The inclusion of the relational space within the therapist in the therapy room

Systemic therapists vary in their perspectives on how much transparency, openness and self-disclosure on the therapist’s part should be included in the therapeutic relationship. For instance, Janine Roberts’ work (2005) includes the dangers as well as the possibilities on the therapist’s self-disclosure and transparency. Every therapist makes the decision about how open and transparent they want to be, depending on their theoretical orientation, their personality, their client, as well as the context of the conversation. Systemic therapists acknowledge that self-disclosure is unavoidable, even if it is used only in joining the client and to a limited degree (Roberts, 2005). As a therapist, I self-disclose information and I am generally transparent with my clients, considering of course that it is their therapy. This becomes particularly clear in this story (Karamatsouki, 2020).

However, this story is more than the self-disclosure of a therapist. As a systemic psychotherapist, I bring to the session not only my professional self, but also the voices of my personal selves, moments with my family of origin, culture, personal beliefs and values, current difficulties in my life, and my thoughts and feelings, all of which create the relational space within myself (Karamatsouki, 2020). My inner voices, what I experience, feel and think (Rober, 2010) affect the way I connect to my clients. In my research, I confirmed what I have noticed all these years that I have been working as a therapist: when more of myself is in the therapy room, more of the client is in there, too. Therefore, I chose to be fully present with my various selves in the interaction with my client, because when I bring all of myself in the therapy room, it makes a difference in the therapeutic relational space (Karamatsouki, 2020).

When I was diagnosed with cancer, it never crossed my mind that I would quit working as a therapist, provided of course that I felt well enough. Therefore, I decided to take Fridays off and arranged to do my chemotherapy sessions on Friday, so that I would have time to recuperate during the weekend and go back to work on Monday. Being a therapist has always been an important part of my identity and since I would continue working as a therapist, I chose to disclose my health condition, keeping in mind my clients’ best interests of course. This decision was based on relational ethics (Gergen, 2015), as, when I disclosed my cancer to my clients, including the therapy group I run, at the same time I was committed to protect the therapeutic relationship. For me, it would be unethical to try to keep such an important part of myself, the part that was facing a life-threatening illness at the time, hidden from my clients. During that time, the relational space within myself included my professional capacity to hear and hold my clients’ own needs and their responses to me, as well as my thoughts and emotions of dealing with my cancer. I wrote in my thesis, when discussing the ethical implications of my research (Karamatsouki, 2020, p. 139):

“I made the decision to disclose my cancer diagnosis, which is a decision that other therapists might find boundary-violating or even unethical, but to me it felt like an ethical decision. For me, good practice means that I am open and honest with my clients, but at the same time I keep their therapy in mind. I choose to speak a truth that other professionals would avoid speaking of, but I choose to do it in an ethical and reflexive manner.”

My decision to disclose my diagnosis of cancer brought a messiness in the psychotherapy process. But isn’t psychotherapy a messy process anyway? Storywriting has helped me navigate through the complexities that happen in the therapy room, especially in a time when a diagnosis with a serious illness came in the foreground.

Autoethnographic storywriting

In my practice, as well as in my research, autoethnographic writing helps me capture the relational space within myself. Autoethnography is “an autobiographical genre of writing and research that displays multiple layers of consciousness” (Ellis, 2004, p. 37). For me, autoethnographic storywriting punctuate moments in therapy where the not-yet-known becomes part of the process (Karamatsouki, 2020). As such, writing stories has also helped me make sense of what happens in the relational space within myself during the time around my diagnosis with cancer and subsequent treatment.

“In this story my vulnerable self takes over the relational space within myself in several occasions, for instance when I announce the results of my medical tests to the group, or when I warn them that my hair might fall out and my appearance might change. Even in these occasions, however, I never forget my professional self who has the responsibility of taking care of my clients’ therapy. Although my inner dialogue hovers over the therapy session, I am able to use the relational space within myself in a way that is beneficial to my clients and opens up opportunities for change.”(Karamatsouki, 2020, p. 189-190)

I wrote this story a few years after that particular session, based on my reflexive clinical notes, on my reflexive diary and on conversations with my colleague and friend, Tatty, who also read the story and offered feedback. I was thinking about this incident for quite some time and I felt I needed to get this story out there, so that I can make sense of events. This process often happens before I write a story, which I use as a learning opportunity.

In my practice and in my research, storywriting has been a way to talk about things that we don’t usually dare to talk about in our profession, such as the subject of therapists living with an illness or a health condition. Most of the stories I write, including the story that is featured in this paper, are about relational ethics and decisions I need to make as a systemic therapist during therapeutic interactions. In an honest and reflexive manner, I tried to give readers insight into the processes that happen in the therapy room. I wrote about my cancer diagnosis and how I used the relational space within myself during that time in the therapy room in order to gain a deeper understanding of myself and my practice. During that process, I found helpful to read other systemic therapists’ dilemmas around self-disclosure and transparency. In a paper she wrote with her dying partner, Liz Day wrote:

“How do therapists create conversations that navigate complex and difficult situations and life events and give meaning to them? How do we make and retain our connectedness? Adversity doesn’t only happen to our clients; it also happens to us. Experiences that cause us pain and distress have the capacity to create resources for us. Learning to steer a way through choppy and treacherous waters can equip us to manage threatening situations with a greater sense of agency. When we are “at sea”, we need  points of connection to steady things and anchor ourselves. These points of connection can be friends and colleagues, but they are also provided by texts and through mapping the network of theoretical knots and intersections.” (Day & Charing, 2018, p. 36)

With this paper, as with most of my writings, I have the hope that practitioners will be encouraged to open up conversations and share their learnings, as each of us allows themselves to include their inner voices in the therapy process.

Then and now

While I was writing this paper, I revisited some of my personal writings from the past, particularly from around the time I had finished treatment for my cancer – chemotherapy and radiotherapy sessions – things that I have forgotten I have written.

“That period, however, also felt like something deeper was happening to me. Not only the cancer had gone, but something else made its appearance. It was a part of me I knew it existed, but since then did not give much attention to. This part first presented itself in a dream. […] When I woke up in the morning after this dream, I was feeling optimistic and at the same time fearful. […] (W)hat was this part? How can I be more in touch with it? I knew that this part had something to do with my cancer and I believed that being in touch with it would protect me against future threats.” (Personal writings from 2012)

This excerpt from 2012, in which I refer to parts of myself, made me realise that years before my doctoral research I had already conceived the concept of the relational space within myself. Reading these writings again reminded me of how my body reacted at that time; I even felt nauseated, like during my chemotherapy sessions. It’s strange how memory works and how bodily reactions are triggered with certain stimuli. As a systemic therapist, I have always paid attention to embodied responses in the therapy room. In addition, during my research, embodied responses were an important part of the relational space within myself, and I dared to pay attention to and talk about them. When a client talked about her mother’s diagnosis of breast cancer, I felt the fear and agony in my chest, as on the day I received my diagnosis. Instead of being afraid though, I used the relational space within myself, in order to respond to my client in a professional way with empathy and concern, despite my emotional reactions.

“The way the relational space within myself appears in my stories challenges the idea of unwelcomed responses in the therapy room and raises questions about whether the therapist can be prepared with prescribed interventions. This means that psychotherapy is not a static process. As such, the relational space within the therapist enters the therapy room without the therapist having a clear idea of what is going to happen. What my inquiry suggests is that the relational space within the therapist cannot and should not be silenced, as it can be a useful resource for the therapy, contributing to the creation of relational ripples.” (Karamatsouki, 2020, p. 200)

My experience with cancer affected me as a person and as a therapist, and it also affected my practice. In order for me to do my treatments and medical tests I cut down on my working hours and declined new referrals. I experienced side effects from the chemotherapy and at times I felt tired. As I got further into treatment, I could see some of my clients worried more about me, although I stayed positive and led an active life. Some of them asked me how I was doing and I answered honestly that I was doing OK and tried to stay positive, although at times I was feeling tired. Some others hesitated to ask me and avoided mentioning my illness, although I could sense they were worried about me, and I kept them updated in the same way I described. When my hair started to get thinner and I eventually lost it, I started wearing headscarves. Although I had warned my clients about the potential change of my appearance, I could see the startled looks on their faces. Eventually, as I showed I wasn’t avoiding the issue of my illness and I was open about it, themes that related to my cancer and my clients’ worrying about me came up, and I did my best to address their concerns in a therapeutic way that would help them – and me – go forward. For instance, in a particularly moving session a client asked me how I always showed so positive and full of life, despite what I was going through. I noticed she deliberately did not say the word cancer.

“Although I try to be, I am not always positive, especially on chemotherapy days, when I am more tired,” I answered with honesty.

She hesitated for a moment and I started wondering whether I had disclosed too much.

“I guess a part of me already knew the answer,” she responded. “But I needed to hear it from you that you also have bad days. Because otherwise, it feels unreal that you seem so well and still have…” she stopped.

“Cancer,” I finished her sentence. “Yes, sometimes it feels unreal to me, too,” I admitted. “The truth is most of the time I focus on positive things, which makes me feel good, so what you see of me being positive is actually how I am feeling.”

She nodded. “Thank you for being honest with me.”

My professional self wanted to make sure I attended to my clients’ needs, so I increased the frequency of my clinical supervision sessions. I made arrangements with a few trusted colleagues about what to do with my clients’ records and clinical notes, how to inform my clients and to whom my clients could be referred in case I die. Thinking about the possibility I might die though, made me focus more on life, my life and my clients’ lives, and I believe it made me a better therapist. My experience with cancer enabled me to embrace my different selves, including my vulnerable self, the part of me that was afraid I might die, and allowed me to use the relational space within myself as a resource in the therapy room. Although my cancer is in remission for eleven years now – and I am considered cancer-free – I can still feel the experience of living with cancer vividly. This happens not only because my emotions at the time were intense, but also because of the learnings I hold, learnings that I can utilise as a therapist.

Now, when something unexpected happens in the therapy room, I find a way to stay with my uncomfortable feelings, focus on my self-reflexive skills and trust myself and my client that we will navigate through the process, as the story describes. The relational space within myself evokes my experience as a therapist and dictates my professional responses (Karamatsouki, 2020). It can also be unpredictable, in the sense that it unsettles the situation in the therapy room. By including all of myself in the therapeutic conversation, I create a professionally employable space for the personal and show how therapy can be done differently (Karamatsouki, 2020). It is noteworthy that, although I gave my clients the option of referring them to a different therapist, they all continued therapy with me. This strengthened my belief that “when the therapist brings more of themselves in the therapy room clients feel more connected to their therapist, the therapeutic relationship becomes stronger, clients find therapeutic conversations more helpful, and thus they are more likely to make changes in their lives” (Karamatsouki, 2020, p. 213).