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PSYCHOTHERAPISTS' USE OF AUTOGENIC THERAPY
Marion Brion
September 2001
CONTENTS
Introduction
Research and the gold standard
The sampling method
The British Autogenic Society Millennial survey
The Qualitative survey interviewees compared with BAS members
Admissions to AT: Methods
Admissions to AT: The importance of the setting
Admissions to AT: Significance of the Trainer's experience
Admissions to AT: Comments on Set One
Admissions to AT: Comments on Set Two
Admissions to AT: Comments on Set Three
Conclusions One: Assessment by AT psychotherapists
Conclusions Two: The admissions process as risk management
Conclusions Three: Recognition of AT with psychotherapy support
Conclusions Four: The effect on my own practice
Appendix
LIST OF FIGURES
1. Number of years practising AT
2. Number of years teaching AT
3. Teaching mode: groups, individuals or both?
4. Factors in the admissions process
5. The AT family of approaches.
Introduction
During its early years the British Autogenic Society (BAS), and its predecessor British
Association for Autogenic Training and Therapy, had to concentrate its recruitment effort
and publicity in key areas. For a small organisation it has been very successful in gaining
publicity in the press and books. It has been essential to project a clear image of what
Autogenic Therapy (AT) can do for most people and to target the medical profession as well
as the general public. GPs are the gatekeepers to free treatment and to referrals, while
consultants and professors control much of the access to research money within the NHS.
Another area where there is a potentially large market is sports applications. The idea of
AT taught in a nine session course to groups is obviously the easiest to get over to both
those markets. Autogenic Therapists have been trained to be aware of the possibility of
doing AT with psychotherapy support for those with greater levels of distress but this has
received much less emphasis in publicity and in training.
When I decided to train for AT I had been attracted by the idea of doing some structured
group work again. It was also important to me to balance my practice. I felt that the
potential of AT for the "worried well" and those with milder levels of distress would help
to counterbalance the tendency to get more and more applicants for
psychotherapy/hypnotherapy who had serious difficulties usually arising from childhood.
However, practice turned out to be rather different.
My first, very small, groups were formed from existing psychotherapy clients who had
reached the stage of moving out or for other reasons seemed likely to benefit from AT. This
included people who did not meet the criteria for doing AT safely which we had been given
in the First Year Therapist Training. My initial reaction when I heard about the criteria
for training people in AT groups, that I would find few applicants who met that standard,
turned out to be justified. Even people being referred were often outside of the most
conservative criteria for group work and might equally well be psychotherapy clients. (For
example one of my first referrals from the BAS had been on hard drugs for 10 years, was
still on controlled drinking, but had held down a responsible job for seven years and was
strongly motivated to do AT). I almost cheered when in my third year I had a referral from
a homeopathic physician and the trainee had mild anxiety and benefited from a
straightforward AT course.
I was very dependent on my AT Tutor for information in how to go about teaching AT to these
applicants who might otherwise have been psychotherapy clients since the Training Course
had been focused mainly around standard groups. As I gained experience with my first groups
and clients I could see more clearly how AT could fit into existing ideas about
psychotherapy. I began to feel a little more confident about AT with psychotherapy support.
I began to make some contacts with other people who had relevant experience. With this help
I was able to take on the applicant mentioned above and his story is one which will feed in
to this essay and the following papers. I felt that there was more practical experience
around in how to work or not work with these applicants.
My original focus of interest for this extended essay was therefore on how other
psychotherapists used AT within their practice. I thought that might also shed some light
on whether the BAS could attract more qualified mental health professionals into training,
and I set about formulating a title for an enquiry eventually ending up with
"Psychotherapists' use of AT" as the briefest and most easily understandable.
The next task was to consider which methods of enquiry to use.
Research and the gold standard
Currently, NHS "Evidence based medicine" emphasises the necessity for "gold standard"
experimentally based research. The benefit of the BAS responding positively to this has
been demonstrated by the impact of Nasim Kanji's work (for example Kanji, White and Ernst
1999). There are many in the complementary medicine field who query whether this model is
suitable for all complementary therapies. (See, for example, Eatock 2001, Jones 2001, Paley
and Lawton 2001). One might also see the current gold standard model as expressive of a
power structure dominated by hospital consultants who have the best access to large scale
samples and the pharmaceutical companies.
Leaving these controversies aside, it is the attention given to this model which obscures
the fact that there are many different kinds of research which are useful for doing
different things. For example market research companies, which are very keen on value for
money, will use in-depth qualitative studies in an early stage of an enquiry or to research
particularly sensitive issues. As a contract researcher for the Department of the
Environment (DoE) I found that policy makers and research managers who were well aware of
the full technical standards would often commission pieces of research which did not
conform to these standards but were more economical and would improve on existing
information quickly and in a methodical way. It was in this spirit that I thought about the
method for this enquiry. The DoE phrase for such a study was "quick and dirty". I hoped
that my study would be reasonably quick and reasonably clean, and still be something I
could do within my resources and improve on existing information. My key question about
research methods was "Will this study provide better information than we had before, in a
systematic way?" I decided that making use of existing resources, including my own
experience, case studies and Trainee Assistantship report, and conducting a qualitative
interview on the telephone would be the most effective and efficient way of getting the
information that I was interested in.
The sampling method
I decided that the group most likely to have relevant experience of AT and psychotherapy
were those who were UKCP registered members, so I took as my initial sampling frame the
1998 list of BAS UKCP registered members. I subsequently added one BAS member who I knew
qualified in the earlier period and worked as a psychotherapist, though not registered with
UKCP until later. This produced 16 names. I knew that I was excluding some other well
qualified and experienced members. But this was one sampling frame I could easily access
and I needed to limit the number of interviewees as I wanted to use a qualitative
interviewing method which is more time consuming. The method I used was to devise a list of
interview topics and send it to all 16 with an accompanying letter (Appendix One and Two).
I then telephoned to see if I could arrange an interview date and called back twice usually
if I had not had a reply.
By this method I achieved interviews with 10 members. A rather higher non-return rate than
I would have wished arose from the fact that one member was on a sabbatical and two others
had their time committed to other major projects. Two were not seeing clients at the time
of my phone call. There was only one person who I failed to contact at all. I feel that the
last three were probably retiring or considering retirement so I am very grateful to all
those who responded. Some of these commented that it had been an interesting experience for
them and expressed an interest in seeing some of the results, which I hope to be able to
satisfy.
Given the small number of UKCP registered members and of interviewees it is important to
see how these relate to the BAS membership in general and for this reason I carried out
some processing on the BAS Millennial Survey.
The BAS Millennial survey
This was a telephone survey carried out in December 1999 by members of the BAS Executive
Committee (8 in all). Every qualified member was contacted. The only ones who were not
contacted were three of those who made the phone calls. Some of the unpublished results of
the survey were relevant to my research so I agreed to do a full processing of the results
as part of this work.
The first questions on the survey were about general characteristics. So we felt it would
be useful to include data from those who had carried out the survey as well and I contacted
all three in January 2001. The other questions were not applicable to this group so were
not asked. Also people sometimes failed to answer a question so the total answering varies
with different questions.
A total of 48 members answered the survey plus the three subsequently included. At the time
there were 54 qualified members listed in the members' list. The response represents 94% of
the potential respondents. This non-response would have included people who had dropped out
of AT, moved out of the country, were ill or had died. Interviewers generally made
significant efforts to contact members, giving several call-backs. Thus a very good rate of
response for a telephone survey was obtained by this method. The input of Committee
Members' time was probably crucial since they were best placed to get a good response once
they had managed to contact someone.
NUMBER OF YEARS PRACTISING AT
Figure One shows that 24% of the current trainers have 16 or more years' experience
of practising AT. Another 29% have 11 to 15 years' experience of practising AT and the more
recently trained make up 47% of the membership (50 respondents to this question). The
membership is unevenly distributed with a peak at 10 years' practice and considerable
fluctuation from year to year with a tailing off in the last 3 years. This may reflect the
BAS/BAFATT record of recruitment to the Trainer Training course, modified by natural
wastage.
NUMBER OF YEARS TEACHING AT
It is not surprising that teaching experience reflects the same pattern. For most people
there was a relatively short gap between their basic AT course and starting the Therapist
Course, although a few people had much longer gaps. As Figure Two shows: 18% of the
trainers had over 16 years' teaching experience while 20% came into the 11 to 15 years
category, 28% had 6 to 10 years' experience and 34% had one to five teaching experience.
This latter figure was boosted by a relatively large group with four to five years'
teaching experience (50 respondents to this question).
It was the awareness of these imbalances in the membership and the low recruitment of
recent years which led the Executive to reorganise the training course and provide the one
year 'fast track' to attract recruits, plus keeping the opportunity for UKCP registration
after a longer course. The Executive also set about creating a new image for AT and an
overall strategy for expansion.
Teaching mode: groups or individuals or both?
Many people do in fact teach both groups and individuals. But the Millennial Survey cannot
reveal how often those who teach groups take groups. Anecdotal information and the
qualitative survey indicate that apart from those who take groups at the Homeopathic
Hospital or in the workplace it is increasingly difficult to get groups together. This
response and its implications will be discussed more fully in the regard to the qualitative
survey.
" One Respondent did not answer this question
" Some respondents indicated that their usual practice was groups only and they have taught
1 individual only. I included them in 'groups only'
" One or two trainers who took individuals only now indicated that they had taken groups in
the past.
The Qualitative Survey interviewees compared with BAS members
All the interviewees except one had been teaching AT for over ten years, and one had learnt
AT over ten years ago but had a longer gap between learning and teaching it. Thus they were
more experienced than BAS members as a whole. My sampling method had been successful in
that respect. Eight of the interviewees took both individuals and groups, one took only
groups and one took only individuals. There was thus another significant difference between
them and BAS members as a whole, possibly connected with their longer qualification period.
Six of those who took groups commented that groups were now more difficult to get together,
confirming current anecdotal experience. However, the one who took individuals only did so
because she "loved the one-to-one situation and practised as a psychotherapist" rather than
because of the lack of groups. (This seemed less true of the Millennial Survey respondents,
several of whom put comments on their forms indicating that they found groups more
difficult to form).
Admissions to AT: Methods
All interviewees stressed the importance of a comprehensive and holistic approach to the
first discussions with a would-be trainee/client and the initial interview. All of them
used an interview - most used an initial assessment form based on the various existing
examples circulating in the BAS.
The remainder of this essay deals with admissions to AT. In the interviews with these
psychotherapists I initially used a classification of applicants into groups. This came
from my own admissions policy which I had devised in my First Year of Therapist Training,
working from my initial training and the recommended texts. The original classification was
Group (Set) One - people unlikely to be admitted, Group (Set) Two - people with conditions
which had been diagnosed and which required careful consideration. Group (Set) Three was
intended to help with the important group of people who might have some condition which
made it unsuitable to do AT but the condition had not been diagnosed. I had been unhappy
about my definition of Group Three so I had added a set of behavioural indicators adapted
from training in another form of psychotherapy. The initial formulation of Group Three is
given in Appendix Two.
During the first two interviews it became clear that the definition of Set Three was vague
and unsatisfactory while the behavioural indicators did provide a sound basis for
discussion. I had given myself the freedom, as this was a qualitative enquiry, to simplify
the schedule in the light of experience. So the last six interviews were completed on the
basis of discussion of the behavioural indicators as Set Three. This final form of the
interview schedule is given in Appendix One. It was a relatively easy task during
processing to transfer comments from the first four interviews into this format.
The remainder of this essay is concerned with the admission to AT of applicants from these
groups. I know that interviewees would want me to emphasise that any comments about a
particular diagnosis or behavioural indicator are to be put in the context of a holistic
approach which aims to look at the whole person and assess whether it is in that person's
best interest that he do AT at that particular time.
Admissions to AT: The importance of the setting
This was acknowledged by all interviewees. For example people would say that they felt that
a certain category of client should only be seen in a clinic setting. It was also stressed
by those who worked at the Homeopathic Hospital or had experience of other Health Service
funded work. This influenced both the range of applicants and who might be taken on for
training.
Admissions to AT: significance of the Therapist's experience and other forms of training
and experience.
This was acknowledged as influential by all interviewees. In particular it became clear
that events early on in a therapist's practice tended to influence their subsequent
policies. For example some therapists said that, in an early stage, they had taken on
somebody with a serious condition and had experienced adverse outcomes. "I started with an
open door and was naïve ... sometimes found people who were not diagnosed ... it's just not
helpful to produce a feeling of failure.. .."
Not surprisingly these therapists had usually become more cautious about admissions and
this became a settled policy. Conversely some people who started off with a more cautious
policy, had been impressed by how AT could help a wide range of people as their experience
grew, and they gradually extended their range.
Other relevant previous and ongoing training and experience was influential on the
interviewees but the effect was not as consistent as might be expected. Somebody who had
previous experience of working as psychotherapist and "was going into deep levels of
distress and early problems" with those clients might be more inclined to "give people a
chance" despite a Set One diagnosis. On the other hand someone else might give training in
psychotherapy and growing awareness of the implications of certain conditions as a reason
for being more cautious about people in Set One. More than one GP gave as a reason for a
broader admissions policy the fact that as a GP you are used to seeing everybody. But in
one case training and experience as a GP was given as a reason for a more cautious
policy.
The implication seems to be that it is training plus experience rather than training alone,
which has a major influence and that other factors such as the therapist's own personality,
preferred style of work and life circumstances also have a significant effect. People who
felt they were nearing the end of their careers as therapists or who had retired from very
stressful jobs might give that as a reason for a more restrictive policy.
The following section looks at the list of "conditions which require special consideration"
and summarises interviewee's responses to these.
Admissions to AT: comments on Set One
There was the most consensus about this category with everybody viewing it seriously. Two
therapists would not usually admit anyone in this Set while others differentiated more
between categories.
Current Diagnosis of severe mental illness (psychosis)
The majority of therapists would not admit someone with a current diagnosis and were
very aware of the risks. Often they mentioned that such patients might benefit from AT in a
residential psychiatric setting where sufficient specialised care was available. Some
mentioned specifically that they would not admit someone with a current diagnosis of
schizophrenia because of lack of predictability. This category was often the trigger for
discussing cases which had arrived undiagnosed or where the applicant had not been
forthcoming about their history (discussed in more detail later). Three commented that this
had never come up in their practice, highlighting the differences in intake in different
areas or for different therapists.
The only condition which provoked more discussion was manic depression. One therapist
"accidentally took someone on with manic depression and they went into a psychotic episode
soon after starting, necessitating a lot of liaison with the GP and client's relatives".
However, one or two therapists had trained people with manic depression with some success.
Suitable experience and supervision, with support from the GP were all mentioned as
important, plus insight and motivation in the client. (This subject will be explored in
more detail in a later paper on AT and depression.)
Current diagnosis of personality disorder
"The majority of therapists bracketed this with the category above and were unlikely to
admit. A couple of others would consider: possibly...it's a rag bag diagnosis … careful
assessment needed and a letter from the GP". "Would decide at interview ... run a
background check ... history of employment, relationships, and notice how they relate to
me...". I would tend to the latter point of view, particularly if the diagnosis was made
some years ago.
"possibly...it's a rag bag diagnosis … careful assessment needed and a letter from the GP".
"Would decide at interview ... run a background check ... history of employment,
relationships, and notice how they relate to me...". I would tend to the latter point of
view, particularly if the diagnosis was made some years ago.
History of recurrent mental illness requiring specialised care and lack of adequate
evidence that the pattern has now changed.
This was a broader category and provoked more discussion. While all therapists felt that
this should be taken seriously some felt that they would be "inclined to give people a
chance". Those who did had relevant training but also stressed the need for careful ongoing
assessment and adequate supervision. They would look at how long it had been since the
episode of illness, what treatment had been for, how the applicant talked about it, the
presence of insight or not and whether the client was still on medication as well as the
usual factors like motivation before making a final decision. A more extended assessment
period was also mentioned as an option. These therapists felt that they had the training
and experience to work safely with people in deeper levels of distress, often had other
types of therapy to supplement with if needed and felt that someone with sufficient insight
and motivation should be given the chance.
Admissions to AT: Comments on Set Two
Therapist feels unsafe with this particular applicant and there is evidence of previous
violent or inappropriate behaviour.
The most usual reaction, not surprisingly, was "Would never take someone like this" or "Not
if I felt unsafe". Several had never come across it. Those who might be prepared to
consider someone with past rather than recent episode usually considered that a clinic
setting and / or one-to-one setting was more suitable.
Here again there was a contrast with my own practice. Prior to setting up as an independent
psychotherapist working at home in an East London area I had spent over six years dealing
with issues around violence and aggression against housing staff, including participating
in national level working parties, training staff and managers. On training courses members
often included someone who had been the victim of violent attack. This has alerted me to
the growing level of violence on members of the helping professions. When setting up my own
practice at home I asked a colleague who had practised as a psychiatrist for many years and
who was also setting up, whether I was over cautious in my approach. Her answer was
emphatically No.
Although I interview applicants quite carefully over the phone I have subsequently
encountered clients who had a record of violence and have been able to work safely with
some of them. Accurate assessment, plus awareness that none of us can be 100% accurate in
judging on the basis of an interview, plus some arrangements for security at home have been
my line of approach. I feel that autogenic therapists do need to be aware of this issue,
and to take informed decisions for themselves, as violence against helpers seems to be on
the increase. Like other therapists I would not take someone with whom I felt unsafe.
However I would usually be able to identify why I felt unsafe.
This is important to me because I am aware that prejudice can influence such decisions if
the reasons for them are not examinable.
I would assess a record of previous violent or inappropriate behaviour in the light of what
triggered the incident, the client's culture, and how things had changed since. Like other
therapists I find that evidence of previous violent or inappropriate behaviour is not
usually forthcoming in the first interview, though it can sometimes be available on
referral. It is in the interests of both client and therapist that violence or
inappropriate behaviour does not occur during Autogenic Therapy courses. Equally I do not
want to discriminate against someone for an incident which may have happened when they were
much younger and very different from how they are now.
Hyperventilation, panic attacks, phobias which have not yet been
resolved.
Most experienced therapists admitted this group and felt that they formed a significant
proportion of all admissions: "lots of these". Since much material of interest emerged
during this discussion a later paper will deal with the different intake processes and
experiences of therapists.
Severe depression or current depression not sufficiently resolved by treatment.
History of recurrent depression still repeating. History of attempted suicide/self
mutilation.
This was another important and common category which therapists felt needed careful and
systematic assessment. Depression and manic depression will therefore be further discussed
in a later paper.
Separation from parents before the age of 5
There was variation between therapists here:
"Depends on what has gone on since. Not necessarily a contraindication. If there is no
memory of childhood I am very wary..". "Wouldn't be a no-no but would need to be alert".
"Caution - often don't know it's there". "Happening all the time. Recently had one referred
woman with incredible anxiety - adopted at 8 weeks - it became clear she was unable to work
through the issues in AT" (and the client transferred to a different type of therapy).
"It's on my questionnaire in terms of death of one parent. I would probably tend to defuse
the issue with psychotherapy." "Significant. Much higher risk of almost everything (based
on own survey of patients). Warn that they might get worse before they get better and the
possibility of having to slow down. Just explore, work on buried stuff if it comes up,
might turn out to be more than AT." "Serious issue when there is separation without
adequate replacement - AT would be too much unless other treatment preceded it." A couple
of therapists mentioned finding clients who were adopted children with issues too extensive
to start with AT.
Has been in an institution for over a year and has not rehabilitated into the
community.
"What kind of an institution - does this include the army, boarding school?" "Can't think
of one like this... would be very wary.. why were they in an institution what has happened
since?" "No way." "Definitely would be alert.. have just had someone like this. . . would
enquire carefully". "I would consider someone who had spent months in psychiatric care for
AT one-to-one only, very carefully. Can teach a level of awareness and use Neck and
Shoulders exercise to help with tension. One client like this now a very effective
person."
By the end of the survey I had come to the conclusion that this was a very dubious category
and one I would exclude. Psychiatric treatment and separation from family are dealt with in
other criteria and using this as it stands seems to me to open the door to unjustifiable
discrimination. This is particularly the case with middle-aged or older applicants since
the original diagnosis might be more uncertain or the period of treatment have been more
extended than at present. In practice the majority of therapists gave more weight to what
kind of self-development a person had done since and how they appeared at interview.
There is an advantage to the interviewer in having fewer criteria to check so I would
delete this one and make sure that others dealt adequately with the underlying issue.
Has had a 'nervous breakdown' or been on serious medication.
Some therapists regarded it as important to differentiate between these two categories so I
will do so.
Has had a 'nervous breakdown'
Most therapists would not regard that as a barrier but simply something which needed to be
checked as to how long ago it happened, the circumstances and what had been learned from
it, and how the person had developed since.
Has been on serious medication
This was taken seriously as an indicator of something in the past. Circumstances would be
very important - for example one client who came to me for assessment had one episode, in
his early 20s, of going into blind rage and acting violently when he had been taking
recreational drugs. It was in New York and he had been committed to a psychiatric facility
and given serious medication. Subsequently he had successfully done various types of quite
demanding personal development while doing a demanding job so I felt he could do AT. If the
original episode had been of long lasting duration therapists then responded to it
according to their own general approach to the more serious conditions.
Admissions to AT: Comments on Set Three - the Behavioural Indicators.
The final six interviewees commented in detail on the list as it is given here. I have
added views and comments from the first four interviewees where these are available.
At the assessment interview stage you find that:
1. The client is sometimes flooded with feelings of anxiety, fear or distress and is not
able to identify eliciting stimuli.
"Would consider. Feel sympathy, suspect dissociation. Might start with some counselling
over a case history. Would want to know a bit more. Would talk them through it. Breathing
fundamental. Supportive ideas or instruction or intervention are likely to be needed."
"I would warn them that they might not be able to do AT; help them with a basic programme
about anxiety. I may give them the anxiety inventory and go from there. Also do a bit of
body awareness to see if they can consciously relax."
"This hasn't been an issue. If it happened I would look at their level of awareness,
previous work, insight, how they talked about their history etc."
"Unless I had a sense of a thread I would not want to teach AT to someone in those states -
too much distraction."
"It hasn't happened but if it did I would investigate carefully, would be dubious about
AT"
My own approach would be similar to the majority here. This is a symptom which needs to be
investigated and the person may need basic anxiety management training before doing AT.
This will be described in a later paper on panic attacks.
2. The client cannot name or describe feelings.
"It depends on the history. I would be very cautious about getting the full history".
"Instinct.. .. How have they got to where they are today? How are they going to work?"
"Difficult. Foreign to teach AT - they don't know what to look for, a lot of them"
"A lot of people are like this - haven't got a vocabulary or cannot put it into words.
Depends on client, may be lazy. . . "
"Some clients won't make the effort to struggle to put feelings into words…. can ask them
to DRAW or sometimes get them to visualise (transpersonal). Very difficult to generalise.
"
"I've seen some men like this .... with some it is a long story .... more likely to be
psychotherapy … this hasn't happened so far."
"I have not encountered this. They may not be able to feel their feeling, may be in denial.
.. need for more investigation and assessment."
Most recognised that this is an indicator which calls for further investigation of what
underlies it: some would refer elsewhere.
3. The client shows persistent depressed mood, low self esteem and cognitive
distortions, but may not complain of depression because the client considers these symptoms
normal.
"A lot of these - get them in touch with themselves. Flexible - depends on interview. I
would discuss AT - give time to think. Some may have had counselling already".
"Would certainly work with the … proviso that they might need more help. Usual checks."
"I would call this denial .... very difficult to work with .... they think they can hear
you and they can't."
"Haven't had this.. if I did so I would seriously wonder whether AT was suitable."
"AT not enough."
"I have encountered applicants like this and would share the concern. I would also want to
investigate/consider whether the person was disassociated from their feelings or had simply
become used to feeling "low". I might do AT with psychotherapy support if the client's own
motivation and their history and interview gave support to that course of action."
Once again this showed a difference in intake for different therapists as well as
differences of approach. In this case the differences of approach were connected with
different approaches to the issue of AT and depression and I will discuss this in a
separate paper.
4. The client has many incomplete projects and avoids dealing with significant areas
of concern.
"Look at motivation. Usual checks."
"I have just taught someone like this - and he completed his AT - much praised and built up
as he went along. There are ways of requesting commitment from people. He was a phlegmatic
type, plodded on, we both knew he'd finish it - mapped out all the sessions. He
procrastinates in life because he is afraid of the risks."
"AT may be tried and not completed - I would discuss it in the first interview."
"May go on avoiding. May only learn AT as a physical release and AT then is not significant
help - I would consider counselling first."
"It depends on how it affects their life."
"Straight discussion on commitment. Set time to reassess. Could start work on AT or
counselling. I would suggest AT - each of us can do it for ourselves. Could offer AT as a
good technique if they are willing to do it."
I had assumed that this indicator would be a no-no for most therapists - in fact the
situation was the reverse, with most being willing to consider but giving emphasis to
assessment, motivation and support during the process.
I have encountered clients with procrastination or failure to complete work as a major
issue in their lives. During supervision and discussion I found that many psychotherapists
and hypnotherapists regard this as one of the most difficult issues to resolve "because
they procrastinate the therapy". Some clients had both a fear of failure and a fear of
success. One mainly needed the opportunity to take decisions at her own speed. So it seems
helpful to me to consider AT with thorough assessment and support as an option. The safety
and structure provided by AT, the flexibility of pacing the AT, doing things in small steps
and with encouragement, give it some advantages over other therapies provided that the
interest in learning AT is there. I would also if necessary use techniques to help them to
investigate how they motivate or de-motivate themselves and then to change this if they
want to. This may need a couple of questions in a session or a separate session. If these
clients can learn AT they have established both a support and a helpful pattern for the
future.
5. The client has episodes in which they cannot speak or can barely articulate their
thought. The client appears overwhelmed by emotional states at those times.
As the interviews proceeded I realised that this criterion appeared to overlap Criterion
One though it is not exactly the same. One interviewee would not take anyone like this.
Three interviewees gave longer responses and they are worth quoting:
"Give them time. Allowing time to get into the emotion and discuss it. What have they got
from learning in the past."
"I can think of someone like this - the most shattered person I've ever worked with. Yes I
would do it."
"Depends on their level of self awareness - I've seen two examples of this - both had been
sexually abused, both gave that response. One goes through AT, one gets stuck. The one that
goes through AT finds it difficult - gets her in touch with feelings - did AT with
psychotherapy support, working well with it. One runs away. Came for AT and the abuse was
uncovered. The reaction may be the same but motivation or direction has given it
shape."
So interviewees recognised this as a serious indicator but some would take such a person if
other things were OK. In relation to finding AT difficult, most clients with sexual abuse
find resolving these traumas difficult. There are a number of aspects of AT which may be
very helpful to that process (see later discussion of AT and trauma).
6. The client cannot give coherent narrative accounts of events of their life or even
of one recent week. Instead the client gives fragmentary accounts of these situations and
lapses into vague self-critical comments.
The majority of interviewees regarded this very seriously and would not take such a client.
Others would look very carefully at background and motivation including possible GP checks
- there was a sense of needing to understand what lay beneath this, both drugs and dementia
being mentioned as possibilities.
7. The client shows poor impulse control (over money, anger, substance use,
sexuality), is accident prone, is unable to achieve or maintain emotional intimacy, or
shows alternating approach-avoidance behaviour with personal goals or
relationships.
During interviews we realised that this was a "compendium" and needs separating out, though
some people felt that the underlying issues were similar. "Look at what trouble they had
got in to. Would tend not to take them on. AT may help them to stabilise if they complete
it."
Substance and alcohol abuse
"Don't take people on drugs. Problems of concern about written records. May lie. If I do
take them on I may return forms at the end." Lack of staying power was mentioned by others.
However one or two therapists had worked with people with substance or alcohol abuse and
stressed that they "can move mountains if they are motivated and have hope. Listen for that
gap".
Accident proneness
"I would be warned now, would not want to teach it to someone who had that propensity in
the recent past - ungrounded, won't face any issues which come up." Others were less
concerned about this, would consider it as a part of an overall picture.
Pronounced dissociation
There is some overlap with other indicators here. Most would avoid it, however there were
exceptions.
"Yes, I have worked with people with Dissociative Identity Disorder. Usually trauma based.
Careful assessment of if and when to do AT - basic psychotherapy and getting into what's
below the dissociation is essential."
Luthe and Schultz (Volume Ill, p 75ff) include a brief discussion of non-psychotic
dissociative reactions, the fact that a patient's symptoms may increase initially during
training and that this requires further investigation. They advise that only under
clinically well supervised conditions can such a patient be encouraged to pass from
standard exercises to prolonged periods of brain-directed autogenic neutralisation.
Like many psychotherapists today I find that many of the clients coming to me have
pronounced dissociation. This is one of the areas of psychotherapy in which there have been
major advances recently. "Our understanding of the role of dissociative symptoms in
psychological disorders has changed significantly over the last decade" (Carlson and
Putnam, 1992). There appears to be a significant problem with diagnosis of complex
dissociative disorders in the NHS which leaves private psychotherapists with the task of
very carefully assessing the degree and function of the dissociation. There is a standard
questionnaire - the Dissociative Experiences Scale - which can be useful. Butthere is no
substitute for training, experience and the careful observation of non-verbal behaviour in
the interview. The traditional approach in hypnotherapy - of getting to know the various
states and how they interact with each other - appears now to be common in other schools of
psychotherapy (the phrase "ego state" being used instead of "state" for example). So one
would not do AT unless all the "states" were in some agreement about it. This was, I
believe, the situation with Client Four, who had a degree of dissociation but had
maintained the wish to do AT over a period of time and through different states. I feel it
would be an injustice to the many people with milder dissociation to bar them from AT.
The dissociation is, as Luthe and Schulz imply, only a symptom. I often explain to clients
this is a natural human ability which they learnt to use when they were young, and
experienced more than they could cope with. Frequently it is a way of cutting off from what
is being felt in the body. So if the client wants to be able to feel again and has
sufficient insight of what that might imply, AT can be a very good way of helping them
reconnect with their body. Given that psychotherapy support is available should there be
too sudden an up-rush of feeling and that the conditions of informed consent are met this
seems to me to be an ethical use of a major resource.
Most of the clients I have trained in AT had significant dissociation and were able to
benefit from the AT. Clearly this was in a context where the meaning of the dissociation
had been explored. However I am beginning to explore the potential of AT offered at an
earlier stage as part of that exploration, provided that the client's system is stable
enough. Two clients I have taught in this way had previous sexual abuse. In one case this
had previously been disclosed, in the other it had not. In the first case the client was
able to retain her ability to cut off from the feeling, both through the AT and some
subsequent work which included a NHS psychoanalyst. She finally decided to go back into
that issue because current life circumstances made it desirable to get a better. I was able
to facilitate this with the use of EMDR while she continued to use AT as a major support in
her life. She was even able to use EMDR to get exactly the level of resolution she wanted
at the moment. I advised her that if in future she wanted a fuller level of resolution,
Autogenic Neutralisation would be her best path. She agreed with this as the values of AT
attract her - however, availability of therapists in the part of the country she is moving
to, would be a problem at the moment.
With the second client I have used AT very carefully and she has been able to use the
Intentional Off-loading Exercises, Short-Stitch and part of the Heaviness Exercise (arms
only). These have all helped her. This is certainly as far as I would go in her particular
case until the central trauma is better resolved, which is currently happening.
Obsessional characteristics
"Usually do well with AT. There must be a limit ... but with one person most of their
obsessional behaviour came to light after the AT course. That person is still using AT…
gets a lot out of it - it's a healthy tool."
"Training a young lad with Obsessive Compulsive Disorder with psychotherapy support. Very
bright. AT is not a cure but will usually modify. Long standing cases can be very difficult
to work with."
"Sometimes it works, sometimes it doesn't. It depends on the degree - if they can become
determined about the AT - good. But if there are other needs probably do psychotherapy
first."
"Probably brilliant at AT. Have had ones like that ... do very well... There would be a
limit - if their lives are totally disrupted refer to other people."
"It depends on what they are obsessional about."
Luthe and Schulz (Volume III p85, 104) discuss both Obsessive Compulsive Reaction and
compulsive personality. They point out the appeal which AT has for these clients and
typical difficulties which may be encountered. These trainees, if they can learn AT, can
benefit a great deal from it though it is emphasised that AT is not a cure but may be a
useful component in a "multidimensional" course of therapy. This function of AT as a
component in a course of therapy has not been much emphasised yet in UK.
Pronounced mistrust
"Had one person like this. Came to persecute me - prove yet again no-one can help. I would
now pick it up faster - would question motivation. Client wanted power might take her for
psychotherapy if she wanted."
"Is it evidence of schizophrenic state - does it go across the board? Or is it someone who
has had lots of disappointment? AT is not a panacea - see if we can get an understanding -
pick up whether there is rationality behind the mistrust, if they say something like 'I can
feel it telling me to'... then stop sharpish."
"Almost a contra-indication. Quite difficult to work with, there must be a consensus but it
may be just a front."
"Is it paranoia or is it just mistrust - I'm not thrown by it. Don't take the mistrust
personally. Do the practice and find out what they are doing for themselves."
"Would take them in ... a nice challenge."
A valuable ability which most psychotherapists build up is the ability to distinguish
between clients with major mistrust, negative feelings about therapy and negative mindset
who will do good work, and those who do not really contemplate any degree of personal
change.
Client Four A couple of years ago I had an applicant referred from the BAS who had
spent 10 years on hard drugs, was still on controlled drinking but had held a good job down
for 7 years. Having taken brief details of his history I could understand how his highly
negative ideas and view that "Psychotherapy is crap" reflected his life experience. His
motivation was shown by the fact that he had come off hard drugs and more recently stopped
smoking largely by his own efforts and had managed to stay in a stressful and responsible
job. Having appropriate supervisory support I was able to take him on. Little was achieved
through the basic psychotherapy I tried as a preparation, except a more thorough
assessment. It became clear to me that AT was what he was motivated to do so that was what
we had better do, having thoroughly warned him of the risks that his depression might be
increased.
After two sessions of AT he became convinced that AT did something - if only to help
relaxation - and he continued through, keeping an excellent diary. After completing the AT
he did face depression but managed with medication and some psychotherapy. He still
continues practising AT two years later.
Schulz and Luthe: the contribution of earlier studies.
My original intention had been to include an analysis of the classic texts' references
earlier in this work. These are the key texts for identifying the wide range of conditions
that AT has been used with. They also provide detailed information about how Autogenic
Training and Therapy is done. I read relevant sections particularly in Volumes One, Three
and Five and found it useful to look at what was said about work with psychotic patients as
well as with those who are not psychotic. I decided against a detailed analysis mainly
because these volumes are now readily available for BAS Therapists to use from source and
it seemed better to devote limited time and space to the unique data from the interviews. I
have given some examples of how interviewees' decisions related to what is said in these
texts. Most of the interviewees had made considerable use of the classic texts,
particularly when starting in practice, while some rarely used them. The latter may have
been mainly those qualifying later in the period since they mainly used training materials
plus their own information from other sources. Many also used the book by Linden (1990).
The volumes concerned with Autogenic Neutralisation also deepen understanding of the kind
of memories and feelings which may surface in psychotherapy.
Modern writers such as Kanji (1999) and Linden (1990) have highlighted ways in which many
of the studies quoted in the original texts do not meet modem standards of research. Much
of the experience quoted was in clinics with treatment by people who were medically
qualified - a different setting to that of most autogenic therapists. And much that is
useful from these sources has been distilled into the current Level 1 Autogenic Therapy
professional training. These sources were produced in what is now a different period in the
evolution of psychology, psychiatry and psychotherapy. There is now for example more
understanding of the influence of different schools and models of psychotherapy (Clarkson
1995) and there has been a rapid acceleration of research into neuropsychology,
developmental psychology and their relationship with psychotherapy (see for example Rossi
(1996, 2000), Stem (1997)). I feel that my own understanding of AT has been very much
enriched by teachings from various schools of psychotherapy and by writers such as E L
Rossi. The research done in the past thirty years and the development of new approaches
provides many new and as yet not definitively answered questions for the autogenic
psychotherapist.
Conclusions One: Assessment by Autogenic Psychotherapists
One of the conclusions which emerged for me was that AT with psychotherapy support was to
some extent a misleading label. It does not sufficiently highlight the importance of the
assessment being done by someone with more psychotherapy knowledge - more knowledge
of the risks and of the potential. An Autogenic Psychotherapist can choose to bring this
knowledge and experience to bear on admissions according to their own preferences and life
circumstances. I am clear that this knowledge is not confined, within the BAS, to those
registered as UKCP psychotherapists, but is spread around, in relation to autogenic
therapists' other training and experience. Thus a psychiatric nurse or someone with a
clinical psychology background would bring to bear a comprehensive level of training and
experience. Other health professionals may have detailed experience with specific groups,
for example people with panic attacks.
A psychotherapy (or similar professional) qualification brings obligations as well.
Currently there is growing pressure to highlight an ethical obligation for a
psychotherapist to refer a client elsewhere if they believe that a different form of
therapy would be more beneficial to them. This raises new questions. For example what are
the advantages and disadvantages, to a client who may have some unresolved trauma, of
following an AT route and continuing if needed with Autogenic Neutralisation or of using a
more recent technique such as EMDR (Eye Movement Desensitisation and Reprocessing) (Shapiro
1995, and Shapiro and Silk Forest 1997)? Interviewees had some common ideas about
characteristics of clients who might do well with AT. On the other hand evaluation of AT in
comparison with other approaches necessarily depends on knowledge of these other
approaches. There is a growing pressure to make it an ethical obligation for a
psychotherapist to refer a client if a different form of psychotherapy might benefit them
more. This has major training and development implications for all psychotherapists.
Figure Four summarises the factors which may influence decision-making in the AT
admissions process.
It is clear that the interviewees were bringing to the assessment process a deeper, more
detailed and experience-based approach than could be applied by most people when fresh out
of training. Their greater knowledge of what might lie beneath diagnostic labels, or
indicators from behaviour in the interview, gave them greater freedom in decision making
.and making a holistic assessment of any risks involved.
Life circumstances may also influence the decision about how much risk to take. A recently
qualified therapist may feel more need to keep closely to the safety criteria they have
been given and to recruit clients who have the greatest chance of success. Somebody else
with a record of years of successful training behind them may be more able to "give someone
a chance". A psychotherapist's greater freedom to transfer a client smoothly from AT to
psychotherapy and back may ease that decision. A therapist who has had a very hectic
working life and wants to proceed in more ordered existence has both a right and a
responsibility to take less risks in admission to AT. Someone who is interested in
maximising the potential benefit which AT can provide and is in a position to take more
risk, can provide a basic AT training service to people who would otherwise miss out.
At the moment, exchange of information about such work is largely via personal contact. I
hope this study has widened the boundaries and that in the future the BAS may be able to do
more.
Conclusions Two: The admissions process as risk management
It became clearer to me during the study that risk management is a very important element
in the admissions process. There are different types of risk.
Risk One: Client experiencing undesirable effects from AT
Risk Two: Client dropping out of AT
Risk Three: Not providing basic Autogenic Therapy to somebody who can benefit.
Risk One is understandably given the most emphasis in initial training.
"First do no harm" is still a sound principle. The risk most commonly mentioned is that the
client may become overwhelmed by too great a level of emotion, will be unable to cope, have
a "breakdown "or psychotic episode. Psychotherapists are used to being aware of this risk
and helping clients through non-psychotic crisis.
Given the present training and the way it is implemented there were very few instances of
this actually happening. Most experienced psychotherapists had however one story to tell of
how things had gone badly wrong, sometimes early in their AT career, sometimes later. The
most common cause seemed to be that the applicant had failed to declare a serious condition
or medication they were taking. Alternatively the applicant had a serious condition of
which they were not aware and either the therapist did not identify it in the admissions
process or, as sometimes happens, the symptoms only emerged during the autogenic process.
In most cases there was nothing which could have been done to prevent these situations. The
best preparation is awareness and a high level of skill in reading non-verbal behaviour.
However, research has shown that no-one can be 100% accurate in this kind of assessment -
most psychotherapists are aware of this necessary margin of error and continue to assess on
an ongoing basis. In some cases the emergence of a higher level of distress had not been
spotted in a group - it may be easier to identify in individual work.
The influence of Therapists' hypotheses
A therapist's hypotheses about AT and about other forms of psychotherapy will influence
their decisions in respect of this risk. As some of the earlier quotations demonstrate, the
key factor may not be that previous abuse or difficult memories are disclosed, but how
therapists and clients deal with it. In my own practice the client is also included in the
decision making process if they have sufficient insight to make "informed consent". For
example the alcoholic client mentioned earlier had spent a long time trying to get well
through his own efforts, had a great deal of insight, accepted that many of his
difficulties arose from early childhood and wanted to be free from the old limitations. The
risks of him being swamped by emotion or "acting out" and going on a drinking spree were,
he felt, no more than what he faced every day.
Risk Two
Most autogenic therapists have a low drop out rate, reflecting the efficiency of the
admissions process. More experienced therapists stress that to give someone a chance of
learning AT and to provide adequate support if they encounter difficulty and stop, is not a
negative thing. Such clients sometimes do recommence AT at a later stage. So a therapist's
willingness to tolerate the risk of drop out will be an important factor here.
Risk Three
This risk was given less attention in training but may need to be given greater attention
in future, particularly if there is funded provision within the NHS or outside becomes more
available. Those with experience of such work emphasised that there is more variation in
applicants in these circumstances. Also the effect of legislation relating to equality and
access in the provision of a service has not been highlighted in the past in AT basic
training and this needs to be remedied. The evidence that ethnic minority clients have been
wrongly assessed in the past by mental health professionals is relevant. Those interviewees
who gave greater weight to this risk were working from their own ethical basis and
therapeutic experience together with the other factors mentioned in Figure Four.
Behavioural indicators: help or hindrance?
The feedback from discussion indicated that the behavioural indicators could be a help in
accurate assessment so long as they were considered in the context of all the other
information about the client. This approach encourages the careful observation of
non-verbal behaviour, which is the main source of information in the initial interview
apart from what the client says, and awareness of the way in which that non-verbal
information is being interpreted. The list of behavioural indicators given in Appendix One
needs a little tidying up, which can now more easily be done, bearing in mind the
discussions during this enquiry.
Conclusions Three: Recognition of A.T. with psychotherapy support
It is helpful that BAS training and policies make it possible for variation in provision to
occur. More can be done to support this particular application of Autogenic Therapy. One
step would be a more public recognition, at least within the BAS itself, of AT as a family
of approaches. A clearer picture of what may be provided would help therapists, especially
in referring potential clients who they may not want to work with but who might be able to
learn AT with someone else. Figure 5 identifies the members of this family and provides
some suggestions for its development.
Conclusions Four: The effect on my own practice.
This study has given me all that I wanted when I planned it, and more. The present essay
has only presented a portion of the information, as I decided to discuss AT and panic
attacks, and AT and depression in separate papers. AT and trauma is another important issue
which I will continue to explore. Because I have a visual disability it is particularly
helpful to me to have the tapes which I can listen to again in more depth. Qualitative
material is always rich, and this material from conversations with experienced autogenic
psychotherapists provides a range of information on AT in practice which might have taken
me years to acquire by other means.
In my current practice I will feel more confident admitting and supporting clients who may
have a higher level of difficulty to start with, knowing that I have a larger bank of
information to use, as well as my own supervision. I will feel more confident about
decisions not to admit in that I have more evidence to use in discussing the case should I
be required to. I am beginning to revise the list of groups and the behavioural indicators
in line with the findings of the survey and of current research as it is published.
I will also feel that decisions about providing psychotherapy before the AT course, or as
support are somewhat better founded, although this is a topic which I feel requires ongoing
investigation. I started off in AT, working with clients who were completing a course of
therapy with me. I can now offer AT as an option to clients who come to me for therapy and
who seem suitable for this approach. Because of this I have generalised the use of what was
originally my AT admissions form to most applicants though I will always check their
reactions to the idea of completing a form. I am beginning to get a much fuller and more
comprehensive understanding of the different ways in which AT can be used with my clients
and feel that there is also a great deal of potential for future development in these
applications.
--oo00oo--
I am and will remain very grateful to all those who made this study possible:
to those who participated in the often lengthy and quite demanding interviews, to Vera
Diamond my AT tutor, to Tamara Callea whose AT group work I observed, and to Jane Bird, my
first autogenic therapist, who gave generous help with the processing of the Millennial
Survey data and discussion of the current context.
I would like to give thanks to my colleagues both from the British Autogenic Society and
the Neuro-Linguistic Psychotherapy and Counselling Association, for their help in
commenting on this article.
Bibliography
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Psychotherapy Journal, UK: British Association for Counselling and Psychotherapy, Vol
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Luthe, W. (1970) Dynamics of Autogenic Neutralization, New York: Grune & Stratton,
inc.
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Autogenic Society.
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systematic review', Perfusion 12; 279-282
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Appendix One
UKCP registered NLP psychotherapist; Registered Autogenic Therapist
Tel: 020 8530 8480
Dear
Re: Psychotherapists' use of AT
I am writing to ask if you are willing to be interviewed for the research I am doing for my
extended essay. I am studying how AT is used by UKCP registered Psychotherapists with the
aim of improving my own clinical practice as well as meeting the BAS requirement.
This would be a qualitative research interview, i.e. based around a number of topics or
questions, with freedom to say what you want to say. I would prefer to tape record as well
as taking notes. The list of topics is included with this letter. I estimate that it will
take 1 - 1½ hours, depending on what you want to say.
In view of the distance I would like to interview you on the telephone. We could divide the
questions into two sessions or do some of it by post, if that would be easier for you.
I already know from past experience and from my Trainer Observation Study that questions
about how people do things are quite complex. I am viewing the extended essay as a
first stage summary of how I have gone about the enquiry and what information I have so
far, rather than any definitive answer. I hope it will add to current information in that
way
I appreciate that you lead an extremely busy life and hope that you will be able to make
this time available.
Yours sincerely,
Marion Brion.
Appendix One continued
Psychotherapists' use of AT
Questions and issues to explore in qualitative interviews.
1. What attracted you to AT.
2. Present Therapist Practice.
Full/Part Time.
AT and other occupation or AT only
Groups/individuals
Setting(s)
3. Present and past psychotherapy and other trainings (briefly). Relationship between these
and AT.
4. Policy and practice on admitting applicants for Autogenic Therapy, either group or
individual.
5. Experience of working with people from Sets 1, 2 or 3 as AT clients.
6. Awareness of other autogenic therapists' practice in this respect.
7. Reflections on Schultz/Luthe including Luthe's technique of using repeated early
exercises
8. Use of other sources of information on AT with "psychotherapy clients."
9. What might attract a psychotherapist (from your own background) to AT?
DRAFT: CONDITIONS WHICH REQUIRE SPECIAL CONSIDERATION
SET ONE
Current diagnosis of severe mental illness (psychosis)
Current diagnosis of personality disorder.
History of recurrent mental illness requiring specialised care and lack of adequate
evidence that the pattern has now changed.
SET TWO
Therapist feels unsafe with this particular applicant and there is evidence of
previous violent or inappropriate behaviour.
Hyperventilation, panic attacks, phobias which have not yet been resolved.
Severe depression or current depression not sufficiently resolved by treatment.
History of recurrent depression still repeating
History of attempted suicide/self mutilation
Separation from parents before the age of 5
Has been in an institution for over a year and has not rehabilitated into the community
Has had a 'nervous breakdown' or been on serious medication.
SET THREE
At the interview stage or from questionnaire you find that:
# The client is sometimes flooded with feelings of anxiety, fear or distress and is not
able to identify eliciting stimuli
# The client cannot name or describe feelings
# The client shows persistent depressed mood, low self-esteem and cognitive distortions,
but may not complain of depression because the client considers these symptoms normal
# The client has many incomplete projects and avoids dealing with significant areas of
concern
# The client has episodes in which they cannot speak or can barely articulate their
thoughts. The client appears overwhelmed by emotional states at those times
# The client cannot give coherent narrative accounts of events of their life or even of one
recent week. Instead the client gives fragmentary accounts of these situations and lapses
into vague self-critical comments
# The client shows poor impulse control (over money, anger, substance use, sexuality), is
accident prone, is unable to achieve or maintain emotional intimacy, or shows alternating
approach-avoidance behaviour with personal goals or relationships
# Pronounced dissociation
# Obsessional characteristics
# Pronounced mistrust.
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