The Past in the Present: Therapy Enactments and The Return of Trauma.
|Publication:||Name: Existential Analysis Publisher: Society for Existential Analysis Audience: Academic Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2010 Society for Existential Analysis ISSN: 1752-5616|
|Issue:||Date: July, 2010 Source Volume: 21 Source Issue: 2|
The Past in the Present: Therapy Enactments and The Return of
David Mann and Valerie Cunningham (eds) (2008). London: Routledge
The book is about what the authors call 'enactments which according to the editors is understood as symbolic interactions between the client and therapist, where personal issues of both parties become unconsciously entwined. Enactments are often experienced as a crisis in therapy and the editors argue that they are especially occurring with clients who have had some form of trauma in the past. These enactments are seen as a potential turning point, whose outcome can either be positive or destructive. The book has come into existence during a clinical discussion of enactments when one of the editors wondered how other therapists understood and dealt with this phenomenon. Thus therapists of both the psychoanalytic and humanistic traditions were asked to write articles on this theme.
The appeal of the book for me came out of the same question during a taxing time in my private praxis when the work with several of my clients seemed to have the flavour of what the editors call a play-within-a-play. Something about the particular interaction and situation between client and therapist trigger associations to past trauma where feelings and ways of beings of both the client and therapist become intertwined and played out. Both client and therapist are trapped in a play where the present and the past are acted out in a manner where momentarily awareness of the here and now is lacking. The therapeutic 'success' depends on the therapist's ability to recognize their part in the play and their ability to bring their insight into the work so that the client can see the reality for what it is.
Something of this sort was my experience, my sense was too, that this did occur with clients who had experienced trauma in their past, which did somehow cross path with my experience of my own traumas. I found little to go by that seemed helpful at the time from my existential training. It wasn't something that had particularly been discussed in my training and I felt that this created a gap in my practice. I found myself looking towards the psychoanalytic traditions, which seemed to discuss such entanglement processes with concepts like transference, countertransference or projective identification. I was curious to see how enactment fitted into that and whether I could gain some further understanding. I was doubly curious to see how authors from humanistic traditions conceptualized and worked with such processes.
The book most helpfully gives an opportunity to engage with the issues of shame and anxieties that surround enactment situations. Mann (Chapter 1) suggests that enactments happen in most therapies. Cornell (Chapter 5) quotes a study about therapeutic ruptures that suggests that mismatches, woundings, or impasses are not avoidable failures but common occurrences, which represent both an opportunity for new understanding and change as well as wounding or disillusioning setbacks. The key is in self-examination to avoid ethical charges, law suits, or premature terminations and that the therapist's working through often is paralleled by the patient's working through.
It is the stories of enactment that I have found most helpful in this book. Description, which is central in the existential-phenomenological approach, is perhaps the most powerful tool in approaching a recognition if not understanding of such an entangled phenomenon rather than the definition or the theoretical model. The stories are all varied and invariably represent fascinating unfolding of the relationship between the therapist and the client.
In Chapter 1 David Mann, a psychoanalytic psychotherapist, writes about enactment in terms of his vulnerabilities as a therapist stemming from his own background and how some of these particular vulnerabilities contributed to on the one hand a significant and positive shift with a client and on the other to an ending of therapy that was experienced as negative. He suggests that 'enactment are most appropriately viewed as a passionate collision between the unconscious of the therapist and that of the patient, which heightens the feelings of love or hate and has a decisive effect on the course of the therapy' (p.28/29)
In Chapter 2 Valerie Cunningham, from a humanistic background, sees enactment as a phenomenon that can be helpfully viewed as 'a mutual desire to remember traumas in order to resolve the ongoing effect of them' (p.31) and concentrates on accounts that illustrate the quality of therapeutic relationship. She concludes that she remains convinced that 'the quality of the relationship which develops, and which is sustained despite unwanted enactment experiences, is the consummating factor for successful therapeutic outcomes, whichever theoretical or scientific model is referred to' (p. 44).
In Chapter 3 Marie Adams, an integrative psychotherapist, courageously recounts what she called a 'sado-masochistic dance of attack and survival' (p. 48) between herself and a client that ended in a complaint against the author. The author candidly recounts how her own story predisposed her to take on an act in this play between her and her client. She writes, 'But the traumatic process and ending of the therapy was also the product of my story, an enactment of my history of avoidance and the need to excel and win.... in order to keep my horror of worthlessness at bay' (p. 60)
In Chapter 4 Celia Harding, a psychoanalytic psychotherapist, concentrates on cumulative trauma from the attachment period and how some clients cannot tolerate any demands or mistakes on the part of the therapist until a strong attachment is formed. This she calls negative enactment. The ones who manage to attach can then potentially tolerate what she calls positive enactments where traumatizing features of the primary attachment are played out. She concludes 'the extent to which therapist and patient together can open and hold a space to make sense of re-enactment, in the context of a secure attachment, will determine the extent to which the patient may experience in the therapist a new and real personalized relationship with its potential for enabling intimacy with others in their lives' (p 79)
In Chapter 5 William F. Cornell, from a humanistic background, gave an engaging account of the unfolding drama of his personal therapy which got entangled with past clients and his own therapist showing courageously how he and his therapist had to 'face the music' together and be honest about what had been going on. He says 'writing about enactment necessitates analysts being willing to write quite openly about themselves and their own intrapsychic conflicts, characterological blind spots, and unconscious vulnerabilities" (Cornell, p. 93)
In Chapter 6 Caroline Case, analytical art therapist, gives examples of enactments with children conceptualized as mis-attunements that can be re-traumatizing or moments of meeting where client and therapist can play and where the therapist's 'coming out of the role' as an enactment has beneficial effects on the client.
In Chapter 7 Raymond Kenward offers and existential perspective, conceptualizing enactments as bad faith. From his perspective enactment is where both client and therapist are playing their part of self-deceit by living out fictionalized versions of themselves where repetitions of old patterns are chosen rather than caused by past events or trauma. In his example he wondered whether he and his client were enacting a folie a deux, which was fuelled by a mutual desire to be artists. He writes 'facing reality is potentially traumatic, for it means accepting ultimate loneliness and responsibility' (p. 122).
In Chapter 8 Patricia Marden and Alison Knight-Evans, both from a psychoanalytic background, provide examples from an eating disorders inpatient ward and suggest that enactments are inevitable and part and parcel of the work of the therapist where their role in a multidisciplinary team is to discuss the client's patterns of relating and the possible meaning of these patterns in the clients internal world.
In Chapter 9 Louise Embleton Tudor and Keith Tudor offer a person-centred perspective more in terms of a theoretical understanding of trauma than of enactment focusing on qualities of being with clients where the therapist tracks the client's states with as much congruence as possible. Resonating with the client is getting a sense for what it's like to be the client. The recovery of trauma amongst other things includes an increased ability to trust oneself and others or the environment.
In Chapter 10 Penny Webster, clinical psychologist and integrative psychotherapist, offers an insight into a particular way of being with the client called the strategic/relational approach where the therapist enacts for the clients traumatic aspects or ways of being as a way of providing relief as no enactment in this instance would have been experienced as traumatic. She talks about the necessity of there being a 'fit' between therapist and client as well as there being room for movement, and thus enacting difference so as to enable change.
In Chapter 11 Janet McDermott, counsellor, tells of her work with refugees and enactment in the form of trauma and guilt. She sees enactment as co-creation illustrating her enactment as the drama triangle of the rescuer-perpetrator-victim where her guilt led her to identify strongly with the role of the saviour. She writes 'the enactment of trauma in therapy that arises out of experiences of torture and state persecution can invest the therapist with either the omnipotence of the guard or torturer, or the mantle of the rescuer (p.180)
In Chapter 12 Christina Wieland, a psychoanalytic psychotherapist, describes her work with a client who continuously provoked her. The enactment in this example was the analyst's attempt at containing the client's acts of provocation by assuming the role of a quasi parent who believes that enough love and understanding will help the child. This however did not help the client and instead was a participation of the analyst in the provocation. This enactment came to an end when the analyst re-acted to the provocation by saying 'no that's enough'. This enabled the client to start thinking about rather than act out her behaviour.
Have I come away with a better understanding? My sense is that I have perhaps come away with more questions than answers and find myself once more stuck with the limitations that language and definitions represent when dealing with the complexity of human relationships. I am still puzzled with those processes that feel removed from reality and have a quality of chaos to them. And don't we always enact, with parts of the enactment being more or less reflected on? And what constitutes a trauma? The introduction of trauma in the book as a further phenomenon in relation to enactment for me at times overloaded the already complex undertaking of understanding enactment.
At times it seemed that authors were describing simply the therapeutic process, which invariably at certain points feels muddled, unknown and messy and then snails its way back into a process that feels clearer and more structured. How exactly this happens is often impossible to say, and can not necessarily and always be linked to a working out with oneself, ones supervisor or any other illuminative resources one has as a therapist in working out what is going on in the muddle of a particular encounter with a client. Therapy and its process can never be fully grasped and always retains an element of the mysterious.
Having said that, it is worth attempting to name and describe such a complex phenomenon that arises in the meeting place of therapy and I appreciated that the editors gave enactment a space to be talked about. An important distinction is made between acting out, which is seen as a unilateral action on the part of the client or therapist and enactment as a bilateral process between therapist and patient where both play out aspects of trauma or unconscious processes.
It seems to me that these accounts are essentially a celebration of the complexity of interactions and ways of relating in the therapeutic space and an important contribution perhaps to the debate of regulation. Human being's emotions and expression of those can't come under rubrics or concepts in a manual and the being- and working-with them cannot be happening in a prescribed way. Rather, therapy is a creative happening between two human beings, who arguably, by their very nature, are essentially creative themselves, by playing their part in their dramas of life and within the therapeutic relationship.
All in all, I can recommend this book to students and practitioners of all orientations who are interested in learning more about the powerful and complex dynamics that can arise in therapy that are not immediately understandable and have the echoes of the past, for both the therapist and the client. If anything, the book helps to think about these 'illogical' phenomena as something inevitable and part of the therapeutic process, which can appease the anxiety and the shame surrounding these happenings. It can help us to recognize that these events can be productive if recognized and reflected on.
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