BACP Therapy Today December 2021 by Think Publishing

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DECEMBER 2021/JANUARY 2022 | VOLUME 32 | ISSUE 10 THERAPY TODAY

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Working behind bars Does therapy have a place in addressing the mental health crisis in our prisons?

What narcissism really means // Is it time to take your practice digital? Class dynamics in the therapy room // Learning from endings

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Contents, 1 VERSION

Contents

December 2021/January 2022

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Upfront

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The big issue Radhika Holmström reports on the mental health of prisoners in the UK’s criminal justice system Going digital Sally Brown looks at the pros and cons of digital practice management systems Narcissism – the therapist’s friend? Duncan Barford explores the real meaning of narcissism Caring for the carers How can we support parent carers of children with disabilities? asks Joanna Griffin Working with the ultimate crisis Zorana Halpin discusses how to cross the gap to reach suicidal men Battling demons Daniel Hand proposes tabletop role-playing games as a therapeutic intervention Class and counselling Roxy Birdsall asks how we can become aware of class dynamics in the therapy room

It changed my life Talking point The bookshelf Dilemmas Analyse me

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Classified, mini ads, recruitment, CPD

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Welcome News round-up CPD and events From the Board Reactions The month

Main features

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Regulars

Duncan Barford (‘Narcissism – the therapist’s friend?’, pages 26–29)

Opportunities

On the cover..

Working behind bars

Radhika Holmström asks if therapy can help address the mental health crisis in our prisons (pages 18–21)

British Association for Counselling and Psychotherapy Board and officers

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Company limited by guarantee 2175320 Registered in England & Wales. Registered Charity 298361 BACP and the BACP logo are registered trade marks of BACP

Chair Natalie Bailey President David Weaver Deputy Chair Michael Golding Governors Sekinat Adima, Punam Farmah, Julie May, Kate Smith, Vanessa Stirum Chief Executive Hadyn Williams Deputy Chief Executive and Chief Professional Standards Officer Fiona Ballantine Dykes Chief Operations and Membership Officer Chelsea Shelley

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‘Perhaps what we are living through is not an epidemic of self-love but of shame-fuelled desperation to maintain self-regard in an age of constant comparison’

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From the Editor

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hen I was training, I spent two years as a Samaritans volunteer (in addition to a clinical placement). On the night shift, we’d frequently get calls from young men – often still in their teens – held on remand at the local prison. The recurrent themes in their stories made for a veritable full house of adverse events in childhood – time spent in care, family violence, bereavement, parental drug or alcohol dependence, extreme poverty. Yet they were often expected to withstand hours alone in segregation (for punishment or their own protection), with no means of passing the time – something that even those with robust mental health would find difficult. Meanwhile, we heard the staff were overstretched and struggling to maintain control in a Victorian building overrun with rats – and that incidences of assaults on staff were among the highest in the country. So I held in awe a counsellor I met during my placement who also had a role as a prison counsellor. Retired from a successful medical career, she had retrained as a therapist and seemed undaunted by the prison environment. ‘They always treat me with respect,’ she once told me, ‘I think I remind them of their nana.’ She radiated calm compassion – I can only imagine what it must have felt like to spend time in her presence, being listened to without judgment. But like many of the counsellors working in our prisons, she was unpaid. The prison governor valued the counsellors’ work, she told me, but budget cuts meant there was no longer any money for ‘extras’. My colleague was qualified and experienced, although many of the volunteers providing counselling in prisons are trainees. Whether this situation is appropriate

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or sustainable is one of the questions asked in our ‘Big issue’ report this month into the mental health crisis in the UK’s prisons. Don’t miss that on pages 18-21. If you need uplifting, If there is a theme running through this issue, it’s making turn to page 38 and read a difference in the community, Daniel Hand’s joyous and I am honoured to be able to showcase some of account of using tabletop the ways members are doing role-playing games as a that, from counselling men at risk of suicide to supporting therapeutic intervention parents caring for children with disabilities. And if you need with young clients uplifting, turn straight to page 38 and read Daniel Hand’s joyous account of using tabletop role-playing games (think ‘Dungeons and Dragons’) as a therapeutic intervention with young clients. Elsewhere in the issue, Duncan Barford unpicks the muchused term ‘narcissism’ in our ‘Clinical concepts’ section, and in ‘Best practice’, Roxy Birdsall invites us to consider the impact of class dynamics in the therapy room. As ever, I hope there is something here that supports you and your practice, and I would welcome your feedback on this and any other issue.

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Sally Brown Editor therapytoday@thinkpublishing.co.uk

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Contributing to Therapy Today We welcome submissions from practitioners. Please send your article or an email describing what you would like to write about to therapytoday@thinkpublishing.co.uk. Please note, we currently do not publish poetry. For further guidelines, see www.bacp.co.uk/bacp-journals/author-guidelines Editor Sally Brown e: sally.brown@thinkpublishing.co.uk Art Director George Walker Copy Editor Catherine Jackson Managing Editor Marion Thompson Consultant Editor Rachel Shattock Dawson Reviews Editor Jeanine Connor Production Director Justin Masters Client Engagement Director Rachel Walder Executive Director John Innes Commercial Partnerships Director Sonal Mistry d: 020 3771 7247 e: sonal.mistry@thinkpublishing.co.uk Editorial Advisory Board Luan Baines-Ball, John Barton, Kathy Carter, Jane Czyselska, Jessie Emilion, Dwight Turner, Christa Welsh. For more details, see bit.ly/3ul8uWb Sustainability Therapy Today is printed on PEFC certified paper from sustainably managed forests and produced using suppliers who conform to ISO14001, an industrial, environmental standard that ensures commitment to low carbon emissions and environmentally sensitive waste management. Both the cover and inner pages can be widely recycled.

Therapy Today is published on behalf of the British Association for Counselling and Psychotherapy by Think Media Group, 20 Mortimer Street, London W1T 3JW. w: www.thinkpublishing.co.uk Printed by: Walstead Roche ISSN: 1748-7846 Subscriptions Annual UK subscription £76; overseas subscription £95 (for 10 issues). Single issues £8.50 (UK) or £13.50 (overseas). All BACP members receive a hard copy free of charge as part of their membership. t: 01455 883300 e: bacp@bacp.co.uk Changed your address? Email bacp@bacp.co.uk BACP BACP House, 15 St John’s Business Park, Lutterworth, Leicestershire LE17 4HB t: 01455 883300 e: bacp@bacp.co.uk w: www.bacp.co.uk

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Disclaimer Views expressed in the journal and signed by a writer are the views of the writer, not necessarily those of Think, BACP or the contributor’s employer, unless specifically stated. Publication in this journal does not imply endorsement of the writer’s views by Think or BACP. Similarly, publication of advertisements and advertising material does not constitute endorsement by Think or BACP. Reasonable care has been taken to avoid errors, but no liability will be accepted for any errors that may occur. If you visit a website from a link in the journal, the BACP privacy policy does not apply. We recommend that you examine privacy statements of any third-party websites to understand their privacy procedures. Case studies All case studies in this journal, unless otherwise stated, are permissioned, disguised, adapted or composites, to protect confidentiality.

Copyright Apart from fair dealing for the purposes of research or private study, or criticism or review, as permitted under the UK Copyright, Designs and Patents Act 1998, no part of this publication may be reproduced, stored or transmitted in any form by any means without the prior permission in writing of the publisher, or in accordance with the terms of licences issued by the Copyright Clearance Centre (CCC), the Copyright Licensing Agency (CLA), and other organisations authorised by the publisher to administer reprographic reproduction rights. Individual and organisational members of BACP may make photocopies for teaching purposes free of charge, provided these copies are not for resale. © British Association for Counselling and Psychotherapy

BACP and the BACP logo are registered trade marks of BACP

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Welcome, 1

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FROM THE CEO

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I’m extremely proud of the work that’s been undertaken at BACP throughout 2021. In what has proved to be another challenging year, colleagues have worked tirelessly to continue to raise awareness of our profession and champion the incredible work of our members. We’ve seen so many successes as a result of this hard work over the last 12 months, including the recent announcement of a new pilot training scheme for NHS IAPT services. This new scheme has been launched by Health Education England and will consist of a fully funded, three-year core psychotherapeutic counselling training to work as a high intensity therapist in IAPT services. As part of our work with the NHS Psychological Professions Stakeholder Group, we’ve been involved in developing both the concept and curriculum for this landmark training programme. You can find out more about the new pilot scheme on page 8. We’ve also launched our own pilot grant scheme, which will support a BACP organisational member in delivering a one-year project to improve equality, diversity and inclusion in the counselling professions. This incredibly important scheme represents the first of a number of significant initiatives in this area. Find out more on the next page. In many ways, it’s been another exceptional year for us all, and one that’s required us to adapt and embrace an entirely new way of living and working. With that in mind, I sincerely hope you find the opportunity to relax and recharge over the festive period, and I look forward to working with you all in 2022. Hadyn Williams BACP CEO

In December, we’re due to hold our final listening workshop of 2021, on the theme of accreditation. We know many members have questions about accreditation and we’d encourage you to attend the session if you’re able or catch up later through our on-demand service. We invite all members to submit questions for our panel to consider in advance of our listening workshops. Where we’re unable to respond to questions during the session, we aim to

found the sessions useful and if you’ve missed any of our listening workshops, you can catch up on our website, at www.bacp. co.uk/membership/ listening-workshops

Review of senior accreditation schemes It’s been 10 years since we last reviewed our senior accreditation schemes, and this, coupled with the possible adoption of the SCoPEd framework, means we believe the time is right to look at these again. The review will help us to ensure that the senior accreditation schemes and associated criteria remain relevant and up to date. We’ve contacted all our senior accredited members to let them know about the review

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provide answers on our website afterwards. We’re planning to hold further listening workshops in 2022 with details due to be released shortly. We hope you have

and will be updating them and the whole membership on the outcome of the review in due course. We’d like to reassure members that there won’t be any impact on senior accredited members while we review the schemes. Titles, logos and designatory letters for senior accredited status can still be used in promotional material. We’ll continue to accept new applications for senior accreditation until Friday 14 January and they will continue

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to be processed in the usual way. You can find out more at www.bacp. co.uk/news/newsfrom-bacp/2021/15october-review-ofsenior-accreditationschemes

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mInutes with… Grace Gardiner

Describe your role at BACP:

My role is to motivate and lead a team of incredibly creative and innovative people to use their skills and expertise to provide content, products and resources that best support the membership. What’s the best thing about working at BACP? Knowing that

you are part of an organisation that is providing a wide range of professional and ethical services to therapists and coaches that are helping people in a time of need.

Grace Gardiner What gets you up in the morning?

BACP’s Head of Member Services answers our ‘getting to know you’ column. Look out for other BACP staff members in upcoming issues.

Currently a very loud alarm and some morning music! I struggle to summon the motivation to get out of bed during the darker months, so find that a ‘morning shuffle’ can change my mindset for the rest of the day. What advice would you give to your younger self? ‘Don’t be afraid…

you’ll be fine.’

Best advice you’ve been given?

If it doesn’t make you happy, change it. Without being a cliché, I have experienced that life can be short, so why spend time doing things that do not make you happy. Find something you are passionate about and makes you smile and then go for it! What was the last book you read?

Jay Shetty’s Think Like a Monk. I thought it was a great read that

gave a balanced perspective of practical guidance and lived experience. ‘Journey of discovery’ or ‘challenging mindset’ books are my guilty pleasure.

BACP third sector grants scheme We’ve recently launched our own pilot grant scheme, which will support a BACP organisational member in delivering a one-year project to improve equality, diversity and inclusion in the counselling professions. This scheme represents the first of a number of new initiatives in this area and will focus on race, ethnicity and access to counselling. A grant of up to £30,000 is available to one organisational member to deliver a project or initiative in partnership with a community-led partner organisation or group. The selected project will improve access to counselling or coaching services for people from marginalised and racialised community backgrounds and will add to the knowledge and learning about improving access to therapy. A dedicated grants panel, made up of people with professional and personal experience related to accessing third sector counselling services, has supported the development of the project criteria. The panel will assess shortlisted applications before awarding the grant to the successful project. Applications for the grant can be made until Friday 7 January 2022.

What’s your go-to karaoke song?

I would never subject anyone to a solo karaoke session from me, so my choice would need to be a duet. Right now I think ‘Don’t Stop Believing’ by Journey would be a great performance song. Your proudest achievement?

Buying my first house. It might seem like a simple achievement or something that is an expectation, but for me it was a positive outcome from a series of difficult decisions that provided me with the stability I needed in order to progress. What would you like to achieve over the next year? From a

personal perspective, I would like to drive across Europe to Italy and see the Colosseum – travel permitted. From a professional perspective, I would like to grow the team to include an effective and efficient hybrid CPD programme, introduce a new Communities of Practice and Events platform and improve some of the core products we provide. I am hoping these changes will allow BACP to embrace a different way of working and provide needed services that continue to support the membership.

PROFESSIONAL CONDUCT

www.bacp.co.uk/about-us/protecting-the-public/ bacp-register/governance-of-the-bacp-register

¢ BACP’s Public Protection Committee holds delegated responsibility for the public protection processes of the Register. You can find out more about the Committee and its work at

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¢ BACP’s Professional Conduct Notices can be found at www.bacp.co.uk/professional-conduct-notices

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Alexis Powell-Howard

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Members in the media Panic buying, sibling grief, impostor syndrome and social burnout were among the topics our members recently spoke about in the media.

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Cate Campbell spoke to the i website about the role of therapy in managing the impact of traumatic news. A feature in Women’s Health magazine on how the threat of male violence can impact mental health included an interview with • Jayne Booth. Jennifer Park discussed siblings grieving the loss of a brother or sister for an article published in the Daily Express, Daily Mirror and Daily Star. Jennifer also contributed to an article for Mail Online examining morbid curiosity, and how it can be a positive way to manage fear. The Huffpost and Yahoo! websites featured Hansa Pankhania • discussing the reasons people panic buy. Hansa also contributed to an article on HGV drivers’ mental health, which was used across several trade publications and websites, including FleetPoint and Safety and Health Practitioner. • Satpal Kaur-Thompson contributed to an article in Cosmopolitan magazine on imposter syndrome and how to overcome it. Matt Wotton • and Graham Johnston wrote a comment piece for politics.co.uk discussing what politicians can learn from athletes who discuss their mental health. They were also on The Meaningful Life podcast, to talk about boundaries in relationships, attachment and parenting. Lina Mookerjee was interviewed on BBC Radio Scotland’s Good Morning Scotland programme about social burnout, while Louise Tyler was also interviewed on the subject by Time Out magazine. Jo Bisseker Barr • spoke on BBC Radio Solent about the benefits of writing for wellbeing for unlocking creative potential, promoting mindfulness and overcoming the inner critical voice. Woman’s Own spoke to Allie Outram about the rise of eating disorders during the pandemic. The Westmorland Gazette talked to Ellen Whitfield about how she incorporates horses into her counselling work. • Dr Kate Anthony was interviewed for The Observer Magazine about online practice during COVID-19. If you are interested in becoming a BACP media spokesperson, email media@bacp.co.uk

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The annual Best Business Women Awards took place in London in October, and we’re delighted to let you know that one of our members won several awards on the night. Alexis Powell-Howard MBACP (Accred), who founded Fortis Therapy and Training, was nominated in four categories, winning recognition in all. Fortis took the Gold Award for the Best Business of the Year category and also secured Silver Awards for the Best Boss, Best Customer Service and Best Working with Children and Families categories. Fortis was the only business in attendance to receive so many nominations and was the only business to be a finalist in four categories. The Best Business Women Awards were founded by Debbie Gilbert in 2015 and have become one of the UK’s most prestigious awards for business women. The awards cover a wide variety of business industries and recognise and reward female business talent, both in the UK and internationally. Huge congratulations to Alexis and all the team at Fortis on this well-deserved achievement.

Funded IAPT training A new pilot training programme has been launched by Health Education England, as part of its investment in the counselling and psychotherapy workforce within IAPT services. The pilot will consist of a three-year, core psychotherapeutic counselling training at master’s level, and will be the first time people can train as counsellors and psychotherapists and work as high intensity practitioners in a fully funded and salaried NHS scheme with no requirement for unpaid work. This development sends a strong signal about the importance of counsellors and psychotherapists to the NHS and marks a positive shift in training and employment opportunities for therapists. It’ll also have a positive impact for therapists who already work within IAPT by strengthening our arguments for consistency in pay grades. The new pilot training programme is part of the work undertaken by the NHS Psychological Professions Stakeholder Group, of which BACP is a member. Over the past few months, we’ve been involved in developing both the concept and the curriculum for the training programme, which will see 60 trainee psychotherapeutic counsellors work with NHS IAPT services to deliver specified IAPT modalities for adults with depression. To find out more, see www.bacp.co.uk/news/news-frombacp/2021/14-october-landmark-moment-for-nhscounselling-and-psychotherapy-training-and-jobs

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News round-up

Working for you ● BACP Chief Executive Hadyn Williams discussed opportunities for our members to support the Welsh Government’s mental health priorities during discussions with Lynne Neagle, the new Deputy Minister for Mental Health, and Tracey Breheny, Deputy Director, Mental Health, Substance Misuse and Vulnerable Groups Division at the Welsh Government. Hadyn was joined at the meeting by Steve Mulligan, BACP’s Four Nations Lead. The discussions highlighted our members as a key asset in the mental health workforce across a range of areas, including in education settings, in local communities, and through GP and third sector provision. ● We made a strong case for key counselling and psychotherapy measures to help the nation rebuild from the COVID-19 pandemic in our submission to the UK Government’s 2021 Spending Review. Our recommendations included funding research into the impact of the pandemic on care home residents and staff, and how counselling and psychotherapy can improve their mental wellbeing. Additionally, we set out a robust case demonstrating how funding therapeutic

Private Practice Toolkit

coaching will help the Government to address issues of mental health among NHS health and care staff. We’re also calling on the Government to address long-standing mental health inequalities faced by black and ethnic minority communities by investing in a national programme of community-based, accessible and culturally sensitive therapy provision. ● Teaching unions and the Local Government Association (LGA) have echoed our call for the Government to fund school-based counselling in all secondary schools and academies. The LGA – which represents councils in England and Wales – has said the investment is needed to help support increasing numbers of children and young people affected by mental health issues during the COVID-19 pandemic. Teaching unions the National Association of Head Teachers (NAHT) and National Education Union (NEU) backed the call.

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● Our Chair, Natalie Bailey, co-signed a letter published in The Daily Telegraph urging the Government to invest in a nationwide network of hubs to provide early support for young people’s mental health. The letter is part of the Fund the Hubs Campaign, launched by Youth Access in partnership with YoungMinds, Mind, The Children’s Society and the Children and Young People’s Mental Health Coalition. It called for the Government to invest in a national network of early support hubs to provide drop-in care on a self-referral basis. ● We joined with the British Psychological Society (BPS) to brief Peers on the Police, Crime, Sentencing and Courts Bill ahead of seven days of committee consideration in the House of Lords. In the briefing, we urged the Government to amend the Bill in order to withdraw Clauses 9, 15 and 16 in Chapter 1, which would afford police the power to override the duty of medical confidentiality.

Over the course of 2021, we’ve developed 12 new resources for our Private Practice Toolkit. We initially created our Private Practice Toolkit in partnership with the Private Practice division in 2020, and have continued to develop the resources based on your feedback throughout the past year. The toolkit resources are designed to support you with all aspects of setting up, managing, developing and working in private practice. The newly developed resources cover topics such as making the transition from student to private practice, understanding tax, contract discussions, blogging, GDPR and social media. Alongside the new resources are articles from our journals, news items and Good Practice in Action resources. Most of the Private Practice Toolkit resources are free for all members to access, but some are only open to Private Practice division members. To access content from BACP journals, you’ll need to sign up for a free subscription to view them online. Similarly, to view CPD hub content you’ll need a CPD hub subscription. You can explore the toolkit at www. bacp.co.uk/bacp-divisions/ bacp-private-practice/privatepractice-toolkit

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Working with gender diversity

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This event has been created in response to demand for more specialist learning from therapists and professionals with lived experience of gender dysphoria and gender diversity. It is for counsellors and psychotherapists who wish to increase their knowledge and understanding around the current best practice for working alongside gender-diverse people. It is pitched at both those looking to begin working alongside gender-diverse people and those who are already working with them in a range of clinical settings. The event will explore what ‘gender dysphoria’ is and will consider the specific terminology, skills and knowledge to use when working alongside gender-diverse clients. Attendees will look at the medical and legal context for gender-diverse clients in the UK and explore key

Be the change

Can we, and indeed should we, from our position as therapists and counsellors, reach beyond our clients’ inner worlds and try to impact on their outer worlds? Our Social Response Cycle online resource, written by Dr Beverley Costa, aims to help you answer this question. Beginning with an examination of our desire to ‘do more’, the resource helps you to consider therapeutically framed social entrepreneurism as a response. Beverley introduces a structure for piloting social enterprises, trialling your project, building up your confidence

What’s new in the CPD hub?

psychotherapeutic themes in relation to gender-diverse clients. You’ll also learn how to support gender-affirming therapy and best practice in relation to working with gender-diverse clients in line with guidance from the World Professional Association for Transgender Health (WPATH), which focuses on standards of care for the health of transsexual, transgender and gender-nonconforming people. The half-day online event takes place in February 2022 and costs £35. For more information, see www.bacp. co.uk/events

and applying your own ideas for social action and response initiatives. This resource is suitable for trainees, qualified counsellors, supervisors, trainers and service managers concerned about issues of social justice. If you’d like to make a difference that goes beyond the consulting room, or you’ve felt powerless to act on what you’ve observed, the resource will guide you through the ethical basis for therapeutically framed, socially responsive action. This six-hour resource is free. To find out more, see www.bacp. co.uk/cpd/social-response-cyclemember-resource

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● Climate awareness How do we support clients to manage their response to the climate crisis? Coach and climate specialist Linda Aspey’s presentation ‘Coaching and the climate crisis’ is suitable for all therapeutic practitioners interested in exploring the range of possible responses that they and their clients might have to the current situation. Practitioners will also consider their own personal and professional needs in response to the crisis, and access signposting to key resources, including frameworks and approaches, to inform and support onward action.

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● Risk management Refreshing your knowledge of safeguarding and risk management can be reassuring and confidence building, whether you’re a newly qualified or more experienced practitioner. In ‘Safeguarding and risk management in action’, Professor Lynne Gabriel discusses the key features involved in working with risk, as well as tools and tips to support safe client work. It costs £25 a year to subscribe to the CPD hub, with access to more than 300 hours of CPD content. You can also download a personalised CPD certificate for each piece of completed CPD content. See www. bacp.co.uk/cpd/cpd-hub The CPD hub is just one feature of the Learning Centre, home to a selection of free CPD resources, including the Therapy Today podcasts. There is also a free CPD planning tool to log all the CPD you complete, within and outside the Learning Centre. See www.bacp. co.uk/learningcentre

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Milestones are a perfect opportunity for us to pause and reflect on what has gone before and what may lie ahead

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Traditionally they would show us what progress we were making towards our destination, as well as highlighting how far we have come. We each create our personal calendars of significant days and dates, as well as the cultural or religious events we may choose to share with others. Whatever roles and relationships we have will also bring a specific cycle of events to add to our routines and rituals. As an organisation, we have a range of cyclical processes that have come to define what we do. There are committees and Board meetings, workshops and conferences and, most recently, our AGM. There is an annual financial planning cycle and a three-year strategy. All of these combine to set the parameters of our world and help us to position ourselves within it. The pandemic has cut through so many of those structures and forced us to reshape and reframe them or to somehow learn to manage without them. As is the case for many of us, I did not fully appreciate how important these were in anchoring me and that, without them, I would feel adrift and increasingly lost. Social distancing has become part of our vocabulary and, while it has a specific meaning, it has also created a space between us all that sometimes feels so much greater than two metres. The world of the school child was defined by term time and holidays, by tests and exams, by sports days and nativity plays. All of this was lost to them when the schools closed and, although parents and teachers tried to recreate it, I imagine that it felt like a shadow creation that barely reflected the real thing.

As the ‘Big issue’ report describes, the prison inmate has been taken from their former world and placed in a system defined by jangling keys and electric bells, where every day must feel the same. They have very little control of their situation and daily lives. I would imagine that, for many of them, the routine is boring at best and could easily become dangerously oppressive. The disconnection that I have felt from much of what constituted my former life has led to a gradual acceptance of my shrinking world, where the actual changes I have had to make have become introjected to the point of now being barely noticeable. It is this disconnection that has shaken the foundation of my personal wellbeing, and I imagine it is an important element for many people experiencing poor mental health. I have become acutely aware of how fragile our constructed worlds can

Michael Golding

Deputy Chair, BACP Board of Trustees

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become when just a few of the pieces are taken away. The cancelled Christmas gatherings, the weddings and funerals we could not attend, the goodbyes that were not allowed – we have absorbed all of these. The losses have accumulated and it is all too easy to keep going without acknowledging that many of us have come perilously near to running on empty. While some people have been able to tap into a resilience they did not know was there, others have been tested and continue to struggle. Sadly, it is often the case that it is only when we pass that tipping point that we, and those around us, acknowledge that we need some help. We are told that there is a mental health crisis, which is often expressed quantitatively as a percentage of the population. I wonder if the most important shift is not so much the scale but the qualities of that mental distress. So many of our reference points have shifted in the past two years that it seems as if the maps we used to navigate by now need to be redrawn. Some developments have been surprisingly positive, with staff given the opportunity to work from home and therapists embracing online work. BACP is now operating a hybrid system for staff, which combines the best of both worlds. As a counsellor, I never imagined not being in a room with a client but I have been surprised how strong a connection can be made online. I also recognise that this improves access for those who might struggle with in-person contact. For a long time many of us have been occupying spaces where no movement has felt possible. I feel as if I have been standing still for far too long and I am looking forward to stepping out on my journey once again.

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Email your views on Therapy Today articles to therapytoday@thinkpublishing.co.uk *Views expressed here are views of contributors, not

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Becoming race aware

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Catherine Jackson’s ‘Big issue’ LETTER (‘Putting race on the training agenda’, OF THE Therapy Today, October 2021) MONTH reminded me of my experience of training in social work in 1995. I will never forget how I had my eyes opened by an experience that changed my life. I am a white woman and, although I thought at the time I was aware of race and difference having lived in a multicultural area, I soon realised I was not. I attended college as usual one day and, unbeknown to me and colleagues, we were all to be treated differently. I was put into a group and we were asked to present our findings on some research. Our group got much praise and it felt good. We had no idea we had been given more information than anyone else. I began to notice that other students were not doing so well. However, before we could all get together to discuss, we moved onto another topic. Later, I was taken aside by a tutor to downgrade one of my essays with no explanation other than the implication that I could not have written it, which was both frustrating and disturbing. In the afternoon, we were told the morning had been an experiential process to prepare us for a discussion on race. It made the subsequent lecture so meaningful and effective. I realised that the few hours of discomfort I had experienced was a daily experience for many, and that challenging myself needed to be an ongoing process. What made the experience so useful was that it was not named a ‘race, diversity and difference’ lecture/day. The discussion of race was not limited to this day but was an integrated part of the course throughout the two years, and I graduated wanting to change the world and with the knowledge that I had a part to play in this. When I later trained in psychotherapy, I was shocked at how little race was explored or openly discussed and that students left the course with their assumption that they were ‘race aware’ unchallenged. Training needs to challenge students as well as enable them to grow and develop, and race training has to be so much more than a day or a lecture for this to happen. Alison Edwards MBACP

Black History Month The October issue of Therapy Today should prove to be a valuable resource for students and trainers wanting to engage with issues relating to difference, diversity and inclusion. If I may single out an article out of many excellent ones, it is ‘Putting race on the agenda’.

It highlighted the importance of appropriate training for trainers, revived a possible focus on ‘cultural competence’, and highlighted the need for counsellors with perhaps limited life experiences to spend time in different environments than they are used to. Good news too that BACP is developing an ‘equality, diversity and inclusion’ toolkit

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for counselling training. There may be implications for training and for accreditation – in the future, perhaps trainees (and trainers) will need to demonstrate that they are ‘culturally competent’. To further all these objectives, I wonder if Therapy Today could offer other dedicated issues on gender, class and disability. Within inclusion discussions, there seems almost to be a hierarchy, with race and ethnicity at the top, and gender, and class and disability rarely getting airtime. It seems significant that, when I wanted to recruit for a diverse supervision group, I contacted the Black, African and Asian Therapy Network, and this generated several enquiries. There isn’t the equivalent for disabled counsellors, making it much more difficult to recruit from this group. Mike Trier MBACP (Accred)

Reconnecting with nature Thank you to Linda Aspey for her timely article ‘Breaking out of the climate bubble’ (Therapy Today, November 2021). I am keen to use my experience as a teacher and a worker in various conservation industries (and my own lifestyle choices) to inform my practice as a psychotherapist when I qualify. I see our role as helping anxious clients to explore the guilt and helplessness they feel and push back their perceived threat of environmental danger. We could do this by framing our history positively – for example, by researching how human adaptability and creativity have driven our survival throughout history and are now managing sea-level rise, pandemics, pollution etc. We can also explore how, for most of human history, we were interconnected with nature, whereas, although we are still dependent on nature, we have distanced this interconnectedness with our current industrialised society. For more soulful clients, it occurs to me that, to exit the climate bubble, we may need a more philosophical or spiritual therapy, as well as a psychological one, to enable clients to discover their place and the purpose of their connectedness with the Earth. To this end, I have been reading Petruska Clarkson and

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Ernesto Spinelli – two authors who advance practice that is both spiritual and philosophical. Simon Clive MBACP, counselling student I was really encouraged to read Linda Aspey’s article (‘Breaking out of the climate bubble’, Therapy Today, November 2021) on the profession’s response to dealing with climate change-related issues. I recently brought the subject up with the professors of my psychology degree – that I was surprised that this existential threat that affects all of us, without exception, is mentioned nowhere in any of our course literature and is not brought up in study. Unfortunately, they weren’t interested in discussing it. I was asked to take part in a meta-study of questionnaires on levels of happiness and fulfilment. It occurred to me that, no matter how content we are with our personal situations or how fulfilled we feel by our achievements, we cannot feel truly happy if we feel guilty for our lack of climate action, deeply disillusioned by our leaders, or fearful for our future lives and those of the children we are bringing into the world in very possible scenarios of eco-decline, mass migration, disease caused by environmental destruction and all the possible social and mental ramifications. I believe, if we’re encouraged to be brave and acknowledge how we’re feeling about these issues, we will both facilitate better mental health and, essentially, be more likely to act both individually and collectively to halt the destruction of our planet. I look forward to hearing more discussions of this type. Chloé Pettersson, psychology student

Placement problems The ‘dilemma’ on the difficulty in finding suitable student placements reflected my own experience (‘Are we sending trainees to placements beyond their competence?’, Therapy Today, November 2021). I passed my diploma course two years ago and, as a trainee, I had to secure a total of six placements, as five collapsed (through no fault of my own). I sourced my first placement at a local drug and alcohol

The notion that a single theoretical model can adequately describe the almost limitless depths and complexities of what can take place within the consulting room is to me unsettling and potentially counterproductive

counselling service, before my diploma course began. Then the counselling service’s supervisor unexpectedly left and my placement offer was withdrawn. My second placement offer was from a well-known general counselling service in town. Unfortunately, my training college was in dispute at the time with this organisation and I was advised to decline their invitation. A course colleague recommended that I apply to another drug and alcohol counselling service, where a friend of hers worked. Supervision was provided, but it clashed with my diploma course days. I explained this to my training college, but was told that it meant I could not proceed with this placement. By now I was becoming desperate. I therefore contacted the first drug and alcohol counselling service again. They welcomed me back and talked me through the induction process. Alas, the agency then lost the lease on their premises and, owing to their sudden move to a smaller building, my placement offer was withdrawn. My training college found a fifth placement for me at a general counselling service in a neighbouring borough but then terminated this placement after seven months, as they were unhappy with the counselling service and with their inability to provide me with enough clients. I applied for my final student placement after seeing an advert on the BACP website. This was at a large college of further and higher education. I was able finally to complete my training hours there and to gain my counselling diploma. I remained working as a volunteer at this college until last summer. I did approach my diploma course tutor for advice and guidance and, although the response was sympathetic, was told that it was ultimately my responsibility to find a placement opportunity. At the beginning of my search, it also became apparent that many placement providers were only willing to accept secondyear students or those who had already accumulated a number of client hours. I feel that unless training colleges and placement providers collaborate to provide suitable student opportunities, this placement crisis will only continue. Annmarie Moseley MBACP

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What works I read with fascination the article ‘What works and why’ by Catherine Jackson (Therapy Today, September 2021). I am a therapist with 16 years’ post-qualification experience and was chillingly reminded of another aspect that can arise from strict adherence to a particular theoretical model, summed up for me by the word ‘dogma’. The notion that a single theoretical model can adequately describe the almost limitless depths and complexities of what can take place within the consulting room is to me unsettling and potentially counterproductive. The particular theoretical idea that I have in mind is that clients should be held within the transference so that they can work through it in the presence of a person with whom the transference is activated – in this case the therapist. At first glance this sounds highly plausible and I am sure that this approach is a highly effective one in many or even most instances, and especially if done from a place of awareness and with love. However, as my own experience in the client’s chair attests, forcing the client (me) to work through the transference was in fact deeply retraumatising. That experience was of sitting evenly but uncomfortably suspended between transferential rage on the one hand and parasympathetic freeze on the other. The result is described by Peter Levine1 as being internally braced against one’s own self, and it has left me feeling further damaged and with a distrust of therapists. It is unrealistic to expect all practitioners to have a broad theoretical base. However, let’s please learn to question any dogma and be sensitive to trauma. If an approach is not working with a client, then ask ourselves why not and be prepared to alter our approach. To retraumatise a client is, I would suggest, contrary to the BACP Ethical Framework principles of beneficence and non-maleficence. Name and address supplied REFERENCE

1. Levine PA. In an unspoken voice: how the body releases trauma and restores goodness. Berkeley, CA: North Atlantic Books; 2018.

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To the Editor We very much welcome your views, but please try to keep your letters shorter than 500 words – and we may sometimes need to cut them, to fit in as many as we can

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Celebrating wildness

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The interview with Nick Totton (Therapy Today, November 2021) on working outdoors and celebrating wildness in both the outer world and our inner psyche spoke to me on many levels. As I consider embarking on a post-qualification course in ecopsychotherapy with children and adolescents, doubts regularly creep into my mind about how this will affect therapeutic boundaries. I found Nick’s idea of boundlessness useful in framing my existing commitment to approach each therapeutic alliance with open-minded flexibility. Some children prefer me to remain in my therapist’s chair, while others want me by the sand tray with them, or standing to play catch, and other quite active interactions. As Nick says, one might choose to hold strict boundaries because the client needs them, rather than because they are of ‘universal validity’; ‘Another client might find [such boundaries] oppressive and unhelpful.’ While all this comes naturally to me in the therapy room, I am conscious that taking it outdoors reaches a new level. I am aware that taking sessions outside has become something of a trend since the pandemic. I was struck by the absence of reference to any in-depth training sought by professionals prior to taking that step. To work ethically, we owe it to our clients not to take this shift lightly. Working outdoors has very profound ramifications and overlooking the deep meanings (for both therapist and client) of such a shift could be detrimental to any therapeutic process. As Nick rightly states, it requires a ‘surrender of control’ – something that cannot be trivialised if one is to continue providing the containment that is so crucial to therapy. Nick’s idea of unpredictability made me realise how much traditional psychotherapeutic boundaries render us so predictable that they inevitably contradict the very nature of the world we live in. While predictable boundaries are essential for some clients and to specific stages of any therapeutic relationship, surrendering to a perhaps more realistic practice may increase relatedness and connectedness, thereby promoting deeper and more sustainable changes in one’s inner self. While having been trained to see the therapy room as an essential boundary, I am, in my personal life, more of an outdoors individual. Safely and ethically bringing therapy outdoors would beautifully merge my professional and personal values. Florence Nadaud MBACP, children, adolescents and families psychodynamic psychotherapist in private practice

Professor Michael King

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Michael King, a wise, witty and compassionate man, and a good friend to many, including BACP, died in September, aged 71. I first met Michael when we sat on a panel together about counselling in general practice. I’d never met a psychiatrist interested in talking therapies before, and he’d never met a counsellor interested in research. It was the start of a long and warm association that was hugely beneficial to BACP and its research and policy. As a GP, a psychiatrist and a professor, Michael was committed to the development of accessible and high-quality, evidencebased services. He was frustrated by the politics and turf wars between the psychological therapy professions and actively collaborated and published and lobbied – to the benefit of all. An outspoken gay man, he challenged attitudes to homosexuality. Working with the forensic psychiatrist Gill Mezey, he was among the first to undertake research with male victims of sexual assault, looking at the impact on their mental health. His book on this was published in 1992.1 Out of this came the definition of male rape used in legislation. He also worked with the Church of England Synod on equality in the church for people of all sexualities and was an outspoken critic of gay conversion therapy. Michael was involved in trials of counselling and supported the BACP Research Committee for many years. To our amazement, he turned up for a Research Committee dinner the evening before he entered into a civil partnership with his long-term partner Professor Irwin Nazareth, a fellow academic – we forgave him for missing the committee meeting the next day! Michael lived life well, had huge intellectual determination and integrity and was one of the kindest people I have known. He always made me laugh and he always made me think. He’ll be missed by many. Nancy Rowland, BACP Vice President and former Deputy CEO REFERENCE 1. Mezey G and King M (eds). Male victims of sexual assault. Oxford: Oxford University Press; 1992.

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Mental health and the human experience in the arts, media and online REPRO OP

Art

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Songlines Film

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The Box, Plymouth’s new and very innovative gallery and museum, has saved us a 10,500-mile journey to see this once-in-a-lifetime show. Subtitled ‘Tracking the Seven Sisters’, Songlines is an Aboriginalled, award-winning exhibition from the National Museum of Australia. Its 300-plus paintings and objects, created by more than 100 artists, are portals to a journey in the footsteps of the Seven Sisters as, pursued by a sorcerer, they fled across three Australian states. It is a story of pursuit and escape, desire and magic and the power of family bonds. What more could a therapist want from an art show? Don’t miss it. It ends 27 February. www.theboxplymouth. com/events/exhibitions/ songlines

Made by Ffilm Cymru Wales, this documentary musical is a celebration of male friendship. It centres on the point when the Trelawnyd Male Voice Choir, founded in 1933, its members now averaging 74 years old, are having to accept that they must recruit more ‘brown-haired men’ if the choir is to survive. But at what cost? The choir’s leader, Ed Williams, is packing up the family home for sale with the help of his son, who has long left Wales to spread his creative wings elsewhere (and directed the film). The choir has been the heart of the Rhyl community for decades – a place where men share anecdotes, the ups and downs in their lives and an essential camaraderie that supports their wellbeing. Can they preserve what is precious while taking on new recruits, or is the choir, literally, history? For screenings, see www.ffilmcymruwales.com/our-work/men-who-sing

Books

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Men Who Sing

How to be happy at work • Written by US thought-leader Minda Harts, Right Within: how to heal from racial trauma in the workplace offers frank advice to women of colour on how to deal with race-related microaggressions at work and how to heal from resulting racial trauma. (Seal Press, out 9 December)

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• Inevitably, we bring ourselves to our work and workplaces. In All That We Are: uncovering the hidden truths behind our behaviour at work, organisational psychologist Gabriella Braun shares fascinating insights from 20 years of disentangling workplace emotional entanglements. (Piatkus, out 3 February)

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• Provocatively titled, Jerks at Work is about how to pinpoint and deal with ‘toxic’ co-workers. Tessa West draws on a wealth of original research to profile classic workplace archetypes – the CreditStealer, the Gaslighter, the Bulldozer, and more – and advise us how to deal with them. (Ebury Edge, out 18 January)

The Month, 1 Know of an event that would interest Therapy Today readers? Email therapytoday@thinkpublishing.co.uk

Podcast

...HEALING Part of ‘The Art of…’ series produced by the Tate gallery that delves beyond the artwork itself to explore universal themes, this podcast looks at how black women use art and creativity as a healing space. We live in a world where black women are expected to be strong, to be support systems for others, to spearhead political movements, to jump three times as high. Through interviews and conversations, the podcast offers a wealth of knowledge from black women and non-binary people about creative ways of taking care of themselves. Hosts Pelumi Odubanjo and Shanelle Callaghan talk with psychotherapist Dawn Estefan, actor Kelechi Okafor, curators Peju Oshin, Aïcha Mehrez and Alice Insley and artist/activist Nina Franco about their perspectives. Available on most podcast platforms.

NETFLIX

Catch-up

SEX EDUCATION Sex Education is much more than a parade of teenage sexual entanglements in the 21st-century Western world, and in the third series, the barriers presented by poverty and disability, the importance of heritage and racial and gender identity, and the complexities that intersectionality brings are all explored. Plus, for anyone who works with young people, this fun romp through teenage angst, with Gillian Anderson at her raunchy and piquant best, makes for great CPD. Rumour has it, a fourth series is planned... Available on Netflix. Exhibition

Melancholy

Don’t miss

Oxford’s Bodleian Library takes us on an inward journey, following the meanderings of the mind of Robert Burton, author (in 1621) of The Anatomy of Melancholy, the world’s first English language treatise on the nature, causes and symptoms of depression and its cures. The book is surprisingly modern – helpful ‘treatments’ include good food and exercise, laughter, reading, friends and music. Burton’s parting words of advice to the reader are: ‘Be not solitary, be not idle.’ Curated by a panel of Oxford-based experts in mental health research and the humanities, the exhibition explores how Burton’s holistic and wide-ranging conceptualisation of ‘cure’ has resonated throughout the past four centuries in contemporary understandings of and prescriptions for mental health. Until 20 March. bit.ly/mel-anatomy

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Working behind bars

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Does therapy have a place in addressing the mental health crisis in our prisons? asks Radhika Holmström

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oor mental health in prisons comes with deadly consequences – self-inflicted deaths are nearly nine times more likely in prison than in the general population. Every five days a person in prison takes their own life, and 70% of these people have already been identified as having mental health needs.1 According to a recently released report from the House of Commons Justice Committee, the ‘disjointed and incoherent approach’ to care in UK prisons has left many prisoners suffering from mental health issues without access to treatment or diagnosis.2 ‘When you look at the data, poor mental health is spread right across the prison estate,’ says Andy Bell, Deputy Chief Executive of the Centre for Mental Health, a mental health campaign and analysis group. ‘There are multiple and complex needs across the population.’

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The recent TV drama Time, said by many in the industry to be true to life, painted a brutal picture of a typical UK prison – noisy, violent, overcrowded and overrun with drugs. The challenges facing the UK prison system are well documented – underfunding has led to staff shortages and high staff turnover, and the prison structure itself is often made up of overcrowded, run-down buildings, where prisoners spend hours locked up with nothing to do. Prison culture, where distress, self-harm and suicide attempts can often be seen as manipulative, rather than indicators of need and vulnerability, contributes to an unsafe environment, according to a 2017 report by the Howard League.3 This unsafe environment also exposes professionals working in prison to multiple potentially traumatising experiences, which negatively impact their own wellbeing

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and the care they can provide, and in turn contribute to a prison environment that is unsafe and non-rehabilitative. There is growing concern that the situation is spiralling out of control. It’s clear that improving the prison environment is fundamental to improving prisoners’ mental health. But until that happens, how can we as a profession support vulnerable prisoners? Do traditional talking therapies have a viable role in UK prisons, and if so, what are the challenges we face in effectively delivering such services?

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Unmet needs One of the challenges highlighted by the Justice Committee report is the practice of using prisons as a ‘place of safety’ for those with acute mental health needs when mental health services are inadequate or absent in the community. The prison population also has a high proportion of people with learning disabilities, as well as those from marginalised groups who may have a higher level of unrecognised and unmet mental health need. Yet, according to a report by the Prisons and Probation Ombudsman (PPO), concerns about mental health problems are only flagged on entry for just over half of affected prisoners. It also found that nearly one in five of those diagnosed with a mental health problem received no care from a mental health professional in prison.4 In fact, screening for mental health issues at prison reception is often done by a staff member, who may have limited training in mental health, according to a recent report from the Centre for Mental Health, The Future of Prison Mental Health Care in England, commissioned by NHS England and NHS Improvement.5 It also found that, although the national specification for prison mental health care sets out a stepped-care model, there appear to be large disparities and the threshold for accessing secondary mental health care is even higher than it used to be.

Adapting to prison constraints Counselling has a key role to play, but providing talking therapies in prisons is not straightforward – Bell points out that prisoners may be moved without notice,

or serving a very short sentence. ‘Knowing that, it’s important to think about brief interventions that can be useful – almost psycho-educational opportunities,’ he says. ‘At the other end, you have people who have very long, and even indeterminate sentences, including some for whom long-term therapy is potentially very helpful.’ There are also fundamental logistical problems with providing counselling in prison, says BACP Vice President John Cowley, who has a long-standing interest in this area and set up BACP’s Criminal Justice Forum (currently inactive). ‘In prison, people’s experience is both chaotic and regimented,’ he says. ‘And if the prison officers decide something won’t happen, it won’t. Or someone may have a single session and then be moved. Prisons are very noisy places, and it’s very difficult to find places for private conversations.’

Gaining trust A further challenge is gaining the trust of prisoners. It’s essential that counselling services are seen to be run by an external provider and separate to the prison system. Counselling also needs to be the prisoner’s choice; autonomy is scarce in prison, points out Andy Bateman, lecturer in counselling at the University of Bradford, who has extensive experience of prison work. ‘In prison, if you’re lucky, you get to choose what you have for dinner or whether you go out of your cell,’ he says. ‘Prisoners need to experience what it feels like when they choose not to go to counselling.’ Prisoners are also a user group who may have low expectations of how talking therapy can help. ‘The people

‘The people you’re working with typically don’t have experience of good professional relationships and no real concept of what psychotherapy is’ THERAPY TODAY

you’re working with typically don’t have experience of good professional relationships, such as in schools and education,’ says Peter Stevens, Head of Psychological Therapies at Greenwich and Kent prisons for Oxleas NHS Foundation Trust. ‘They also may have no real concept of what psychotherapy is.’ There needs to be a lot of reassurance work before therapy starts, says Emma Coulson, a service development manager for The Forward Trust, specialists in working with addiction, who deliver IAPT services in prisons in London, Hertfordshire, Essex and Suffolk. ‘We do an induction session for all potential clients before they start any work, and we talk about what they want and how it’s a collaborative process. We talk about expectations and the process, and how they can stop at any point. And to make it prison specific, adapted to the environment they are in, we have changed the language in our workbooks to make them more accessible. It’s about normalising what we’re going to do, the different approaches, any concerns they’ve got about the term “therapy” and so on.’ Bateman says that therapeutic work in prisons doesn’t always need to be provided by counsellors – the key is that the person can be trusted. ‘I think there are lots of people offering what we might think of as counselling services, who we might not necessarily think of as counsellors. What is needed is someone who will come in and sit in front of a person in distress, and in prison that may well be based in the chaplaincy,’ he says. Listening schemes, a Samaritans initiative that trains prisoners as peer supporters, also provide a key service for prisoners at risk of self-harm and suicide. Reaching this client group also means thinking beyond traditional one-to-one work. ‘Lots of men who have kids will hook onto parenting classes because they probably haven’t had very good parenting themselves and have a fantasy of how things will be when they come out. There may be a way of working counselling into that, in terms of how to be a man and how to build relationships with your family,’ says Cowley. He has also had

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surprising success with teaching guided relaxation exercises to prisoners. ‘However it’s delivered, I think there is a space for something that teaches prisoners how to manage their thoughts and find a safe space in their head.’

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All prisoner healthcare is provided by the NHS. The stepped-care model of mental health common in the community is also applied in prisons and is flagged as best practice in the Centre for Mental Health report.5 But, just as in the community, therapeutic work is often delivered by psychologists and mental health nurses. The first step typically involves shortterm interventions and guidance for people to support their own mental health. The second moves up to groupwork, involving different approaches over several weeks; the third involves one-to-one CBT work; the fourth, multidisciplinary support for people who have been given a formal diagnosis, and step five is for people with the most severe mental illness. Steps one to three effectively mirror IAPT provision in the community, with some important differences. ‘We’re in a very different setting, working with people with a level of need who wouldn’t be appropriate for IAPT anyway,’ says Dr Janet Swift, Psychology Lead for Devon Partnership NHS Trust, working with prisons across Devon. ‘However, we are very clear that this is a space to think about their mental health, the same as for anyone in the community. Our focus isn’t on their offending behaviour or their risk to others. I think we present a really clear message that the service is part of the NHS, not the prison. We’re also very clear that there is some specific information we might share with the prison but otherwise the service is confidential.’ Referrals come from staff who have contact with incoming prisoners on reception, but anyone who works in the prison service can refer a prisoner at any time. ‘Prison residents can also self-refer. There is no barrier for them coming in – that’s our aim,’ says Sarah Krys, Service Manager for Prison Mental Health for Devon Partnership NHS Trust. ‘One of the things we see in prisons is that, if we

‘There is a space for something that teaches prisoners how to manage their thoughts and find a safe space in their head’ involve prisoners, it lends more credibility to the service. We’re working on employing peer support workers – prisoners who are currently serving a sentence, who do an initial training programme and are paid for their involvement. We hope in future they’ll be able to co-deliver and even deliver some of the groupwork.’ As is increasingly the case in the NHS in general, roles for therapists within this stepped model are limited. A psychotherapist may supervise therapeutic groups for prisoners, for instance, but the groups will be delivered by assistant psychologists. Experienced psychotherapists may also be involved at stage four, the equivalent of a referral to a community mental health team, but not always. ‘At this stage we’re often looking much more at the medical model, with access to a psychiatrist, possible prescribing and/or transfer to a secure mental health hospital. Talking therapies may be involved here too if it’s appropriate for the individual,’ says Swift. At the same time, there is also increasing recognition that most prisoners have experienced significant amounts of trauma and adversity in their lives. ‘We are interested in how that manifests in, for example, PTSD or anxiety,’ says Dr Laura Blundell, clinical psychologist and senior psychological therapist with Oxleas NHS Foundation Trust. ‘That’s the core of our model, that we’re always thinking about trauma-informed delivery, and we’ve done a lot of work training operational staff in how we’re working with a complex client group that has experienced significant trauma.’ Oxleas follows a similar steppedcare model to the Devon one, and it’s at stage three or four that longer-term

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psychotherapeutic interventions are brought in. ‘The approaches we usually take are predominantly trauma-based such as EMDR or trauma-focused CBT. Step four is when a longer-term programme of 10 to 16 sessions of psychotherapy or counselling might take place.’ Voluntary and independent-sector counselling services can tender to provide IAPT and other NHS services in prisons. The Forward Trust, for instance, provides substance misuse sessions in 21 prisons across the UK, as well as IAPT-style provision in five of the 21. ‘Most of our referrals wouldn’t have been accepted onto IAPT in the community,’ says Emma Coulson, ‘as a lot have a number of disorders and they may be misusing substances and/or medication. We have flexible criteria.’

Working through shame NHS services aside, much of the counselling in prisons is provided by small services local to the prison, often initiated by individual practitioners in response to need. Mo Smith, a BACP senior accredited counsellor, set up and manages a counselling service at HMP Stocken, a Category C prison in the East Midlands, which she has documented in her book Journey to Release: counselling in a UK prison (Waterside Press). The service is currently staffed by 19 counsellors, half qualified and half trainees. ‘We listen to prisoners without judging them, and we help them understand who they are and what is behind their behaviour. We ask for client feedback at the end of a series of sessions. One prisoner said that counselling “helped to solve real time problems – I have to do the last bit on my own”. Another said, “It helped me understand that it is OK to love myself”.’ But, at the moment, many of the counsellors involved in prison work do so on a voluntary basis due to budget constraints. As Smith says, ‘No matter how much a prison governor may be behind the service, if there isn’t enough money in their budget, they can’t pay for it. I do prison work because it is rewarding and I know it is needed. The volunteers who work with us may initially come to get their clinical hours, but they stay because they

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love the work. You are making a difference to some of society’s most disadvantaged people, most of whom have suffered abuse and trauma. A common theme is that trainees say they feel privileged to do the work. As one said, “No two sessions are the same and it certainly keeps me challenged in a positive way.” Another described how he always comes out of sessions feeling elated that he has enabled the client to have insight into themself.’ Smith only takes on counsellors or trainees with a background in support work or with at least 50 documented clinical hours. ‘Trainees also need a letter from their tutor saying they’re fit to practise in this setting,’ she says. ‘There is also a prison induction process highlighting security and safe practice before they start with clients, and very close support by a line manager and a supervisor. I think all trainees need nurturing, and if they’re going to work in prisons and be safe, they need that nurturing to be very specific.’

Training There is no doubt that working with the prison community is complex and challenging – and also very isolating, says Peter Jones, BACP Fellow. He set up the Counselling in Prisons Network (CiPN) in 2007 to support counsellors working within the criminal justice system. They often feel ‘unsupported and with little acknowledgment of their work or, in some cases, their actual existence as professionals’, he says. Part of the CiPN five-year strategy is to promote the development of a co-ordinated, formal, UK-wide academic network to provide accredited training for prison counselling.6 Jones says his vision is that there will be a postgraduate diploma for therapists working in the prison setting. ‘Students need to be adequately prepared before they go into that setting, and they need to be quite aware of the whole prison context,’ he argues. Right now, the training is gained ‘on the job’, which is why the right supervision is key, says Smith, ideally from a supervisor with experience of the prison service. There also needs to be an awareness that prison counselling is not appropriate for every counsellor, says John Cowley: ‘There

‘You are making a difference to some of society’s most disadvantaged people – most have suffered abuse and trauma’ are all sorts of hidden dangers. Prisoners have nothing to do all day, so one of the games is to find out as much as you can about the person in front of you. Quite conversational questions – Where did you come from? Did you have a nice weekend? – appear very innocent but actually give away quite a lot that could be used against you. It’s an environment where counsellors really have to have their wits about them. Counsellors need supervision from someone who knows about prisons and knows about the risks.’ As Peter Stevens says, counsellors in prisons are ‘working in an environment that is traumatising in itself. You’re sending people back into that, at the end of the session, whatever you do.’ Changing the currently fragmented approach to counselling in prisons starts with taking stock, says Cowley, and finding out how many counsellors are working directly with offenders. ‘Around 10 years ago, when I was Chair of the BACP Criminal Justice Forum, I met with Professor Louis Appleby, then the UK’s first “Health and Criminal Justice Tsar”. He asked how many BACP members worked in the prison system, and I had to admit that we did not know. If the same question was asked today, the answer would be the same. The most powerful thing BACP as a membership body could do now to support counsellors working in prisons is to find out how many are doing this work. Then we can plan how to support them in their valuable work to change lives.’ This data collection is underway. From October 2020, BACP began distributing a Workforce Mapping Survey to all renewing members to build up a picture of the employment landscape, and within this there is an option to indicate prison work.

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Talk to any counsellor who has worked with prisoners, and they will tell you how important it is. Many believe, like Smith, that counselling has a key role to play in preventing reoffending and it should be part of the rehabilitation process of a prison sentence. ‘Counsellors give the clients something they have not had before – the chance to be heard,’ she says. ‘We work with prisoners to help them accept the circumstances that have been beyond their control, as well as explore how they look at their future, and that is potentially life changing. I have a firm belief that there is a need to have quality counselling services within our prisons and I have seen for myself their value and importance.’ Time will tell whether this role becomes universally recognised – and remunerated accordingly – and if counselling in prisons evolves in a way that makes it sustainable for counsellors.

• Are you offering therapeutic support in prisons? We are interested in hearing from you – email therapytoday@thinkpublishing.co.uk

About the author Radhika Holmström is a journalist specialising in health, mental health and learning disability issues. www.radhika-holmstrom.com

REFERENCES 1. Morse A. Mental health in prisons. London: National Audit Office; 2017. bit.ly/3ASw3r9 2. Neill R et al. Mental health in prison. House of Commons Justice Committee. Fifth Report of Session 2021-22. bit.ly/3AR0o9C 3. Preventing prison suicides: staff perspectives. London: Howard League for Penal Reform; 2017. bit.ly/2Z4etUd 4. Newcomen N. Learning from PPO investigations: prisoner mental health. London: Prisons and Probation Ombudsman; 2016. bit.ly/3C0quII 5. Durcan G. The future of prison mental health care in England. London: Centre for Mental Health; 2021. 6. Jones P. Promoting excellence in therapy in prisons: the 5-year strategy. Counselling in Prisons Network; 2019. bit.ly/3GBuORk

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s any therapist working in private practice, or any service provider, will tell you, the admin involved in running a practice can be time consuming. At its most basic level, it includes scheduling and booking appointments, tracking payments and recording and safely storing client notes and other personal data. I’m assuming I’m not the only practitioner who uses a mixed bag of digital and manual/ paper- based approaches. It seems to work fine, but I often wonder if it could be done more efficiently, saving time and freeing up headspace, if I embraced one of the many software programs on offer designed for therapeutic practitioners. I also wonder whether clients will increasingly expect the kind of service offered by many of these programs, such as text or email reminders of sessions, invoices with one-click payment, and the option to log onto a website and view available appointments. And then there is the question of security and GDPR compliance – cloud-based practice management software allows you to securely store client notes and data separately from your personal devices. It also offers a potentially more streamlined ‘clinical will’ option, whereby the practitioner/supervisor designated to inform your clients in the event of serious illness or death could securely keep (for example password protected on their device) the log-in details for your software, so they can access your client contact details in an emergency. Keeping digital rather than paper records also solves the problem of where

to store your growing collection of client notes. It’s telling that the retailer John Lewis recently announced it would no longer stock filing cabinets, suggesting that, as a nation, we have used the lockdowns to finally transition records and paperwork to digital.1 But practice management systems are about more than record keeping – software providers are now striving to be a ‘one-stop shop’ for practitioners, with many offering integrated

Practice management options All services offer a free trial and, except where indicated, services are suitable for both individual and group practices bacpac. A collaboration between BACP and NHS software designers Mayden, launched in 2015, bacpac is simple and therapy specific. From £18 a month (concessions available for newly qualified, charities and group users). Pragmatic Tracker. Talking therapy-specific software system with a focus on tracking client outcomes using a range of measures, as well as record keeping and appointment scheduling. From £150 for a 12-month contract. BACP has a number of free licences for members as part of the Advancing Practice through Tracking (AdaPT) project. See bit.ly/Proj-AdaPT WriteUpp. A popular choice for talking therapists, launched in 2008, with an emphasis on friendly customer support. From £17.95 a month for one user. Power Diary. Launched in 2008 in Australia, it’s now a slickly designed market leader with global support teams. From £4 a week for the first six months. Cliniko. A global program launched in Australia in 2011 and originally aimed at health clinics. Free for registered charities (normally £29 a month). Counsel360. Launched in 2017 and UK based, specialising in programs for counselling services. Prices vary by volume of user, but the typical cost works out at less than £1.50 per client session. Kiku. UK-based talking therapy-specific system with an emphasis on practitioner support and community. From £9.99 a month.

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videoconferencing and client invoicing systems with one-click payment options linked to financial service software such as Stripe, which means clients’ bank account details are held separately and securely. One size does not fit all when it comes to therapy, and one of the most appreciated features of today’s practice management systems is how customisable they are. That means you can create your own templates for client messages and record keeping, either by tweaking the system’s templates or starting from scratch. And there is much to be said for using a personalised template for process notes – filling in information under subhead prompts can be a time-saving way to ensure you record key information after a session in a consistent way. One of the other main advantages of a subscription-based platform is that you get unlimited access to cloud-based storage, freeing up space on your laptop or tablet, and also offering you security and continuity should your device crash

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or get hacked. All this does come at a cost, however: monthly subscriptions average at around £18, although, in an increasingly competitive market, all offer free trial periods and some reduced price introductory deals.

Getting started If you’re just starting out in private practice, it makes sense to start from scratch with a digital system. More established practitioners may be wary of the perceived ‘hassle factor’ involved in transitioning over to such a system, and then getting the hang of it. But providers are aware that this is a major barrier, along with lack of personal confidence in getting used to new technology – the ‘not-good-with-computers’ factor. Much of the work that has gone into designing these systems has been focused on making them user friendly – simply because, otherwise, users won’t use them. ‘We have designed the system to feel intuitive and natural,’ says Damien Adler, a psychologist turned CEO and co-founder of Power Diary, an Australian-originated system that is now being promoted in the UK. ‘We also hire good “people people”, then we train them about IT – we don’t hire technical wizards, and then try and teach them to be “people people”. So the team are very aware that this is novel to many users, and the emphasis is on explaining and adapting to user-learning style, which might mean watching videos, having a conversation, or being walked through a test site step by step.’ Getting started can seem daunting but, as Bob Bond, co-founder and CEO of the British-based system WriteUpp says, you don’t have to do it all at once. ‘Taking a step-by-step approach can be more achievable for many. Some practitioners, for instance, start by using the appointment management side only, to book in client sessions and send reminders, while still using paper client records. Once they feel comfortable with the booking system, they can then think about trying the record-keeping system. Some people do it the other way round, starting with the digital record-keeping side but continuing to use their paper or digital diary for client appointments.’

‘It can be a value-for-money way to streamline your practice’ Kelly Porch is a counselling trainer and a Kettering-based counsellor in private practice who manages her practice with WriteUpp ‘I was looking for a digital system as I work from home and didn’t feel comfortable with the idea of paper client notes stored in my house. As WriteUpp was developed for NHS talking therapy services, I felt reassured about the level of security and GDPR compliance. I signed up for a free trial and just worked out how to use it myself – support was on offer, but I found it was straightforward after watching the video tutorials. There are lots of features I like, such as tracking your income against a target you have set. I also like that the client messaging is customisable – I ask clients to pay 48 hours in advance of their appointments so I have an email message that goes out to remind them. I find it particularly useful for supervision – I can just pick up my tablet and take all my client notes with me in a safe way. You can tag your client records as “open” or “closed”, which means you can see your current active caseload in an instant. I think I could probably make more of it if I spent some time exploring all the options, and there are features I don’t need such as the client payment system and the videoconferencing, as my clients are comfortable with Zoom and paying by bank transfer. If you are just starting out with one or two clients, the monthly fee may not feel worth it, but once your practice is established, it can be a value-for-money way to streamline your practice.’

If you’ve previously kept digital notes, such as password-protected Word documents, you can easily upload these to most systems. With handwritten notes, Bond suggests taking a ‘start from scratch’ approach. ‘Choose a date from which you’re going to go digital, and record client notes on the system from then onwards. You could create a summary document of key points for each client’s history and progress so far. It’s the model NHS services took when they transitioned to digital.’ You may want to keep your existing paper notes for the length of time suggested by your liability insurer (usually six years after the work has ended, which is the window within which a client can bring a complaint), but at least they will no longer be growing.

Practice growth Not surprisingly, most software providers saw an increase in demand last year, especially from counselling services who were suddenly faced with the prospect of co-ordinating several practitioners

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working from home. ‘It can feel like a big leap for a service that has been entirely paper based,’ says Gareth Creaney, co-founder of Counsel360, a British- based company providing digital solutions for counselling services employing 25-100+ practitioners. ‘We start with a system that the admin team can work with. Then it can be rolled out to the individual counsellors. Services are increasingly looking for a way to deliver consistency of service that is GDPR compliant, even if counsellors are working mainly from home. The appointment booking and reminder process is particularly valuable – one manager told us that the text reminder service reduced client DNA rates from 25% to 5%.’ Many software management systems aimed at services also offer an efficient way to track outcome measures such as CORE, PHQ-9 and GAD-7 to demonstrate the effectiveness of the service, and also as a way to map typical client profiles, both of which are increasingly necessary when bidding for

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grants, funding or contracts. ‘Investing in a practice management system can play a key role in helping a service grow, and we can design it with that in mind, to fit where the services want to be, as well as where they are now,’ says Creaney. Some of the newer providers market their products to holistic ‘therapists’ in the broadest sense, to widen their customer base. Of course, many of the features – client records, appointment booking – are transferable to talking therapists, but some features may be redundant. Would you use a function that allows new clients to book a session with you directly from your website, for instance, or for existing clients to be able to log in, see what sessions you have available, and move their appointment? Many systems also offer the option of client log-ins so they can access their notes and records, which not every talking therapist would want. ‘Don’t pay for all the bells and whistles if you won’t be using them,’ says Bond. bacpac is one system that was specifically designed to be simple – ‘the first logical step away from pen and paper,’ says Martin Davies from Mayden, the software company that collaborated with BACP to create this talking therapyspecific practice management system in 2015. ‘Our emphasis is on secure and consistent record keeping, simple analysis of outcome measures and diary management. Sometimes therapists start with us and then move on because they want more, such as an invoicing or direct payment system, and that’s fine. You can download your data into a secure file and easily upload them to a new system.’ No system can suit every practitioner, however, as we all work in different ways. For Newcastle-based counselling psychologist Dr Rhian Lewis, the solution was developing her own program, Kiku. ‘I went to a local software developer and said, “This is what I need, can you design that for me?” and they did,’ she says. She initially offered it for free to other practitioners, and recently started to charge for it. The choice of systems can be overwhelming, and the basic functions are offered by all, so it might help to think

‘It has saved us loads of time on voicemail ping-pong’ Rebecca Fox is Clinical Lead and Managing Director at Trauma Recovery CIC, a Hertfordshire-based counselling service, which uses Power Diary ‘Pre COVID, all our work was based at the centre and most of our records were on paper, apart from a basic client database. As soon as we started to work remotely, it became clear we needed a digital system. I did some research and settled on Power Diary as it seemed to offer what we needed at a price we could afford for our team of eight counsellors and an admin assistant. Transitioning over to the database was quick and simple, and we took a “start from scratch” approach with process notes (we still have the old paper notes in a secure lock-up). I learned to use it by trial and error, and found the templates for the client notes and email responses simple to customise. When I did need support, it was available through messaging via a chat box, with follow-up emails. Our admin assistant also adapted very quickly, but the counsellors found it more difficult, so I had to do individual training for them, using a split screen and talking them through it step by step. Apart from consistency of client messages and record keeping, one of the biggest benefits has been simplifying our assessment process. We work with victims of sexual violence and get funded client referrals from several agencies. Now we can send new clients a link to a portal where they can see available appointments and book their assessment online – that has saved us loads of time on voicemail ping-pong. It has also made case management more efficient – I can quickly pull up the notes before the meeting and also look at them at the same time as the counsellor working from home. Teething troubles aside, going digital has been time saving and has certainly helped me manage the service during COVID.’

about what else is important to you to help you choose. If, for instance, you are interested in tracking and analysing client outcomes, make sure the software offers this analysis. Does it, for instance, allow clients the option of inputting outcome measures directly into the system? Does it present client progress as a graph? Or if you would like to simplify your payment system, look at one of the more sophisticated packages. For therapy services, a program that incorporates a secure videoconferencing system could save you the costs of a professional Zoom licence.

Try before you buy

Most systems offer a free trial, and full ‘onboarding’ support should be available during this trial period, so, as well as the functionality, be sure to test that. How quickly do you get a response to a query? What other ways can you get support – for instance, are there instruction videos to watch?

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Trialling a system properly does require time and effort to enter the details of your active clients and appointments into the system, so it’s a good idea to do some research first. But, as with bacpac, most now offer simple ‘offloading’ options, where everything you have entered in the system can be transferred to a secure file, from where it can be uploaded to other programs. It’s worth visiting the websites of the main systems on offer (see the panel on page 22) – many offer sample pages to view so you can assess if you like the look and feel of the product. Of course, no system, however sophisticated, will offer you exactly what you need. But every practitioner I have met who uses a digital management system says they couldn’t imagine running their practice without it. ■ REFERENCE

1. Wicks P. How we shop, live and look. London: John Lewis Partnership; 2021. bit.ly/3nC0H3c

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was curiously reluctant to have therapy when I was diagnosed with bowel cancer at age 39. I say ‘curiously’ as I refer people to talking therapy all the time in my work as a GP. I see its benefits – it works. Yet I didn’t want to go, not because I was worried about stigma or taboo, or concerned that it wouldn’t help. I didn’t want to go because I didn’t want to be a cancer patient and I didn’t want to talk about cancer all the time. Of course, that seems rather ridiculous now – I was a cancer patient and I was talking about cancer all the time, whether or not I wanted to be. My diagnosis of bowel cancer was out of the blue. No one was looking for a cancer and it was as much of a surprise to my medical team as to me. And then things happen so very quickly, because time is indeed of the essence when it comes to cancer treatment, and I found myself in hospital having major surgery, with an ICU stay, within a week of my diagnosis. There is no time to process, no time to think, and I put my energy into preparing my three young children, and practical things like filling the freezer. After overcoming my reluctance, I started therapy within a couple of months of my diagnosis, and during my first session I barely let the therapist get a word in edgeways. She maybe spoke three or four sentences the entire session, as the words streamed out of my mouth. Like the women I see postnatally who have a need to tell their birth story, I needed to tell the story of my diagnosis and everything that had happened since. In my early sessions, I told it over and over. I have wanted to be a doctor for as long as I can remember, because I want to help and care for people – a cliché, but the truth. But I don’t just help

and care as a doctor; I do so as a mother, a wife, a friend, a charity ambassador and more. Therapy showed me that I have to also look after me and, importantly, that it is vital – not selfish – for me to do so. Contrary to the advice to go to hospital appointments with a loved one, I chose to go on my own, because I wanted to absorb the information and begin to deal with it for myself before I had to deal with someone else’s reactions. I struggled with other people’s emotions throughout the whole of my treatment, and it meant that sometimes I couldn’t truly express my feelings. I knew people were sad that I was sad, I knew they hurt that I hurt, so I couldn’t keep hurting them more. I also struggled with people’s need for me to be positive, telling me I was strong and brave, reminding me that I was halfway through chemo. I felt their need and didn’t know how to separate that from my own. But therapy was – and still is – my space, both literally and figuratively (although the literal bit got harder when doing it on the phone, hiding in the bedroom from the kids during lockdowns); a space where my feelings are simply allowed and held, be they rage, sadness or pain. It is a place where there are no expectations or judgments made; a place to be held emotionally; a place to allow that release of the flood of feelings that I worry overwhelms others, and a place to be seen simply as myself and not all the roles I play and responsibilities I have. A safe place – that is what therapy now means to me: a place to heal my mind as I heal my body. With cancer, I never felt safe; in fact, even having just had my first set of negative scans and scopes, I do not feel able to trust that I am safe as yet, but for that session, once a week, my mind is safe.

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About the author Dr Philippa Kaye is a GP, author and broadcaster. Her newest book, Doctors Get Cancer Too, is published by VIE.

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Narcissism has become a term of abuse, but for therapists it is also a useful therapeutic concept, says Duncan Barford

ocial media usage is cited as evidence for increasing levels of narcissism among the general population, where ‘recording mundane events becomes proof of your importance’.1 Rather than facilitating a form of communication, the suggestion is that social media somehow creates and proliferates a type of personality. Supposedly, Donald Trump, the former US president, was among them,2 and younger people are increasingly likely to be so.3 But are the exhibitionists and trolls really driven by excessive self-regard, or actually by too little? An alternative to simply calling out the narcissist is to shift our focus onto how he or she appears as such. The journalist and author Jon Ronson describes social media as ‘a great renaissance of public shaming’4 that has enabled the return of public humiliation

as a means of social control. Greater interconnection increases communication and opportunities for comparing our lives with others’, and a means of censuring those perceived as falling short of the norm. An internet driven by shame and its avoidance might not look any different from one supposedly powered by too much self-regard if, as Phil Mollon suggests, ‘shame functions to enhance and preserve the sense of self’.5 From this perspective, shame is a feeling that protects us from vanishing entirely when we feel contemptible in comparison with another. Perhaps what we are living through is not an epidemic of self-love but of shamefuelled desperation to maintain self-regard in an age of constant comparison. The philosopher and cultural theorist ByungChul Han suggests this is an underlying feature of neoliberal politics, which

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harnesses new technologies in order to transfer mechanisms of social control from external authorities right into the mind of the individual themself. In an economy where everyone is constantly comparing themself with others, and striving to remain comparable, ‘everyone is an auto-exploiting labourer in his or her own enterprise. People are now master and servant in one. Even class struggle has transformed into an inner struggle against oneself.’6 The auto-exploitation described by Han leverages the individual’s shame to fulfil the function of external authority. But maybe the response to shame for many people is actually a defensively heightened self-regard – a defiant shamelessness, rather than increased self-regulation.

Labelling and blaming Originally introduced by Sigmund Freud to describe an impersonal force at work within

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every human soul, the term ‘narcissism’ is now frequently used to describe a personality type: ‘Narcissists believe they are better than others, lack emotionally warm and caring relationships, constantly seek attention, and treasure material wealth and physical appearance.’7 People like this certainly exist but using the concept to define a type of person introduces problems. The author and cultural essayist Kristin Dombek has written critically on this subject, after feeling ‘worried by the way the word “narcissism” helps us fetishise our own empathy, as if “we” always have it and “they” don’t’. If we work with clients relationally, rather than diagnosing them, then it is essential to consider the kind of criticisms Dombek raises: ‘When others look more selfish than we do, that’s often the moment when we’re most stuck in our own position, mistaking it for the centre of the universe.’8 Presently, narcissism risks being used too readily as a means of labelling and blaming clients for behaviours that therapists and organisations find challenging.

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A modality of love By looking back to Freud’s introduction of the concept, I do not want to imply that Freud should have the last word, but to remind us what his idea originally enabled therapists to accomplish. If it is true that narcissism has now become an ‘epidemic’,7 then it is timely to revisit how, at first, it was an exceedingly helpful concept to

clinicians, rather than the problem it is viewed as today. For Freud, instead of expressing itself in outward behaviour, narcissism was always silent and internal: ‘This part of the allocation of libido necessarily remained hidden from us. All that we noticed were the emanations,’ he wrote.9 Narcissism is a modality of love – love directed at the self, rather than external objects. Like all love, narcissism is not a problem; only where there are disturbances or injuries to self-love will turmoil arise. In the Greek myth, it was not any excess or shortage of self-admiration that drove Narcissus to suicide; it was grief, arising from the impossibility of possessing his reflection in the pool.10 The US psychologist Leon Seltzer describes the narcissist as ‘intensely driven to succeed, or at least see themselves as successful’,11 yet, surely, someone truly in love with themself would make no effort to be or seem anything other than what they

‘Like all love, narcissism is not a problem; only where there are injuries to self-love will turmoil arise’ THERAPY TODAY

already are. Indeed, it cannot be actions and behaviour that define narcissism (because a person might be driven to succeed by many other considerations), but an inward attitude toward self. The therapeutic usefulness of narcissism is not as a label for behaviour, but as a means of casting light on a client’s relationship to themself. Freudian narcissism is never something a person expresses directly, but an influence working silently inside that affects how he feels and thinks. Consequently, what emerges indirectly from the influence of narcissism spans a wide range of clinical presentations.

Inadequate grandiosity A client, Carl,* had been told by a cousin not to bring his sister, Susan, who was addicted to alcohol, to his uncle’s wake. But Carl decided to bring her anyway. When challenged at the wake, Carl accused his cousin of hypocrisy, because it was well known that the cousin’s wife was also a problem drinker. Carl was surprised when his cousin then broke off contact. Carl would not entertain the idea that his own actions had contributed to this. He insisted his cousin’s hypocrisy was the cause. Despite appearances, Carl’s inability to criticise himself, or consider the impact of his criticism of others, was not due to an over-inflated ego. Carl was still emotionally dependent on his elderly mother, who described her son as ‘my grown-up baby’. His overprotective parents had conveyed

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the message that he should never expect to cope with life. His rejection of responsibility proceeded from a sense that he actually made no impression on people. Negative events were others’ fault because they had agency, and he had none. Rather than too much ego, Carl had too little. Despite his superficial grandiosity, our work involved growing his self-esteem by highlighting how well he coped in other parts of his life, contradicting his parents’ assumptions about his capabilities. A tenet of mentalization-based therapy (MBT) – designed for clients likely to demonstrate narcissistic traits – is to ‘focus on the patient’s mind, not on behaviour’.12 This chimes with the recognition of how Carl’s narcissistic behaviour belied his true underlying feelings towards himself. Narcissism was a revolution in Freud’s thinking. He always retained his idea of the mind as a battlefield of forces, but was obliged to revise his views several times on what those forces actually were. Earlier, the most significant struggle had seemed to be between the ego and the sex drive,13 yet this failed to explain the withdrawal from reality that occurs in psychosis, which evidently serves neither self-interest nor sexual relationships. Freud suggested that narcissism explained the withdrawal. He wrote how the patient in psychosis seems to give up completely on relating to people and things, rather than (as people do more usually) relating to fantasy versions instead. Where fantasies do appear in psychosis, they are treated like external realities: ‘the process seems to be a secondary one and to be part of an attempt at recovery’.9

The world turned inside out In her early 20s, Anne* received a diagnosis of schizophrenia. When she came to counselling she had been taking antipsychotic medication for more than 20 years, and was socially isolated. She believed she was being watched and followed by agents for Mossad, the Israeli national intelligence agency. She also spent many hours browsing department stores because she felt she sensed energies there that provided insights into social and political events. Often these foretold crises, but she had also received a vision of the

‘It felt like we had made contact when she said, “Perhaps it is possible for the two of us to survive in this room”’ universe. Later, she discovered an identical vision described in a book on Jewish mysticism. This was disastrous because it proved her vision had been a lie. It felt like Anne and I were separated by thick glass – she rejected or ignored all my comments and interpretations. She stared intensely, which scared me, until I linked my fear with what our meetings might feel like for her. This signalled a way to continue – not to try to ‘break the glass’ by understanding Anne, but offering to join her on the other side by simply listening and reflecting. It felt like we had made contact when she said, ‘Perhaps it is possible for the two of us to survive in this room.’ Compassion for clients in psychosis feels easier, even though the narcissistic withdrawal is at its most extensive. Maybe this is because it seems so evident that their retreat from reality is needed for survival. Carl disregarded certain aspects of reality, but Anne’s defences were more radical. The deflection of interest from the external world back on herself sometimes replaced reality with images from her inner world, presenting as if they were perceptions. The Mossad agents were frightening, but also, perhaps, the ‘attempt at recovery’ Freud described – intrusive interruptions from an external world that would not allow her to vanish completely. The energies she sensed were also a form of compensation for her social isolation. However, discovering her vision in a book was an unwelcome link back to reality; it felt to Anne as if part of her mind had been taken over by some external force. From this, I understood my interpretations were having the same effect: when I linked Anne’s experience back to reality, it felt to

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her as if I was taking control of or ripping away her mind. Narcissism makes the ego into a libidinal object, and in this way can collapse the usual distinction between inner and outer worlds. Previously, for Freud, some drives were sexual, but not the ego drives. After discovering narcissism, all drives stood revealed as sexual, but whereas some were directed externally (‘object-libido’), others were directed at the ego (‘ego-libido’). As I tried to join in Anne’s reality by listening and reflecting, her behaviour became less strange, and we met more regularly and punctually. Narcissism as a working concept offered the possibility of redressing a supposed imbalance between Anne’s dominant ego-libido and her limited object-libido. There were wonders alongside the horrors in the box that Freud opened. Our mind treating our ego as an object casts light on self-reflexivity. It opens up the domain of what Phil Mollon has called ‘the narcissistic affects’,5 including guilt, shame and self-consciousness, all of which take as their basis the view of the ego as someone else. Narcissism is never renounced, but takes a crucial developmental step when, instead of loving the ego as it is, a person loves what he wishes his ego might become. ‘What he projects before him as his ideal,’ wrote Freud, ‘is the substitute for the lost narcissism of his childhood in which he was his own ideal.’9 This ‘ego ideal’ is the prototype for what Freud later named ‘the superego’. Orienting ourselves to what we feel we should be, rather than what we are, elevates us to the realm of mature, external relationships. Yet this and all our highest aspirations and obligations share a common origin in narcissism, which remains forever close at hand.

Never better Brian’s* ex-wife had custody of their two sons. His contact with them had been limited to a minimum by the Family Court. He took an overdose after the judgment and received a diagnosis of borderline personality disorder. His sons had a chaotic upbringing. Brian brought their behavioural difficulties to sessions – he described his sons’ involvement in

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shoplifting and drug dealing, and their frequent arrests, with a kind of gleeful relish. A father enjoying his children’s difficulties horrified me, but I sensed he would leave if I challenged him directly. From his perspective, he had been prevented from being a good father by his ex-wife and the authorities. He talked about his obsessively houseproud mother, who forbade him to touch items or enter rooms that she had cleaned. His father was addicted to gambling and rarely at home. Brian grew up in an atmosphere of constant criticism. To someone who never felt good enough, aspiring to be better may have remained an elusive concept. Although he made gestures toward supporting his sons within the contact arrangements, this often felt too much. He would angrily withdraw, complaining of excessive demands. He cancelled most of our sessions because he felt too depressed or angry to attend. It felt as if he was only allowing me to see him at his best, and then it was the chaos of his sons he spoke about, rather than his own. Brian seemed obsessed with trying to find what he had never had – a sense of himself as a good person. He was so desperate for this, he could even resort to using tales of his children’s dysfunctionality to demonstrate that he was better than them. Brian’s emotional instability seemed due to the absence of an ideal that might have guided and contained his feelings. Saying anything that made him feel or look bad seemed unlikely to help. At the same time, with my supervisor’s guidance, I was trying to avoid colluding with his sense of victimisation. I focused with Brian on his cycles of withdrawal and feeling overwhelmed as a route into exploring his interactions with others, but I failed. I was ‘a wonderful therapist’, but Brian declared himself beyond help. I suspected he had somehow perceived my horror at his attitude toward his sons, subjecting him again to that often-encountered sense of disapproval, and giving me a taste of how it feels to be rejected as not good enough.

Narcissism now Of these three clients, Brian is most likely to be described as overtly narcissistic, and it is no coincidence he was the one

I struggled most to help. Yet, in each case, despite the contrasts in presentation, narcissism offered a means for understanding more about how the client processed his or her experience – ways to focus on the mind rather than on the behaviour. Psychologists and psychiatrists diagnose, and their diagnostic categories presumably align with actual states of affairs, but theories of narcissism, as the philosopher David Livingstone Smith remarks, are ‘not the sort of story that can be objectively evaluated against evidence [… but] are more visions than theories’.14 Psychotherapists relieve distress by accompanying their clients. Therefore, although a therapeutic concept may not correspond to anything that exists in reality, it can still be helpful if it enhances an understanding of the client and deepens the accompanying. In The Narcissism Epidemic, psychologist Jean Twenge asserts that ‘Freudian theories are not research’. Nevertheless she has devoted herself to showing how narcissism, a Freudian theory, ‘is unfortunately real’,7 arguing in effect that something with no empirical basis can be quantifiable by psychometric tests such as the Narcissistic Personality Inventory.15 Where the psyche is concerned, the word ‘real’ can often mean something different from ‘detectable by the senses’. In the myth, Narcissus was a person, and so, from the very beginning, ‘being a narcissist’ could be taken to mean ‘being a certain kind of person’. But perhaps the myth of Cupid and Psyche16 is a better template for understanding self-love. Cupid (or Eros, the god of love) falls in love with mortal Psyche (the human soul). After many tribulations, eventually they are married. The myth conveys how love and the soul, despite all manner of serious and strange disruptions to their union, should be together. Rather than about a specific person, it is the story of a relationship, which undergoes many developments, changes and trials. It implies that love for the self is a healthy state of nature, and that only obstacles to it create unhappiness. It is perhaps closer than the myth of Narcissus to what Freud’s theory of narcissism set out to reveal. ■

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About the author Duncan Barford MBACP is a psychodynamic counsellor with a particular interest in the problematic aspects of spiritual experiences and the practices that give rise to them. www.duncanbarford.uk * Client names and identifiable details have been changed.

REFERENCES

1. Williams Z. Me! Me! Me! Are we living through a narcissism epidemic? [Online.] The Guardian 2016; 2 March. bit.ly/2984l0Y (accessed 30 September 2021). 2. Lee B. The dangerous case of Donald Trump. New York: Thomas Dunne; 2017. 3. Twenge J. How dare you say narcissism is increasing? [Online.] Psychology Today 2013; 12 August. bit.ly/2R8poCo (accessed 30 September 2021). 4. Ronson J. So you’ve been publicly shamed. London: Picador; 2015. 5. Mollon P. The fragile self. London: Whurr; 1993. 6. Han B. Psychopolitics: neoliberalism and new technologies of power. London: Verso; 2017. 7. Twenge J, Campbell W. The narcissism epidemic: living in the age of entitlement. New York: Free Press; 2009. 8. Embury S. Are we too quick to call everyday assholes narcissists? [Online.] Vice 2016; 17 August. bit.ly/2sG7JYL (accessed 30 September 2021). 9. Freud S. On narcissism: an introduction. In: Williams A (ed). On metapsychology: the theory of psychoanalysis. Harmondsworth: Penguin; 1984. 10. Graves R. The Greek myths. London: Penguin; 1992. 11. Seltzer L. The narcissist’s dilemma: they can dish it out, but... [Online.] Psychology Today 2011; 11 October. bit.ly/2FSF62f (accessed 30 September 2021). 12. Bateman A, Fonagy P. Mentalization-based treatment for personality disorder: a practical guide. Oxford: Oxford University Press; 2016. 13. Gay P. Freud: a life for our time. London: J.M. Dent; 1988. 14. Livingstone Smith D. A brief history of narcissism. In: Cooper J, Maxwell N (eds). Narcissistic wounds. Northvale, NJ: Jason Aronson; 1995. 15. Open Source Psychometrics Project (OSPP). Interactive version of the narcissistic personality inventory. [Online.] OSPP; 2011. Available from: openpsychometrics.org/ tests/NPI. 16. Apuleius. The golden ass. Ware: Wordsworth; 1996.

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Becoming a parent carer opened Joanna Griffin’s eyes to what this client group really needs from counselling

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uring the COVID-19 pandemic many parents of disabled children (parent carers) saw their already limited support networks completely disappear. It has exacerbated existing problems and highlighted the impact of cuts on care packages, structural inequalities and the discrimination that disabled people and their families experience. Even before the pandemic there were increased risks to parent carers’ wellbeing.1 A report by Contact, a charity for families with disabled children, states that social, emotional and financial isolation causes almost three-quarters (72%) of families with disabled children to experience poor mental health.2 Parent carers may feel angry, guilty, helpless, confused and jealous of families who do not face this challenge. The fight for services can take its toll, leading to caregiver burnout, and parents are often fearful of what the future holds for their child.3 There is also a growing literature on the potential positive aspects of parenting a disabled child, given the right circumstances and when appropriate support is in place. These responses include increased meaning or sense of purpose. Parents may report having grown as a person, gaining a new perspective and appreciation for what is

really important in life. In this article, I share, in italics, anonymised experiences of parent carers, with their permission.

Theory versus lived experience Even though I had worked in the NHS and other settings, including with adults with autism, when my own son received the diagnoses of cerebral palsy, a learning disability and autism, I was completely unprepared. I could not believe how unhelpful certain services were and how poorly they were co-ordinated. Suddenly my eyes were opened to stigma and discrimination. I was also surprised by the lack of acknowledgment of the emotional impact on the family as a whole among the plethora of professionals who appeared in our life. For the past few years I have been undertaking doctoral research into emotional wellbeing in parent carers, exploring how, despite the additional pressures, parents are managing to support their own wellbeing. I specifically focus on parents of children with a learning and/or developmental disability, but many of the reflections here may have relevance across disabilities. In my research, I developed seven dimensions that support emotional wellbeing in parent carers, some of

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which I explore in this article. I use the mnemonic SPECTRA to represent them:

S Having a Sense of purpose and meaning

P Connecting to Positive others E Feeling Empowered C Our relationship with our Child and gaining insight into their perspective

T Finding, and protecting, ‘Time that is mine’

R Engaging in ways to Replenish and recalibrate (a Swiss army knife of self-care) A Awareness of our emotions and the human condition.

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Emotional wellbeing is a term that is both simple and complex. Most people have some understanding of what it means to them, but there is also a broad literature attempting to define it. One image used to illustrate wellbeing as an ongoing, dynamic process is a see-saw.4 I prefer to use an analogy of weighing scales instead, as this allows for the ‘spare capacity’ identified as helpful by some parent carers interviewed for my research, including the one quoted above. Parent carers’ emotional responses are complex and can vary day by day. Professionals can help by framing these emotions as an understandable reaction to an unexpected, and sometimes overwhelming, situation. The analogy of grief is commonly used in the academic (and parent) literature on parent carers’ experiences, although it is also critiqued as perpetuating a negative narrative around disability. And rather than a singular ‘event’ to grieve over, there may be many moments throughout a child’s life that disrupt the family unit and require adjustment. Models of loss that encapsulate the complexity and oscillating nature of emotional responses may be of greater relevance to this client group than Kübler-Ross’s five stages of denial, anger, bargaining, depression and acceptance,5 such as the dual process of loss and restoration.6

Complex responses ‘If you have a child with additional needs, your mental load is higher than a family who has a typically developing child. It’s just that you worry more about more things and there’s just more load, so then, when other things happen, they have more of an impact. It’s like my cup is already full. You have to allow a little bit of capacity. It’s a bit like you know you are going to get a tax bill, so you really should put some time aside each month, some money aside each month. If you wait ‘til the end and you suddenly get a massive tax bill you won’t be prepared, so it’s

‘I needed counselling at the very beginning to get me past the shock. And then I think I needed it again,

‘Denial is often seen as a negative coping strategy, but it may be beneficial in some circumstances’ THERAPY TODAY

because after you come to terms with what’s happened, there are other feelings that you need to make sense of.’ I think it is important to handle the grief analogy with care, for a number of reasons. Parents and professionals may expect a linear pathway that leads to an endpoint, not realising that the process is often more uncertain and unstable. Events can continue to disrupt the life of the family in an ongoing emotional rollercoaster. We love, and are grateful for, our child. Yet this means that, when terms connected to grief are used, it can layer on guilt, which parent carers commonly describe as detrimental to their wellbeing. We still need to do all the jobs involved in having a disabled child, our parenting and caring roles continue, so there can be little time to reflect on our emotions. Although some parents do relate to the grieving analogy, it may be a loss of employment, spontaneity or independence that is ‘mourned’, rather than the ‘imagined’ child per se. And, in direct opposition to the grieving analogy, there are many parents who do not identify with grief or loss at all. Professionals need to remain open to the individual’s experience.

Coping strategies Considering the high levels of stress parent carers report, it is unsurprising that different theories of coping are commonly applied to this client group. Distinctions are often made between emotion-focused and problem-focused coping, but this can be overly simplified. In fact, attempts to categorise coping are fraught with difficulties. A review by Skinner and colleagues7 found that no two studies included the same set of categories. They comment that coping is not ‘a specific behaviour that can be unequivocally observed or a particular belief that can be reliably reported. Rather it is an organisational construct used to encompass the myriad actions individuals use to deal with stressful experiences.’ Denial is often seen as a negative coping strategy, but it may be beneficial in some circumstances. In my research,

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like I have to build into my time the possibility of things happening, issues with [my son], so there’s a buffer.’

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some parents found denial helpful in the early days as it allowed them to continue in their day-to-day activities without becoming overwhelmed. Venting can also be portrayed as an unhelpful emotionfocused coping strategy for escalating negative mood.7 However, several of the parent carers I spoke to found venting a supportive strategy, particularly in safe, non-judgmental spaces such as with other parent carers. This was especially helpful in dealing with situations that could not be changed. To make sense of lived experience in a way that is functionally useful may require acknowledgment that coping is contextual. In a study on chronic illness,8 the authors comment that ‘avoidance of thinking about the future was not used as a way for participants to hide from their problems, as “avoidant coping” is often depicted in the popular stress/coping literature; rather it was a way of directly and consciously addressing the task of adaptation.’ This connects with findings that psychological flexibility supports emotional wellbeing. Kashdan and Rottenberg9 warn that ‘we should be wary of simple, universal strategies’, and refute the idea that some strategies (such as cognitive reappraisal) are always better than others (such as suppression).

Trauma and growth Many parent carers will have been through a traumatic experience such as witnessing the fragility of life or our loved ones experiencing invasive medical interventions.

‘Where there is trauma there may also, over time, be the potential for growth, although that is never guaranteed’

‘I’ve seen my daughter have a lumbar puncture without any anaesthetic and they literally held her down. It was a room full of doctors and they held her down like an animal and they shoved a syringe in her spine. I swear nobody wants to ever see anybody have that happen to them, but for a parent to see that happen to a five year old, you know, that’s brutal.’ Day to day, cumulative, small ‘t’ traumas, such as seeing your child struggle, can also take their toll. Even receiving a diagnosis for your child can be experienced as catastrophic by some parents, although others may find it a relief. As Emerson10 comments: ‘Professionals seeking to support disabled children must recognise the potential of diagnosis or health crises to be traumatic for the parents, and this must shape the service that they deliver.’ Trauma-informed ways of working can lessen the negative impact of services. There are two main requisites: ● the need for physical, psychological and emotional safety through trustworthiness and transparency ● opportunities to build a sense of control and empowerment through choice, collaboration and equality. Where there is trauma there may also, over time, be the potential for growth,11 although that is never guaranteed. Earlier pain is not removed; rather, it morphs into something more manageable or even transformative.

Reorienting

My research identified a process reported by parent carers that I have named ‘reorienting’. The process of reframing, when our mental model of the world becomes challenged and does not work in a new situation, involves deconstructing, rebuilding or adapting in some way. This was relevant to parents in my research, who described a common phenomenon of changing, and changed, values, thoughts, emotions and behaviours, in line with a new life path, wider awareness of the world and their family’s place in it. They had to leave behind fixed, unhelpful views in order to

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respond, in a balanced and flexible way, to the new environment. The term ‘reorienting’, used by a parent carer, integrates the physical sense of being in another world and the cognitive shifts experienced, as well as describing the depth and all-encompassing nature of their journey. Parents report changes in life perspective as well as in how they parent their child. ‘I don’t even try and shoot for normal anymore. I don’t think I ever could even if I wanted to, but I used to try and aim for it and then fall short of it, and that would be a bad mental loop, whereas [now] I’m much more accepting.’ The published literature touches on this phenomenon, but there were differences of opinion as to whether participants’ experience of change was a cognitive shift of perspective or deeply transformative (and everything in between). Reorienting provides a way of representing the full spectrum of ways of understanding the process. It is also relational – the process is supported by connection with positive others, both direct and indirect, including disability and neurodiversity activism, advocacy and representation. ‘It’s just so disorientating when you have a disabled child that you can never find your footing, so you’ve kind of got to get this collective balance.’ One parent carer described how the reorienting process had occurred before the birth of her child. As a strong advocate for the social model of disability (which highlights that, while an impairment can be a challenge, it is the environment that is disabling, not the diagnosis itself), she said: ‘I didn’t see her birth and her disability as a disaster.’ These findings suggest that, if society were more inclusive, accessible and positive towards disability, there would be less of a need for the reorienting process.

The role of counselling As the practical and emotional aspects of wellbeing are often deeply intertwined for

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‘Working with parent carers can ensure services are family centred and focus on outcomes that are meaningful to them’ parent carers, having a counsellor who understands the context is important. ‘[The general counselling] was quite helpful, but then in the same breath, it wasn’t, because the counsellor didn’t clearly understand what it’s like to have a child with a disability and you can talk about it until you’re blue in the face but it doesn’t change it, it’s still the situation, it’s still there… and support is less and less.’ Many parents welcome advice or strategies alongside the counselling role that may require a certain level of expertise – for example, around behavioural strategies or an understanding of sensory overload. Flexibility about frequency of attendance is also crucial – some parents were discharged part-way through their allotted number of sessions with their local IAPT service because they missed a session when their child was in hospital. It can sometimes be useful to refer parents on to other services to get the appropriate advice. Because of the potential strain on the relationship between the parents, couples counselling can be useful at certain times. This can include discussions about each parent’s own upbringing and parenting style, to raise awareness of any tensions between them.

Helping others

A final finding of my research was a strong desire among parents to help others, particularly other parent carers.

In the process of embracing their own child’s difference, parents can develop greater tolerance and empathy in general. They also gain new skills and expertise, although they are rarely asked to collaborate with services, organisations or research more widely. This can be disempowering and negatively affect their wellbeing.

About the author Joanna Griffin MBACP is a parent carer, counselling psychologist, supervisor and senior research fellow at the University of Warwick. She is the founder of www.affinity hub.uk, an emotional support resource for parent carers. Joanna’s book Day by Day: emotional wellbeing in parents of disabled children is published by Free Association Books.

‘Until teams do co-production properly, meaningfully, not just “let’s ask a few parents what they think”, but actually employ parents as consultants within a service to advise, then it will never change.’ Working with parent carers can ensure services are family centred and focus on outcomes that are meaningful to them, which, in turn, supports the wellbeing of the whole family. This desire among parent carers to help others may be directed towards helping themselves. Counsellors can remind carers of the need to take care of their own emotional wellbeing day to day, not only in times of crisis. The therapeutic support I received when my son was younger was helpful as it was offered flexibly over a longer period, rather than just at the point of diagnosis. At times, though, it felt like the emotional support existed in a silo. It would have been preferable if all of the professionals who were involved in our life had some basic empathy skills. There appears to be an urgent need, more widely, for training in active listening skills, emotional literacy, sensitivity and the confidence to have difficult conversations. If more appropriate discussions happened in the initial stages of contact with families, it might mean that referral on to specialist emotional support services would not always be necessary. My own journey has reflected many of the findings in the research, including a need to make meaning of my experience and the recognition that, by helping others, I have also supported my own wellbeing. A key factor that supports parent carers is knowing that they are not alone. ■

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REFERENCES

1. Totsika V, Hastings R, Emerson E et al. A population-based investigation of behavioural and emotional problems and maternal mental health: associations with autism spectrum disorder and intellectual disability. The Journal of Child Psychology and Psychiatry 2011; 52(1): 91–99. 2. Forgotten families: the impact of isolation on families with disabled children across the UK. London: Contact; 2011. bit.ly/3iUvvuE 3. Griffin J. A report into the emotional impact of parenting a disabled child. Researchgate; 2019. DOI:10.13140/ RG.2.2.15565.08169. 4. Dodge R, Daly A, Huyton J, Sanders L. The challenge of defining wellbeing. Journal of Wellbeing 2012; 2(3): 222–223. 5. Kübler-Ross E, Kessler D. On grief and grieving. New York: Simon & Schuster; 2005. 6. Stroebe M. Coping with bereavement. In Folkman S (ed). The Oxford Handbook of Stress, Health and Coping. Oxford: Oxford University Press; 2011. 7. Skinner E, Edge K, Altman J et al. Searching for the structure of coping: a review and critique of category systems for classifying ways of coping. Psychological Bulletin 2003; 129(2): 216–269. 8. King N, Carroll C, Newton P et al. ‘You can’t cure it so you have to endure it’: the experience of adaptation to diabetic renal disease. Qualitative Health Research 2002; 12(3): 329–346. 9. Kashdan T, Rottenberg J. Psychological flexibility as a fundamental aspect of health. Clinical Psychology Review 2010; 30: 865–878. 10. Emerson A. Room of gloom: reconceptualising mothers of children with disabilities as experiencing trauma. Journal of Loss and Trauma 2020; 25(2): 124-140. 11. Cadell S, Hemsworth D, Smit Quosai T et al. Posttraumatic growth in parents caring for a child with a lifelimiting illness: a structural equation model. American Journal of Orthopsychiatry 2014; 84(2):123–133.

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Zorana Halpin describes how a counselling service aims to reach suicidal men who are falling through the gap ames, a 21-year-old student at the University of Newcastle, experienced a rapid decline in his mental health following a routine operation. Feeling distressed, he sought help and was advised at a walk-in centre to attend A&E. There he was asked to wait. He left shortly after, without being seen by any medical staff. Two days later, he died by suicide. His parents, Clare Milford Haven and Nick Wentworth-Stanley, strongly believe that, with the right help, their son’s death could have been prevented. After several years of raising awareness of anxiety, depression and suicide, James’ parents wanted to create a service that could have helped their son. Liverpool was chosen to host the service because of the active network of organisations and individuals in the suicide prevention community, including Mersey Care NHS Foundation Trust, Liverpool John Moores University and Liverpool City Council. In 2018 they set up James’ Place in Liverpool, a community-based therapy centre for men in suicidal crisis. Following the success of the Liverpool centre, a second centre opened in east London in April 2021. Around three-quarters of registered suicide deaths in 2020 were for men, which follows a consistent trend starting in the mid-1990s.1 Before the COVID pandemic, male suicide was at a 20-year high. The centres are needed more than ever and my work as a therapist at James’ Place has shown me that therapy can make a difference to suicidal men.

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Environment matters People working in health or community contexts will know that therapy can often take place in both overly clinical and, let’s face it, quite shabby settings. I still vividly recall

the errant mouse that ran across the room I was practising in as a trainee, just out of my severely depressed client’s eyeline. Before I worked at James’ Place, I’d never really thought about why environment matters, but now I can see why it does. I have spoken to men who find the prospect of being in medical places intimidating. They think they will embarrass themselves, that people will look at them, that they will be expected to talk to lots of people – or even that they will be sectioned and taken into hospital. James’ Place in Liverpool is peaceful and calm, designed with the help of a focus group of men to get it right. Clients talk about it feeling like a ‘homely, safe space’.2 It is easy to see why. It is housed in a beautiful Georgian building; clients are greeted with a hot drink, and taken to a comfortable reception room while they wait. There are beautiful prints on the wall, not the usual posters telling them how to stay healthy. They can use the private, landscaped garden at the back to sit and take some time out. It is vastly different to A&E.

Filling a gap James’ Place has so far seen more than 400 clients, with approximately one-third of referrals coming from A&E. This tells us that, in Liverpool at least, suicidal men are presenting

‘The focus is on men who aren’t already being supported by secondary care services... most people who die by suicide are not under the care of specialist mental health services’ THERAPY TODAY

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to A&E and practitioners in A&E view therapy as an appropriate source of help. James’ Place is not aiming to replace 24/7 emergency provision, however, and the service will always signpost to A&E and crisis support through the Samaritans or Shout 85258 for people at imminent risk. What we are trying to do is to fill a gap. We do that by providing an intensive service for men in acute suicidal distress who do not need psychiatric care but whose crisis precludes services such as IAPT. We don’t operate a waiting list, as the men we see may be in the aftermath or on the brink of a suicide attempt. They may have concrete plans and be taking steps to put those plans into action – for example, stockpiling prescription drugs in order to overdose. It’s crucial they are seen quickly. We respond to all referrals on the same working day and aim to invite men in for assessment within two working days. The focus of the service is on men who aren’t already being supported by secondary care services, such as hospitals or community care teams – in other words, those without access to a suicide prevention intervention. The reality is that most people who die by suicide are not under the care of specialist mental health services.3 A third of those who die by suicide

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have not been seen by health services in the 12 months before their death.3 It’s one reason why the Liverpool service accepts self-referrals, although making sure men know about James’ Place is a challenge. Word of mouth and communications campaigns accelerated by social media can help, and we are working with stakeholders to identify and reach out to specific groups of men. Work with voluntary organisations such as the male wellbeing charity Men’s Sheds can be a route to reaching men from particularly marginalised groups. But we will always need to do more work to find the men that need help the most.

Trusted supporters Once a man is accepted by the service, he will have an hour-long assessment with a therapist within two working days. James’ Place is not always the right place for the men who come to us. If a man is assessed and we think he is unable to keep himself safe, we will support him to get the help he needs. In some cases, this means calling an ambulance. However, what we find in practice is that, once men are

engaged, we can work with them to keep them safe, without the situation escalating. When working with men, we routinely provide information about 24/7 crisis support and support them to create safety plans. As we are a charity founded by parents bereaved by suicide, we encourage all the men who attend to tell their family and friends that they are getting support from us. This reflects a belief that involving a trusted ‘supporter’ will increase the likelihood of success. Research indicates social isolation is a risk factor for suicide, so there is a logic to involving others in the lives of people feeling suicidal.4 Intuitively, the idea of involving friends or family feels right to me, but I am aware it challenges traditional boundaries around confidentiality. We are also aware that clients experiencing suicidal crisis may feel ashamed and could easily be overwhelmed at the prospect of reaching out. We will, of course, still work with a man who cannot provide the name of a supporter. In Liverpool, a network of peer mentors has been established, so that a man who prefers not to involve friends or family may find a supporter through this route.

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Perceived burdensomeness The integrated motivational volitional (IMV) model of suicidal behaviour is one way of understanding how suicide happens and is instructive on why involving a supporter is significant. It highlights ‘perceived burdensomeness’ – the perception that you are a burden, particularly on loved ones, as a core psychological factor in suicidality.4 I notice this playing out when clients tell me they are wasting my time. The way I respond depends on the client, but I may ask: ‘What would it be like to continue with counselling, even if you are wasting my time?’ or ‘I wonder if you think counselling might be a waste of your time?’ I hear clients readily say things like, ‘… it would be better for everyone if I wasn’t here,’ and I have spoken to colleagues who have responded by asking: ‘What does “not being here” look and feel like?’

Cue cards Clients see their therapist twice or three times a week initially, and then weekly, for up to 10 sessions. This frontloading of sessions recognises that clients need intensive

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support. A frank approach to talking about suicide that starts with the assessment continues with therapists encouraged to weave in a specific intervention that asks men to ‘lay their cards on the table’, and involves cue cards designed to prompt or guide conversation. This intervention was designed specifically for James’ Place, led by Jane Boland, the clinician who also helped establish the service.5 I’ve found that using the cards to ask men to reflect on questions such as ‘How did I get here?’ and to offer possible answers, such as ‘I feel overwhelmed by my responsibilities,’ can accelerate the process of unpacking what is going on, both externally and internally. Throughout our work, we focus on the ending of therapy and plan for what support the men can access next, should they require it. If someone was in an acute suicidal crisis at the end of 10 sessions, there would be a discussion about whether the client could benefit from further sessions or be better helped elsewhere.

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Keeping men alive

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Clients arrive at therapy in different outward states – desperate, upset, bleakly humorous, in denial and angry. The changes I see or that clients notice about themselves can be small. By the end of 10 sessions, a client may have tolerated letting someone into their life for an hour a week and no longer be actively planning to kill themself but still feel utterly hopeless and have suicidal ideation. The work is not predictable or straightforward, and it is demanding. I feel physically tired at the end of a working day, which I put down to the emotional ‘rushes’ I am experiencing. For instance, a DNA (did not attend) takes on a whole new meaning in this role. In previous roles, when clients did not show up, I used the space (where I could) to reflect on the client, what might be going on for them and what their non-attendance might mean. Now, I experience an unmistakable flutter of concern. When a client did not attend recently and I was considering how long to leave it before

Help and support

calling the supporter (allowing the client to get in touch), I recalled the experience of James’ mum, and her belief that it would have helped if someone had contacted her and shared their concern. It reminded me what our purpose was – James’ Place has a clear ambition to stop men dying by suicide. It is driven by the idea that therapy might be a crucial intervention in the fight to keep men alive. However, while we exist to help men in suicidal crisis, we can’t stop men dying if they are determined to end their lives. There is a strong culture of support for staff within the organisation, with each therapist having an external supervisor, paid for by the organisation, as well as a separate line manager. This is heavy-duty work and needs heavy-duty support.

BACP has recently updated the following Good Practice in Action member resources on suicide:

● Suicide issues for the

counselling professions in England and Wales (GPiA 057 LR)

● Working with risk within

the counselling professions (GPiA 120 FS)

REFERENCES 1. Suicides in England and Wales: 2020 registrations. London: Office for National Statistics; 2020. bit.ly/3viYFIS 2. Saini P et al. James’ Place evaluation: one-year report. Liverpool: James’ Place; 2020. bit.ly/JamesP2020Report 3. Understanding and preventing suicide: a psychological perspective. BPS position statement. London: British Psychological Society; 2018. bit.ly/3pETH8D 4. Van Orden KA et al. The interpersonal theory of suicide. Psychological Review 2010; 117(2). 5. Boland J. Co-production in a UK community-based non-clinical service for men in suicidal crisis: competencybased interventions and training for suicide prevention. Liverpool: James’ Place; n.d. bit.ly/Bolandpresentation

Measuring outcomes

There is little evaluative research into suicide prevention work with men, so much more needs to be done to understand the mechanics of why therapy might help. A smallscale evaluation for James’ Place suggests that clients completing therapy experienced significant positive change, with results from the CORE outcome measure indicating that, on average, clients’ distress levels reduced from severe to mild.2 Clients spoke to us about positive changes to do with ‘their feelings of hope, improved relationships with family members, and ultimately reduced suicidal thoughts’. 2 Pinning down exactly how and why the James’ Place model is effective will be a focus over the next couple of years as the organisation seeks to grow and help more men. In the meantime, the experiences of men such as Liam* tell of a need for something like James’ Place, and keep us going: ‘I wasn’t going anywhere… I just had one thing on my mind and one thing only. I wouldn’t have survived. [Without the service] I might not be talking to you now. So that’s the sort of impact that it’s had.’

About the author Zorana Halpin MBACP (Accred) is a senior therapist for James’ Place, a charity that runs centres for men in suicidal crisis in Liverpool and east London. She previously delivered group and individual psychological interventions in an inpatient psychiatric unit in London and a rehab unit for dual-diagnosis addiction and mental health conditions in Sydney, Australia. www.jamesplace.org.uk

* Client consent obtained; name has been changed.

‘I wasn’t going anywhere... I just had one thing on my mind and one thing only. I wouldn’t have survived. I might not be talking to you now. That’s the sort of impact it’s had’ THERAPY TODAY

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Battling demons Daniel Hand explores tabletop role-playing games as a therapeutic intervention

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ou’re in a dungeon. You’ve spent the past few hours exploring dark corridors and making your way past various bizarre obstacles – including, but not limited to, flying eyeballs, chests with teeth and giant cubes of jelly – and now you find yourself face to face with the ‘Big Bad’ – a brightly coloured dragon, flames and poisonous fumes pouring from its jaws, its ancient eyes filled with malice. How it got this far underground is a mystery, and how you’ll get past it, a greater mystery still – but the fact remains, it’s here, and it stands between you and the glorious treasure that was the whole point of this entire escapade. So what do you do? As mental health professionals, we know that there are no ‘right’ or ‘wrong’ answers to life’s problems. Every client’s solution is unique to them, and it’s our privilege to aid them in their reasonings. But let’s face it – in truth, there’s only ever one course of action to take when you’re up against dungeons and/or dragons. Reach for the dice. Welcome to the world of tabletop roleplaying games (TTRPG) – a place of epic struggles, larger-(or smaller)-than-life characters and, above all, powerful, deeply impactful relationships. TTRPGs have been a staple of ‘geek culture’1 for half a century now, providing hours of fun, excitement and at times even heartbreak to countless players all around the globe – and that international community is only getting bigger. Frequently described as ‘communal storytelling’, role-playing games (RPGs) see players taking on fictional personas and, using various narrative techniques (and the judicious application of dice rolls), travelling through imaginary worlds of glory and wonder. To an outsider, a role-play session might look rather mundane, perhaps even boring – a group of individuals, gathered around a table, talking. To the players, however, these exercises are nothing less than an escape from the real world – a chance for them to become whoever and do whatever they wish, no matter how impossible, daft or morally questionable those things might be. After a day of reading emails and sorting through spreadsheets, they can, for just a few hours, live a life of high adventure – battling

against evil, robbing the rich to feed the poor, becoming a champion of society. Living, loving, fighting, dying – all without stepping away from the table.2 I’m sure many of you reading this will have spotted within that brief description the almost magical potential RPGs possess when it comes to therapeutic intervention. So why aren’t more of us using them?

Enter the dragon

I’ve been playing RPGs of various systems and settings for (mumble mumble) years now, and even during my basic counselling training I harboured suspicions that RPG-esque activities might prove powerful tools in a therapist’s box. My fellow students frequently had to put up with bizarre presentations about drawing maps, structuring stories and using games in a counselling setting. But I only truly recognised just how powerful a tool they could be when a young client of mine began to talk like a ‘Dragonborn’. Eleven-year-old Eustace* came to see me when his mother grew concerned about his attitude towards his new school, which he had moved to when the family relocated to the UK after an extended period living in China. Put simply, this new place terrified him – there was a huge fear of getting things ‘wrong’ (making decisions was nothing less than traumatic); he struggled to engage both with his peers and with his teachers and, most alarmingly, he had become all but mute for much of the day. Early counselling sessions, with the weirdness of being left alone in a room with an unknown man, were very frustrating for

‘They can, for just a few hours, live a life of high adventure – battling against evil, robbing the rich to feed the poor, becoming a champion of society’ THERAPY TODAY

Eustace. Although he was clearly trying, it was difficult for him to move beyond a whispered ‘yes’ or ‘no’. That is, until Lung came along. Lung (Chinese for ‘dragon’) was a ‘Dragonborn spellcaster’ (that is, one of his ancestors was a dragon – don’t think too hard about it!), who could breathe lightning and send burning symbols flying through the air. It turned out that he had had to leave home because of a volcanic eruption, and now found himself alone in a strange new world. He wanted to make friends but was quite shy; he wanted to help the people of his new home but also really missed his old one. Sound like anyone we know? Bear in mind, Lung came entirely from Eustace’s imagination; I merely offered guidance on the technical details of how the character would play in-game. Within minutes of being created, Lung found himself knocking on the door of an inn, asking if anyone had news of a manticore. And suddenly Eustace was talking! Not just talking, mind you – growling in a deep, raspy voice that one would expect of a being whose throat was constantly scratched by massive blasts of electricity. In a split second, the timidity was gone and only a powerful personality remained. He asked the innkeeper for some food, enquired of any strange happenings in the area, and very quickly formulated a plan to track down and engage – hopefully with words rather than lightning – the terrible monster that was stealing all the local farmers’ livestock. Over subsequent sessions, Lung (and so Eustace) went on many quests – and it was fascinating, insightful and joyful to watch this reserved young man charge his way through a forest of giant spiders, going left and right

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as the mood took him, solving dastardly puzzles and happily chatting to fellow adventurers along the way. By the time his therapy concluded, Eustace understood that decisions don’t always have to be overwhelming (does it really matter which way you walk around a tree?), and had accepted that his voice, his words, his feelings, mattered. On top of that, he was the proud owner of a very nice set of rainbow dice, and – most exciting of all – had invited a friend from school to join him in playing an RPG that Eustace himself would run. And it all started with a single, deep-chested, ‘Hello.’

Through the looking glass

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Role-play has of course been a staple of mental health provision since its inception, providing a directive, action-oriented approach that helps clients discover and try out new behaviours.3 The concept of learning through imaginative play is nothing new, either; as any play therapist or primary school teacher will tell you, imaginative games provide a window into a young person’s state of mind. In many ways, then, the use of RPGs in a therapeutic setting may be viewed simply as play therapy and therapeutic role-play taken to their natural conclusions. Like those better understood forms of intervention, here the practice hinges predominantly on projection, displacement and symbolisation. Taking elements of one’s self – wants, needs, hopes, fears – and attributing them to a third party (in this case, a fictional character) affords the client an opportunity to acknowledge these parts of themself without needing to fear real-life reprisals, and this in turn lets them (sometimes literally) get away with murder – if the character does something morally reprehensible or socially inappropriate, the client is able to hold their hands up and say, ‘It wasn’t me.’ This arm’s-length approach means that clients can try out different ways of actually being people, safe within the boundaries not just of the therapeutic relationship but also of the imaginary world that has been created and populated entirely to meet their needs. Social skills, communication, collaboration, problem solving, frustration tolerance – all these and more can be practised over and over again, for as long as the client needs.4 In his case, Eustace could experience that act of talking, safe in the knowledge that Lung was the one doing it.

‘The use of RPGs in a therapeutic setting may be viewed simply as play therapy and therapeutic role-play taken to their natural conclusions’ And if self-development is one productive aspect of RPGs, another is the opportunity they provide to confront various real-world threats, safe from any chance of harm. Antagonistic personalities or frightening scenarios can be reduced to more manageable dimensions, again to be faced by ‘someone else’. Bullies and abusive parents can manifest as oversized monsters to be challenged, fears and uncertainties may be placed directly in the character’s way – but at no point is the client in danger. These confrontations will usually come about as a result of the therapist’s pointed intervention; but there will be times when the client themself might lead in the creation, thus ensuring (consciously or subconsciously) that their particular issues will appear in-game.5 For example, another client, 15-year-old Jill,* whenever asked to contribute to the game’s world-building, universally suggested that a local character’s father had been kidnapped (or otherwise gone missing). I’m sure it will come as no surprise when I reveal that Jill’s father, long ago divorced from her mother, was soon to remarry. By tracking

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down and rescuing these characters’ errant fathers, not only was she able to act out ‘getting back’ at the individual responsible for her own father’s perceived abduction, but she could also face the realisation that her relationship with her father wasn’t ending just because someone else had entered his life. Above all, though, RPGs are fun, and there are few better means of ensuring a client’s engagement. Rather than a slightly intimidating 50 minutes of unpleasant feelings and difficult questions that hang over an entire week, sessions become an event actively to be looked forward to. Clients who previously turned up late and spent much of the session sitting in resolute silence quickly become enthusiastic participants in the therapeutic process, eager to face their emotional demons as long as it means swinging a sword at an imaginary one. Not only that but (whisper) the therapist might have a good time too.

Trait identification

Central to RPG therapy, as with other modalities, is relationships. Here, though, it is not just the relationship between client and counsellor that is important (though obviously that plays the same vital part as it does in all interventions), but also the relationship between the client and their character. Recent research, focusing primarily on television but equally applicable to other media, has demonstrated that when consumers become immersed in a narrative and relate very strongly to fictional characters, they use the same part of the brain that they use to think about themselves.6 Essentially, this ‘trait identification’ means that we actually internalise and experience a character’s emotions as if they were our own, even when those characters (and emotions) are entirely implausible. You can probably recall a time when you experienced this phenomenon, yourself – remember that time you cried at the movies, cheered when your team scored a goal (too soon?), or groaned at the behaviour of a public figure? That’s you identifying with thirdparty characters. The implications of these findings for the therapeutic process – particularly with regard to self-reflection – are readily apparent, and RPG therapy is perfectly placed to take

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advantage of them. After all, these characters, with whom we ask clients to identify, come entirely from their own imaginations; therefore, they automatically know what, how, and why the characters think/do as they do, without any need for external input. When Lung was surrounded by goblins, Eustace knew exactly how he was feeling because Eustace decided how he was feeling; Jill could empathise with her character’s drive to rescue father figures because she created that drive to rescue father figures. At no point did I need to play emotive music, zoom in on the scene, or wax lyrical about the power of a particular moment – they both just knew. Of primary importance to this approach, then, is the need to help the client create a character that captures their imagination. The huge variety of available RPGs eases this task – if the client wants to play a spearwielding elf or a dog-riding halfling, fantasy is the way forward; if they’d prefer to leap tall buildings or shoot lasers from their eyes, a superhero setting might be more appropriate (indeed, given the current ubiquity of comic book movies, superhero characters are enjoying an extended moment in the spotlight7); or if a galactic fighter pilot is more their cup of tea, perhaps best to go with a space opera. There really is something for everyone, and it’s just a case of grabbing an idea and running with it. Once that core concept is established, simply apply it to the game’s system – and before long, the client will have a shiny new character sheet before them, a handful of dice (don’t forget the dice) and a yearning to see what shenanigans their creation can get up to. Help the client get the character right and everything else will fall into place.

That ‘everything else’ is where the therapist’s imagination comes into play. By taking into account the client’s presenting issues, they can create a scenario that the client will enjoy playing through but that will inevitably lead to a confrontation between the newly designed character and those issues. A client struggling with their sexuality? Perhaps they’ll meet an openly gay wanderer. Anger issues? An enormous green rage monster might need to make an appearance.8 The possibilities are endless. And, once you’ve got all that preparation out of the way, there’s just one thing left to do – have a great time.

About the author Daniel Hand MBACP is an author, illustrator, game designer and integrative counsellor in private practice. For more information on RPG therapy, or to get in touch, see www.monomythcounselling. co.uk

Grab the dice

There are downsides to using RPGs in therapy. For a start, the therapist must familiarise themselves with a daunting amount of literature – even the simplest RPG systems tend to come with countless rules to learn, statistics to understand and terminology to master. The fifth edition of Dungeons and Dragons, billed as ‘the world’s greatest RPG’,9 requires the lead player to be intimately familiar with at least two whole books, both of which are more than 300 pages long. This stumbling block isn’t insurmountable, of course, but it can and has put many people off. Stick with it, and your efforts will pay off – but the first step is always the hardest. It also goes without saying that this approach – as with any other – will not be universally appropriate for every client. The concept of putting on a funny voice and giving yourself a name with too many consonants is not what most people associate with therapy, and it may not suit every individual. Additionally, it is perhaps a little early in terms of empirical research to risk introducing expressly fictional worlds to clients who struggle with some form of psychosis. As always, it’s our responsibility to judge the best way forward. In spite of these niggles, though, tabletop role-playing games are rapidly taking their place within the world of mental health – and I for one couldn’t be more excited. So grab those dice, ready that character sheet and tell your client to pack their imaginary bags. To paraphrase a certain well-known hobbit: ‘[We’re] going on an adventure!’10 Are you coming?

REFERENCES 1. Bean AM, Daniel Jr. ES, Hays SA. Integrating geek culture into therapeutic practice: The clinician’s guide to geek therapy. Fort Worth: Leyline Publishing; 2020. 2. Tresca MJ. The evolution of fantasy role-playing games. Jefferson: MacFarland & Company, Inc; 2011. 3. Miller MJ. Role-playing as a therapeutic strategy: a research review. The School Counselor 1980; 27(3): 217–226. 4. Wilson K, Ryan V. Play therapy: a non-directive approach for children and adolescents (2nd ed). Oxford: Elsevier Limited; 2005. 5. Crawford R, Brown B, Crawford P. Storytelling in therapy. Cheltenham: Nelson Thornes Ltd; 2004. 6. Broom TW, Chavez RS, Wagner DD. Becoming the King in the North: identification with fictional characters is associated with greater self other neural overlap. Social Cognitive and Affective Neuroscience 2021; 16(6): 541–551. 7. Rubin LC (ed). Using superheroes and villains in counselling and play therapy: a guide for mental health professionals. Abingdon: Routledge; 2020. 8. Whedon J, Penn Z. Marvel’s The Avengers. [Motion picture.] Burbank: Marvel Studios, LLC; 2012. 9. Mearls M, Crawford J. Player’s handbook. Renton: Wizards of the Coast; 2014. 10. Walsh F, Boyens P, Jackson P, del Toro G. The hobbit: an unexpected journey. [Motion picture.] Burbank: Warner Bros Pictures Group; 2012.

* Client names and identifiable details have been changed

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How can we become aware of class dynamics in the therapy room? asks Roxy Birdsall

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’ll be honest, despite my own personal experiences, I had until recently been overlooking class in my counselling practice. Throughout my life, I have had a complicated relationship with class. I have faced microaggressions and barriers due to class, from the middle-class, high-school peer who expressed shock and near contempt that I had attained an equal grade to him, to the ongoing struggle to own a home on low income and insecure employment contracts. On the flip side, I have been privileged to access education to a doctoral level and have, at times, benefitted from family members’ wealth and networks. So, even though my life and sometimes sense of self-worth have been shaped by it, class has still managed to fly under my radar. However, I suspect that many other counsellors and psychotherapists may also fail to consider class in the counselling room. In this article, I will explore class in the present day, reasons why class may be overlooked in counselling, the implications of this on practice and, finally, considerations for practitioners to develop awareness of and explore their attitudes towards class. In my exploration of class, I will be using the understanding that social class is about inequality of material wealth and the status it consequently gives an individual. I will also make links between poverty and workingclass identity.

A middle-class profession? Class as an issue of client diversity and an area requiring competency within counselling practice is severely neglected in the UK. Social class features infrequently

in the counselling literature, research and academic discussion, arguably because class is increasingly considered an outdated and irrelevant notion. Despite this, I would argue that class is as important as ever. Many of the UK’s top universities have been found to be rife with classism,¹ working-class women have been found to be the worst affected by job loss during the COVID-19 lockdowns² and rising numbers of people are experiencing destitution year on year.³ So why is class so neglected within the counselling profession? To begin with, it may be pertinent to consider the social class of the counsellors and psychotherapists who make up the profession. Training as a counsellor is expensive. Personal therapy, supervision and sometimes placement fees and travel costs are necessary expenditures on top of course fees. This is not to mention the time spent on undertaking the unpaid work required to gain client hours for qualification. This subsequently creates a barrier for those without established financial wealth, resulting in more middle-class individuals undertaking and completing training. As one participant in Ballinger and Wright’s co-operative inquiry into social class and counselling succinctly put it, ‘You need money to train as a counsellor.’4 Post-qualification, circumstances do not necessarily improve. In the area where I trained, there are two universities producing large cohorts of counsellors and psychotherapists in a region with very few relevant employment opportunities for them. Furthermore, in the same way that many counselling trainees are middle class due to the costs of training as a counsellor, this can be assumed to be true for counselling trainers

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and tutors too. This lack of diversity risks creating a counselling culture with middleclass norms and ideals.

Class blind Beyond a lack of awareness and class-blind attitudes, another issue may be a discomfort in acknowledging or even naming class in the counselling room, even if awareness of this difference is present. Balmforth explored the effects of class difference between counsellor and client on the therapeutic relationship.5 She found that the clients who identified as working class experienced the class difference as profoundly present within the counselling relationship. Although the working-class clients were open to discussing the difference if initiated by the counsellor, the class-based power imbalance meant that it felt risky to introduce the issue themselves. Although potentially a sensitive and tentative task for the counsellor, addressing the class difference may have had profound effects for the clients and therapy. One participant stated that, if the counsellor had addressed the class difference, then they would have felt ‘less inadequate’ and ‘more confident to be myself’. In the commonly practised models of therapy, there can be a predisposition to focus on the internal circumstances of the individual, rather than also acknowledging the injustice of the individual’s external circumstances. As the predominant models of therapy are derived from white, Western thought, it can be said that there is an emphasis on individualism and self-determination. A final issue may be understanding class in the modern age. As Britain has evolved

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economically, socially and politically, what it means to be ‘working class’ or ‘middle class’ has also changed. For example, classification systems such as the National Statistics SocioEconomic Classification group individuals by occupation and employment, and while this may have provided an accurate measure of class in previous decades, it is arguable whether this is still the case. Is an individual’s occupation still relevant as a sole indicator of class or does this single-factor classification fail to capture the current-day nuances of class? The Great British Class Survey (GBCS)6 could be considered to be a more nuanced and updated way of measuring and defining class as it brings in the

role of cultural taste, social circles, financial savings and property. This has yielded new and extended groupings beyond ‘working’ and ‘middle class’, including a class of ‘new affluent’ workers, a group of ‘emergent service workers’

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and a ‘precariat’ characterised by very low levels of capital and lasting precarious economic security. However, these new groupings may arguably be more representative of where someone is in their life stage as they may ‘grow out of [their current class] simply by ageing’.7 Despite this, the GBCS can still serve to highlight the interplay between the many factors that can contribute to class identity, in addition to occupation.

Class in practice As previously explored, there are many barriers to considering class in practice. However, failing to overcome these barriers

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can impact the therapeutic relationship. In Balmforth’s study, an identified issue was a lack of ‘psychological connection’ and, instead, there was a perceived distance within the therapeutic relationship caused by the class difference.5 Across therapeutic approaches, the relationship between therapist and client has been shown to be instrumental in client ‘outcomes’ and ‘improvement’.8 The failure to consider class risks impairing the whole therapeutic relationship. It may also harm the client. If it is considered that the client’s struggles and hardships are solely resulting from internal responses that require better management, or a perspective change, then the very real external oppressive systems that the client is subject to are ignored. While it may undoubtedly be helpful to equip an individual to cope with external stressors and triggers by regulating their inner responses, failing to identify oppressive systems, ‘isms’ and prejudice experienced by clients risks colluding with injustice and may put the onus on the client to accept an unacceptable situation. Finally, it must be acknowledged that there is a link between poverty and an increased likelihood of experiencing mental ill health.4 Despite this, it is notable that workingclass people are less likely to access talking therapies.9 We as a profession must question and examine why this is, and how we are contributing to this differential. Whether it is due to working-class perceptions of therapy, financial barriers, impaired therapeutic relationships due to class difference, or all of the above, it is our responsibility as a profession to make therapy inclusive and accessible to all.

Class competency So, now we have an understanding of the reasons why class may not be considered and why it is important to do so, we can explore what can be done to increase self-awareness both in life and in counselling practice. These suggestions are far from exhaustive and are representative of ideas that have helped me in developing greater sensitivity and awareness of social class.

● Be mindful of the media

Popular culture and media are littered with examples of classism and the use of workingclass caricatures for ‘comedy’ and voyeuristic

CASE STUDY Mehmet* was a man in his mid-30s experiencing stress and anxiety. In his sessions, he spoke about the difficulty of living on a low income and feeling disempowered around others. During sessions, Mehmet’s experiences were not only explored on a personal level, but also placed within a wider social context – for example, that feeling disempowered around those holding greater structural power was not only a personal experience but one that reflects the power dynamics inherent within society. Within this, the different aspects of Mehmet’s identity were addressed individually and intersectionality, considering how his race, sexuality and class identity interacted and uniquely shaped his experiences. Additionally, Mehmet’s distress at living in poverty was explicitly acknowledged as a reasonable response to difficult circumstances. Following this, Mehmet commented that it was great to have someone who spoke to the very real difficulties and challenges of life and did not frame them as simply an internal problem or neglect the discrimination present within society. *Client name changed

entertainment. Some well-known examples are The Jeremy Kyle Show and the ‘Vicky Pollard’ character from Little Britain, both of which have now been acknowledged as examples of classism. We must consider who the individuals generating this content are, and whether they are from privileged, upperand middle-class backgrounds, with little lived experience of working-class life, poverty and economic hardship. This is an important factor to keep in mind as it reminds us that the lens through which working-class experience is being portrayed is frequently distorted, inaccurate and prejudiced.

● Check your bias

Following from this, as classism is socially pervasive and often goes unchallenged and unnoticed, it is necessary to examine our use of language, judgments and assumptions regarding class. For example, accent bias has

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been found to still be alive in the UK, with attitudes ‘largely unchanged from 50 years ago’.10 This is illustrated by the classism that has been exposed in a number of the UK’s universities, where students have reported being ridiculed, bullied and harassed because of their regional accents and working-class backgrounds.³ Again, it is important to check whether, as a counsellor, you have absorbed this bias. By beginning to think more deeply about language and judgments, we can begin to mitigate classist behaviour both in and outside of the counselling room.

● Meritocracy (or not)

Another problematic idea is that of meritocracy – that what you achieve is due to hard work, skill and merit rather than luck or circumstances. On the surface, this notion may seem acceptable – I know that I want to be rewarded for my hard work and want to believe that opportunity is equal for all, regardless of identity. However, meritocracy inspires uncompassionate views of others. If we are to believe that someone is materially successful because they deserve it, it follows that we must believe that those who are ‘unsuccessful’ deserve to be poor and struggling. It also fails to consider how we are all susceptible to the twists and turns of life, which are outside of our control and may alter our circumstances. A study by

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King’s College London highlights this very point, as almost half of those participating believed that work performance was an integral factor in whether an individual lost their job during the COVID-19 pandemic,11 rather than economic factors. Research is also increasingly demonstrating that belief in meritocracy makes people ‘more selfish, less self-critical and even more prone to acting in discriminatory ways’.12 A belief in meritocracy may lead to discrimination against workingclass people and an inaccurate belief that difficult life circumstances may be due to personal decisions and traits – a viewpoint that could limit empathy, compassion and ultimately therapeutic connection.

● Acknowledge the external

Linked with meritocracy is the acknowledgment of external factors in your life and in clients’ lives. That means noticing whether, when external oppressive systems are brought into the therapy room for exploration, such as racism, classism, sexism, homophobia or ableism (this is not an extensive list), you focus on the internal responses of the client rather than explicitly communicate that these external systems are unjust, harmful and in need of change. Notice how considering this sits with you personally and professionally, and whether it feels like a departure from your approach or technique. If you work from a person-centred approach, it may be argued that, if the client is communicating that they feel that the issue is within them rather than society, introducing a different viewpoint would be moving from their perspective. Additionally, approaches such as cognitive behavioural therapy would state that it is not the external event that is the issue, it is the individual’s response to it. However, I would argue that it can be a harmful collusion with the oppressive systems in question to communicate that a distressed response to prejudice is problematic and in need of change. While it may be more in the client’s (and the counsellor’s) power to explore individual responses to external events, this can be supplemented with the acknowledgment of the external and activism for societal change.

● Think intersectionally

The client’s social class is not the only identity that they bring into the room; the

accumulation of identities that they possess – LGBTQI+, black, Asian and minority ethnic, disabled, neurodivergent – will all impact and shape their experiences. An intersectional lens helps to capture the complexity of what it means to be a person navigating myriad social situations and meanings, without being reductive. It is important to understand that the client’s working-class identity will interact with other facets of their identity and affect the type of discrimination they face; being working class plus their other identities will create varying experiences and, in turn, augment and affect each identity.

● Situate yourself

To be fully aware of class and to address and work with class more effectively in the counselling room, we as counsellors need to situate ourselves as individuals. Where have we come from and where are we now? How is our life shaped by what we have or don’t have? Where do we live and who do we interact with? What is our class, and – honestly – what perceptions do we have of those from a different class? This may not be a simple exercise. As I have explored my own class more, I have seen the barriers that I have faced and the many privileges that have helped me better myself and become more socially mobile. My background and past experiences, financial circumstances, level of education, employment and interests do not all neatly point to a single traditional class group. Class is more complex and nuanced, and our knowledge and understanding of it needs to reflect this. Ultimately, I believe that being a counsellor who is aware of class is not about learning stereotypical definitions of class or class traits. Rather, it is being aware of our own prejudices, assumptions and judgments about class and the socially pervasive narratives surrounding worth, wealth, success, language and belonging. As a profession we need more exploration of social class as a form of difference – one that deserves discussion and acknowledgment in practice, research, training and everything in between. We need therapy to be accessible and inclusive to all who need it. And one way that we can move towards becoming a profession that is more inclusive of social class differences is through at least beginning to talk and think about it more.

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About the author Roxy Birdsall is a counsellor working with children and adults, and a doctorate student at the University of Chester. Her interests include social class, issues of employment within the counselling profession, and increasing both client and therapist diversity. Roxy can be contacted at roxybirdsalltherapy@ outlook.com

REFERENCES 1. Parveen N. UK’s top universities urged to act on classism and accent prejudice. The Guardian; 24 October 2020. 2. Warren T, Lyonette C. Are we all in this together? Working class women are carrying the work burden of the pandemic. London: London School of Economics and Political Science; 2020. 3. Fitzpatrick S. Destitution in the UK 2020. York: Joseph Rowntree Foundation; 2020. www.jrf.org.uk/report/destitutionuk-2020 4. Ballinger L, Wright J. Does class count? Social class and counselling. Counselling and Psychotherapy Research 2007; 7(3): 157-163. 5. Balmforth J. The weight of class: clients’ experiences of how perceived differences in social class between counsellor and client affect the therapeutic relationship. British Journal of Guidance & Counselling 2009; 37(3): 375-386. 6. Park A, Bryson C, Clery E et al (eds). British social attitudes: the 30th report. London: NatCen Social Research; 2013. www.bsa-30.natcen.ac.uk 7. Mills C. The great British class fiasco: a comment on Savage et al. Sociology 2014; 48(3): 437-444. 8. Norcross JC, Lambert MJ. Psychotherapy relationships that work III. Psychotherapy 2018; 55(4): 303-315. 9. Holman D. What help can you get talking to somebody? Explaining class differences in the use of talking treatments. Sociology of health & illness 2014; 36(4): 531-548. 10. Levon E, Sharma D, Watt D et al. Accent bias in Britain: attitudes to accents in Britain and implications for fair access. London: Accent Bias in Britain; 2020. bit.ly/3BT1e6M 11. Duffy B, Hewlett K, Hesketh R et al. Unequal Britain: attitudes to inequality in light of Covid. London: King’s College London; 2021. bit.ly/3vf5JX8 12. Mark C. A belief in meritocracy is not only false: it’s bad for you. Princeton University Press; 2020. bit.ly/2YNAg1M

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Best Practice, 2

Best practice

VERSION

Please join our ‘Talking point’ panel! Email therapytoday@ thinkpublishing.co.uk

REPRO OP

Learning from endings

‘My own therapy has taught me a great deal about ending avoidance’

SUBS

Endings emerge throughout the work in a number of ways, within the client material as well as breaks and relational ruptures, but those have a different quality for me than endings to the sessional work. Perhaps the nature of an ending with the possibility of repair or containment within a dyad contrasts with the ‘unknowable’ ending where, as a counsellor, I have to hold my own feelings and hope that the work was ‘good enough’. There is something repetitious here, linked to the separation of birth and, later, the individuation process. Of course, I have my own relationship with endings and, personally, I have to be wary of a desire to compartmentalise and distract from the feeling of an ending – this is the case for me whether the ending is joyful, painful or somewhere in between. My own therapy has taught me a great deal about ending avoidance and so I make a point when ending with a client to hold a single session without them, at their usual time, after the ending. This allows me to experience my own feelings while holding them in mind.

What have endings in your practice and life taught you?

‘I remind myself it is OK to feel some loss and sadness’ ART PRODUCTION CLIENT

I specialise in working with people with chronic illness and chronic pain. A large part of my work is managing the endings that clients have experienced in their own lives, and their grief and loss. This can include the loss of mobility, a chosen career, independence, or the plans they had for their lives. Most of my clients were not born with their chronic conditions and developed them later, often very suddenly. So many clients have been told by well-meaning people, ‘Well, just think of what you can do!’ While it is important to have hopeful plans for the future, I think the losses need to be acknowledged and processed in order to heal. Working with this client group also means that flexibility is needed. Sometimes the work ends quite suddenly, if a client’s circumstances change with a serious flare-up, for example. I always suggest an ending session, and for all endings (planned or unplanned) I explain that clients are free to get back in touch in the future. Many do that, and it is interesting to meet them again months or years later, when the work we did has bedded in and they are ready to push deeper. With unplanned endings, I do feel a loss. I reflect on the work and wonder if I did anything that caused the abrupt ending – a personal reflection I take to supervision. I remind myself it is OK to feel some loss and sadness, because it is a result of the genuine connection I had with that client.

‘It is never too early to have the idea of our ending in the room’ A number of my clients are children in care. Their experiences of endings are that they are unexpected, sudden and traumatic, and usually based on the decisions of adults in authority. In these cases, I feel that it is never too early to have the idea of our ending in the room. For time-limited interventions based on funding, the child will know from the first time we meet that we have a certain number of sessions together. Some longer-term clients, particularly in schools, welcome a ‘graduation’, where they will receive a certificate and they can invite a teacher or support worker to witness the ending, if they choose. When a client is in therapy with me, I invite them to consider ways they might like to mark our ending together. For some people, that might be a creative exercise, to bring a piece of music or transitional object. Others prefer to acknowledge the journey and leave quietly. Whichever way, the ending is addressed in the room. Modelling positive endings can help a client to experience that an end can be within their control, and they can call on that experience moving forward. Georgia Swift, psychotherapist

Emma Thompson, integrative counsellor and supervisor in private practice

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Jenny O’Gorman, psychodynamic counsellor and psychotherapist

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Talking Point, 1

Talking point

I remember the ‘endings lecture’ on my personcentred counselling course that covered how ending the therapeutic relationship should happen. As I understood it, we would have a series of sessions; then, as the client began to self-actualise or feel more resilient, we would start to work towards an ending. In retrospect, I realise that this was a somewhat unrealistic ideal, rarely achieved in practice. For example, I have found that clients sometimes don’t return to therapy after having time off to recover from illness, go on holiday or have a job change. We are often left speculating what the real reason for not coming back was. One of my specialist areas is ambiguous loss, and I think there can be an element of this when clients end therapy without warning. Of course, our clients are at liberty to choose when and how they will end therapy, and ending abruptly in this way may be the most painless way to do so. Clients’ fears about becoming too attached, worries about how much the therapy is costing and concerns around being able to cope as the therapy deepens may well be possible explanations. However, I always try to have a final session or part of a session where the client and I can reflect on the work we have done together. I feel that the way we end can be a significant part of the therapy for clients, especially those who have struggled with being able to trust in their relationships. The ending of some personal therapy I had a few years ago gave me a clearer understanding of this very subject. If I recall correctly, I told my counsellor I was ending therapy in the session but left it until the last 10 minutes. She, very congruently, remarked that I seemed to have a problem with endings, as I had sprung it on her with no previous hint of my intentions. It was a classic ‘light-bulb’ moment for me and sparked a period of selfgrowth after the therapy ended.

SHUTTERSTOCK

‘The therapeutic relationship is only part of a client’s life journey’ Endings are ubiquitous and we cannot escape them. In our profession, we all begin by starting on a lengthy training in the knowledge that it will eventually come to an end. I am, however, curious as to why some of us just can’t seem to stop – perhaps in avoidance of the ending that indicates we ‘should’, by now, know what we are doing? In the last quartet of Little Gidding, TS Eliot invites us to consider endings by describing their potential to generate new beginnings. Particularly relevant to the therapeutic endeavour is Eliot’s further suggestion that exploration is an ongoing phenomenon from which we ‘shall not cease’. This speaks to me as a reminder that the therapeutic relationship is only part of a client’s life journey. Ideally, of course, we hope to work towards a timely and mutually agreed ending. But what about when a client ghosts us, never to be heard of again? Depending on our own private logic (an Adlerian term based on a person’s unique evaluation of self, others, the world, and what is required of them), this may leave therapists feeling rejected, wondering what went wrong; perhaps nothing at all. Endings may be sad, happy, reflective, planned or unplanned. Importantly, we need to understand our own take on them. Jude Adcock, arts-based counsellor, psychotherapist and clinical supervisor

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Jenny Hodson, integrative counsellor

THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN

‘Clients are at liberty to choose when and how they will end’

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The bookshelf

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For exclusive publisher discount codes, see www.bacp.co.uk/membership/book-discounts

SUBS ART PRODUCTION REVIEWS COMPILED BY JEANINE CONNOR

CLIENT

Depression: an introduction Barbara Dowds (Phoenix, £18.99)

Hope: the dream we carry Tia DeNora (Palgrave Macmillan, £15.76)

Within minutes of starting this book, I was persuaded that therapy training needs to draw more heavily on neuroscience or, more broadly, a biopsychosocial model to refresh our understanding of where depression originates, how it solidifies and how it can be shifted. The idea that neural pathways are laid down in our brain so that certain behaviours become default shines a whole new light on clients who seem to be hopelessly stuck in patterns of behaviour they want to change. It feels right that therapy training roots itself in the connection between physical processes and the mental anguish we experience. We brandish the light of optimism. Talking our clients through the idea that new neural pathways can be created within our brains could be a source of relief for many. For Dowds, depression is a communication to be examined, and healing can take place. Yet, although this book feels thought provoking and timely, and I really wanted to like it, I found it difficult to digest. The key points, concepts and case studies could have been emphasised in the text to make things simpler for the reader. At times I skimmed the text rather than engage with the plethora of acronyms. The extended case study exemplifies working integratively with depression – and I was left thinking Dowds is probably a very talented therapist – but the numerous concepts and techniques and scant explanation made it more suited to an advanced-level text. As a reader new to this way of thinking about the subject, I had to work hard, which is fine, but not for an introductory book. There is much to be excited by here, but more needs to be done to pitch the material at an appropriate level. Zorana Halpin MBACP (Accred) is an integrative counsellor

Don’t be fooled by the poetic title. This book, while in parts beautiful and deeply moving, is thorough, critical, academically referenced and informed by the latest research. It spans a variety of disciplines including sociology, politics, music, poetry and medicine, resulting in a persuasive manifesto on the importance of hope. In therapy, we might be used to the idea of hope as an emotion. I often find myself feeling hopeful at times when my clients aren’t able to, in the hope that perhaps one day they will. DeNora, however, argues that hope is also a practice, something we undertake either to create the space for change by imagining a different possibility or just to help us survive the present, perhaps. There is a variety of brief vignettes throughout the book, which I found very helpful in illustrating and dispersing the otherwise quite dense and complex writing. DeNora’s background in working in end-of-life care is evident, though the content is by no means limited to this particular client group. I was struck by how closely some of my work with adolescent clients resonated with DeNora’s descriptions of the need for hope in social activism and the world we will leave for future generations, as well as on an individual level. Hope is sometimes uncomfortable, often unrealistic and occasionally downright unhelpful; DeNora doesn’t attempt to provide a one-sided view on the power of positive thinking, exploring all of these scenarios in some depth. Having said that, DeNora’s way of conceptualising hope is intrinsically linked to what happens in the therapy room because hope ‘makes a change to the present’ by introducing, however vaguely or unrealistically, the idea of change and possibility. Emily Harrison is an integrative therapist

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A Healing Relationship: commentary on therapeutic dialogues Richard G Erskine (Phoenix, £28.99) This is a gem of a book and one to be wholeheartedly recommended. Erskine brings a wealth of experience and knowledge to three transcripts of sessions with clients, with a commentary on his understanding of the issues presented, his reasons for choosing to pursue his questioning in a certain direction and unresolved issues within the session. The approach is refreshing, not least due to the transparency of the process, but it also shows a humility only seen in those who have a great deal of skill and experience. Erskine invites comments, discussion and challenge. He works integratively, with a background in psychoanalysis, but he brings this together with other influences such as Gestalt approaches and a focus on the body, described as developmentally based, relationally focused integrative psychotherapy. There is an emphasis on healing trauma relationally by accompanying clients in validating and regulating emotions, meeting developmentally unmet needs, as well as normalising the function of a client’s thoughts and behaviours, especially those rooted in surviving the past. Not least, there is also online access to videos of the sessions, as well as case discussion between Erskine and a colleague, ideal for both teaching and experiencing the session first-hand. The only criticisms I have are that the cases are quite similar, but this has the advantage of reinforcing the rationale of the approach. The videos also involve a simultaneous interpreter, making them a little less fluid. However, it is refreshing to have such a solid integrative approach explained, backed up by theory and demonstrated in practice. I shall be seeking out other books by the same author and hope to see more of this clinical openness in other publications. Michele Head is a clinical psychologist

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The Bookshelf, 1

Reviews Please note, we do not accept unsolicited book reviews. To join the review panel, email therapytoday@thinkpublishing.co.uk

First Steps in Counselling: an introductory companion (5th ed) Pete Sanders, Paula J Williams and Andy Rogers (PCCS Books, £22.99) Now in its fifth edition, this core text has been updated to consider the impact the 21st century has had on the counselling profession. Primarily aimed at individuals at the beginning of their counselling journey or those in (broadly) helping roles, it is easy to digest and provides an interesting and explorative overview of the counselling process from beginning to end. The clever structure gives you the opportunity to read it cover to cover or select specific chapters based on your studies or interests. Chapters include ‘What is counselling?’, ‘Where do ideas in counselling come from?’ and ‘Counselling attitudes and skills: ways of being a helper’. The new edition also takes into account our evolving cultural context and touches on topical issues such as the Black Lives Matter movement, highlighting the relationship between whiteness and racism within the profession. Similarly, the reader is asked to consider their relationship with sexual identity, poverty, power and much more, and to examine the impact this could have in the counselling room, and the book helpfully outlines steps we as professionals can take to address inequalities. The book draws on a compendium of definitions, narratives and articles throughout, helping bring the theory to life, and all references are usefully located in the footnotes. This book indeed provides the foundations for further study towards a fuller understanding. Overall, First Steps in Counselling is, without a doubt, an essential text for the counselling profession and I can honestly say I will be referring to it over my next few years of study, and beyond. Olivia Brown is a trainee integrative psychotherapist

Perspectives in Male Psychology: an introduction Louise Liddon and John Barry (Wiley-Blackwell, £39.99) The authors, in my opinion, bravely transgress the taboo embedded in all disciplines influenced by critical theory that functions to obscure sex differences and limit the freedom to speak about them. A holistic approach to masculinity is presented, incorporating biology, evolution and humanistic philosophy, and the authors elegantly integrate the cultural process of socialisation with the evolutionary and biological elements of masculinity. Refreshingly, the reader is introduced to a male-friendly, empathic, compassionate and, crucially, embodied understanding of masculinity, crystallised in a range of positive male archetypes, providing a potent antidote to the ideological concept of ‘toxic masculinity’. Importantly, childhood trauma, life-event trauma and social deprivation are highlighted as contributors to negative male behaviour. By looking beyond the individual to a wider range of influential variables across multiple science disciplines, a more complex, evidence-based and empathic male psychology is presented, together with a more diverse set not only of therapy interventions but also of social interventions. The discussion and research are of high quality and presented in a very accessible way, as exemplified by the ‘Spotlight’ features in each chapter, which provide concentrated shots of knowledge addressing particular male psychology concerns. I highly recommend this book, which introduces and skilfully addresses a broad range of highly relevant men’s issues. The contents have the potential to repair the bias that has shaped our deficit model of masculinity and caused us to grievously misunderstand men. Sue Parker Hall is an author and psychotherapist

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The book that shaped my practice

Tantric Love: feeling vs emotion. Golden rules to make love easy Diana Richardson and Michael Richardson (O Books, 2009) Sex is important, but in this book the focus is on the relationship. This refreshing exploration of being ‘triggered’ by your partner shapes my practice by encapsulating and exploring ideas and principles that I already incorporate into my relationship work. Differentiating between feeling (the live expression of here-and-now experience) and emotion (the re-emergence of past, repressed feelings) is a crucial feature of the book, but uncommon in psychotherapy/counselling. However, it can enable us not to take personally our partner’s expressions of emotion, which can include blame, judgment and criticism. This frees us to remain emotionally present, which is often what our distressed partner needs. Richardson’s practical yet profound approach to the familiar relationship impasse (trying to communicate while being mutually unavailable) has given me a framework I return to with individuals andHas couples again and again. a book contributed to shaping your practice? Geoff Lamb is a psychotherapist, Email a few sentences to author psychosexual therapist and reviews@thinkpublishing.co.uk

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Dilemmas VERSION REPRO OP

OUR ETHICS TEAM AND READERS RESPOND TO A MEMBER’S DILEMMA ABOUT WHETHER IT’S OK TO OPT OUT OF PAID SUPERVISION WHEN NEWLY QUALIFIED

SUBS

IS PEER SUPERVISION ENOUGH WHEN YOU’RE NEWLY QUALIFIED?

ART

I have just completed my counselling training and am in the process of setting up supervision for myself. Several of us who trained together have decided to form a peer supervision group. This seems an ideal arrangement, since we already know each other well, we have built up a bond of trust between us, and we were all trained in the same modality. One of our former tutors is questioning whether this will be suitable and whether, on its own, it will be enough, but we would like to avoid the expense of paid supervision, if we can, while we get established. What are the drawbacks of this approach?

PRODUCTION

BACP’s Ethics Consultant replies:

SHUTTERSTOCK

CLIENT

There are some obvious benefits from having peer supervision, not least the cost saving. Reciprocal supervision with one or more peers can also be appealing because you are there as equals, with no hierarchy or power imbalance. However, according to the Ethical Framework, ‘Supervision requires additional skills and knowledge to those used for providing services directly to clients. Therefore supervisors require adequate levels of expertise acquired through training and/or experience’ (Good Practice, point 62). Participants in peer supervision need to remember that they are each taking on the role of a supervisor, along with the attendant responsibilities. A starting point in assessing your own competence to offer supervision, or that of your peers, is the Supervision Competence Framework (2021). This could be used as a self-assessment tool to measure your competence – and that of your peers – for this role. The responsibilities of peer supervisees are described in the Good Practice in Action resource Peer supervision within the counselling professions (GPiA 121), and can be summarised as session and group management; facilitation of the supervision

of others’ work, and ethical and professional gatekeeping. Peer supervisees are accountable to each other, so all the peers need to be aware that they are both giving and accepting that accountability. This is one reason why peer supervision is ‘not advised for newly qualified or minimally experienced counsellors’ (GPiA 121). You say that you ‘know each other well’, which could mean that you are able to identify each other’s needs readily and be sensitive to them. There could be a strong element of mutual trust and support within the group that would otherwise take time to build with a new supervisor. However, you need to be aware of possible blind spots and the danger of collusion. Peer supervisors may also be less able to challenge each other, which is less likely in a supervisor holding a greater professional distance, with less personal involvement. A peer relationship can become safe and non-confrontational, with more emphasis on the ‘restorative’ function of supervision, and less on the ‘normative’ or ’formative’ aspects. Old group dynamics might be played out, especially since you trained together, and you would therefore all be in some kind of dual relationship. ‘Any dual or multiple relationships

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will be avoided where the risks of harm to the client outweigh any benefits to the client’ (Good Practice, point 33b). How would conflict be managed, old rivalries handled, or cliques within the group called out? Who would exert their authority in the way that a supervisor may need to, and would such authority be accepted? Although the historical relationships might create a feeling of familiarity and cosiness within the group, some members might be at risk of feeling quite vulnerable or inhibited, instead of accepting their ‘responsibility to be open and honest in supervision and to draw attention to any significant difficulties or challenges that they may be facing in their work with clients’ (Good Practice, point 72). ‘Good supervision… includes working in depth on the relationship between practitioner and client in order to work towards desired outcomes and positive effects. This requires adequate levels of privacy, safety and containment for the supervisee to undertake this work’ (Good Practice, point 61). You refer to having been ‘trained in the same modality’. While this might understandably enable you all to feel comfortable and affirmed in your way of working, you could be missing out on the opportunity to broaden your horizons now that you are qualified – to learn from others and be encouraged to look at your client work from different perspectives. It would be strongly advisable to draw up a contract between you to clarify the shared responsibility and accountability, as well as addressing issues such as participation, commitment and attendance and how you would divide up the supervision time. Would you take it in turns to facilitate the sessions? Confidentiality would be particularly important, with strict observance of the boundaries. Otherwise, it could be tempting to lapse into discussing clients (or colleagues) when you meet colleagues outside supervision sessions. Consideration might also need to be given to your client contract, so that clients are aware of who you would be sharing their information with. ‘All communications concerning clients made in the context of supervision will be consistent with confidentiality agreements with the clients concerned and compatible with any applicable agency policy’ (Good Practice, point 64). On a practical note, bear in mind BACP’s requirements for supervision and how group supervision time is allocated. For groups of

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Dilemmas, 1

Peer supervision is a valid form of supervision and could well form a constituent part of your supervision arrangements, but it is normally seen as additional to, not a substitute for, individual supervision

four or fewer, each supervisee can ‘claim’ half the time, but for groups of five or more, the supervision time needs to be divided by the number in the group. Peer supervision is a valid form of supervision for experienced therapists and could well form a constituent part of your supervision arrangements, but it is normally seen as additional to, not a substitute for, individual supervision. One recommendation would be to appoint an experienced group supervisor for your group for the first year or two after qualifying. That would certainly help to spread the cost. It is recommended that all practitioners keep their supervision arrangements under review, and ensure that they are meeting their current personal needs, and that they are appropriate for their stage of professional development and their caseload. Stephen Hitchcock MBACP is a senior accredited counsellor and supervisor with 20 years’ experience, and has a private practice in the Lake District. Stephen previously worked with BACP’s Professional Standards department as an accreditation assessor and a moderator. This column is reviewed by an ethics panel of experienced practitioners.

READER RESPONSES ‘A peer group can conjure up a disruptive kind of multi-visioning’ I value one-to-one supervision very highly – and yet, it’s not enough. What does it lack that peer group supervision provides? Thinking about my experience of three peer groups I’ve been a member of at different times, I reckon the missing ingredient is play. I’m not saying my supervisor and I are never playful in our work – far from it – but with more players (my current main peer group has four), there’s more stuff happening in the space and there’s more movement. Of course, it can become fragmented and even incoherent at times. I don’t mind that, because very often something unexpectedly useful emerges from the spontaneous interplay of contrasting reactions, opinions and stories. An intentionally reflective space benefits from a bit of wildness occasionally. The collegiality of a peer group works especially well for me when my colleagues are practising in settings I don’t know much about. I want to learn through other people’s experiences and extend my own knowledge. If, in turn, I somehow help others to extend theirs, then so be it. Hopefully we’re all learning all the time, which also means unlearning. How does this happen? For me, it’s a mostly conscious decision to keep myself open to seeing things differently. Not always easy, of course. What a peer group conjures up can be a disruptive kind of multi-visioning. Divergent forms of knowledge and eccentric sensemaking often arise in the space. Putting this free-flowing creativity to work in the service of clients is enjoyably serious play. In my experience, peers who genuinely appreciate and trust each other can offer challenges well, knowing they will be taken in

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good faith. There’s an advantage in numbers here. Disagreement or confrontation between two members of a group of four, for example, invites the two who aren’t directly involved in the argument to step back and comment on the encounter – an additional supervisory witnessing, which isn’t available in one-to-one supervision. Similarly, with four minds and bodies in the field, manifestations of parallel process and other curious transferential phenomena are more likely to be noticed by someone who feels moved to take an observer position. When colleagues and supervisees talk to me about being in a peer group, or wanting to start one, I usually ask if they see a difference between peer support and peer supervision. Obviously these functions overlap, but the distinction is important. Supporting each other is really not the same as supervising each other. In either case, the double meaning of ‘peer’ is relevant. To peer is to look closely. To peer with peers is to look closely at each other – surely a good thing. We could even call it supervision. Jim Holloway MBACP (Snr Accred) is a counsellor and supervisor in private practice

‘We all learned about ourselves as well as about the group process’ Some time ago, when the peer group I was in at the time had been meeting for a year, a disagreement arose between us. We’d spent several sessions grappling with the issue but were getting nowhere. I was getting tired of it and decided to solve the problem by taking action, but without consulting the others first. Unsurprisingly, my colleagues thought this rather high-handed! We became curious as to what was going on and helped each other realise what personal patterns or trauma each of us was replaying. I shared that I had once

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Dilemmas VERSION REPRO OP SUBS ART PRODUCTION CLIENT

again stepped into the role of the eldest child who had been made responsible for looking after her siblings and sorting out any problems. This ‘storming’ experience, described in Tuckman’s model of group development that includes the stages of forming, storming, norming and performing,1 helped us to form a cohesive group where each of us felt safe to share difficult stuff, in the knowledge that support and appropriate challenge would be forthcoming. We all learned about ourselves as well as about the group process and trusted that, if problems arose again, we would be willing and able to thrash them out. Sometimes, however, people experience challenge as a personal attack and may feel judged. They may then find excuses for missing meetings, leading to further problems as the remaining group members feel that the absent person does not take the supervision seriously. In order to grow and develop as practitioners, we need constructive criticism and challenge, but for this to really work, we also need to feel valued and safe. If a peer group is to survive, it is essential that the ‘storming’ stage is not bypassed, as this is where real learning often happens. Unless issues can be brought out in the open and worked with in a collaborative and professional way, there may well be an explosion, leading to the group losing members or disintegrating completely. Alternatively, group members may be so focused on getting on with each other that there is no real challenge, which can lead to collusion and groupthink. As a result, the individual practitioners may not get what they need, and ultimately it is the clients who lose out. Whereas a peer group of recently qualified counsellors may be supportive, there is no substitute for experience when difficult and unusual situations inevitably arise. Thus, each person should also have regular individual supervision with a more seasoned practitioner they trust and feel held by. Not only will this facilitate good and ethical practice, it will also contribute to personal and professional growth. Dr Els van Ooijen BACP (Accred) is a psychotherapist and supervisor, and author of Clinical Supervision Made Easy (PCCS Books) REFERENCE 1. Tuckman B. Developmental sequence in small groups. Psychological Bulletin 1965; 63: 384-399.

‘This peer supervision group could be ideal in many ways’ You trained together, you know each other so well, you already have a bond of trust, what could go wrong? Well, not necessarily that much, but I think it could certainly limit the opportunities for learning and development that a more experienced supervisor could provide. A group of peers who trained together may all be at the same stage of development. There would perhaps be no one who is further on the journey and could guide and enrich (and safeguard) the journey with their knowledge and experience. Nevertheless, this peer supervision group could be ideal in many ways. Trust has already been established and there is a common modality. Furthermore, peer supervision meets the supervision requirement for BACP, including its accreditation application process. However, as pointed out in the Good Practice in Action resource Introduction to supervision in the counselling professions, ‘challenging the other may be difficult, collusion can occur, and role confusion is possible’ in peer supervision. With the tutors no longer there, the group members would have to take shared professional responsibility, hold firm boundaries and ensure safety is maintained. Without this, there is a risk the group might lapse into a social group and not attend to the tasks of supervision. The restorative function would doubtless be achieved, but the normative and formative tasks may be (perhaps unconsciously) avoided. On reading the dilemma question, I also wondered what the writer’s experiences of supervision had been like during their training course. Had something led them to not value supervision? I remember feeling frustrated at having to pay for supervision, membership fees

There is a risk the group might lapse into a social group and not attend to the tasks of supervision. The restorative function would doubtless be achieved, but the normative and formative tasks may be avoided

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and insurance after having qualified and when my counselling income was so low, especially after having paid so much for the training! However, as I have progressed on my practitioner journey, I have come to appreciate just how invaluable good supervision is, and also (most importantly) what I need to do to make it a valuable experience, which I certainly didn’t do enough of in my early years when I would passively accept mediocre supervision. The key thing is making sure the supervision you pay for is worthwhile – check you’re getting your needs met and, if not, explore it, raise it or find a new supervisor. If money is tight, a newly qualified counsellor might consider looking for free or low-cost supervision with a trainee supervisor. I believe peer supervision groups are most effective when a practitioner has some post-qualification experience, when they complement individual supervision, or when groups have a mix of practitioners at different stages of development. This is when they can provide an enriching, supportive learning environment, not to mention a costeffective arrangement. Susie Renshaw MBACP (Accred) is an integrative psychotherapist

‘Paid supervision is a worthwhile investment in a practice’ I can well remember the desire to keep costs low while starting to build a private practice. I did weekly peer supervision post-training with a colleague, in addition to having weekly supervision. For me, it provided a supportive space to explore not just client work but things around it in a different way than with my supervisor. This wasn’t what was on offer from my supervisor, who was, rightly, far more focused on my being better for clients. Broadly, I’ve seen supervision as either being challenging and progressive or very supportive. I do think that’s possible in a group, and I’ve been in a supervision group like that, but it was facilitated by a very experienced supervisor, and I was the junior therapist with two peers who’d trained in different modalities but who were some three years ahead of me in experience. It may be that you and your peers can create a challenging, progressive and very supportive group, but I doubt the range of experience and training will allow that. As a supervisor, I encourage supervisees to have different arenas for support. Ultimately

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Dilemmas, 2

there is a distance between me and them, and in some cases we work quite differently in terms of modality and the setting we’re in. For example, I supervise somebody who works in an NHS setting and my ethical approach to contracting and boundaries is at odds with the system that they work with, so I’m aware and have encouraged peer supervision where they can explore issues more easily with people who understand the context directly. I wonder if the writer could negotiate a reduced fee with a supervisor? In one contract I had with a supervisee, we agreed a sliding scale of payment based on how many clients they had, and when they reached their goal target, the payment stayed there, at my normal rate. I think, ultimately, I’d agree with the tutor at this stage. I’d also suggest paid supervision is a worthwhile investment in a practice. If something ‘big’ happens, such as a client dying by suicide or a serious complaint, a supervisor is more likely to be able to offer clarity and professional holding than peers with the same level of experience. A question for the member to consider is, what’s the point of this as a career – to earn money or to really make a difference? If it’s the latter, I wonder if they are selling themself and their clients short by not exposing themself to a different critique. Ben Scanlan is a psychotherapist and supervisor in private practice

‘Peer supervision helped my awareness of power in the counselling room’ When I was in training, I had a monthly peer supervision group that continued for three years, as we were required to accumulate a certain amount of peer supervision hours, in addition to one-to-one supervision. I found it most valuable, and I would certainly recommend trainees set up their own peer supervision groups. However, such groups are complementary to one-to-one supervision and could never be a substitute for it. My entire working life prior to counselling was spent in hierarchical structures, so I rarely experienced flatter, more democratic ways of operating. Person-centred counsellors accept that it is perhaps impossible (and undesirable) to set up a completely equal relationship with a client, but it is important to be aware of the power dynamic. Seeing this modelled in our peer supervision group definitely helped my awareness of power in the counselling

SUPPORT AND RESOURCES You can find more information and guidance in these BACP resources, which are all available online at www.bacp.co.uk/gpia:  How to choose a supervisor (counsellors) (GPiA 008)  How to choose a supervisor for your service (GPiA 009)  Monitoring the supervisory relationship from the supervisor’s perspective (GPiA 010)  Monitoring the supervisory relationship from the supervisee’s perspective (GPiA 011)

 Supervision in England, Northern Ireland and Wales (GPiA 032)  Introduction to supervision (members) (GPiA 054)  Ethical mindfulness in supervision and training (GPiA 084)  Peer supervision within the counselling professions (GPiA 121)

BACP’s supervision competence framework can be found at: www.bacp.co.uk/media/10930/bacp-supervision-competenceframework-feb21.pdf room. There was also less pressure than in the training group – I could experiment with being myself, warts and all, and bring along doubts and mistakes. Many years later, as an established couples counsellor, I joined an existing peer supervision group, which continued for 13 years. I again found this valuable and complementary to my one-to-one supervision, but noticed different benefits from my first experience. The other members were also established couples counsellors and I learned a lot from them. They were from different modalities to mine (including psychodynamic, systemic and

integrative), which provided useful challenges and different perspectives. I was constantly amazed at how, when we started discussing a case, it seemed like we were climbing the same mountain by different routes. When we arrived at the top, we nearly always achieved a consensus! Both peer groups provided the company of like-minded people, which helped counter the inevitable isolation that I and many other counsellors experience in our work. Mike Trier MBACP (Accred) is a person-centred counsellor, supervisor and group facilitator

HOW WOULD YOU RESPOND?

Honesty in supervision I am an experienced supervisor, and I suspect that one of my supervisees is not being totally honest in supervision. They never admit to making ‘mistakes’, or even any weaknesses or possible areas for development. I fear that they are not reporting some client work for fear of being judged, but whenever I challenge them over this, it is denied. Because I can only work with what they choose to bring, I’m not sure what to do about this. We welcome your responses to this upcoming dilemma. If you would like to contribute, please email the editor at sally.brown@thinkpublishing.co.uk for guidelines. The dilemma reported here is typical of those worked with by BACP’s Ethics Services. BACP members are entitled to access this consultation service free of charge. Appointments can be booked via the Ethics hub on the BACP website.

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Analyse Me, 1

The questionnaire VERSION

me Analyse

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Maria Albertsen speaks for herself What motivated you to become a therapist? I experienced a really

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meaningful therapeutic relationship with my counsellor at university, which inspired and encouraged me to become a counsellor myself. However, about six months into the training, I emailed her to say that I thought I had started the training as an attempt, on a subconscious level, to keep in contact with her, and I wasn’t sure if I should continue. She replied, ‘The fact you’re aware of that already puts you ahead of most when they first start out. Keep at it.’ And I’m so glad I did. How has being a therapist changed you? I think almost every

person I’ve met could tell a story that could break your heart and, as a result, I feel I’ve become more tolerant as a person and able to accept people just as they are. I also believe that I understand sociopolitical influences on psychological wellbeing more acutely, but this knowledge is growing in depth every year and is also impacted by the work we do at the campaigning group I founded, Counsellors Together UK (CTUK).

Where do you see yourself in five years’ time? After seeing my first-ever

client in 2003, I’m actually thinking about retiring from clinical work once I have ended with my current clients, to focus on CTUK. We recently raised £10,000 to pay for several retreats around the UK for therapists who are feeling stressed and burnt out, including sending 20 counsellors on

What do you do for self-care/to relax? Living on the

north-east coast, I’m lucky to be surrounded by beautiful beaches and masses of countryside. I’m a single mam with three children under 13 years old, and we spend most of our spare time as a family walking and exploring this area.

fully funded sailing retreats with the charity Sea Sanctuary in Cornwall. In five years’ time, I would like to have raised enough money to open our own retreat and provide much-needed time out for therapists all year round, free of charge. What do you find challenging about being a therapist? I’ve worked

in many settings, including the NHS, education and several charities. However, most challenging was working in a GP surgery. More than 80% of the patients referred to me were prescribed antidepressants, but it was clear that they were feeling depressed because of the effects of social issues and poverty. It wasn’t unusual for patients to ask me to ring a food bank or print out a job application form for them. Those clients needed money more than they needed therapy. And rewarding? Seeing people change throughout the therapeutic process and begin to live the life they want to, on their own terms.

one of the most significant figures in the history of Gestalt therapy. I was shocked when she ended her own life in 2006. However, what I remember Petruska for may be slightly different to others’ memories of her: I have one of Petruska’s manuals, Everything You Ever Wanted to Know About Extraordinary Sex, which she used in what I believe was Britain’s first

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What book/blog/podcast do you recommend most often? Women

Who Run With the Wolves: contacting the power of the wild woman by Clarissa Pinkola Estés. It changed me as a woman for the better, on an instinctual level. I felt able to take space in the world that is rightfully mine. I’m also currently reading The White Hotel by DM Thomas. It’s a powerful read about eroticism and violence, as told by a young woman to her analyst, Sigmund Freud. It reads like poetry in parts and is beautiful yet terrifying. I highly recommend it.

About Maria Now: I have a small private practice in North Shields, Tyne and Wear, where I work mostly long term with adults. You can otherwise find me managing Counsellors Together UK, and plotting and planning our National Counsellors’ Day conferences. Once was: Women’s officer in a hostel for homeless young people. First paid job: Junior worker at a local youth club when I was 15 years old.

What is your favourite piece of music and why? ‘Clair de Lune’

Who is your psychotherapy/ counselling hero? Petruska Clarkson,

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sex school. It’s very explicit in talking about how to achieve maximum sexual pleasure, either alone or with others, for both sexes, but it’s also about intimacy, tenderness and love. I remember her as someone who wasn’t afraid to speak about things that others shy away from.

by Claude Debussy takes me off somewhere dreamy where everything feels just a little bit better.

What is the meaning of life? Love. What would people be surprised to find out about you? Just before

I qualified, in my early 20s, I was employed to set up and manage a young people’s counselling service. I later won an award for my outstanding contribution to children and young people’s mental health.

Who would you like to answer the questionnaire? Email your suggestions to therapytoday@ thinkpublishing.co.uk

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