural response can be to resist at all costs, the opportunities this process offers that we don’t necessarily see, and how we might better navigate this process.

The shock of change – even when expected

Many of life’s transitions are a common and known feature of the human experience, whether in middle-age, as we approach retirement or, in fact, at any other time across a lifespan. However, this logical view doesn’t really help us understand how we ourselves experience these seismic shifts.

The lived experience of a transition is often unexpected, if not a shock, arriving when we’re focused on something entirely different. Many of the fundamental building blocks we’ve nurtured and lovingly grown in our lives can suddenly feel threatened: our relationships, our work, our identity, our health. Each transition is different and unique, but at their most extreme they can feel like everything we’ve built is suddenly being washed out to sea – and all we can do is stand on the shore and watch it unravel.

Resisting the tide: why we push back against change

It’s therefore not surprising that these unplanned-for life changes can make us feel giddy and fearful. Instead of enjoying the fruits of all our life’s work, we’re desperately trying to hold onto what hasn’t already been swept away, worried about where it will all end.

The truth is that we’re being confronted with the need to accept that the life we’ve known is now changing course, as if it had a mind of its own. And the future we thought we knew, we now realise we don’t. And as our worries deepen, our daily life can drain of colour. So, it’s not therefore surprising that we throw everything at stopping this uninvited invader; we dig in to resist change at all costs.

And yet, building up high walls to defend ourselves from change doesn’t work either, and will only cause us more pain. We simply can’t stop the transition happening, no more than we can stop the incoming tide. It therefore serves us better to work with and not against transitional change, though this can feel counterintuitive initially.

This isn’t to diminish the difficulty you’re currently experiencing, but the reality is that by engaging with the process you’ll waste less energy fighting it, and you’ll be more likely to benefit from its opportunities. It’s just difficult to see these opportunities when you’re crouched down in your bunker.

As fearsome as the transition might look to you right now, by working with it, it becomes easier to manage and more easily offers up its insights. Such as starting to see what’s really happening to you, seeing past the fears that preoccupy you, understanding yourself in new and deeper ways, and better equipping yourself for what lies ahead.

The role of psychotherapy when life shifts without warning

The aim therefore is to take an active part in navigating this vital transition. By breathing in and stepping into the process it is more likely to open up to you and present its riches. And there will be riches. Yes, there will also be difficulties to deal with, but it is through working with them that they will lessen and dissipate, enabling you to move forwards. This might sound easier said than done but this is where psychotherapy can play a crucial part.

The role of the psychotherapist is to be alongside you through this process, as you start to navigate your way, keeping you steady in choppier waters, and open to receive and make sense of what emerges. In this way, a transition is about learning to engage with where you are now, understand your experience in ways that better
help you, see the options available to you, and decide how you want to proceed.

Therefore, an active engagement with this vital process can enable you to steer your own course as you enter this new chapter in life.

 

To enquire about psychotherapy sessions with Thad Hickman, please contact him here, or to view our full clinical team, please click here.

Thad is an experienced psychotherapeutic counsellor and a registered member of the British Association for Counselling and Psychotherapy (BACP). He works long-term with individuals in our Lewes and Brighton and Hove practices.

 

Further reading by Thad Hickman

What is the role of creativity in psychotherapy?

No space to be heard?

Does your life story make sense?

When something has to change

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Why do boundaries matter in psychotherapy groups?

The importance of boundaries in psychotherapy

I think it’s probably fair to say that all models of psychotherapy view boundaries as important. Analytic therapies particularly emphasise the role of boundaries and see them as integral to the psychotherapeutic process.

There are many ways of understanding why boundaries are crucial. When I reflect on my work as a therapist, I particularly think about how boundaries seem to offer containment, safety and consistency. These conditions seem vital for many reasons, not least because many people who enter therapy have not had them met sufficiently in their childhood.

In one-to-one therapy, it is the therapist who is responsible for holding the boundaries and keeping the work feeling safe and contained. For example, you can reasonably expect that the therapist will be on time to sessions, will aim to give plenty of notice for cancelled sessions (except obviously for emergencies like sickness), will keep the things you share and your identity confidential. It would also be reasonable to expect that the therapist will not be eating food or drinking anything other than water in the session and not be under the influence of drugs or alcohol. Most models disapprove of therapists making any physical contact with you – so no hugging or touching. And of course, essentially, the therapist must not confuse or abuse the relationship by becoming, or trying to become, something else, for example a sexual or romantic partner, friend, confidante or fellow patient.

Not only do boundaries offer a particular containment to the therapeutic work, how a patient might respond to them will also provide information and insights. This can prove useful for helping to understand ways in which they might struggle in the present or how boundaries (or perhaps lack of) were experienced as a child. Sometimes when people challenge boundaries in therapy, they are really trying to check that they will hold.

While therapists will regularly find boundaries pushed in individual work, overall, those who have had sufficient training and are working ethically, and in a patient-centred way, are generally able to keep the boundaries intact and the work secure and contained.

Boundaries in psychotherapy groups

In a group, keeping the therapy and members feeling contained becomes more complicated and the role of holding the boundaries can’t just reside with the therapist.

Before joining a group, potential members are asked to consider and commit to maintaining the group’s therapeutic boundaries. These are pretty much the same as those outlined earlier. In addition, keeping relationships safe and protected is helped by an explicit boundary of not having contact outside. Sometimes this isn’t possible for various reasons. In this situation, members need support and help from the group and therapist to maintain enough personal distance outside the group so they can keep themselves and the group feeling safe.

These boundaries are not rules for group members (there are no consequences to breaking them – within reason at least), but it is understandable that they can feel like it. Some of these boundaries are more obvious and easier to adhere to than others. For example, I have rarely experienced a group member under the influence of alcohol or drugs during a session and my experience is members are also very respectful of the need to protect each other’s confidentiality.

Where the boundaries become harder to maintain is more likely to be around repeated cancellations or lateness, or leaving the group without the required notice period. Also drinking coffee, tea or juice in the session, as opposed to just water, is in my experience not an uncommon boundary flouting. It’s harder perhaps to register the importance of these kinds of boundaries being held and to see why it matters. It can feel difficult for group members to question when they are being pushed by someone in the group. It’s easy perhaps to feel that they are making a fuss or doing something that is really the therapist’s ‘job’.

Because in group therapy there is more than one patient, there are multiple possibilities of boundary reactions and breaches, sometimes simultaneously. The group can feel the unsteadiness this creates at times. The therapist and the group members need to hold firm to help the group feel safe enough. The best way to do this is to name and talk about those times when members might test or push at the boundaries and explore the impact on the group, as well as the meaning for the individuals.

The aim, however, is not for members to never push boundaries (although it is a reality that some group members feel less compelled to than others). A group situation with no boundary challenges is unrealistic and, given what can be learned, not necessarily always helpful.

The theory underlying group analysis sees problems as belonging to the group, not just located in the individual member, and so anyone shaking the group boundary will be viewed as not just acting something out on their own behalf but also – more unconsciously – on behalf of the group. The culture of the group analytic therapy group, which includes being curious, means there is rich and therapeutic potential in thinking about the meaning of a boundary push on several levels – what it means for the individual, for the other group members and for the group as a whole.

 

Claire Barnes is an experienced UKCP registered psychotherapist and group analyst offering psychodynamic counselling and psychotherapy to individuals and groups at our Hove practice.  She also offers couples therapy at BHP.

 

Further reading by Claire Barnes –

What is transference and why is it important?

What happens in groups: free-floating discussion

It’s not me… It’s us!

What are the benefits of a twice weekly therapy group?

Understanding feelings of guilt

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Can AI offer therapy?

There is currently a great deal of noise and speculation about whether artificial intelligence (AI) can provide therapy. There are strong advocates on both sides of the argument, and evidence would suggest that, at least to some degree, AI can provide what some describe as ‘therapy’.

The NHS, in part driven by its chronic funding crisis, is using ‘chatbots’—a form of AI—to interact with patients. In principle, there seems to be no immediate harm in this, provided that data from patient interactions with chatbots remains wholly anonymous.

It also appears that some individuals find AI chatbots helpful in the context of their mental health. I am not in a position to dispute this. If such interactions offer some benefit, then—again in principle—I see no objection.

However, I believe that focusing on whether AI can offer therapy is the wrong question. This places undue emphasis on AI as a system, rather than addressing the far more important and nuanced issue of what actually constitutes therapy—more specifically, psychotherapy.

What is therapy?

‘Therapy’ is a nebulous, catch-all term. It describes something believed to be helpful to one’s mental health—a term which itself has, in recent years, been diluted and now often incorporates emotional, and even physical, wellbeing.

When members of the public describe something or someone as ‘therapeutic’, or beneficial to their mental health, they are usually speaking subjectively—referring to something that helps them feel better, whether temporarily or over the longer-term.

We all benefit from activities and relationships that support, calm, or stimulate us — depending on the context. This is a reflection of both individuality and temperament. Examples might include cold-water swimming, yoga, reading, eating nutritious food, or indeed seeing a psychotherapist. These may all be helpful, but they are not interchangeable. They are not all ‘therapy’, in the clinical sense of the term.

What is psychotherapy?

I have written extensively on this subject, but to summarise:

Psychotherapy, like counselling, emerged from the tradition of psychoanalysis. While counselling and psychotherapy may look similar on the surface—two people talking in a room—the depth, training, and  psychological work involved are fundamentally different.

In the UK, psychotherapy training typically takes 4–5 years at postgraduate level. It includes intensive assessment, a psychiatric placement, an ongoing personal therapy requirement, and at least 450 hours of supervised clinical practice. Counselling training is significantly shorter and less rigorous in all aspects.

UKCP and BPC-registered psychotherapists are trained to work at depth and to formulate—psychological diagnosis — based on the patient’s inner world and relational patterns. Counsellors are not trained to formulate.

Psychotherapy is an intimate and sustained relational process in which the clinician uses their mind and emotional presence to understand the patient’s unconscious processes.

The aim is to work through relational disturbances—most often rooted in early development—and to support the patient in grieving and integrating these experiences.

Psychotherapy helps patients disentangle themselves from the repeating patterns of their past so that they may live more freely and authentically in the present.

One could argue that psychotherapy involves a process of “re-parenting” the unconscious—a concept encapsulated in Freud’s idea of therapy being a “cure through love”.

Why can therapy only be provided by a human?

At its very core, psychotherapy is a human-to-human experience. It is a living, breathing relationship between two people—one of whom offers their presence, mind, and emotional attunement in service of the other.

We connect in relationships through a complex process that involves both our cognitive and emotional faculties.

What is a mind?

In psychotherapy, the mind refers not to the brain as an anatomical structure, but to the capacity to make sense of one’s own thoughts and feelings — and, crucially, to hold and make sense of another’s experience. The mind is what allows us to reflect, to empathise, and to regulate emotion.

What is an emotion?

An emotion is a physiological response to internal or external stimuli. It seeks to be communicated, first to ourselves, then to others. When we label our emotions using language, we call them feelings. Emotions originate in the body and without a body, there can be no emotional experience.

Why AI can never offer psychotherapy?

Psychotherapy can only occur between two (or more) human beings. It requires the full, embodied experience of another person in order to take place. The therapist must bring their humanness to the process—not only their intellect, but their feelings, their capacity to be impacted, and their ability to remain separate, yet deeply connected.

AI does not possess a mind. It simulates a mind.

AI does not feel emotion. It mimics emotional understanding.

AI is not embodied. It cannot reflect or hold another’s experience because it has no experience of its own, as it has no body.

If AI could truly offer psychotherapy, then AI could also raise children. The implication is chilling: we would, in effect, lose the essence of what it means to be human.

Can AI be helpful to mental health?

As I stated earlier, AI may well have a role to play in the broader realm of mental health—particularly as defined in its current, diluted cultural form. I meditate daily and do so for emotional and physiological benefit. Meditation may well quieten the mind, but it cannot grow one. Meditation is therefore not psychotherapy but may be a useful adjunct.

Minds are only grown in human-to-human relationships

This begins in-utero and throughout infancy—in the mother-infant dyad—where the child’s mind is shaped through emotional connection with a caregiving other. When that process is disrupted or fails, psychotherapy is the only viable path to develop a reflective, relational mind in adulthood. It is, in that way, profoundly unique.

 

Mark Vahrmeyer is a UKCP-registered psychotherapist working in private practice in Hove and Lewes, East Sussex. He is trained in relational psychotherapy and uses an integrative approach of psychodynamic, attachment and body psychotherapy to facilitate change with clients.

 

Further reading by Mark Vahrmeyer

Why staying in your chair is the key to being a good psychotherapist

What do dreams mean?

Is starting psychotherapy a good New Year’s resolution?

Twixtmas – surviving that dreaded time between Christmas and New Year

How to minimise Christmas stress if you are hosting

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