‘The wound is the place where the light enters you’ (Rumi).
Writing this article is my attempt to shine some light on the possible impact of my visible ‘wounding’ by multiple sclerosis (MS) on my relationships with clients and supervisees. I have always been encouraged by Jung’s ‘only the wounded healer heals’. As therapist and client, we have wounds.
I have been a therapist for over 25 years. I am integrative and work full time in private practice with short and longer-term clients, including teenagers. I also supervise therapists and healthcare workers. I had neurological symptoms over 30 years ago but was only formally diagnosed with MS about three years ago, after developing a combination of symptoms including some increased difficulty walking. I now walk with one or two sticks, depending on the distance and terrain. I have a number of therapies that help maintain my mobility. I see a therapist intermittently, and talk with my peer supervisor. I have a therapeutic will in place. MS does dominate my life somewhat, as it has to be constantly taken account of. How should I be taking it into account in my practice?
Society’s attitudes to visible disability enter the consulting room with me and the client. What beliefs, implications and assumptions regarding disability are brought and constellated? Disability tends to be seen within the framework of dependency and inability (the medical model). It can also be viewed as a punishment for sin, or even as being contagious (the moral model). These attitudes are influenced by many factors, including myth, superstition and an able-bodied anxiety around losing body integrity. As a disabled person, one can also be viewed as courageous, saintly and empathic, or even ascribed intellectual or psychological gifts as compensation for disability (the tragedy model).
Some psychoanalytic thinking would suggest that a defective body leads to a defective ego and that a distorted self-image leads to a distorted image of the world. As a visibly physically disabled therapist, some of my woundedness is consciously or unconsciously there between me and the client from the first moment of meeting. It can raise all sorts of questions and thoughts in the minds of clients including (to name but a few):
- ‘Are you well enough to do the job?’
- ‘Are you physically and/or emotionally resilient enough to see me?’
- ‘I came to you wanting to be taken care of – am I going to have to take care of you?’
Some, perhaps all, of these thoughts are around at some level for many clients who come into therapy with able-bodied therapists but they are possibly brought into more focus, unconsciously if not consciously, when the therapist is physically disabled. Before becoming disabled I tried to hold in mind the possible impact both of my emotional woundings and the fact that I am a large woman with, I am told, quite a strong presence. Becoming disabled has added a new, sometimes complicated, sometimes helpful dimension.
I could find very little in the literature about disability and the therapeutic relationship other than from the perspective of a therapist working with a disabled client. Quite a few articles address therapist illness and death. I found three articles written by therapists about working with a disability.1-3 Of the three, only Chaudhuri3 addresses the impact on the therapeutic relationship.
How should I deal with questions about my disability in the consulting room? I want to be authentic and take account of my disability but I don’t want it to dominate, if this can be avoided. The questions that have arisen for me around discussing it with clients include:
- who is the disclosure for?
- what is private – what is public?
- what do I need to take care of therapeutically – and with whom?
- what is enough information – and for whom?
- what is too much information – and for whom?
- what should I leave to fantasy – and for whom?
How the information is handled can create a rupture in the relationship but it can also be a useful opportunity for therapeutic work. I have reviewed my caseload and do not think there is any increase in the rare instances of clients not returning for a second session or not attending or not being able to explore issues around, for example, their parenting, health or body image.
O’Connell,4 in his study of disabled therapists, outlines two types of self-disclosure, which he names logistical and process-orientated. Logistical self-disclosure describes disclosure by disabled therapists whose disability has a practical impact on their work. Process-orientated disclosure is used to further the therapeutic process – to take account of the client–therapist dynamics or to model something. He proposes some useful guidelines.
With logistical self-disclosure, the therapist should:
- disclose early
- keep the disclosure brief
- differentiate function from history – disclose only what has a direct bearing on the work
- explain assistive technology.
With process-orientated self-disclosure, the therapist should consider if the disclosure is:
- client focused
- beneficial to the client
And ask him or herself:
- why am I making this disclosure?
- does my physical disability have potential at this moment in time to be useful?
Below I offer some very brief composite case examples that illustrate how I work with my disability.
A female client in her early 50s who was seeing me privately had returned to do a second piece of work with me after a gap of about a year, during which I had started to use a stick. It was snowing and she brought me a pair of shoe grippers. She handed them to me saying, ‘I bought a pair for myself and then thought you would find them useful.’ I was touched by her gesture and said so, and made no other comment. I was aware that she could be ensuring I would be there for her. I held in mind that her mother, who was not there for her emotionally, had MS for many years. Interestingly, at this time she worked on her relationship with her parents and found some healing.
A simple question
A long-term client who is also a therapist and with whom I have a good working alliance asked if she could ask me a question about my sticks. I invited her to do so. She said, ‘Do you have a condition that could result in you being in a wheelchair?’ I replied ‘Yes it could,’ in a straightforward way, and she nodded. I asked if she had more thoughts or questions and she said no. I said that, if ever she was concerned, I hoped she would feel able to ask. She said she thought that she would and has never asked anything else.
I saw a man for six sessions who, after surgery on his leg, walked with a stick. He had been on long-term sick leave and then been ‘let go’ by his company. He was having problems adjusting to his changed body image and physical capacity, his unemployment and his changed role at home. I noticed him noticing my stick when I opened my consulting room door for his first session. I said nothing and nor did he. When we ended he said as he left, ‘Thank you, it’s been very helpful. I have been able to befriend my stick.’ A few days before I had visited my mother-in-law’s partner who had dementia. He unusually made a spontaneous comment when I was preparing to leave. He said, ‘Don’t forget your wands!’ I told my client what had been said to me. He left his final session laughing. He wrote to me a few months later saying he no longer needed his wands, that he imagined I might always need mine and he hoped they would continue to cast some magic.
A policeman who had been attacked in the course of his work and had needed surgery on his leg came to see me when he was using crutches. He had become depressed, feeling helpless and useless. He was obsessed with what he could not do and was very angry about what had happened and how it was interfering with his life. He appeared oblivious to my stick, worked through his anger and frustration and returned to work.
Not ill – disabled
A woman in her 80s arrived for her first session and before she had even sat down declared, ‘I obviously shouldn’t be here burdening you. You’re obviously ill.’ I suggested that she should sit down so we could talk about her concern. I told her bluntly: ‘I don’t consider myself to be ill. I view myself as disabled.’ She then said, ‘Oh well, then let me tell you why I am here.’ I continue to see her and some of what she has brought has been about caring for her first husband, the death of her daughter-in-law and the illness of her young grandson. She has made no further comment about my sticks and nor have I.
A 14-year-old boy was referred to me for ‘anger management’. In his second session he said, ‘Don’t you get pissed off with having to use that stick at your age?’ I said that I did and that I could not change it and had needed to get used to it. I said I still got frustrated sometimes but I didn’t smash windows. He laughed and said, ‘OK, so how are you going to help me to cope when I get pissed off?’ We worked together for 10 sessions and he now has new coping strategies.
A young woman with breast cancer came to see me as she had been told she would need a mastectomy. In her second session she said, ‘I hope you don’t mind me saying but you seem to be OK with needing to use a stick. I have wondered about that and how you cope with needing one.’ I said, ‘It has been a process and one that I sometimes still struggle with a bit, depending on the circumstances.’ We were then able to talk more about adjustment being a process and some of that process being ongoing.
A trainee therapist who I have been seeing for supervision for several years asked me if I had MS. I said I had. I asked her what this meant for her. She said she felt this knowledge could deepen our work together. Later in our work she said my directness had helped her to ‘feel held’.
Stability and falling
Very occasionally I fall, usually when I am multi-tasking or/and not paying full attention to my movements. I fell when I was with a long-term male client who is significantly anxious and has a very longstanding hoarding problem that he has begun to understand and work on practically. Before the falling incident he had not commented on my changed mobility. He was leaving the room and had his back to me when I fell. He then wanted to help me up. I said I was OK and would be able to get up. I asked him to see himself out. I telephoned him later to reassure him that I was OK. We had a brief conversation and he said he wished he could have done more for me as I had done so much for him. Over the next few sessions he acknowledged some anxiety that I might fall again at the end of the session. I acknowledged that we both had vulnerabilities and explained that falling for me was rare. I asked him if there was anything he wanted to check with me. He said there wasn’t. Session endings have since settled down again – for both of us! Since my fall we have been able to talk about the stability that hoarding has given him and how getting rid of his piles of newspaper is de-stabilising him. We have used the metaphor of my stick to help us to find a way through.
Viewed through O’Connell’s framework,4 my disclosures are essentially ‘process orientated’. Using this framework to reflect on how I manage my own disability and questions about it in my work, I would add the following to O’Connell’s list of considerations:
- my intuition
- the nature of the relationship, my countertransference and attunement, whether they are a client or supervisee
- which inner aspect of the client needs to know – is it, for example their vulnerable child that is afraid I won’t be able to look after them?
- whether the work is short or long term
- whether something in the client’s material could be triggered – for example, might they have concerns about their body image, health or problems with tolerating difference
- the safety of the space
- the timing in the work.
In particular I consider the timing in the work to be of importance – the client needs to feel met and held.
In his study O’Connell found that disability appeared ‘to have added more than is has taken away’.4 Overall I feel that becoming disabled has added depth to my work; just as working when I am feeling vulnerable can make me feel more attuned to my client, I feel my MS has afforded me this too. As Erskine has said: ‘Attunement goes beyond empathy. It is a process of communion and unity of interpersonal contact.’5
A colleague and friend whom I supported through her breast cancer treatment asked me early on if I had found any jewels in my experience of MS. At the time I felt a bit irritated, although I understood what she meant. I said, ‘No, but I am looking out for them’ I would now say that I have found many, of many different colours. She encouraged me to write this article. I thank her for that. It has helped me to work through some issues and shine more light on my wounds. I hope it will help shine some light for others too. I am now more able to wonder what may be enabled as well as disabled by my wounding.
Maggie Fisher is an integrative BACP senior accredited and UKCP registered psychotherapist/supervisor in private practice. She is also a nurse with extensive experience as a clinician and manager in palliative care. She has published a training pack, articles, a poem and contributed to text books and conferences. See sussex-psychotherapy.co.uk
1. Baird E. Not giving up. Healthcare Counselling and Psychotherapy Journal 2013; October: 20–21.
2. White A. There by the grace of. Therapy Today 2011; 22(5): 10–14.
3. Chaudhuri R. Dynamic psychotherapy and the disabled psychiatrist. Journal of the American Academy of Psychoanalysis 1999; 27: 239–251.
4. O’Connell C. Self-disclosure and the disabled psychotherapist: an exploration of how psychotherapists with visible physical disabilities or differences speak to their clients about these issues. Dissertation Abstracts International: Section B: The Sciences and Engineering 2013; 73(10 B(E)). http://tinyurl.com/n72v2yk
5. Erskine R. The psychotherapy relationship: integrating the common ground of different approaches. Common ground and different approaches in psychotherapy. VII annual conference of the European Association for Psychotherapy. Rome; 26–29 June, 1997.