My belief is that therapy is a process jointly created by the people involved. Therefore, I need to have an awareness of what effect I have on that process and notice the effect of the client(s). Therapy begins with the first telephone call or face to face contact with the potential client. It is during this period that any contra-indications for therapy might be elicited and perhaps even a referral made without any further work needing to be done on my part.

During this part of the communication with the potential client there are two main objectives; information gathering and gauging commitment. The information gathering activity is to see what evidence procedures are being sought and if the described problems fall within my area of expertise. Its also important to gauge the level of commitment from the potential client. It may be that this person is shopping around, is not yet clear as to what they want or is not ready for therapy. An agreement to engage in therapy can be made at this point as practical details; location, cost, number of sessions and a brief explanation about the process can be discussed. Only when the client explicitly agrees to attend a session can the move be made to precondition the therapy.

Preconditioning occurs both at this first contact stage and in the first few minutes of the first therapy session. This process; frames the therapy placing it in context and clarifying my approach, I aim to raise expectations of change in the client, information about myself can be provided, a time-frame can be set, small therapeutic interventions can be made and finally commitment from the client can be obtained and also agreement to work collaboratively.

Before the first session I ask the client(s) to write down a list called “What I want”. This guides the client to engage with their problems and provide a useful positive agenda for the first session. During this first session there are a number of criteria that I need to be aware of to ensure that the therapeutic process is effective; I need to be aware of my own state and how this may be affecting the process, the preconditioning that was started in the initial contact may need re-enforcement, during the initial contact and later in the therapeutic process I need to elicit the attitudes, beliefs and presuppositions of the client, all through the process there is both information gathering and checking – written notes help this activity, at any stage I can ask myself if the client would be better served by referral or re-assessment. Finally there is the formal beginning of therapy – a way to offer the client space for them to fill with their thoughts, needs and ideas. A focus for the change process. I use the question “What are we here for ?” This is where the list plays a useful role.

There is one other issue that runs throughout the therapeutic process and that is transference. This can occur both in the client and well as in the therapist – sometimes called counter transference. This is simply where events or people in the past are seen as forming an active part of the therapeutic process.

In order to examine such occurrences there are a number of questions that I ask of myself so that I can manage the process:

What am I being expected to do ?

What role am I being asked to adopt ?

What is my response to the client ?

Who does this person remind me of ?

What do we want to achieve here ?

When the answer to any of the above questions produces a negative or uncomfortable response in me or my client then they are questioned and/or challenged. Positive responses are also explored to ensure that the therapeutic process actually benefits. Sometimes when resolution appears difficult then a physical change of space, of topic or of body position can provide a new more helpful perspective. Throughout the time of therapy I find it important to refer back to the initial list of outcomes for the therapy to see how these are being achieved.

Claire is a 52 year old woman with a drinking problem who was referred to me by her GP. She has been drinking heavily for the past 3 years and has a history of both social and heavy drinking throughout most of her adult life. Coupled with this she has also had periods of depression and anxiety. She has the fear that the anxiety will come back. In fact it seemed to be with her all the time but that she had grown tolerant to its presence.

At referral the GP asked me if I would consider lowering my charges as Claire was not in employment. I agreed that arrangements could be made. Claire was pleased that I had agreed to this but she said she wanted to pay her way and at that time was able to do so. We agreed to meet for six sessions and then review progress. {Contract ?}

Claire had experience of hypnotherapy in the past that had not been effective for her and was now on Ativan (for some 13 years), HRT and an asthma inhaler. She had a disturbed sleep pattern getting to sleep very early in the morning and then sleeping until late in the afternoon when she would drink. She would spend time at night completing puzzle books until the early hours.

During the first session it quickly became clear that Claire’s life and history had a jumbled structure and issues were difficult to separate out and prioritise. The first job was to begin to create a structure and I asked her for a metaphor for her life. This generated the image of a pond – dark and stagnant. This also reflected her living conditions at the time. Through the metaphor of the pond we identified those issues that belonged to her and those that belonged to others in particular those that belonged to her mother.

We spent some three sessions looking at her relationship with her mother. During these sessions I was conscious of the need to work on Claire’s drinking but also on the fact that the drinking behaviour was being generated and maintained from somewhere. Until the source was identified the drinking would continue.

I find that the exercise called the Meta-Mirror to be one of the most profound processes for clients. By using this process with Claire we elicited the fact that in her relationship with her mother Claire was in the position of being 20 years old and thus depowered. In fact she often feared telephone calls from her mother and took a week or so to recover from such calls. In the process of the Meta-Mirror this was revealed and prompted me to ask the question “What will Claire be when mother is removed ?” Her reply was “Powerful”. This was beginning of Claire taking control of her life again.

In regaining her power we were able to explore Claire’s view of her Jewish culture and how this had been experienced as a negative force of shame for herself. This was accompanied by her stopping completing the puzzle books. We returned often to the pond metaphor and the pond was cleaned by removing items that belonged to her mother or were no longer of use. This provided a much more effective and useful view of life and led to Claire leaving the flat she was currently occupied and moving to a much more healthier environment.

This brought us to the sixth session and we reviewed our progress. She felt that her relationship with her mother had changed radically for the better and that having moved home she wanted to tackle her drinking. I had noticed that at times Claire had attended sessions having been drinking. My belief was that she was not classically drunk in that she was coherent. We agreed to change her appointments from afternoon to morning to help her structure her day. At this point I asked Claire what she would do with all the time she would have when she stopped drinking – this she said was great fear she had. We worked on the beginnings of a more structured timeline for her and I asked her to keep a diary of her activities and thoughts. At this point she was drinking two bottles of wine a day and four to five double vodkas. {How does this help us understand your managment of therapy.}

We discussed her panic attacks and how the drinking was affected by them. She said that the alcohol soothed the panic attack. I asked her who she was when the attack came. We discovered a part of Claire what was about 7 years of age and alone in the family home, crying. She believed that she had been looking for her mother because she felt ill but that mother wasn’t around – this caused the panic. When her mother arrived in the house some ten minutes later Claire felt berated by her mother for crying.

This led Claire to learn that no-one could be trusted and that her mother would always be angry with her. This was resolved by suggesting that Claire could now comfort her own 7 year old self. This reinforced both Claire’s sense of power and a maturing of her relationship with her mother.

At this time Claire decided to seek out other help to deal with her alcoholism. I accepted her need to explore else where for help and ensure that I said she could return to me at any time. Three weeks later Claire returned and we focussed on her drinking.

Over the next few sessions we discussed what Claire would do with the time that she would have when she stopped drinking. This proved to be a fear for her so I helped her reframe her view of that time. I suggested that there were many things that she no longer did because of her drinking that would again be possible. Over a period Claire began to remember the interesting things she did before she started drinking and how she could benefit from participating again in those activities.

What I have learned from Claire is the need to uncover issues as they come up and take time to allow issues to develop. I have understood the changes that Claire needed to make and have been able to stand back and allow her to make those changes. Even during phone calls between sessions I have been able to make a distinction between what is my responsibility and what is Claire’s. I have seen Claire for 23 sessions and we are still working although we can both seen an end in sight. This has allowed me to put in place learnings from an other client whom I saw for 33 sessions. Long term work is as valuable and effective as short term brief interventions. In fact long term work is a series of short brief interventions. {Boundary Issues ? - Some great detail and a many good explnations for interventions chosen - but Martin's own thought proceses remain unclear to me.}

1 Assessment:

My first supervisor, trained in Gestalt therapy, worked with a specific assessment interview where he gained a lot of background detail and defined the contract before beginning therapy. I work with no assessment interview other than the first visit. We discussed my supervisor’s need to explore the client’s needs and have a formal start to the therapy. I countered with the idea that therapy can start immediately. In fact if therapy cannot start with the first interview then why have a second one ?

This was new thinking to him and so I shared my experience that no client had yet been put off because there was no free assessment interview. Further, that therapy could start at the first interview.

2 Choice of Intervention:

I am working with a client at the moment who is dealing with his being fat. I described his situation to my NLP supervisor. This client is 37 and is 22 stone in weight – he wants to be 16st. During our session he had indicated that there was a part of him that was very young that was contained within his stomach – where the majority of his fat was located.

I was working on the intervention of parts work to re-integrate this young part. Beyond obtaining a communication with the young part no resolution seemed to be occurring.

My supervisor suggested that I introduce a metaphor of my client being pregnant and that it was time to release this child part in a kind of birth process. During the next session I discussed this with my client and said that the idea of being pregnant had come from my supervisor – my client immediately agreed with this concept and brought out the child part to stand behind him rather than be inside him. This released a lot of tension and uncovered a number of other issues that are being resolved.

3 Boundary Issues:

During my time with my first supervisor I mentioned the fact that whilst shopping locally I had met an existing client. We had said hello and I allowed him to lead the topic of conversation. He talked about the changes he was going through and then we parted. My supervisor explained that in some Gestalt circles no such meetings should take place outside the therapy room. We discussed the possible options for handling such situations. I explained my belief that people and therapists have a life outside therapy and that the purpose of therapy was to enable people to live in the real world.

My supervisor’s reaction led me to re-examine my thoughts on this aspect but I returned to my original belief that I should be comfortable with meeting clients in social situations. I do, however, make a point of bringing up such possibilities with my clients at the first interview.

I shared with my supervisor that all my clients have been able to understand this and none have shown any problems with it. After all we are a model for the client and if we are uncomfortable with meeting clients outside the therapeutic context the message given to clients cannot be healthy.

{This is one example of a boundary issue. But I would have likeed to have lerant more about how Martin deals with his own unresolved personal issues as they come up in therapy.}

4 Contracts

I worked with a young Asian girl of twenty on issues to do with her relationship between her family and her boyfriend. I talked with my supervisor about issues regarding Asian culture and the specific nature of the issues that she brought. My feeling was at the start that although we agreed six sessions there may be more than that needed. My supervisor suggested that I ensure that other topics were covered to ensure that the issues presented by the client were in fact the ones that needed resolution.

After the third session I began to see that the issues were being resolved fairly quickly. Although there were some other issues to do with self development and practical ways of living I believed that, unless something new was brought up, this work was finished. My supervisor helped me to clarify for myself exactly what the initial contract had been with the client i.e. was it for a set number of sessions or was it until the client felt that she was able to continue on her own. I felt that although the contract was for six sessions I couldn’t spin out the work, and her money, simply to justify that first agreement. My supervisor suggested that I draw up a list of criteria with the client to help us to recognise the end of this therapeutic work. We also discussed the purpose of a contract.

{Contracts also include agreements on:
Issues addressed
Likely interventions
Criteria for change
Timing /Frequency / Fees etc }

On the fourth session I reviewed progress with the client to measure what had been achieved. The criteria were drawn from statements made by the client in the first interview about what she wanted to achieve together with observations I had noticed. This led us both to the conclusion that in fact we had achieved her goals. We spent a few minutes in reflection and agreed to end the therapy at this point.

I now use contracts quite flexibly. Unlike my first supervisor I don’t have them in writing and I frequently ask myself and my clients how close we are to achieving our goals.
{I don't understand how "Flexible" is being used as a term here. Does this mean contracts can change in mid-stream ? If so - they aren't contracts. But if M. just means "number of meetings" this is insufficient for a contract. See last page.}

5 Referral Procedures.

I discussed my client Claire, above, with my supervisor on a number of occasions as she has more experience with clients and alcohol problems. Claire and I had decided that she would benefit from attending a detoxification programme and I asked my supervisor about this decision. My supervisor said that people with a dependency on alcohol often needed a great deal of time, compared with other issues, and that I needed to understand how my role would change should Claire decide to go on such a programme.

I believed that it was my role to organise the placement, inform Claire’s GP and give Claire every help in attending short of going with her. I also felt that is was important that this referral should been seen as an adjunct to our therapy rather than a replacement. My supervisor agreed as, she said, many people using alcohol feel that they are moved from therapist to therapist. It would be important that I make it clear to Claire that I would still be available to support her.

Although I was not seeking either permission or approval from my supervisor I felt much more secure having discussed this course of action. Over the next few weeks we returned to Claire’s development to ensure that I was confident with the decision I had taken.

6 Use of NLP Material.

My first supervisor was Gestalt trained and had no NLP training at all. This meant that I had to explain each NLP intervention, its goals and background. Although I found this very useful as I had to review the basic procedures and ideas I felt that I was not getting the extra advice and information that I needed.

My second supervisor is NLP trained and we have been looking at language patterns. Specifically language patterns that I use that may not be the most effective; from the simple replacing of the word “but” with the word “and” to more complex metaphor constructions. An exercise that I use frequently is the meta-mirror which is not used as much by my supervisor and we have discussed its strengths and limitations. We are now reviewing belief change work.

MARTIN WEAVER

July 1999