Segal JC 1996 Whose Disability? Counter-Transference in work with people with disabilities in Psychodynamic Counselling 2.2 May pp 155-166
Counter-Transference in work with people with disabilities
Some of the meanings which disability and illness may have for therapists or counsellors as well as for their clients are examined. The effect of a client’s illness or disability on the counsellor as well as on the client has to be taken into consideration. Under the pressure of counter-transference feelings arising from both client and counsellor the counselling itself may be disabled. The counsellor may have unrealistically limited expectations of an ill or disabled client’s ability to tolerate painful emotions. Difficulty in relating to ill clients as parents in particular is discussed.
Counter-transference; disabilities; illness; counselling; psychotherapy; parents.
Sickness and ill health, ugliness and deformity all have symbolic meaning to do with badness of particular kinds. Literature is full of characters where disability is equated with evil: from Shakespeare’s Richard III to Captain Hook in Peter Pan. D.H.Lawrence and Charlotte Bronte have more equivocal views of disability (in Lady Chatterly’s Lover and Jane Eyre), but for both the message is clear that disability reduces a man. Melanie Klein and her colleagues found that our earliest phantasies may involve attacks on our mother which leave her in phantasy dead, dying or deprived and revengeful; awaking persecutory phantasies, or strongly reparative or omnipotent phantasies towards ill or disabled parent-figures. Children’s literature often involves dead or dying mothers, sometimes saved by their children (eg C.S.Lewis’ The Magician’s Nephew). The ugly witch of fairytale can be interpreted as a mother distorted by the child’s envy: deprived of her sexuality and her love but not her power, shaking her stick at us through our childhood nightmares.
Both client and counsellor share this inheritance. Counter-transference has its origins in two strands: the counsellor’s own unconscious phantasies evoked by the client for reasons to do with the counsellor; and the phantasies, feelings or thoughts which the client cannot bear but manages to communicate to the receptive counsellor. In both of these strands disability and illness may be disturbing. The effect can sometimes be, I suggest, to temporarily disable an inexperienced counsellor.
Faced with pressure both from our own psyche and from the client, we may find ourselves reacting with paranoid-schizoid mechanisms. We are tempted to keep the “bad” (which in phantasy may include the ugly, the ill, the deformed and the disabled) separate from the “good” (which may include life, love, sexuality and thinking). Splitting perceptions of the client into the disabled and the able; the healthy and the unhealthy; the envying and the enviable is a natural reaction. When we work with madness and sanity we know the perils of splitting the client in this way: Klein showed us the mad person inside the sane: Bion ensured that we would remember the sane person hidden inside the mad one. But our training with people with disabilities has probably been considerably less rigorous. In place of the insights of Bion and Klein we have the pious instructions to “behave as you would normally” or “treat people with disabilities as you would anyone else”, neither of which work. It is not normal to expect an ill person to think intelligently about painful issues. I suspect it is hardly normal not to try to avoid someone with a disturbing illness or disability. It is not normal for a counsellor to pretend.
The question is how to behave appropriately as a counsellor in an abnormal situation. By bringing into the open some of the phantasies which may come into action we can think about and modify some of our thoughts and behaviour. In particular I want to look at phantasies in which disabled aspects of the client and the counsellor are kept separate from more able ones. Where the disabled part of the client is seen as a priori bad, dangerous, malevolent and manipulating or excessively weak, helpless and impotent; in need of protection from a threatening able-bodied, thinking world; the counsellor may be unable to use their normal therapeutic skills. Bringing together ideas of disabilities with ideas of sex and the responsibilities of parenthood may be particularly difficult for counsellors just as for the rest of the population.
I want to look at some of these ideas in more detail.
In training sessions I ask professionals how they imagine they would react to being disabled themselves. One counsellor said she would be most frightened of being in a wheelchair. Invited to expand, she said it would mean being pushed around: I asked if that was something she often felt and she said it was actually a current issue at work.
The symbolic meanings which influence people’s fears of disabilities often include present realities like this. The counsellor saw herself as at risk of becoming a helpless victim at work and attributed this part of herself to the self-in-a-wheelchair: her abilities, including the ability to fight for herself, she stripped from this figure. Thus she was left with a view of herself-in-a-wheelchair which was deficient not only in the use of her legs, but also in emotional strength and power.
This, I suggest, is how we often create images of disability or illness. We strip our own potency or power from the more frightening aspects of our characters and imagine that this is what we would be left with if we were ill or disabled. Clients do this too: it is the counsellors’ job to pick this up and restore more wholeness to the client’s view of themselves. Difficulty arises if the counsellor has reacted to the client’s disability by in phantasy stripping the client of emotional strength: the necessary strength to respond to therapy.
It goes against the grain in normal life to challenge someone who is ill. We want to wait until they are better. If they are not going to get better many people would simply avoid the challenge if at all possible, and may end up avoiding the person. For counsellors too the sense that “they have enough to cope with as it is” is strong: we know that therapeutic interventions can be experienced as attacks, and their therapeutic effectiveness may be temporarily forgotten. We may also feel that the disabled client knows better than we do how to cope with their disability: who are we to challenge this? If we split the client as a thinking, participating person with the ability to make psychic changes off from the disabled person, we may feel there is no point in challenging them. Thus we may avoid bringing to the client’s attention some of their most painful feelings which are obvious to us, and we may deprive the disabled client of proper counselling or psychotherapy. In this situation the counsellor deprives themselves of a client and disables themselves as a therapist.
It took me a long time with one very disabled client to point out that for all the scorn he poured on his apparently useless father (who I think had Parkinson’s) there was one thing his father could do better than he could, and that was to have children. It seemed such a cruel thing to say to someone who at the time looked as if he would never have a girlfriend, let alone children. The temptation to allow him to retain his fantasy that he was so much better than his father in every conceivable way was very strong. How could the reality of his own impotence in relationships be better? What would be the point in drawing it to his attention? How could I expect such a disabled man to have the capacity to grieve for such a loss? Would it not be kinder to let him continue to deny it? In fact, some time after this intervention he did find a girlfriend. His physical and mental difficulties were not in fact insuperable barriers, though I suspect my difficulty in trusting his capacities and thus working with him to the best of my ability could have been.
“Disability means envy”
When I started working with people with MS I thought that envy of the healthy would be strong among the unhealthy. I was surprised to find that gratitude for and enjoyment of others’ health were also strong, even if alongside some envy. I now think that I had created from several sources a “disabled part-client” whose main characteristic was envy. Partly it came from my expectation of how I thought I would feel if I were disabled. Experience of a different, more disturbed client group also played into it; I think envy of sanity by those who feel they have lost it is a much bigger problem. It also arose, I think from a general feeling that envy is itself disabling. An envious self, split off from a more life-loving self, may be seen, quite rightly, as a real threat to our own and others’ abilities and a source of real disability in our own lives. Fortunately both we and our clients are more than simply envious, disabling part-people.
Constructing a part-object “disabled client” is easily done. It is not just that “we see the disability and not the person” as the slogan goes: the chances are we do not see the actual disability at all; what we “see” is our own construction; our own invented disability with characteristics drawn not only from our own experience but also from our own most disturbing anxieties or nightmares, using processes of idealisation, denigration, splitting etc. Try putting that into a slogan.
I do not think I am alone in associating envy with illness or disability. One counsellor gave up her job working with people with MS because, she said, it ought to go to someone with MS. There was nobody with MS who was either available or qualified to take it on. I suspect that it was a feeling of being envied; a sense that someone with MS envied her ability to work which in this case resulted in the counsellor actually preventing herself working. Attributing one’s own bad, envious self to the client may leave the counsellor feeling excessively enviable.
With one of my clients who suffered terribly from envy I found myself apologising sometimes when I managed to say something which seemed it might be useful. It seemed terribly painful to both of us, that I, along with all the other people she knew, was healthy and working and she was not, and we spent many months doing, I think, very little other than acknowledging the pain of this.
It may be that fear of the client’s envy may contribute to other ways in which counsellors somehow limit their work with people with disabilities.
Splitting off the “disabled” from the “normal” client can result in the counsellor paying attention only to the “not disabled” aspects of the client’s life; ignoring or blanking out references to the disability or illness. This may happen particularly after an initial period in which the disability is new and interesting. The counsellor may begin to feel they have had enough of it and to convey subtly that they do not want to hear about physical symptoms, or to listen with only half an ear to descriptions of them and to “move the client on” to more familiar ground where the counsellor feels more comfortable.
Some people with disabilities actively want everyone to ignore their disability: they have chosen this way to deal with it. The counsellor is then under some pressure to ignore the contribution the disability makes to the relationship between counsellor and client, and to join the pretence that it is irrelevant. A relationship based on pretence is not good for counselling, so the counsellor who goes along with it is confirming the phantasy that disability means getting a second class service and having to pretend you are getting the same as anyone else. At the same time the counsellor may suspect that the client’s view is that it is the counsellor’s problem, not the client’s. Bringing it to attention means acknowledging that the disability affects others, not simply the person who has it, and cannot be ignored in an honest relationship. It means tolerating the fact that having a disability means being different and having to cope with the effect of this on other people, however unfair this may seem.
The chances are, of course, that the counsellor’s own feelings about the disability may be similar to those of the client. Being tired and bored with the disability: wanting to be rid of it; feeling that the only way to be free of it is to ignore it; unnamed discomfort at ignoring it; guilt at being affected at all; uncertainty how to cope with the situation: these are all feelings which perhaps belong in the therapy, making up the “here and now”. When they can be verbalised, rather than acted upon, the disabled and able aspects of both counsellor and client can be brought together and can work together rather than being kept separate.
Idealisation of client/self
Disability or illness do not simply mean “bad” things. They may mean an opportunity for reparation; for making someone better: another chance to show that we and the world have some goodness in us. Our enthusiasm may be increased by the fact that we know we did not cause the damage – it is not our parent who is ill or disabled, only our client. The question is whether we can be fully reparative or whether we will succumb to manic reparation which is not reparation at all.
It is not uncommon to feel that ill or disabled people are somehow more deserving than “ordinary” people and that they require the counsellor to be more considerate, kinder, nicer than usual. When we are ill we do like people to be kind to us and we may feel we “deserve” it. People have a sense of paying their dues to society by suffering a reasonable amount: not too much: just enough to prevent the envy of the gods. The feeling of needing to be particularly kind and good to those who have had more than their share of bad luck also has roots in placation; a fear of people who might be sour, angry or resentful of our good fortune.
More than one of my clients have been convinced that their being ill was somehow protective for other members of the family: as if there was only so much bad luck to go round, and their getting MS protected their sister from it, for example. A mother felt she was bad because she did not wish she had it instead of her daughter. One woman was told by a nun that she was atoning for the sins of the world by her illness. Our placation of ill or disabled people may include a sense of needing to keep them at a distance to prevent them throwing their bad luck at us: a witch might turn us into a toad. Our fears of not being politically correct about disabilities may be somewhat exaggerated. The disabled lobby has both moral superiority and primitive fears on its side.
Clearly these phantasies of people with disabilities as dangerously threatening on the one hand and excessively deserving on the other are both products of splitting and they complement each other. The “witch-like” qualities which we dread, and the helpless, powerless princess/victim, waiting to be rescued, are two sides of the same coin. We set ourselves up for trouble when we fail to acknowledge the potency of an ill client, seeing them as a “poor dear”: we may fear that we are too powerful, that we have the potential to be the cruel witch.
A social worker rang me and asked me to help her with a client with MS. “I feel so sorry for her!” she said. I enquired a little further and eventually she confessed that the woman drove her mad; she was hardly the object of pity; more a woman who made everyone angry. The social worker said she didn’t like to admit this to anyone, certainly not the client: “she has so much to cope with!”. Her attempt to see the client as the helpless victim of circumstances left her, I think, afraid of her own capacity to attack. Not wanting to admit that the client was capable of standing up for herself emotionally if not literally, the social worker was left feeling scared of her own anger.
Denigration: people with disabilities don’t deserve good things
The other side of the idea of needing to be especially kind and considerate to people with disabilities is the feeling not only that such people are bad but that they actually do not deserve as much of the good things of life as they do get.
One woman with MS told me how she feared people feeling pity towards her. I asked what she based this on and she said she used to feel like that before she got ill. There was a woman she had worked with.. her boss actually; came to work in a disabled trike sometimes, one of those blue ones; sometimes the chauffeur brought her… Her husband was extremely rich.. they had a mansion in the country and three children.. It was becoming clear that “pity” was hardly the appropiate word; this woman was hugely envied and the underlying thought which the client very soon verbalised was a furious “how could a disabled woman have all that when I have none of it?”
For many people being ill or disabled means being unlovable or unloving: in groups there are always some professionals with the conviction that “If I had X, (be it any particular illness or disability), I would not think it right to get married (again)”. Not far behind comes the feeling that “If I had X I would be better dead” or “my family would be better off if I were dead”. It is important for the sake of the client that a counsellor uncover and examine such feelings or beliefs.
One young professional told me that if he injured himself to the extent of disfiguring his legs he would rather be dead: he was a physiotherapist. Others have said they would want to be dead if they were totally paralysed or demented. One trainee counsellor was very insistent that nothing could be done about this: it turned out that she had nursed a client who was severely spinally injured and who had later killed himself.
I remember one woman who came to me asking for information about how to kill herself. On exploration it turned out that her marriage was appalling and she was convinced that with her disability, (MS, with no visible symptoms), her husbands’ rejection of her was perfectly normal, nobody else would ever want to marry her and she could not possibly live on her own. My suggestion that she needed help to get out of her marriage rather than to kill herself was received as a revelation.
The idea that the ability to give and to receive love is a characteristic only of health and beauty is probably as common as it is unrealistic and potentially destructive. A counsellor who shares it may be at risk of colluding in some kind of unrealistic hopelessness. If the “disabled” or “ill” part-person is unconsciously characterised as bad or evil in the way I have been describing, or as a helpless victim in a vicious world, splitting this from a more able, alive and loving person may well lead to the conclusion that somebody would be better dead.
Emphasising only abilities which remain
Valerie Sinason in a talk once drew attention to the name of the “Sunshine Homes for the Blind”. She was referring to the way we can split off the grief, suffering and loss involved in an illness or disability. Recognising the abilities which remain to someone with a disability can be important: using this as a defence against grief is not therapy nor good counselling.
One client was very upset, she said, because her (not very well trained) counsellor had waxed lyrical about mouth painting when she had expressed fears of paralysis.
A young woman was very upset because her sister would not think positively: she insisted on crying about her MS diagnosis.
A nurse said she had been told always to try to be positive with patients and not to allow them to dwell on their difficulties.
The injunction to “think positively” as a defence against frightening or depressing thoughts may affect counsellors as well as clients. Thinking positively can be healthy, but only perhaps after sufficient time to allow negative thoughts and feelings to be brought into the open and made more realistic. The idea that people who are physically or mentally damaged are incapable of grief may deprive them of the opportunity to grieve in company and force them either to maintain a damaging and disabling denial or to grieve alone.
Those who do not succumb to the temptation to retreat into positive thinking may suffer from its opposite, of placing too much emphasis on the miseries of a condition and failing to recognise the realistic good and optimistic self which survives and lives.
One young woman told me how her mother would not acknowledge the worst possibilities of her future with MS. She herself was extremely preoccupied with anxieties about these. She was astonished when I pointed out that her view was no more realistic than her mother’s: they seemed to have divided up the good and bad possibilities between them, perhaps so that neither had to cope with real uncertainty.
This division of labour can also happen between client and unwary counsellor. It is helpful to remember Klein’s idea that idealisation is a defence against persecution, not reality. The bad thoughts which are felt to be unbearable reality are likely to be as unrealistic as the nice ones put in their place defensively. Thinking them through with a counsellor either changes them for the better or allows grief for real losses to be shared.
One of the serious consequences of the splitting which goes on when faced with disability or illness is that we may ignore the need for our ill or disabled clients to contact aspects of themselves which have to continue to function, however ill or disabled they are. Working with ill parents, for example, it is easy to ignore the fact that such clients continue to be parents.
In the Narrative of a Child Analysis (Hogarth Press and Institute of Psychoanalysis 1975) Melanie Klein’s small patient Richard responded to his father’s illness by phantasies of making his father the baby and Richard the father, looking after him. Dorothy Judd (Erskine and Judd, !994 p.89) describes a child of a single mother with severe psychiatric problems whose response to his own illness was to ‘continue to take care of his mother as if she was the patient’. I think this is a very common reaction which we need to keep an eye on. Parents, children and professionals may collude in seeing the ill parent as a child and the child as a competent care-giver. Anything rather than to see a small child needing a parent, and that parent irreplacable, ill and even, perhaps, about to die.
A therapist described how he had been working with two parents and two small children where the father was facing death. The father and mother had been talking movingly of their preparedness for this event, and both seemed to have come to some peace with it. There was a sense of satisfaction in the room with work well done. Suddenly the daughter piped up, “What about us?” Parents and therapist were dumb. When I asked the therapist what had happened he said he felt the parents couldn’t take any more. My feeling was that it was the therapist who was temporarily disabled and unable to take any more.
In therapy adults often experience childlike dependent feelings, allowing the counsellor to feel parental. Illness also encourages such reversion to infantile feelings. When the two happen together it may be very difficult indeed to remember that the sick client is in fact an adult parent with responsibility to think for and about their children. It is very tempting to split off the idea of an ill and dying man, supported by his wife and therapist, from the idea of children bereft of a father.
A young social worker who told me that the mother of a boy he worked with was “quite useless” was also, I think, unable to take on board the reality that a damaged, partially disabled mother is still a mother with very real characteristics and value for her son. Of course teenagers think their mothers are useless anyway, but a good social worker would not, I think, normally go along with this to quite such an extent. It turned out that the mother was actually performing all the functions of a housewife. Her “uselessness” resided in the fact that she could no longer drive. The temptation to denigrate an ill parent, to assume that they have lost all ability to be a parent, can be very strong.
Klein’s work on damaged mothers
If we think of Klein’s work on the phantasies of small children towards their mothers, (eg.Klein 1975) and the damage she and her colleagues have described being inflicted on mothers in phantasy in adulthood too, it is not surprising that we may turn away from the concept of a truly damaged mother. Klein thought that children search the real world to find evidence for or against their worst phantasies: if they find a really damaged mother, the terrible fear is that they have really damaged her, by their envy or rivalry, greed or hatred, perhaps. Counsellors have such phantasies, along with strongly reparative ones, and for counsellors too the idea of a client being a damaged mother may be the hardest to really see, think about and understand. The risk is that working with ill or disabled mothers or fathers we may continue to inflict damage by splitting off their ability to be a parent at all. (Segal and Simkins 1993)
In this paper I have looked at some of the meaning which disability and illness may have for counsellors as well as for their clients. I have suggested that under the pressure of counter-transference feelings from both client and counsellor the temptation to work with a split part-client and a disabled counsellor may be very strong.
I have attempted to spell out some of the ways in which we may observe ourselves doing this, in the hope that we might be better armed against it. Unless we withstand such pressures we risk failing our clients in the way they may often have been failed before. We risk confusing their disability with our own phantasies of disability, split off too strongly from our able selves. We risk disabling ourselves as counsellors and giving a second-class service.
Erskine, Aleda and Judd, Dorothy. (1994) The Imaginative Body. Psychodynamic Therapy in Health Care. London, Whurr Publishers.
Klein, Melanie. (1975) Love, Guilt and Reparation and other works 1921-45. The Writings of Melanie Klein, vol I. London, Hogarth Press and Institute of Psychoanalysis.
Klein, Melanie. (1975) Narrative of a Child Analysis The Writings of Melanie Klein, vol IV. (Hogarth Press and Institute of Psychoanalysis 1975)
Segal, Julia and Simkins, John. (1993) My Mum Needs Me. Helping children with ill or disabled parents. London, Penguin Books; to be republished by Jessica Kingsley Publishers 1996.
Sinason, Valerie. (1992) Mental Handicap and the Human Condition: New Approaches from the Tavistock London, Free Association Books,
Morris, Jenny, ed.(1989) Able Lives. Women’s experience of paralysis. London, The Women’s Press Ltd.
Parker, Gillian.(1993) With This Body. Caring and Disability in Marriage. Oxford, OUP
Morris, Jenny. Independent Lives, Community Care and Disabled People. MacMillan Press. 1994
A version of this paper was presented at a conference titled Counter-Transference and Working with People with Disabilities held in June 1993 by The Association for Group and Individual Psychotherapy.
Julia Segal trained with Relate and has been working freelance as a Counsellor and trainer/lecturer since 1980. She has been interested in applying the ideas of Melanie Klein to situations outside the pyschoanalytical consulting room since 1970 and has written two books on the subject: Phantasy in Everyday Life (Penguin and Karnac); and Melanie Klein: Key Figures in Counselling and Psychotherapy (Sage). She has been counselling people with MS since 1983 and currently works as Senior Counsellor, CMH Multiple Sclerosis Unit, Central Middlesex Hospital, London NW10 7NS.