Unconscious Conflicts Between Professionals Within a GIC

Rosemary Grimshaw

Senior Nurse Therapist, Leeds Gender Identity Service. Presented At Transgender Conference 2001, University of Norwich.
Gendys Conference, 2002

 
At the last HBIGDA conference in London I spoke about a specialist nursing role at the Leeds Gender Identity Service. Since that time the Nursing team has grown. There are two of us, each holds our own case load and have responsibilities to monitor and support clients, using information on physiological aspects of treatment to link the physical and feeling self of the client; and when necessary acting as advocate for our clients.

Recently I read the newsletter from, "The Universities Psychotherapy and Counselling Association", and account of "General Hospital Therapy: Describing the Work of a Psychotherapy Support Team". Mr Madison outlines essential components which have contributed to the programme success, the integration of ideas which allow the professional to relate to the client in a whole way, these are the same components we have found useful they are:

• Most clients attend a gender identity service for medical treatment, not because they feel they have psychic disturbance. While there is a place for counselling and psychotherapy for gender dysphoric people it is not in a gender identity unit where referrals for "medical treatment" are made.
• While a multidisciplinary approach is a positive development it does not address the embodied experience as it is lived. Therapists who do not pathologise clients' experience are more likely to address their plea, to be treated like a human being.
• An equal relationship between client and therapist which relies on a common language as opposed to jargon enables each to acknowledge the existential reality that each has a vulnerable physical body affected by other's mortality, attitudes, social norms etc.
• The therapist must be reflective and utilise available supervision/therapy to explore the clients questions relating to "What would it be like for you if you were in this situation instead of me"?
• The therapist's orientation needs to enable him/her to acknowledge their own humanity/mortality by exploring how "human beings", respond to isolation, frustration, anger, uncertainty and responsibility. This has more meaning if explored in the client's everyday language.
• The therapist needs to be open to the role of client advocate when an issue arises between client and other staff who work in the gender identity service, especially when the client asks the therapist to act on their behalf.
• The Therapist needs to be flexible enough to provide short term focused work to enable the client to work through issues. This is in addition to the long term supportive integrated therapy for clients undergoing gender reassignment.

In my experience these are essential for the specialist nurse role which does not aim to provide psychotherapy or counselling, rather to support the client. The concept of a neutral place relates in my experience to the mental health team's needs for shared supervision.

Having established information, health monitoring, support and advocacy we aimed to develop the mental health aspect of the service to address the client's need for supportive therapy. Individuals who required more in depth work were to be referred outside the clinic. For my part I found myself increasingly involved in the assessment of new clients due to my experience and increasing training which carried with it responsibilities as a senior nurse specialist/supervisor/trainer.

Within nursing exist hierarchies, which are internalised during the socialisation of training and career. In my experience the notion of senior and junior posts endorses this thinking, so there is an inevitable tension between these roles, ultimately they illuminate the limitations of this system.

Due to numerous factors, some quite outside our control, we have found ourselves with clients who need more intensive input. Whatever the reason we have found ourselves with clients who are so fragmented and distressed focusing on their gender issues would compound their problems. In my experience being part of a gender identity team focuses the client on issues relating to their gender identity so we are not in a neutral position, this is currently exacerbated by having only limited medical input.

Counselling and psychotherapy cannot be given as part of the diagnostic treatment programme. Assessment of a new client requires a unique mixture of creative lateral divergent thinking and focused deductive reasoning, an ability to see beyond Cartesian thought, to understand the connections between mind and body, to assess the individual's expectations of contact with us and of medical treatment which is limited in what it can achieve.

In our practice we believe good supervision is the key, as only a small proportion of communication is verbal; the majority is unconscious and occurs without our conscious knowledge. It affects the professional as well as the client, in an unsupervised professional unconscious over-identification with a client may produce practice which is undesirable. In my experience no professional is immune to these processes however experienced they are. We often talk to clients about hormones acting as keys which open locks or receptor sites on cells producing a cascade of affects. Feelings are no different, we all have locks and keys which are not under our conscious control.

Therapeutic input as part of a gender identity service can only be supportive in nature, psychotherapy training in professionals who work in a gender identity service enables them to supervise colleagues and contain the anxieties of the general adult psychotherapist who is reluctant to see gender dysphoric individuals, claiming this is a specialist area, or relating everything to the client's gender dysphoric condition. This labelling and avoidance often misses the deeper human issues at play which need attending to prior to or in tandem with treatment.

Ideally members of a gender team should meet regularly to engage in supervision provided in a neutral place free from the hierarchy of the organisation. The potential of a specialist nursing role is to deliver an integrated supportive environment which empowers the client to challenge stereotypical, socially prescribed roles, but there is a certain reality to the fact that this level of expertise is only acquired through an apprenticeship so there is an inevitable hierarchy.

In my experience the majority of health professional are socialised into Cartesian thinking. Mind and body are somehow separate. Acquiring new knowledge and skills is challenging, especially when they encompass an integration of ideas which challenge the concept of mind body duality. Primitive defences such as splitting, denial and projective identification are employed by team members who identify with the powerlessness of the client. The professional is likely to feel powerless themselves and may cling to theoretical concepts which are familiar, striving to remain Cartesian, hierarchical and powerful. Withholding information, inappropriate use of theory, superiority, contempt, aggression, absences, avoidance and extreme like or dislike are all examples of this. In more complex cases the need of the professional for neutral supervision is paramount especially when it is difficult to establish what prompts a client to seek gender re-assignment. It is too simplistic to assume focusing on gender issues and medical treatment will solve all the client's relational difficulties. Such a client in the hands of an unsupervised professional who is more concerned about their own status in the organisation is potentially dangerous.

Yet a neutral place for supervision provided by an individual whose responsibilities include a management/training role needs to be protected by negotiating boundaries around the various roles to protect the developing specialist. Without such structured safeguards abuse of power relationships embedded in the nursing hierarchy are constant concerns.

In an atmosphere where powerful primitive anxieties are evoked lack of adequate supervision to enable the profession to explore their contribution to the relationship with their clients is potentially emotionally expensive for both. Concepts such as the therapeutic frame inform practice but may be counterproductive when used to prevent the introduction and integration of strategies proven to empower clients. Withholding information aimed at promoting psychological health is an example. The unsupported inadequately supervised professional is likely to be unaware of their over-identification with a vulnerable client. Especially when the projected expectation of the client is that they will be rejected and not understood. Unchallenged hostility presented as helplessness/powerlessness may combine with the professional's unconscious conflicts regarding competency and self-worth resulting in feelings of anxiety and confused turmoil; such feelings of not being in control are avoided and the rationale for practice becomes more and more biased to support the theoretical orientation of the professional. Internalised hierarchies accumulated during training and practice dictate problem solving solutions dependant on Cartesian thinking. The process of gender migration, pacing the social and psychological transition is forgotten, the process becomes problem orientated.

The ability of the nurse specialist to think divergently, mapping the process of integration is only acquired through regular supervision, as is learning how to balance a duplicity of roles, however this supervision needs to be as far as is possible free from the organisation's hierarchy. Traditional devaluing of the therapeutic role is compounded by the lack of attention to the power relations inherent in line management often leaving the supervisee feeling powerless. Rather than identifying supportive structured supervision as a need, the blame culture of the NHS disempowers clinicians further. Complex clients are avoided and mistakes are made. Ideally these mistakes are an important part of the supportive relationship as they bring the specialist and client face to face with reality. If the power or unequal power relationships within the dual role of management cum supervisor are not discussed it becomes increasingly difficult for the supervisee to explore their unconscious motives, in consequence the client is likely to become the focus of parts of the supervisees self he/she cannot face.

These issues are not simply related to our work, but will increasingly become problematic if the government's directive on psychological therapies is developed. The dual role of line manager/supervisor presents potential dilemmas with authority at one end being accountable for another's actions, yet expected to supervise, work through mistakes and differences of opinion. In my experience most health professionals with their unique socialisation will evoke their own hierarchical authority in the face of a mistake by the supervisee.

Unless the supervisee feels appreciated they may build a wall with their supervisor. The bricks which make this wall are less easy to recognise in supervision than in therapy but they are made of the same material. Projection of uncontaining critical parental images. Sibling rivalry may be acted out between supervisor and supervisee in the form of "who can manage the client better", especially with the more challenging complex client and when the supervisee avoids supervision, fears challenging the client in case they themselves are seen as unkind, uncontaining or overly critical. In such circumstances gender re-assignment and its programme take prescriptive priority over the client's projected expectation of not being good enough.

Developing a specialist role which is flexible enough to address the complex needs of clients is a process in itself. Ideally there should be clear boundaries around duplicitous roles, however safety needs to be built into this. Traditional supervision is integral to the developing practice of the counsellor/psychotherapist and is separate from organisational, managerial roles but there is a danger that this protected space may compound the secrecy which surround anything to do with sexuality and gender. Aspects of personhood which do not have the same social sanction as more mainstream aspects such as arms and legs etc. If this secrecy is ignored it may be compounded by the blame culture of the NHS. Difficult issues will be shelved and ignored in case the professional becomes the scapegoat for blame. The conspiracy of silence can do nothing to raise awareness of the client's need for supportive integrated therapeutic input.

In summary the reason for sharing these issues is that we are acknowledging them. The most difficult aspect of this specialist role in my experience is coping with "not knowing" and "not feeling in control". This is an evolutionary process; if management were to impose criteria from above the evolutionary process would become crippled and stagnant. To practice at the cutting edge requires that mistakes made in the past are not repeated. More often than not attempts to promote health have failed in the past because the practice of professional has been informed by their own assessments of clients needs. Theory is applied to practice in a way which supports the professional's orientation. These assessments have repeatedly fallen short of addressing client's needs. All too often we hear the plea to be treated like a human being, a whole person not a theoretical construct. Past attempts to promote health have ended up in victim blaming when the client doesn't appreciate or value the service provided. If we begin to examine the cost to the professional, provide support to explore the part themselves play in their relationships with clients, do not blame but seek solutions we have the foundations for good practice.

Bibliography

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