Welcome to the Winter 2017 edition of the dilemmas page, in which we ask for answers to fictional ‘what if’ nightmare scenarios that we might find ourselves in as psychotherapy trainees. The range of responses from our readers from within the psychotherapy world provides us with tools should anything similar ever happen to us in our personal practice.
Mother and Daughter
You have been working with a client who has brought the presenting issue of being bullied at work by their two female bosses. At 6 sessions into the therapy the client arrives with their mother in tow and asks for you to see them both for the session, without giving you any prior notice – her mother seems insistent that you let her join in with the session. There has not been much discussion of the relationship between your client and her mother in therapy so far, which has focused more on the issue of the relationships at work. You know that in general the client has not complained too much about her mothers behaviour, but you do not have a clear image of how their relationship has been in the past. As therapist how do you deal with this situation?
Psychotherapist Suzie Chick says:
As soon as I read this dilemma, I felt quite anxious and unsteady, as if the walls of our therapeutic container were being compromised and shaken up. I felt ambushed and pressured to go along with her mother attending. I immediately felt a need to put up stronger walls to combat this. In these unexpected situations, trusting my instincts and intuition is key. My key points would be:
I would tell my client and her mother that this situation is not usual practice and acknowledge that there has been no prior discussion or warning.
Given this, I would tell her mother that it is not appropriate to attend her daughter’s session today.
I realise this might seem quite strict, but I am sensing clear and strong boundaries are needed. Plus I would be keen to mirror to my client that her therapy is her space (not to be shared/invaded by her mother) and that I take its safety very seriously.
If my client/mother refuses to agree to my stipulations then the session will be cancelled and I would suggest that the client returns next week (alone) to talk this through. There is a risk that the client might not return, but my hope would be that over our 6 sessions, the therapeutic alliance has begun to be formed and that this would encourage the client to return.
Needless to say, there is a lot to unwrap here with the client. The ‘mother door’ has been well and truly opened. The client has given me a gift of showing in real time the dynamics of her relationship with her mother.
Given the client is experiencing bullying from women at work; it’s probable to assume that this could be reflective of difficulties with her relationship with her mother. The very fact that her mother has turned up without any prior discussion seems to confirm this (i.e. who really is driving this request, the client or their mother)?
I would want to discuss with my client why she wants (or not) her mother to attend her session and how this proposal came about. I would keep checking in with my client as to how she was feeling in the here and now including any body sensations. I would also keep a monitor of my own feelings, as I may be experiencing transference.
After exploring the matter, if my client does want her mother to attend her session, then a date can be agreed with all concerned and we can prepare for the meeting in prior sessions. Within this preparation, I would want to address boundaries and confidentiality with my client.
I am not against her mother attending a session, but the chaotic way this proposal came about, concerns me. I would want to feel sufficiently assured that this is something my client wants and that the reasons behind it are to serve my clients best interests.
My sense is that this chaotic episode has given us more than sufficient material to work with and therefore the need for her mother to attend an actual session may fall away as our work progresses.
Psychotherapist Nick Opyrchal says:
Like Suzy I would keep strong boundaries and prevent mother from entering into the therapy session. The fact that there is no protest from the client and that it is the mother who is insisting that she attends the session suggests to me that there is very little if any boundaries between mother and daughter. I would be concerned that the mother’s presence would ensure that my client would have to censor the material that they produced in session, and that should I fail to draw a boundary I would be tacitly admitting to my client that the therapeutic space belongs to her mother rather than her. It would no longer be ‘safe’ to explore difficult material involving her family should I not stick to this boundary. I am also modelling the ability to set boundaries to her mother to my client.
I would be interested as to why it is that the mother wants to intrude – perhaps she feels like she needs to police the answers of my client, or is afraid of something in their relationship being exposed. To me this may suggest an element of narcissism – the need for the mother to be portrayed in the best possible light by her daughter, or alternatively could suggest a measure of guilt being defended against. This could bring up possible avenues to explore with my client in the future. In this I would be interested in the threat that mother feels in the responses of her daughter not being monitored and would wonder about how this might possibly have manifested in my clients psychological organization as a particularly controlling maternal superego.
I would also be interested in my role as perhaps providing a separating ‘father’ role in the relationship between me, my client and her mother. There is a strong paternal presence needed to modulate the devouring power of mother, and I would suspect that my client does not have this in their life currently.
Next Issues Dilemma – Infection
You have been working at an addiction placement with a client for the last 4 months who is a heroin addict. This client injects in order to take their daily dose of the drug. You know that they share needles with their girlfriend and others. Your client comes back to session from a midweek doctors appointment to discover that they have contracted H.I.V. but they tell you in the session, seemingly nonplussed that they will continue to share needles with their girlfriend and others and “just wont tell anyone”. How do you address this situation?