FAVOURABLE FACTORS

101 enabled the application of it by keeping Bongi in therapy. Although the empathic, nurturing part of the relationship is not made explicit in the Ehlers and Clark model, without it, the model is unlikely to be applied successfully. These aspects become more important with more severe pathology, such as with individuals exposed to continued longer term trauma; or when the trauma occurred within the context of interpersonal relationship (see section 8.4.2 (a) for further discussion of this).

At times I found it difficult being in a position where I had to offer both, and finding a balance was not always easy. This was most clear in session two when Bongi became openly angry with me, telling me that I do not understand her situation and struggles. At the time my focus was on the content of intrusive memories as this is an important part of the model. This is an example of how easily the client‟s current needs can be missed when there is pressure, from whatever source, to apply the model. In this particular situation, I felt pressurised to speed up the therapeutic process as the assessment phase was long and the first session was spent on her accommodation problems.

Supervision assisted me in realising that the therapeutic process will be slow, and that paying attention to contextual and situational factors forms an important part of the model, even if they are not explicitly discussed by Ehlers and Clark (2000). For this reason, although the model provided guidelines, supervision and personal reflection by the therapist is required in order for the therapy to be effective.

102 relationship as well as the limited reparenting proposed by Young et al. (2003) in schema focussed work.

Herman (2001) goes on to propose that disempowerment and disconnection from others are the core experiences of psychological trauma. At the end of our very first meeting which lasted less than 40 minutes, there was already an indication that Bongi felt these core experiences counteracted through me providing her with something her parents did not: when it came to light that Bongi was raped, I immediately offered to refer her to a female therapist. This gesture, of inviting her to make an important decision concerning her own life, contributed to her deciding to continue therapy with me. Why? It is hypothesised that this seemingly trivial offer made Bongi feel empowered, even if it was for only a short while. This becomes more significant if one considers that this occurred in the context of an assessment session, where Bongi was given the opportunity to speak and be listened to, and as a result felt less disconnected. As therapy progressed, Bongi continued experiencing empowerment and connection in the context of the therapeutic relationship. In this way the relationship had a very important impact on therapy as it helped Bongi to stay in therapy.

The literature regarding the Ehlers and Clark (2000) model does not make explicit reference to the therapeutic relationship and it is thus easy to miss the important role it can play in the implementation of the model. The importance of the relationship is however supported by the collaborative aspect of the model.

Young et al. (2003) describes two approaches that can be used therapeutically in the context of the therapeutic relationship; empathic confrontation and limited reparenting. A continuous attempt was made to use these therapeutically through employing the relationship at a process dimension. Empathic confrontation was used whenever I became aware of a schema being triggered. This most frequently happened when Bongi felt helpless and unable to exert an influence on her situation and when she became angry. This was usually followed by me relating how the specific issue causing her reaction related to her childhood and why it is important to address it. Some examples of limited reparenting used with Bongi included: being a transitional source of stability

103 (being available consistently on a weekly basis and responding to messages and requests); by being honest, open, genuine and creating a nurturing atmosphere through providing care, warmth, and empathy by preparing her for, and postponing difficult techniques such as imaginal reliving, and by responding to external stimuli (setbacks in relationships, problems with accommodation); providing encouragement and acknowledging progress made academically and in therapy; inviting her to make choices regarding therapy goals, techniques used, and homework; and assisting her in asserting her own rights and needs and in setting appropriate boundaries for herself.

Due to its flexibility and fact that it is formulation driven, the Ehlers and Clark (2000) model allows for interventions based on the therapeutic relationship to be incorporated into the treatment plan. It also provides the client with the opportunity to speak about many different experiences, memories, thoughts, believes, and struggles, which will lead to the activation of schemas.

(b) Ongoing Formulation

At the end of the assessment phase a case formulation was drawn up. Due to the interrupted start to the therapy phase, this formulation was shared with Bongi in only the fourth session. She said that it helped her to gain insight into many of her problems, and that she realises her need to be in therapy. The timing of sharing the formulation with her turned out to be good because it served as motivation at the time we entered a new phase of therapy.

As was stated in section 4.7, the Ehlers and Clark model is formulation driven, allowing for flexible application. Through a process of continuous discussion in supervision it was possible to reflect on the content and the process of therapy sessions. In this way the formulation was continuously consulted, elaborated, and refined. Formulating the case turned out to be an ongoing process which proved useful for two reasons. Firstly, as my understanding of both Bongi and the case deepened, I was able to make better sense of previously obtained information and of what was going on in sessions. This assisted me in being better able to attend to Bongi‟s needs and to plan sessions in a way that maximised the potential benefits. Secondly, in session 6 I shared an updated

104 formulation with Bongi; and new ways of conceptualising issues were shared continuously throughout the intervention. For example in session 6 we discussed the important relationships in her life, especially those with her parents. The aim was to provide her with insight into how these relationships has influenced her current unhealthy ways of relating, and also how these can be responsible for her feeling depressed and hopeless.

From her responses it seemed that each time she gained from this in that she came to a better understanding of her struggles, herself, and of the reasons why some of the techniques employed can be beneficial. She reported feeling empowered by the knowledge and it made her more willing to continue therapy despite the difficulty thereof.

This flexibility the model offers in terms of formulation was thus used to great benefit.

8.4.3 CULTURAL FACTORS INFLUENCING THE APPLICATION OF THE MODEL