Better Late than Never: The Reparative Therapeutic Relationship in Regression to Dependence, by Lorraine Price

Regressing to move forwards

russian-dolls

My search for healing began many years ago, when I was experiencing unhappiness and extreme anxiety with panic attacks. I entered into a therapeutic relationship which at the time was supportive and useful and helped me through some difficult times.  Some years later I trained in psychotherapy, partly to understand myself, and entered into therapy again. This time the work was at greater depth and began to address the source of my pain, my early infancy and the relationships in my family. During my training I came to understand my object relations and the failed dependency I had experienced in infancy and so continued to search for. Fortunately for me, my therapist was open to wherever I wanted to go and was not afraid of my developing dependency. This relationship and my response to it has healed me. My personal interest and my need to develop my practice to aid clients with similar difficulties led to my research into this area, and to my book – Better Late Than Never.

41NjqUuazsL._SY344_BO1,204,203,200_ (1)The book explores the process of regression to dependence. It  is about working with clients who need to regress to early infant experiences in order to heal and continue their development, and who Winnicott describes as those who must address “the early stages of emotional development before and up to the establishment of the personality as an entity” seeing that therapeutic work must account for “a very early development of a false self”. Therefore, with such a presentation, regression to a therapeutic dependent relationship is necessary to allow development of the previously undeveloped true self.

Van Sweden recognises the difficulty of determining if a client requires such a process, because “the false self presentation disguises the severity of the patient’s trauma”. He describes potential presentations as follows: “A sense of futility about life, feelings of hopelessness, a belief about no one ever being there, and inability to form meaningful personal relationships, the manifestation of ego deficits, and a variety of other personality disturbances, including depression and/or eating disorders.”

611HxGoLvwLWhen attempts to connect in infancy fail, Hedges considers that they remain “imprinted on the psyche”. He views these infant scenarios as reappearing “in the psychoanalytic relationship as replicated transference modes of interacting that pervade our character and body structures.” These ruptured strivings for human contact in infancy can be manifested in adulthood and in the therapeutic relationship. He identifies this as the continued search for the lost mother of infancy, the empty place where the needed love and acceptance were never received, which has left “its own definite and indelible mark on personality”. This “living record of failed connection” leaves them searching for a relationship to fulfil the need and complete them, a stance taken by both Freud, and Van Sweden. Erskine recognises the impact of pre-verbal trauma, whether acute or cumulative, on the individual which may not be available to consciousness because of the pre-verbal origins, yet surfaces at points, usually times of stress, throughout adult life.

It is these theorists, in making the link between infancy and clients in therapy that form the underpinning for this theoretical stance and so allow for the concept of therapeutic relational repair. The presentation of these clients may include:

  • feelings of alienation,
  • fear of emotional dependency,
  • having difficult intimate relationships,
  • fear of abandonment and of being alone,
  • feeling that life has no meaning,
  • feeling panicky and anxiety ridden,
  • feeling that they are living behind an emotional façade,
  • feelings of sadness and loneliness even though being a high achiever,
  • omnipotent defences and avoidance of vulnerability.

251427-MIt was with these clients, whose struggle I recognised both personally and as a therapist that I found myself challenged to find ways of working effectively. It is evident that there is no one classic presentation of such clients. Some clients may have more borderline traits, seen in the great fear of abandonment and desire for and avoidance of closeness and intimacy, while some may seem more schizoid, holding no sense of the possibility of relationship.  Johnson’s description of the oral character seems to be most frequently presented and identified. These clients have not been allowed to fully inhabit the appropriate dependent position in their infancy because of abuse and neglect, more subtle failures of attunement, or the emotional unavailability of the caretaker, and so continue to search for it into adulthood. In some clients their deep need of relationship is evident on first meeting, but for some high-functioning, adapted clients it is effectively defended against, and out of awareness, to emerge much later in the work.

 

The nature of this therapy 

When the client experiences regression to a needed relationship it allows a reprise of the dependent phase of their developmental history. In this regressed experiencing, the therapist is emotionally available and alongside the client in the experience in a way that did not occur in their infancy. Because the client needed to be appropriately dependent in infancy, and this was not allowed or possible, it remains searched for in adulthood, leading to relationships characterised by excessive need, control, and fear of abandonment. The therapist’s presence and availability allows this re-experiencing, permits the repair of damaged aspects of self and can allow progression towards integration and psychological health.

Modern integrative psychotherapy has an important relational tradition, but some significant concepts, which I consider necessary when working with clients with early relational trauma, may have been insufficiently emphasised, lost or overlooked. This may be because training has focused on appropriate developments in the understanding of intersubjectivity, relational depth, and therapeutic repair, but has resulted in the side-lining of this body of theory and research from the psychoanalytic tradition. This knowledge of human relationship, both intrapsychic and interpsychic, is essential for psychotherapists working with this client base to absorb.

Klein identifies that “our need for others has its roots in our earliest experiences, and is bound up with our deepest feelings”. Object relations theories, upon which this book is theoretically underpinned is concerned with the relationships that we develop as a result of our need, and how these relationships affect our lives. Object relations theories consider that our earliest relational experiences guide and define our subsequent adult relationships. Therefore, understanding is the key to unlocking the relational patterns that can be seen in later life.

As a paediatrician and psychotherapist Winnicott observed similar processes occurring between mother and infant, and between himself and his psychotherapy patients. When studying human relationships he stated that the “paediatrician and the psychiatrist badly need each other’s help”, feeling that “those who care for infants […] can teach something to those who manage the schizoid regressions and confusion states of people of any age”. “I am saying that the proper place to study schizophrenia and manic depression and melancholia is the nursery”.

 

The concept of regression to dependence

9780415045087-uk-300My theoretical model is integrative, which brings together theories that are compatible within a relational/developmental philosophical stance. My initial training directed my interest towards object relations theorists and it was the work of Balint and his understanding of the “basic fault” which sparked my interest. Balint describes the necessity of working with the client at a level of relationship which existed prior to the development of the fault that is at the level of primary anxiety, as Winnicott would view it, in order to repair infantile wounding, so allowing the client the possibility of a new beginning.

There is an increased interest in the relational component of therapy, even within theoretical orientations that have previously eschewed the importance of the relationship to the therapy, such as cognitive behavioural therapy (CBT).  Mitchell calls this the “relational turn”, recognising the importance of the relationship as a healing factor. Integrative psychotherapists focus on the therapeutic relationship, but to work with regression to dependence requires a more in-depth knowledge of infant development, and of the connection of the original dyadic relationship between caretaker and infant and the therapeutic relationship between therapist and client.  Object relations theory identifies the self as developing in relation to its early environment, the caretaker, and others. Once the influence of this dyadic relationship is acknowledged, then theorists move towards the construction of the importance of such a relationship and the consequences when it is considered as insufficient for optimal development.

41KyeO4JXWL._SY344_BO1,204,203,200_Psychotherapists as early as Ferenczi have understood that psychotherapy needed to be more than an intellectual reconstruction; it needed to be an emotional reliving.  The problems presented by our more distressed clients occur as a result of deficiencies in early environmental provision.  Love, acceptance, and nurture are essential for a child’s healthy development and such a relational stance is also essential for clients.  Ferenczi considers that where there is a trauma there is always a split in the personality, whereby part of the personality regresses to the pre-traumatic state. Different techniques would be needed to enable the client to come to a regression in search of their true self. He believed that no analysis was complete unless it had penetrated to the level of the trauma, a position that Winnicott would later also hold.

 

The possibility of therapeutic repair

These clients, whose reparative need is in the dyadic relationship, need “management” according to Balint and the “mother actually holding the infant” according to Winnicott. These regressive experiences, where “talking therapy” (I believe they mean the interpretation aspect here) is neither useful nor therapeutic, offer an opportunity for reparative experiencing. The therapeutic task is simply to be in tune with the client and their developmental needs, to acknowledge and validate, to be fully present within the relationship, and to offer some appropriate gratification.

Clients frequently present with chronic anxiety as the motivation for attending therapy. This anxiety is often spilling out into every part of their life, at times reaching its culmination in chronic panic attacks, whereby the fear has been described to me as of death, collapse and/or annihilation. Cognitive therapies aim to change thinking about these outcomes, but in my experience these fears re-appear in a slightly different form. It seems clear to me that whilst short-term therapy for these issues may address symptoms it does not holistically address a person’s life issues. In depth therapy offers the possibility of addressing this anxiety by revisiting the early developmental phase in which it first developed and offering corrective emotional re-experiencing.

41Bvr6enLfL._SX331_BO1,204,203,200_The theories I use come from a relational/developmental philosophy, where I integrate object relations, attachment, transactional analysis and trauma work.  The work of Winnicott has been very important in helping me to understand the infant within the adult client. I consider that as the field of contemporary psychotherapy has developed, “the baby has been thrown out with the bath water”, meaning that the importance of concepts from analytical exemplars, such as Winnicott, who recognised the significance of early infantile experience to adult clients in psychotherapy, have been largely overlooked in the move to embrace either humanistic relational concepts or cognitive interventions.

I aim to re-establish the importance of these “archived” aspects of theory in order to illuminate the processes emerging in client work. Johnson identified that many therapists of his generation prematurely gave up on psychoanalytic psychotherapy. He commented, “large portions of analytic writing are unnecessarily obscure, dominated by an imprecise and often archaic jargon”. He also recognised that the newer therapies lacked in terms of theory, limiting the capacity of the work.  My aim is to reintroduce these important theoretical concepts, but set them in the relational and developmental frame, which is integrative psychotherapy. I consider that all therapists would benefit by understanding regression to dependence, whether they choose to work with it or not.

In my book I highlight these theories and identify their application to practice. I also explore the implications of working at this depth, for both client and therapist and the necessity of flexibility and availability on behalf of the therapist.  I also address the traumatic aspects of childhood neglect and deprivation.

 

The need for flexibility and boundaries

419G4U4PxaL._SX324_BO1,204,203,200_Those practitioners working from a relational/developmental position, using object relations theory to understand the experiences of their clients, view that the troubling symptoms experienced by some of their clients have their roots in their early infantile relational experiences and the experiences of trauma which resulted. Erskine and Trautmann describe the process of integrative psychotherapy referring to the integration of theory with a perspective of human developmental tasks and needs. The theoretical foundation focuses on child psychological development, the understanding of attachment patterns and the lifelong need for relationship. In this formulation of the therapeutic process it is considered appropriate for the therapist to use his or her self-experiencing to assist the integration of developmental process through the client’s childhood needs, their experience process, and interventions, including touch and holding, as dictated by the perception of the client’s developmental age regression.

When working with regression to dependence, I may adjust the boundaries of my usual therapeutic stance, particularly those around contact outside sessions and touch, I must stress the importance of supervision when working in this way. Stewart considers that work on this area of analysis has not received the recognition it deserves because of the adaptation of technique that it requires, and the necessity of the therapist living without knowing for long periods. In my experience, rather than seeing a regressive phase which is clear and distinct, which clients approach and then move away from, I have experienced an overarching movement to deeper levels of regression over the course of therapy and I have also noted that clients may move in and out of regressed states within any session. Bollas describes working with patients in the process of breakdown and the difficulties for the analyst when patients tip into psychosis. He makes an interesting statement though, about regression to dependence, “if the analysand regresses to dependence in a rather ordinary way – lessening defences, opening up the self to interpretive transformation, abandoning disturbed character patterns – the self will usually break down in a slow and cumulative way”.

3895952Professional therapists are trained and motivated to expand and develop their knowledge and experience. Van Sweden identified that this search may be motivated by complex patients, that “[…]there will always be those patients for whom our current proficiency is not enough”. Since Van Sweden wrote this, experience, knowledge and understanding have continued to evolve. Some of this evolution has been towards understanding the intersubjective nature of the relationship and its healing potential, and some has been towards treating the majority of patients minimally, where cost is the prime consideration, as in the upsurge in CBT. Whilst I have no doubt that for some people these minimal interventions are relevant and effective, for others the complexity of their presentation requires other, more significant forms of help.

This book is useful for practicing psychotherapists and supervisors, trainee psychotherapists, psychotherapy training programmes, and those with no formal training, but having an interest in the subject. Researchers who are interested in the heuristic process and reflexivity may also benefit. My research has contributed to the theory and practice of psychotherapy and will be of interest to a range of audiences. Members of other disciplines may also have an interest in these findings, such as social scientists involved in understanding the development of personal identity, identity process and the development of self.  Those who work with trauma survivors may wish to consider the impact of earlier developmental trauma upon recovery. Mental health professionals may also consider these findings when service users do not respond to other treatments or protocols.

My aim has been to develop understanding of the process and experience of regression to dependence. I have identified how holding a narrative for the client’s early years can describe and account for the experiences of clients, how this narrative helps clients to make sense of their experience and enables an effective clinical formulation to be used within the therapeutic context. When practitioners have knowledge of relevant theoretical concepts and an understanding of the necessity to address the pre-verbal stages in an appropriate manner, they can offer a therapeutic “second chance” for their clients to have “a new beginning” which both mourns the loss of what should have been, and celebrates the emergence of their true self as the ultimate outcome (Balint). The education and training of psychotherapists is incomplete without an understanding of this process and the particular needs of these clients. Practitioners must be able to recognise such a process, and the potential for it, to enable recognition of the most effective ways of working.

37172Lorraine Price worked in the civil service and local government before training as an Integrative Psychotherapist and supervisor. She is currently Programme Leader of the MSc in Integrative Psychotherapy programme at the Sherwood Psychotherapy Training Institute, Nottingham. Lorraine has a private practice near her home town of Lichfield, Staffordshire and a supervision practice in Ireland. She is accredited both with the British Association for Counselling and Psychotherapy (BACP), the United Kingdom Council for Psychotherapy (UKCP), and the Irish Association of Humanistic and Integrative Psychotherapy (IAHIP). Lorraine also successfully completed her Research Doctorate in Psychology with De Montfort University in 2014 where she pursued her ongoing interest in the effects and treatment of early infantile trauma upon clients in psychotherapy, therapeutic regression, and the reparative capacity of the therapeutic relationship. Her book, Better Late than Never: The Reparative Therapeutic Relationship in Regression to Dependence, is published this week by Karnac.

 

 

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