By Dr Ella Davey

Powerhouse singer-songwriter Kelly Clarkson[1] famously claimed that:

‘What doesn’t kill you makes you stronger, stand a little taller, doesn’t mean I’m lonely when I’m alone, what doesn’t kill you makes a fighter, footsteps even lighter…’

Post-Traumatic Growth, or PTG, best known through direct comparison to its first cousin Post-Traumatic Stress Disorder (or PTSD), purportedly involves the experience of a positive transformation in the wake of a traumatic event or situation. Beneficial changes can occur across a variety of different areas leading to aspects such as a new appreciation of life, closer relationships, increased resilience, and spiritual connectedness.

Whilst, historically, PTSD has tended to dwell on the negative consequences of trauma, the newer, adjunctive concept of PTG highlights the more welcome experiences that can sometimes occur following highly challenging events. Psychologists Richard Tedeschi and Lawrence Calhoun[2] have suggested that people can sometimes find new meaning, purpose, and strength following experience of great loss and trauma, noting, however, that positive changes do not necessarily stem from the difficulties themselves, but rather from some people’s ability to positively engage with and make meaningful sense of their traumatic experience.

Transformational changes such as these tend to occur across 5 key dimensions:

New Possibilities

As well their potential to cause devastation, trauma can also hold the possibility to re-evaluate aspirations and life goals. Some trauma survivors pursue new or more fulfilling opportunities, careers, or activities, potentially opening doors to possibilities they may never have considered before.

Relating to Others

Positive changes can be felt within personal relationships or social contexts due, perhaps, to an increased understanding of the potential for human suffering leading to greater empathy and compassion. Some survivors have expressed feeling inspired to connect with others going through similar challenges or they feel more willing to take greater emotional risks.

Personal Strength

A feeling of strength and resilience has been reported among many trauma survivors who also identify with an experience of post-traumatic growth, often describing an increased sense of power or determination.

Spiritual Change

In the aftermath of trauma, a theme has been noted among some of discovering a more direct or intimate understanding of any existing spiritual beliefs or even an entirely new sense of purpose or existential meaning in life.

Appreciation of Life

Related to this, processing and growing around a traumatic experience might cause some people to radically re-evaluate their life and its course, leading to a deeper appreciation of life and a feeling of more presence in it.

As with most things, some people may be more likely to experience post-traumatic growth than others. For example, those who have an optimistic, open-minded personality style who also draw on more objectively positive coping strategies like self-acceptance and cognitive reframing are probably more likely to proactively engage with the practical and psychological challenges traumatic experiences can create. Trauma research also consistently highlights the crucial value of a supportive social network both for initial recovery[3] as well as for any post-traumatic growth[4].

And yet, whilst post-traumatic growth may be a useful addition to the previously rather rigid, arguably negative focus within mental healthcare suggesting that traumatic events invariably cause debilitating mental illness and social dysfunction for some, it is equally important not to promote this additional concept to such a degree that even greater pressure ends up being put on survivors’ shoulders. As Valerie Tiberius[5] puts it:

The answer to the question of whether there is post-traumatic growth (PTG) seems to be sometimes, for some people, there is some kind of growth; for other people, at other times, or in other ways, there isn’t…. (G)rowth narratives can be hurtful to people who aren’t “growing” from their trauma. This can be because the possibility of growth makes people who are suffering feel inadequate if they aren’t growing from it or (more perniciously) because the narrative of PTG can be taken to support blaming people who do not get over their troubles and become better people. (p. 2)

One final thought. Post-traumatic growth, if experienced at all, is often seen to co-exist with post-traumatic stress and any number of other phenomena and diagnoses involving the mind and body. People are well-known to be capable of simultaneously experiencing what may initially appear to be highly conflictual mental and emotional states in the aftermath of adversity, including hope and despair, progress and stuckness, and darkness and light, all of which serve as useful reminders of the diverse and complex nature of human responses to trauma.

[1] Clarkson, K. (2017). Stronger [Song]. On Stronger. RCA Records.

[2] Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: measuring the positive legacy of trauma. Journal of traumatic stress, 9(3), 455–471. https://doi.org/10.1007/BF02103658

[3] Charuvastra, A., & Cloitre, M. (2008). Social bonds and posttraumatic stress disorder. Annual review of psychology, 59, 301–328. https://doi.org/10.1146/annurev.psych.58.110405.085650

[4] Ning, J., Tang, X., Shi, H., Yao, D., Zhao, Z., & Li, J. (2023). Social support and posttraumatic growth: A meta-analysis. Journal of affective disorders, 320, 117–132. https://doi.org/10.1016/j.jad.2022.09.114

[5] Tiberius, V. (2021). Growth and the multiple dimensions of being: A philosopher’s take on the idea of post-traumatic growth. In F. J. Infurna & E. Jayawickreme (Eds.), Redesigning research on post-traumatic growth: Challenges, pitfalls, and new directions (pp. 1–11). Oxford University Press.

By Dr Ella Davey

“Do I have to lie on a couch?”

“You’ll need to scooch your chair closer, I’m afraid,” she said.

I was sitting opposite my former therapist in her tiny attic office, our knees almost touching. What I remember most about this therapy, apart from her chairs, was how she would share so much about herself during our sessions trying perhaps, I thought, to forge a connection with me.

By contrast, years later, in a different room, a very dissimilar former therapist chose to sit much further away and said virtually nothing except with her eyes which, now and again, would linger on the couch opposite.

“Do I have to lie on it?” I wondered, “For this therapy to work?”

Sometimes I did lie down on it and stared upwards with my eyes half-open, trying to verbalise whatever was running through my mind. An oddly freeing sensation.

***

With all the kinds of therapy on offer, it can be hard to know which to choose. There are certainly differences between them, mostly theoretical ones. I personally think that therapy types can vary along two main axes or continuums.

The first ranges from a preference to address issues largely relating to the here and now all the way along to those largely relating to the there and then.

The second ranges from a preference to having a profound relational connection with one’s therapist all the way through to preferring an impartial clinical diagnosis and some symptomatic treatment.

Wherever they lie, all psychotherapies leave plenty of room for interpretation. There might not even be that much between them when it comes to their healing potential. Though some may be more useful for certain kinds of problems[1].

The most well-known, commonly practised talking therapies include psychodynamic, cognitive-behavioural, and humanistic types.

Psychodynamic therapies, rooted in Freud and others’ theories, tend to highlight the importance of the unconscious mind and early childhood experiences. Classical techniques include ‘free association’ either in a chair or on a couch, with the therapist’s role being one of an interpreter of possible motivations, dreams or fantasies, or parts of ourselves we may cherish, despise, or are blissfully unaware of.

Cognitive-behavioural therapies, originating in behaviourism and cognitive psychology, tend to focus on identifying and changing unwanted thought patterns and behaviours. Therapies such as CBT are usually highly structured, directive, goal and time-focussed. Techniques include noticing and reframing negative thinking patterns, trialling alternative responses, and combatting stress.

Based on the so-called ‘Third Force’ of humanistic psychology, humanistic approaches such as Person-Centred therapy espouse the view that everybody has an inborn ability to heal themselves given the correct ‘core conditions’ of empathy, congruence and unconditional positive regard[2]. A person-centred therapist aims to provide these to their clients in a non-directive way (unlike cognitive behavioural therapy), and in a way which is client-led (unlike classical psychoanalytic therapy).

Integrative psychotherapy combines elements from these and other approaches in an effort to avoid a “one size fits all” approach. Integrative therapists draw on their own blend of theories and techniques that they feel are most suitable for the client and their issues. They try to remain adaptive throughout the therapeutic process. Integrative therapies can take many different forms but also uphold the idea of the client’s innate self-healing capacity as well as the transformative power of empathy.

Almost without exception and across the board, the therapeutic alliance (or helping relationship between therapist and client) is agreed upon as supremely important when it comes to effectiveness. Sometimes, this alliance has different names or shapes – such as transference in psychodynamic therapies or collaboration in CBT. Whilst terminologies, techniques, and the self-appointed role of the therapist may differ, all approaches aim to provide a supportive environment within which people can grow and make meaningful changes.

If you’re thinking of entering therapy yourself, or perhaps considering learning or training as a therapist, it’s worth considering what shape of therapy best lines up with your needs and your views about human problems.

For example, does the problem you’re thinking about correlate with something occurring right now such as a crippling fear or phobia? Or does it feel connected to something that may have been going on slowly and in a more complex way, perhaps since childhood?

Someone struggling with intrusive thoughts who finds themselves going to extreme lengths to avoid unpleasant beliefs or feelings might benefit from an approach directed towards thoughts, behaviours and beliefs, such as CBT.

On the other hand, someone who is tortured by their paradoxical-seeming feelings of tenderness and rage towards a loved-one may benefit from a therapy encouraging a deepening awareness of the unconscious mind, such as psychodynamic therapy.

Benefits could also be seen from choosing an integrative therapeutic approach in which these and other ‘lenses’ can be drawn on at different times for different reasons.

[1] McAleavey, A., & Castonguay, L. M. (2015). The process of change in psychotherapy: Common and unique factors. In O. C. G. Omar, A. Pritz, & B. Rieken (Eds.), Psychotherapy research: Foundations, process, and outcome (pp. 293–310). Springer.

[2] Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Houghton Mifflin.

By Letticia Banton
Photo by Marianna Smiley

“It’s starting to get dark early.” After several years of working together, I knew this was my client’s code for ‘Christmas is coming’, which for him meant a reminder of his family’s estrangement and the prospect of spending another festive season alone, with intense feelings of loneliness, grief and shame resurfacing.

‘Family estrangement’ is a term used to describe the breakdown of a relationship between family members. In the UK, it is estimated that 1 in 5 people are estranged from their family, with numbers on the rise (Stand Alone, 2015). Yet it is an area of relationships that has received little attention by psychotherapeutic theory, research and training. To help address this gap, the Inner Citadel Institute welcomed Dr Samantha Barcham for a two-part CPD on family estrangement. Dr Barcham (2021) has conducted doctoral research into this area, and it is her specialism in clinical practice.

While every person’s experience is unique, Dr Barcham emphasised that “family estrangement often comes with incredible sadness and heartache for all those involved, and it is not something done on a ‘whim.’” Her research describes estrangement as a ‘relational injury’ or trauma (Barcham, 2021). As relational beings, a person’s sense of self-confidence and self-worth may be significantly impacted by family estrangement. Exploring a person’s lived experience of family estrangement and its impact on their sense of self in psychotherapy is nuanced work. In this post, we share six takeaways from the CPD sessions on working therapeutically with people who are estranged from/by their families:

1. Reflect on your own assumptions towards family estrangement

Family estrangement is an area that may not have been explored during core psychotherapy trainings. Drawing on Blake’s (2020) research, Dr Barcham highlighted several common biases that people carry toward those who are estranged from their families:

• Reconciliation bias: Are you encouraging reconciliation, pushing the client to reconnect and make amends? Why might you hold this agenda?
• Estrangement bias: Do you believe the client should ‘just walk away’ without exploring this fully and the consequences? Why might you be holding this position?
• Perspective bias: Do you hold one side at fault? Why? How much does being human and always thinking one person is ultimately to blame factor in your perspective?
• Forgiveness bias: Are you pushing your client to forgive to move on? Or encouraging them to make an apology, even if they don’t mean it? Why might this be the case?

2. Recognising and holding the complexity of family estrangement is important

Pathways to estrangement can be multifaceted and complex. These can include harsh or poor parenting, divorce, a problematic child-in-law, mental illness or addiction. It can also include divergence in values and lifestyles, such as gender, sexuality, religious and political beliefs. For some people estrangement might mean no contact, while for others it could be infrequent communication.

For others still, there could be physical proximity but an emotional distance. As a therapist it is important to demonstrate insight into this complexity. During therapy, collaborative and phenomenological inquiry can help to build a picture of what is known/unknown about a client’s family and their idiographic experience of estrangement.

3. The therapeutic relationship may play a reparative role

While the therapeutic relationship lies at the heart of any effective therapy, for people experiencing family estrangement, an attuned and trusting relationship carries reparative potential. While the client’s family relationships and attachment-bonds may have broken down the expression of intense feelings and conflicts, a good-enough therapeutic relationship can withstand this.

The therapeutic relationship may play a pivotal role in offering a relational experience that was missing in the client’s family-of-origin and self-development. It can offer warmth and compassion when the family environment may have been harsh and cold. Or flexibility when the family may have been rule-based and rigid. A safe and trusting therapeutic relationship can also help a client to face disavowed or shadow parts, which may be painful to revisit. For example, their role in the estrangement, or the experience of ambiguous loss of grieving for someone who still lives.

4. Left-brain and right-brain interventions are important

Using therapy as a space to dialogue about a client’s experience can help them to process complex emotions about estrangement, including shame, guilt and anger. As well as left-brain dialogue can enhance insight, right-brain interventions can expand a person’s capacity to ‘be in relationship’ so they can face the relational ‘other’. For example, a therapist offering affective co-regulation through grounding and breathing exercises could be important developmentally for people who may not have had emotional co-regulation modelled in their family of origin.

5. Working towards a form of acceptance

Fully accepting and moving beyond the immense pain of an estrangement may never be possible in a person’s heart. However, when someone learns to live with the estrangement, they can often feel a sense of relief and reduced suffering. Accepting the lived reality of the estrangement can help someone regain a better sense of control. They begin to grieve the ambiguous loss they may feel around being estranged from a family member.

It may also enable them to step back and have more insight and perspective into how the estrangement took place. A therapist plays an important role in helping a client to face the complex feelings they may hold around the estrangement so they can move into a place of acceptance. Through acceptance often comes a stronger sense of agency.

6. Reconciliation as a process not an event

Parents with estranged children may often come to therapy with the hope of working toward a reconciliation. Reaching this point requires both parties being able and willing to participate and does not happen overnight. To empathise with the child’s experience and make amends will require for parents to process all the difficult feelings this may entail, including guilt and shame, rather than staying in a defensive position.

There is also the risk that the reconciliation may take more time than anticipated or in some cases it may never be possible. Being able to stay with a client through the uncertainty a reconciliation process needs, rather than reaching for answers, is central to the therapeutic work. 

If you would like to learn more about family estrangement, you can join Dr Barcham’s next CPD course, taking place in September 2024, or you can also visit Dr Barcham’s website, which has lots of helpful resources here: https://familyestrangements.com/

References

Barcham, S. (2021). A mother without a mother: Women’s experiences of maternal estrangement in motherhood [Doctoral dissertation, Metanoia Institute]. https://repository.mdx.ac.uk/download/142bd92b5984ef4bb32647c94063b503fb6449a2ae504a12737f08721084a53c/1767763/SSSBarcham%20thesis.pdf

Blake, L., Bland, B., & Imrie, S. (2020). The counseling experiences of individuals who are estranged from a family member. Family Relations: An Interdisciplinary Journal of Applied Family Studies, 69(4), 820–831. https://doi.org/10.1111/fare.12385

Standalone (2015). Hidden Voices: Family Estrangement in Adulthood. https://www.standalone.org.uk/wp-content/uploads/2015/12/HiddenVoices.FinalReport.pdf

By Dr Ella Davey

What do you think makes a good therapist?

Their depth of experience? Their expertise? How quickly you can see improvements, perhaps through feeling calmer or less conflicted? Or perhaps you conceptualise a good therapist as being someone who makes you feel heard and valued? Or do you rather appreciate the insight a good therapist can help bring about?

The truth is we all have slightly different ways of evaluating the goodness of our therapists. I, for example, once had a therapist who was not only warm, patient, and creative, but also owned an elderly tortoiseshell cat who would sit and purr on my lap during sessions, comforting me to the core and – I’m sure about this – simultaneously regulating my anxious breathing and heartrate.

Such seemingly intangible aspects of what was, for me, an overall positive therapeutic experience can be difficult to quantify, let alone recreate. Yet, the best therapeutic experiences, and the best therapists, are definitely never completely perfect, nor even, necessarily, great. In fact, evidence tells us that the very best therapists are only ever just good enough.

Based on Donald Winnicott’s[1] concept of an infant who requires a ‘good enough caregiver’: one who is fallible and human as opposed to one who is perfectly responsive every time, so it has been said that what clients need most is a therapist who can show them, through their realness and humanity, that faultless care is neither attainable nor necessary when it comes to their healing path­[2]. Instead, a ‘good enough’ therapist should, ideally, embody core qualities such as empathy, authenticity, and competency which the client can then experience within a relationship characterised by safe boundaries and an attitude of mutual curiosity.

The good enough therapist, essentially, is constantly communicating to their client:

“I know I can’t reliably make all your challenges disappear, and sometimes I’ll even get things wrong. But that’s OK, because what’s important is that I’m here now and we’re going to work this through together, as best we can.”

To illustrate this idea further, several schools of therapy, despite their outward differences, have tended to agree that therapists should ideally aim to:

Give a hoot

At the heart of every good enough therapist, lies an ability to care about, attune to, and resonate with another person’s experiences. Of course, some people are naturally more empathic than others, but empathy is also something that can be cultivated and practised. Research has consistently shown it is essential for therapists to be capable of finding ways to authentically connect with their clients and to show them, often without words, that therapy is somewhere they will be listened to and also felt with. Empathy is the thing that, more than anything else, enables the development of a rapport capable of supporting even the most difficult or painful of conversations.

Be a real human being

A good enough therapist knows therapy works best when it’s a collaborative process in which neither party is anything other than themselves. Often, the right therapist for someone isn’t necessarily the person who appears the most polished, or the most qualified. What people often discover is that they tend to benefit most from someone who can provide them with a safe, affirming space where they can explore their thoughts and feelings. People also benefit from someone who is aware that everybody, including them, still has a lot to learn and who is open to receiving feedback in terms of what they’re getting right or what they might need to work on.

Good therapists, ideally, are similarly self-aware enough to know they’re likely trying to do the best they can in a line of work which, on a bad day, can make them feel quite the opposite. The ‘good enough’ bit comes in balancing the endeavour to be a skilled helping professional whilst acknowledging the inevitability of being a perfectly imperfect human being. A sense of humour, too, is useful since sharing laughter with someone in the midst of the occasionally bleak, black comedy of life can sometimes be the best treatment of all.

Not be a know-it-all finger-pointer

Everybody knows how difficult it can be to speak our worst bits out loud: the qualities we don’t like in ourselves or some of the things we’ve done in the past or, perhaps, we still do. Ten times more difficult is to have finally found the courage to tell someone about these who, in their response, inadvertently confirms the certainty that we really are these awful things, except now, instead of them simply festering in our own head, they are being evaluated by the calm-faced, know-it-all therapist who is sitting opposite us, nodding, purse-lipped, and head tilted.

As an antidote to this, Carl Rogers[3], founder of the client-centred approach, encouraged therapists to try hard to embody a non-judgmental warmth and acceptance of their clients, and to view each as cherished and valuable, no matter what. Such humanism can enable a space in which people can feel okay (enough) to explore their deepest worries without fear of censorship, in turn, leading to the fostering of security, empowerment, and a greater willingness to take ‘risks’.

Actively listen using the mind and the body

Some people might be surprised to realise that we not only listen with our ears but also with our bodies[4]. A good enough therapist will be listening carefully to what their client is telling them in words and hopefully then responding sensitively or insightfully. At the same time, good enough therapists will also be listening to what the client is telling them in other ways, including with their tone of voice, facial expressions, posture and even their silences since these modes of communication can, sometimes, tell a rather different story.

Furthermore, there are other therapists, including those who work psychodynamically or relationally, who will also be actively listening to a number of signals which may be coming from their own mind or body. These so-called ‘countertransference’ communications can provide an eerily accurate ‘reading’ of the client’s difficulties and also highlight matters of importance within the therapy itself which can be worth paying attention to, such as when the client feels bored, blocked, or angry but may be struggling to express or even realise this themselves.

Walk the Line

And finally, good enough therapists know how important it is to establish clear, appropriate therapeutic boundaries so that their clients can come to appreciate the extent of the therapeutic relationship and, crucially, the sense of safety and privacy it can provide. Often, therapeutic work around so-called ‘boundary issues’, whilst sometimes highly challenging, also proves transformative for clients through being helped to discover important aspects about themselves or their relationships outside the therapy room.

A good enough therapist will be careful not to introduce confusion by sharing too much about their own lives or by giving the impression they are a friend, rather than a professional. Much has been written on this subject and many debate the exact ‘lines’ therapists should aim to walk, but common standards of conduct exist which all strive to respect clients’ dignity and autonomy and for good reason, since when major boundary issues occur, therapeutic disasters can sometimes be the result[5].

In summary

Being a good enough therapist involves aspects of both doing and being. By cultivating skills such as empathy, active listening, non-judgement and safe therapeutic boundaries, therapists can provide their clients with an open space that promotes curiosity as to what it is to be human whilst embarking on a journey towards healing and personal growth.

[1] Winnicott, D. W. (1971). Playing and Reality. Routledge Classics.

[2] Borg, L. K. (2013). Holding, attaching and relating: A theoretical perspective on good enough therapy through analysis of Winnicott’s good enough mother, using Bowlby’s attachment theory and relational theory: A project based upon an independent investigation [Master’s thesis, Smith College]. https://scholarworks.smith.edu/theses/588/

[3] Rogers, C. R. (1961). On becoming a person: A therapist’s view of psychotherapy. Constable.

[4] Schore, A. N. (2014). The right brain is dominant in psychotherapy. Psychotherapy, 51(3), 388–397.

[5] British Association of Counselling and Psychotherapy (BACP) (2024, May). Boundaries: what complaints tell us. https://www.bacp.co.uk/about-us/protecting-the-public/professional-conduct/what-complaints-tell-us/boundaries/