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Ruth Birkbaek

Psychotherapy of Obsession, Habitual Worrying and Repetitive Fantasizing – with Dr Ruth Birkebaek (Feb. 2021)


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We were pleased to welcome back Dr Ruth Birkebaek, a very well-respected Relational Integrative Psychotherapist to Bramham Therapy via Zoom, for a stimulating workshop on the psychotherapy of obsession, habitual worrying and repetitive fantasizing.

Despite the limitations of meeting on Zoom, Ruth ensured that we all felt connected, by means of smaller break-out rooms in which we could share our experiences and responses to what she was teaching.  

Ruth began by inviting us all to remember childhood fantasies and to think of what purpose they may have served, which reinforced her suggestion that we think of obsessions and fantasies as existing along a continuum.   Clients may present with a mild style of obsessive behaviour or something more severe, with more OCD presentation.  

She outlined Richard Erskine’s six ways of working with obsession, habitual worrying and repetitive fantasizing, making the point that although they are taught in a linear form, when working with clients the different areas would be far more interchangeable and flexible.  She went on to talk about each facet and its link with the subject matter.

She began with the 1st facet, the Reliable Relationship, suggesting that loneliness and the absence of a meaningful relationship is a core issue for this client group and that worries and repetitive patterns can be put in its place, unconsciously pushing people away for fear of past relationship failures being repeated.  As she said, the internal dialogue fills up the emptiness felt inside.  

In order to meet such clients in relationship, Ruth spoke of the importance of contact in the therapeutic relationship and spoke of contact occurring internally, externally and interpersonally.   In particular, it is phenomenological inquiry into the client’s subjective experience which can progress genuine contact for this client base who often have no awareness of what is going on internally.  She suggested that by asking questions about how the client is feeling both emotionally and bodily and what it might mean to them, all questions without a ‘right’ answer, clients have the opportunity to begin to know themselves. 

She spoke about  8 relational needs and also of the need for the client to feel safe in the therapeutic relationship, which is more than simply saying that you, the therapist is trustworthy, but rather demonstrating this, both verbally and non-verbally by offering a contactful, consistent, reliable and predictable relationship, so that the client can feel secure.

Secondly, is Avoidance and Ruth suggested that the anxiety associated with obsessing or fantasizing is often about avoiding one’s feelings, thoughts and memories as a distraction from the difficult feelings of shame, despair or loneliness.   She suggested that a way to work with this avoidance is to ask what the client might be feeling if they weren’t so worried about…. Or what would they be remembering or what they might be doing differently, thus helping to change the script beliefs the client has assumed.  

Thirdly, Ruth spoke about Life Script and the Script System, saying that life scripts are often developed by infants, children and even adults as a means of coping with disruptions in significant dependent relationships that repeatedly fail to satisfy crucial developmentally-based needs.  These script beliefs, typically around the self, others and quality of life, work to protect from pain by avoiding what they are actually feeling or remembering.

Fourthly came Intrapsychic Reorganisation and Ruth explained that in looking at working with a client’s archaic experiences via a developmental perspective, the therapist will be going beyond the content of the narrative and looking for the client’s unconscious stories.  In concentrating on the feelings and needs of the young child, therapy aims to create a reparative relationship 

Fifthly is Homeostatic Function and here Ruth used the acronym, PICS, standing for Predictability, Identity, Continuity, Stability and highlighted the importance of working collaboratively with the client to uncover and understand archaic habits of worrying and obsessing and transpose those to more helpful forms of self-regulation and self-enhancement. 

The sixth facet revolves around Living in the Present by changing familiar patterns of worries or fantasies which are used to attempt to influence either the past or the future which serve as a distraction from living in the present.  The hope is that clients, through mindfulness and awareness  of what is happening both internally and externally can change to living in the now.

Although Ruth’s seminar was full of theoretical approaches to working with this group of people, her over-arching message was that it is the therapeutic relationship that is paramount.  Rather than pathologizing clients, she stressed the importance of really listening for the developmental difficulties revealed within their narrative.  It is in really showing, both verbally and non-verbally, that you want to find out about the client that healing can begin and, in sharing many examples from her own client work, Ruth was able to demonstrate how this can happen. 

Through her empathic approach both with clients and with the delegates, Ruth set a very calming, cocoon-like environment within which we were able to understand and learn about this relational approach to working with this client base.  In spite of the virtual nature of the seminar, I found that her warmth and openness permeated through the ether to create a connected and inspiring place to be and I thank her on behalf of us all for such a great day.

By: Mel Dundas, Counsellor BACP & UKCP Accred.

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Average feedback scores from our event:

Organisation of event: 4.8 out of 5

Speaker: 4.8 out of 5

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Feedback from our event:

“Wonderful speaker, very good style and very inclusive.” Annie Rapstoff, Didcot

“Certainly the topic of obsessive worrying is so prevalent, not just because of the pandemic, but because of the general and societal insecurity and seemingly overwhelming self-demands to be perfect in every way, which puts such a lot of pressure on people. Ruth is an excellent speaker and shows by example the value and efficacy of the truly supportive therapeutic alliance, which gives us such gentle guidance into seeing past the ‘headlines’ to the client’s story.” Louise, Ramsbury

“Really enjoyed the speaker and found her manner and demeanour very easy to listen to.” Dave, Hungerford

“Excellent speaker – insightful, concise, clear.” Helen, Bristol

“The client examples brought the seminar to life and excellent presenter.” Kate, Winchester

“Ruth is a great speaker – so empathic and welcoming of questions. I really enjoyed the workshop.” Mel, Marlborough

“Good speaker. Ruth definitely has that therapeutic charisma – you trust what she says. Very accessible. Very grounded. Very human.” Maria Siepe, Bristol

“Very accessible and well run, well held, good size group, excellent speaker. Great.” Anonymous

“I liked Ruth’s sharing of the ways in which she gently explores what a client would be feeling, remembering or doing if they weren’t worrying. I really liked her prosodic voice and “I am not the expert” approach to both her client work and also to the questions from her audience today. It made me feel valued and my offerings, significant. There was a very ambient, warm and inclusive feeling about this workshop which echoed the content of her relational approach. It felt much more personal than many other online workshops that I have been on. The organisation presented and hosted the workshop very competently.” Sue Ivey, Hook

“Excellent presentation and easy to understand and relate to. Ruth works in a similar way to me and I found it useful that the focus stayed on the topic. Any areas of the literature, that was forwarded prior to the seminar, that I was going to question were answered within the live presentation. I feel I have another worthwhile perspective to consider and possibly develop into areas of my work with clients. Thank you.”  Tom, Stroud

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