A Portfolio of Academic, Therapeutic Practice, and Research Work Including an investigation of ‘Attitudes towards Self-Injurious-Behaviour among Mental Health Professionals and Adolescent Self- Harmers’ By Arabella C. L. Bowen Submitted for the degree of Practitioner Doctorate (PsychD) in Psychotherapeutic and Counselling Psychology University of Surrey August 2001 ProQuest Number: 13803904 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a com plete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. uest ProQuest 13803904 Published by ProQuest LLC(2018). Copyright of the Dissertation is held by the Author. All rights reserved. This work is protected against unauthorized copying under Title 17, United States C ode Microform Edition © ProQuest LLC. ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106- 1346 Acknowledgements I would like to thank the members of the counselling psychology course team, Dr. Adrian Coyle, Dr. Martin Milton, and Dr. Jill Owen for their help and guidance throughout my three years of training. Special thanks are extended to Dr. Riccardo Draghi-Lorenz, my third year research supervisor, and Dr. Alexandra M. John, my first year research supervisor, along with all my placement supervisors for their inspiring support. I am grateful to Mrs. Kay Hambleton and Mrs. Marion Steed for all their help and assistance. I also wish to express my gratitude to my fellow trainees, for their tremendous support. Finally, I would like to thank all the participants in my research and my clients throughout my therapeutic training, who have enabled me to learn from them. I am indebted to my family for their love and support throughout this experience. This portfolio is dedicated to my husband-to-be, Ben, for his holding, inspiration, and encouragement. Contents Page Introduction to the Portfolio 1 Academic Dossier 2-49 Introduction to dossier 2 Theory & Advanced Theory Papers: Compare and contrast the theoretical aspects and clinical implications 3-14 regarding ‘anger’ according to the following analysts: Klein and Winnicott. Discuss an aspect of the therapeutic relationship in relation to 15-26 psychoanalytic ideas: The therapist’s and the client’s use of silence in the therapy room. In cognitive therapy, therapeutic change is not dependent upon the 27-43 system of delivery but on the active components which directly challenge the client’s faulty appraisals. Discuss. Issues in Counselling Psychology Report: Ethical Issues encountered in qualitative research: Reflections on 44-49 interviewing adolescent inpatients engaging in self-injurious behaviours. (Published Article) ii Therapeutic Practice Dossier 50 - 85 Introduction to dossier 50 Descriptions of placements 51-55 Integration Paper: A personal account of integrating theory and research into clinical 56-85 practice. Research Dossier 86-255 Introduction to dossier 86 Literature Review: Gender differences in presentation and conceptualisation of 87 - 124 adolescent self-injurious behaviour: Implications for therapeutic practice Appendix 125 - 126 Qualitative Empirical Research: Understanding adolescent self-injurious behaviour: An interpretative 127-159 phenomenological analysis of patient’s views and experiences. Appendices 160-204 Quantitative Empirical Research: Attitudes towards self-injurious behaviour among mental health 205 - 241 professionals and adolescent self-harmers. Appendices 242 - 255 iii Introduction to the Portfolio This portfolio consists of a selection of work that has been carried out in part fulfilment of the PsychD in Psychotherapeutic and Counselling Psychology at the University of Surrey. It is comprised of three sections that represent the academic, practice, and research components of the training. Statement of Anonymity: The confidentiality of clients and participants has been protected throughout this portfolio. Whenever client or participant material is referred to, names have been replaced with pseudonyms and any identifying information has been changed or omitted to preserve the anonymity of those involved. © Arabella C.L. Bowen 2001 1 Academic Dossier This dossier contains a selection of academic papers and reports submitted during the three years of my psychotherapeutic training. The first two papers are concerned with ‘Theoretical Models of Therapy’ and ‘Advanced Theory and Therapy’ respectively, and address issues relating to the integration of theory into therapeutic practice. The former explores the psychoanalytic theories and clinical implications of anger, and the latter explores the therapist’s and the client’s use of silence in the therapy room. A paper from the final year ‘Advanced Theory and Therapy’ explores the cognitive-behavioural therapeutic system of delivery alongside recent advances in research and practice. Finally, a report that addresses ‘Issues in Counselling Psychology’ is submitted. This report explores some of the ethical issues I encountered in qualitative research with a group of adolescent inpatients who engaged in self- injurious behaviours. The paper was published in Counselling Psychology Review. 2 COMPARE AND CONTRAST THE THEORETICAL ASPECTS AND CLINICAL IMPLICATIONS REGARDING ANGER ACCORDING TO THE FOLLOWING ANALYSTS: KLEIN AND WINNICOTT This paper focuses on Melanie Klein and Donald Winnicott’s conceptualisation of the roots and functions of anger and aggressive behaviour in mental life. Clinical examples from both their works will illustrate the relative influence case material had on their theorising over the course of their lives. Some close comparison of theory can be made since both were undisputedly heavily influenced by Freud’s work, yet chose to base their theories grounded in the direct observation (even if subjectively interpreted) of young children. Both appear to eschew an attitude of understanding the individual as a person interacting in their environment (more than the sum of their presenting ‘medical’ or ‘pathological’ disturbance), than the abstract theoretical hypothesising of Freud. As the idiom goes: you can fit a person to a model, but must allow them more than one possible ‘script.’ While this may feel to be a wild sweeping statement with regards to Freud’s theories, this paper will attempt to illustrate how much further our understanding of primary aggressive (as opposed to sexual) impulses, has impacted on therapeutic practice with clients in counselling psychology today. Having said this, from a personal and philosophical outlook on life, Klein and Winnicott appear to come from opposite extremes. Winnicott is consistent throughout his writings about the very nature of ‘goodness’ or inborn curiosity and joy of living in the young infant. Klein on the other hand, is often associated and remembered for her more depressive view of the young infant: as constantly struggling with ‘bad’ or ‘negative’ destructive internal and external impulses. From a Kleinian point of view Winnicott is to be criticised for making the baby too benign and for idealising motherhood, which even feminists have held against him (see Chodorow, 1978; 1989). And from a Winnicottian perspective, Klein only tended to see the positive side of individuals as a ‘reaction formation’ against aggression and destruction, placing the latter rather than the former at the core of the personality. Mrs Klein developed her play technique in the 1920’s, which permitted working with much younger children than had previously been dreamed possible. On closer 3 inspection of the roots of aggression, she isolated early anxieties in the very basic notion that a child acts and dramatises its thoughts and unconscious phantasies through play. This could be equated with Freud’s ‘free association’ of adults. Having provided her children with the freedom to manipulate and interact with small toys and figures, she linked their fate in the play to the child’s worries about what would happen in reality between the child and the important figures in his or her life. She found repeatedly, that interpretations (if she was correct in what the play ‘meant’) provided significant alleviation of anxiety and relief for the child. This meant the child was then ‘free’ for further less constrained play and phantasy life (Klein, 1932b; 1955). The interpretation of persecutory anxieties remains a crucial mark of a Kleinian approach today (see Hanna Segal, 1981; 1988). She saw these aggressive impulses as instinctual in the child, arising from Freud’s ‘death instinct,’ which was in conflict with its opposite the ‘life instinct’ from the very beginning. The effect of the life instinct was to redirect aggression from life itself towards an external object. The original fear of the death instinct was then transformed into a fear of a persecuting object. Through this process of projection, in an attempt to preserve the internal goodness and ward off the destructive impulses of envy, ‘splitting of the good and the bad breast’ was necessary. Termed projective identification, this was seen as having manifold aims. It could be directed towards the ideal object to avoid separation, or it could be directed towards the bad object to gain control of the source of danger. Klein later called this the paranoid-schizoid position (1946). Clinically, when the death instinct is said to predominate, this can be seen in forms of perversion,