When Death Enters the Therapeutic Space: Existential Perspectives in Psychotherapy and Counselling.
Article Type: Book review
Subject: Books (Book reviews)
Author: Lee, Simone
Pub Date: 01/01/2010
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: Jan, 2010 Source Volume: 21 Source Issue: 1
Topic: NamedWork: When Death Enters the Therapeutic Space: Existential Perspectives in Psychotherapy and Counselling (Nonfiction work)
Persons: Reviewee: Barnett, Laura
Accession Number: 288874134
Full Text: When Death Enters the Therapeutic Space: Existential Perspectives in Psychotherapy and Counselling. Laura Barnett (ed.) (2009). London: Routledge.

To-morrow, and to-morrow, and to-morrow, Creeps in this petty pace from day to day, To the last syllable of recorded time

Macbeth

Lulled into mechanical routines and habits of daily life, even as therapists, we are often oblivious of or we choose to ignore the ubiquity of human mortality, that counterpart and complement to life, that fearful non-state. In this excellent book, death in many guises is brought into sharp, often poignant, focus, defying us not to be roused.

There are two main complementary threads to this book--the dialogue between existential thought and therapeutic practice, and the theme of mortality.

The editor tells us the book: 'is aimed at those with a special interest in the existential perspective and its philosophical roots and those who are primarily concerned with the theme of working with clients who have been faced with their mortality'. In an array of narrative styles, the contributors of the core chapters of this book, home in on and share aspects of their therapeutic work and thinking, not all of them typically existential; what they have in common is a shared interest in existential issues. These practitioners work in a variety of settings and represent a range of working styles, thinking and techniques with clients who themselves have very distinctive experiences of and relationship with life, threat, dying and death. So we see in the mix of chapters, those entitled 'Surviving Intensive Care' , ' When The Therapist or Supervisor Dies' and ' Working with Bereaved Parents'. Interleaved between the core chapters, Laura gives us 'theoretical inserts' : erudite, often poetic, yet accessible, distillations of the main concepts of existential thought and therapeutic practice, which include 'Being-in-the-world' and 'Authenticity' , and also a few surprises such as the often over-looked 'Gelassenheit' and an excellent and responsible summation of John Heaton's chapter 'Suicide and despair: keynotes for therapy'. The editor also introduces and concludes with chapters on the Existential Foundations which she tells us are 'aimed at existential therapists and are likely to be difficult for those approaching philosophical roots of existential therapy for the first time'.

I read this book as a therapist wanting to stimulate my own thinking around death in the consulting room since it is rarely out of it. And interestingly, reading this book at different levels, I continually found myself moved, something surfacing for me, as if the essence of death somehow worked its way out out of the pages from the voices of the authors and reached me. Very often, I found myself wiping tears from my eyes even when the area in focus was not being presented with evident emotion. To paraphrase John Heaton's message, one cannot understand death or even what it is to be with another in their despair by learning about it, as if it were a neutral object, it 'involves reflection on the part of the writer or reader, or indeed the therapist, who must understand that the meaning of [despair] is beyond the letter: it can only be conveyed indirectly. Indirect communication is directed towards its appropriation by the individual addressed. When we appropriate a communication we make it our own. It brings us home and only we can be the authority on that, your home not mine'.

At the heart of the book is the idea of personal dialogue and this is the book's great strength, permitting inspirational and varied writing from the authors who contribute most of the main chapters. And the mood of the book, I think, allows us readers to make greater engagement with its contents. The editor has unapologetically hallmarked the work in her editorial decisions and this has permitted the quirky structure, organisation and contents of the book, but at the same time the book contains excellent writing, which balances well philosophy and practice, some superb editing and a very good index; and thankfully it is not bland.

The editor's missionary zeal comes through. She is clearly passionate about our profession, good practice and the potential value of good ethical therapy; she so obviously wants us to enter dialogue with the philosophical questions for ourselves as she does; she rues that too few therapists struggle with issues of death, loss and endings and that these subjects are neglected in therapy training. I agree. So often, in spite of paying lip service to the sacrosanctity of endings, therapists are often as rubbish at endings as everyone else. The paradox, as I see it, is that existential therapists do not appear significantly better than any other brand of therapists at engaging with mortality and ultimate situations. Very recently, it occurred to me that perhaps this was no coincidence and that perhaps it was because of this irresolution that people chose to place themselves in the existential camp in the first place. Which might suggest why it is imperative for existential people, more not less than others, to pick up a copy of this book and read it and grapple with the hardcore issues of life and death that are not assuaged simply by knowing a lot about Heidegger and Sartre.

I have talked above about the structure of the book. What is striking in reading this book is how many of the ordinary dilemmas of therapy constellate and are magnified in those situations at the edge of life and death. Boundaries and frames, disclosures and being emotional, being with another, the place of theory and knowledge, the limits of therapy, what makes the client a client and a therapist a therapist are a few of these. And it seemed to me that these themes had an independent and fluid voice, that transcended any kind of structure; so here are some that caught my attention and provoked my thinking, which I review without following the order of the chapters.

Paul Smith-Pickard, write vividly and movingly in Chapter 8, sharing 'The experience of working with patients with a short prognosis'. He inquires into the nature of the therapeutic relationship and identifies a particular quality of encounter when something shifts between some hospital patients and himself, which might be for only a short time; he describes this as 'when the patient becomes the client' .

In the same chapter, the mood shifts to the politics of our profession. While clearly acknowledging the importance of accountability and ethical practice, Paul challenges the current culture of evidence-based practice where proof of efficacy extends, in 'ridiculous and tasteless' fashion even to those on death's door. In contrast to this, therapists' vulnerability and questions of burnout are mentioned throughout the book, a subject not to dismiss given how poor at self-care so many of us are in this field. David Horne alludes to 'Vicarious Traumatization' (VT) in his work with HIV patients; he deconstructs the thinking behind the label and calls us to responsibility suggesting that a good life balance and self-care might in part dilute this extreme emotional stress. While some healthcare professionals suggest we need to be protected from our worldviews, identities and spirituality being challenged and disrupted, David seems to suggest that being shaken out of our 'natural attitude' as Husserl calls it, might actually benefit us. Alison Diffley seems to echo this when she says, 'I know that is it important for me to be in touch with how and why patients impact on me, so that I can separate my own issues, enabling me to continue to deliver a service and guard against burnout. '(p.157)

'And how do we stay congruent and at the same time offer containment of feelings that we ourselves experience as totally overwhelming?' Ann Chalmers asks in Chapter 11, 'Working with Bereaved Parents', and suggests that a real human response can in fact be therapeutic. Her client, Cheryl, seemed to think so:

Is this an example of 'professional closeness' (p158) or is do such moments transcend such definitions?

Notwithstanding, appropriate support is necessary for practitioners. Dick Blackwell in Chapter 6 offers views of the work at the Medical Foundation with survivors of torture and organised violence. In this useful and disturbing chapter, Dick talks about a stage that can happen in the therapy work when clients are not granted asylum and face deportation to a place where attrocities and death are a real threat. This is a critical time in the therapy, yet one when therapists typically feel 'impotent and helpless' ; this is why it is imperative to get good team support for '[I]t is almost impossible to bear these sorts of situations alone'. While we are not below responses to these tragic situations, nor should we be, it is good to be reminded that one can continue even though there is no hope, and it is important not to give up. At the Medical Foundation, it is the team commitment and support that can enable the therapist to carry on with the work even in this dark time of shared despair.

Team work and support is not only talked about but represented, in the compilation of Chapter 9 'Palliative care, pastoral care and counselling' which is a composite work and journal by Alison Diffley, The Revd Hilary Fife and Melanie Lockett, each reflecting on their shared work with a dying patient, 'Kate'. This chapter intrigues me me as each of the three 'practitioners' defines the domain and limits of their practice and the therapeutic territories of their colleagues. Are three people better than one in such a situation when the team cohere so well? When else might that be the case?

Sanja Oakley gives us another perspective on the value of group support and community in Chapter 5 in talking about her work as a trauma therapist who worked with Transport for London workers who were trauma survivors of the London 7/7 bombings. Whereas, after a shocking trauma, a person might be expected to take stock of one's life and stride out in new directions, Sanja reports differently. '[The Tfl survivors] were moved by the kinship they felt with colleagues alongside whom they had worked' and, many returned to their work, continuing to feel strongly connected with their community of fellow workers and Londoners. This question of universality brings in the question of the potential therapeutic value of groupwork as compared with individual work. Family work and group work and its value is discussed by Dick Blackwell as a medium used at the Medical Foundation.

Most chapters raise more than one central question about therapy work and Sanja, in her same chapter, entitled Creating Safety for the Client, advocates a style of practice that for many existential therapists may feel challenging; that is an approach to working with trauma that is unashamedly biological, procedural and behavioural. '[T]he best place from which to meet clients' dramatically changed experience of themselves is through their body, via an embodied encounter'. Sanja describes how she explains to clients who are in trauma how they exhibit 'animal responses' and explains 'our shared heritage with animals' and the theory of the 'triune brain'. (In Chapter 9, Dick Blackwell also expounds thinking about fight, flight and dissociation in trauma victims' responses.) Sanja reports how clients typically feel 'understood' on learning that their responses ' derive from a primal, instinctual mechanism'. Being part of the animal kingdom is not something we tend to sing about as existential practitioners, as if it is a return to Freud's post-Darwinian views or even behaviourism; and yet this is inconsistent with a commonsense fact of being human: that we are embodied and therefore it follows there are norms in embodied responses. Touching, as it does, on such an important area of experience, it is good that Laura Barnet dedicates a section in her introductory chapter to PTSD.

The question of normalising arises in elsewhere in the book and appears in 'Surviving Intensive Care and Working with Bereaved Parents'. Sarah Young in a rich and full chapter ' Working with Bereavement' reminds us how all theories 'limit understand and reduce experience to what can be explained.' She is talking at this point about models of bereavement, but the message is true of all assumptions and presuppositions, 'By trying to fit experience into a prescribed model, we are in danger of losing sight of the experience itself.' As phenomenologists, finding a way to evaluate the merits and demerits of any assumptions, constructs or even theories and to maintain a naive stance so we can open the client's awareness and possibilities is a delicate and fine balance, which is not constant. However, it is true also, as Sanja suggests, that making a safe and appropriate space, is necessary for more detailed exploration to take place.

'Reflections on Cancer Counselling', introduces Melanie Lockett. She is openly emotional and disclosive about her own breast cancer. She brings her own experience to bear in her work. The fear of traumatisation looms large in our work and Melanie recognises that counsellors typically, 'worry about making an already vulnerable client suffer more by speaking openly and directly about such difficult material' She continues,

It is important for us therapists to take up these questions so we can recognise and distinguish between situations where trauma might be 'reignited' and which could potentially have a deleterious effect on a person, and those, by contrast, where it it can be helpful and rewarding to engage with existential concerns, which is for many of us, our work.

Another area that creates much disquiet among therapists is working with the suicidal and despairing. I found John Heaton's down to earth yet profound reflections on these topics, in Chapter 7, refreshing and practical, but not dismissive. He helped me to recognise the unacknowledged despair of everyday living, which for many is not necessarily less profound than that expressed by the parasuicidal. I shifted a notch in reading this chapter and wondered about the distinction between 'despair of' and 'despair from' he expounds. Sometimes it is these subtle nuances that can open up rich worlds of new thinking as is the case in ' Surviving Intensive Care' in which Laura Barnett distinguishes between 'survival from death' and 'survival for life' .

I have shared a few of my own dialogues with themes in the book; now I hope you shall engage in your own. I have already recommended this book to many therapists and trainees and would recommend the book to any practitioner at any level of experience and of any orientation who wants to be provoked into new thinking about questions of mortality and its different manifestations in the therapy room. And if you are a cynical practitioner who is complacent or indifferent about death and intimations of mortality, I think it even more important that you confront your fear, get stuck in and read this excellent book and dare to resonate with the generous offerings of these committed writers.
It mattered to me that my counsellor looked visibly moved the first
   time I told her how my son had died. It was the most awful thing
   that had ever happened in my life and seeing that we was affected
   somehow validated my feelings and the enormity of my loss.

   (p.187)


Despite my own fragility, I have appreciated talking about my fears
   and continue to welcome the curiosity and care of others. It has
   helped me to feel less along, stronger and to live my life more
   fully. I believe that by helping clients to connect with their
   deepest anxieties, they will actually gain deeper insight, more
   control and a greater calm.
Gale Copyright: Copyright 2010 Gale, Cengage Learning. All rights reserved.