BACP Therapy Today February 2022

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FEBRUARY 2022 | VOLUME 33 | ISSUE 1 THERAPY TODAY

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Our mood is both us and yet not us

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Image conscious FEBRUARY 2022 | VOLUME 33 | ISSUE 1

How social media is shaping our profession

Mental health effects of physical symptoms // Understanding intergenerational trauma Microaggressions in the supervisory relationship // Selfies, self-image and self-esteem

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Contents, 1 VERSION

Contents February 2022

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Upfront

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The big issue Catherine Jackson explores the influence of social media on our profession The healing power of place Psychiatrist Linda Gask explores her battle with her own mental health Snapshots and self-reflection Photographs can enhance communication and insight in therapy, says Paola Borella The butterfly in the room We need to be alert to the mental health effects of physically generated symptoms in clients, says Geraldine Marsh Echoes of captivity Louise Reynolds explores the devastating intergenerational trauma experienced by families of prisoners of war Cross-cultural congruence Congruence can help us address microaggressions within the supervisory relationship, says Rajita Rajeshwar

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It changed my life My practice 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 Obituary From the Editorial Board The month

Main features

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Louise Reynolds (‘Echoes of captivity’, pages 38–41)

Regulars

On the cover..

Full disclosure

Catherine Jackson explores how social media and public presence are shaping the therapeutic professions (pages 20–25)

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‘My father never talked about his experiences but I have always felt haunted by something unknown and unknowable’

Opportunities

British Association for Counselling and Psychotherapy Board and officers 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 Interim Chief Operations and Membership Officer Adam Pollard

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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

Contact us by emailing: therapytoday@thinkpublishing.co.uk

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clients want and changing social mores? These are just some of the questions explored by Catherine Jackson in ‘Full disclosure’, which you can find on pages 20–25. It’s the start of a necessary and important conversation – we would Do we ‘run the love to hear about your relationships risk of overtaking the with social media and your views on its impact on our profession. narrative’ every time we This issue also sees the introduction disclose something about of two new columns. ‘My practice’ (see page 33) is a chance for you to share ourselves on social media, how you work. In the first column, Sarah Edge describes her work with postnatal or are we responding to clients. I am also delighted to introduce what clients want? a new column from Therapy Today’s Editorial Advisory Board (page 16) – the team of talented practitioners who are on hand to ensure the content of your magazine stays relevant and inclusive. I’d like to thank John Barton for agreeing to go first with a thought-provoking piece on ‘getting over ourselves’. You’ll hear from a different Editorial Board member each issue.

I’d also like to thank all the contributors to this issue, who have so generously shared their views and innovative ways of working. If you have feedback or would like to contribute in some way to Therapy Today, we would love to hear from you. Do write to therapytoday@thinkpublishing.co.uk Sally Brown Editor

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

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s part of the BACP News pages every issue, we feature a list of ‘Members in the media’ who have voluntarily given their time to contribute to newspapers, magazines and websites and appear on radio and TV programmes. I’m always impressed by the broad range of coverage – and we should not overlook the BACP Communications Team’s strategic work behind the scenes to promote our profession and communicate what we do to the general public.

Many members also have a very active and confident presence on social media platforms, such as Instagram, Facebook and Twitter. For an increasing number of us, particularly those in private practice, posting and interacting on social media are an important way to let clients know what we do and who we work with, and also to share important public mental health messages.

But are we getting the balance right? Instagram is about sharing pictures from your life – is it OK that a therapist posts a picture of the beautiful view they saw on their walk that morning, or the delicious cake they’re about to enjoy with a cup of tea? Does this humanise us, or blur our professional boundaries? And what about potential clients who come across therapists verbally attacking each other and their professional bodies on Twitter? Do we, as Brett Kahr says, ‘run the risk of overtaking the narrative’ every time we disclose something about ourselves, or are we simply responding to what

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 to the first edition of Therapy Today in 2022.

Despite a very challenging end to 2021, I’m extraordinarily proud of our collective achievements over the past 12 months, and I’m very hopeful that the year ahead will bring many more positive developments for our members and the profession.

In November, NICE launched an unprecedented third consultation on its updated depression guideline. We’ve submitted a detailed response and look forward to seeing the final guidelines when they’re published in May. You can read more about this work on this page.

In response to our strategic goal to ‘listen to and learn from’ our members, I’m very pleased to share an important update regarding our internal Listening Group (see page 7). You can now view on our website monthly reports that summarise the key feedback we’ve received from members and any action taken as a result.

Finally, I’m thrilled to share that our Coaching Today journal is celebrating its 10th year this year.

Since its launch in January 2012, the journal has supported the development of BACP Coaching, which has grown into a dynamic resource for counsellor-coaches within the profession. Huge congratulations and thanks to all those who have dedicated their time and expertise to the Coaching Division since it began in 2010.

Hadyn Williams BACP CEO

As part of our ongoing strategy to raise awareness of how counselling and psychotherapy can change lives, we’ve been working with the media agency 23red.

Towards the end of last year, we launched a campaign to encourage owners of small and medium sized (SME) businesses to look after their mental health and signpost them to our members. It was on the back of our survey of 500 small business owners which found that 96% keep the stress of running a

about Christmas. The campaign encouraged people to think about their mental health ahead of the festive season. It was covered in national newspapers, and our members Indira Chima, Dee Johnson, Philip Karahassan, Lina Mookerjee, Natasha Page and Louise Tyler spoke to broadcast media including regional BBC radio stations and national TV. Look out for further campaigns this year as we continue to raise awareness of our profession.

NICE guideline consultation

In November 2021, NICE launched a third consultation ahead of the planned publication of an updated depression guideline this year.

We were pleased to see that the latest proposed guideline has made positive steps

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small business ‘bottled up’. Kris Ambler, BACP’s Workforce Lead, provided expert comment for the campaign, along with member Michelle Seabrook, which featured across the media including coverage in The Sun, The Independent, The Express, The Mirror and trade magazines and websites. With the help of 23red, we also launched a ‘Seasonal Stress’ campaign on the back of our survey which found that 9.1 million UK adults felt stressed or anxious

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towards recognising the substantial evidence base for the effectiveness of counselling and psychotherapy for the treatment of depression, something for which we’ve campaigned strenuously throughout the year. After an extensive review of

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the guidelines, we submitted a detailed response to the consultation. The final guidelines are due to be published in May, but in the meantime, you can read our response to the consultation at www.bacp.co.uk/ news/campaigns/nicedepression-guidance

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mInutes with…

Matt Smith-Lilley

Describe your role at BACP: I lead

BACP’s work relating to the NHS. I work with services, politicians, civil servants, commissioners and members to advocate for improvements to mental health care and to increase both the availability of talking therapies within the NHS, and also the range of paid opportunities for our members to work in the health services.

What’s the best thing about working at BACP? The real sense

Matt Smith-Lilley BACP’s Policy and Engagement Lead for Mental Health

of community among the staff and a feeling that I can play a small part in helping counsellors and psychotherapists to help people.

What gets you up in the morning? Two kids under three!

What advice would you give to your younger self?

Time is meant to be spent not saved.

What’s your goto karaoke song? In a small act of

mercy, I don’t often inflict my singing on people, but I’d probably go with ‘Where the Wild Roses Grow’ by Nick Cave and the Bad Seeds.

Your proudest achievement?

That’s a tough question – I’ll come back to you when I’ve done something I’m proud of!

What would you like to achieve over the next year? I’ve got my

entry booked for the world’s toughest Ironman Triathlon, ‘Extreme X’, which takes place in the Lake District. I’m hoping that COVID won’t prevent me taking part for the third year in a row!

Best advice you’ve been given? Eighty per cent of

something is better than 100% of nothing.

What was the last book you read? Either

The Gruffalo or The Snail and the Whale by Julia Donaldson – both current bedtime favourites with our two little ones.

PROFESSIONAL CONDUCT

Last year we formed a new Listening Group in response to our organisational strategy to listen to, learn from and work with our members to inform BACP’s work. The group brings together every month a number of colleagues from across BACP to review the feedback we’ve received from you. We want to share this important work with you, so we’ve started producing a monthly report that helps to illustrate some of the key feedback we’ve received and action we’ve taken. You can read the reports from 2021 at www.bacp.co.uk/membership/ listening-group You can also catch up on all of the listening workshops at www.bacp.co.uk/membership/ listening-workshops

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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Our members have been speaking to the media on a range of subjects, including eco-anxiety, money issues and mental health, eating disorders and pet bereavement.

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• Emma West contributed to an anti-ableist guide to dating feature in Cosmopolitan. An article in The Sunday Times on eco-anxiety included an interview with Linda Aspey. HuffPost interviewed Anjula Mutanda • about why hangovers exacerbate anxiety, Nicola Vanlint about the impact of the pandemic on friendships, and Paul Mollitt about the emotional impact of a sibling leaving home.

• Andrew Harvey contributed to a Daily Mail piece on shopping and compulsivity, while Ruth Micallef talked to Pick Me Up! magazine about eating disorders.

Lina Mookerjee • spoke to the Press Association (PA) for an article that was syndicated across the regional press about coping with the mental health impact of the new Omicron variant. PA also interviewed • Philip Karahassan and Matt Wotton on how money issues can impact mental health, and Louise Tyler on improving perseverance and tenacity.

• Kemi Omijeh spoke to PA about how to call out bad behaviour online for Social Media Kindness Day, and to The Daily Telegraph about family relationships and therapy. Glenda Roberts • discussed pet bereavement counselling with Your Cat magazine for National Grief Awareness Week. Cate Campbell • spoke to Prima magazine about how to face winter with a smile. A Red magazine piece about seasonal stress included an interview with Sally Brown.

Our organisational member Spokz People CIC has launched a new online platform that aims to improve the mental health and wellbeing of disabled people and their families, with the help of a National Lottery Community Fund grant. Spokz People aims to enable more disabled people and their families to access disability-affirming psychological support. It has recently teamed up with Disability Horizons, an online disability lifestyle publication, to launch the Spokz People Wellbeing Community and Programme.

The platform will enable disabled people and their families to work with a peer to improve their mental health and wellbeing.

It also includes information and toolkits on how to improve self-esteem, build resilience, find meaning in life and manage the challenging situations being disabled brings. To find out more, see www.bacp.co.uk/news/news-from-bacp/2021/19november-lottery-grant-launched

Highlighting professional standards Caroline Jesper, BACP’s Head of Professional Standards, was interviewed for an important BBC documentary, to promote the ethical and professional standards of BACP members. The programme, I Can Cure You: online mental health cures, examined the risks of unqualified and unregistered practitioners offering online treatment for mental health issues. As well as highlighting the extensive training our members undertake, Caroline also raised her concerns about unqualified therapists who aren’t members of a professional body. ‘I feel angry for members of the public who are potentially being exploited by these people and harmed,’ she said. Coverage of the documentary also featured on the BBC website, BBC1’s Morning Live, and national and regional BBC radio stations, reaching an estimated 34 million people so far. The programme is available to watch on BBC iPlayer.

If you are interested in becoming a BACP media spokesperson, email media@bacp.co.uk

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Working for you ● We’ve been working with the Royal Foundation to create a directory of therapists with the skills, qualifications and experience to work with emergency responders.

The Royal Foundation is funding the creation of the Blue Light Together Network of Emergency Services Therapists (NEST), which will be made available to all those in need of support via referral partners. As part of an expert reference group, we’re helping to develop a role profile for emergency responder therapists who’ll then be listed on the directory. Specialist CPD will also be available. Kris Ambler, BACP Workforce Lead, says, ‘Once the directory is developed, it will help our members achieve parity of esteem with professions that have traditionally dominated this space. These will be paid roles across the UK that reflect the skills, experience and specialism of our members.’ ● There was cross-party support from MPs for ring-fenced funding for mental health and counselling during a debate in Parliament. We briefed MPs ahead of the session and were pleased to see our data and key points about school counselling raised in the

debate. Our briefing highlighted the trained workforce of counsellors specialising in children and young people that would be available if more funding is put into this area. Jo Holmes, BACP’s Children, Young People and Families Lead, says, ‘This debate was the first time MPs have had the opportunity to publicly scrutinise and challenge the Government’s position on school-based counselling in detail. It was excellent to hear support for school counselling voiced so strongly and we’ll continue to build relationships and campaign on this vital issue.’ ● Our Four Nations Lead, Steve Mulligan, welcomed the Scottish Government’s £4 million investment in psychological therapy services, on top of £5 million allocated earlier in the year.

The funding will allow health boards to recruit additional mental health professionals, including counsellors and psychotherapists, to reduce waiting times. It will also allow practitioners, where appropriate, to use digital services to reach people in more remote locations and those not able to attend in person. Steve says, ‘When we met with the Mental

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Wellbeing Minister, we emphasised the important role that counsellors and psychotherapists are playing in supporting the mental health of the nation and the need for increased investment in the counselling workforce to ensure more people can get the support they need, when they need it. So it’s great to see this additional funding.’ ● We produced a briefing for the Afghanistan and Central Asian Association on the importance of specialist counselling services for refugees arriving from Afghanistan. We’ll also highlight the high levels of mental health need in refugee populations in our response to the Northern Ireland Executive’s current consultation on its refugee integration strategy. ● We worked with the Department of Education in Northern Ireland to update its guidance on supervision for counsellors working in primary school settings to one-and-a-half hours per month. This brings the guidance in line with BACP’s Ethical Framework and has now been issued by the Department of Education in its latest specification.

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Coaching Today is 10!

Coaching Today, the journal of BACP’s Coaching Division, is celebrating its 10th anniversary.

Since its first issue in January 2012, the journal has showcased the evergrowing and exciting developments in therapeutically informed coaching. It’s also the platform for sharing the work of BACP Coaching, launched in 2010 and aimed at promoting ethical, effective and professional coaching for the wellbeing and enhancement of individuals and organisations.

Since it was formed, BACP Coaching has gone from strength to strength and brings together counsellor-coaches within the profession to develop coaching competences, provide CPD and network opportunities and support best practice guidelines. All BACP members can subscribe free to the online version of Coaching Today and access the archives at www. bacp.co.uk/bacp-journals

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Professional Development Days

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Our Professional Development Days (PDDs) are continuing to take place online, and cover a range of themes.

These specialist online workshops have specific learning outcomes and are delivered by presenters who are experts in their field. The delegate numbers are kept low to allow maximum engagement and interaction during the event.

Topics covered in our PDDs include race and culture, coaching, erotic transference and countertransference, artwork, anger, private practice and groupwork. More specialist events will be added throughout the year.

To attend a PDD costs £35 for members and £75 for non-members. To find out what’s currently available to book, see www.bacp.co.uk/events

Coaching for social change and impact Our next Working with Coaching event takes place in March and focuses on cutting-edge coaching for social change and impact.

You’ll hear from experienced and enthusiastic coaching practitioners engaged in groundbreaking work that aims to empower individuals and communities who are disadvantaged in current social structures. You’ll also find out about a new model for coaching for social impact and contribute to its development.

Staying Connected in Scotland

Bookings include access to the live event and the on-demand service after the event. You’ll also have the opportunity to send your questions directly to the presenter during the live Q&A and you can download a CPD certificate for your records.

You’ll learn why coaching can be an excellent approach for bringing about social change and impact and review the experience of practitioners already engaged in this work. There will also be space to reflect on your current practice and assess your recognition of the impact of social change. The event will create an environment to discuss, engage and network with other practitioners with social change in focus.

This online event takes place on Wednesday 23 March 2022, from 9.30am to 1pm. If you’re unable to watch on the day, the content will be available on demand for three months.

This event costs £35 for members.

For more information, see www.bacp. co.uk/events

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Our next Staying Connected event will be in Scotland, in March. The event is free for members and will feature one presentation with a general CPD theme and two further presentations that focus on areas important to our members living in Scotland.

There’ll also be an opportunity to watch a series of two-minute platforms from our staff and divisional volunteers and the option to join breakout sessions on different themes. This event includes a chatroom so you can network with your peers, the option to submit your questions for our presenters during live Q&A sessions and access to the three-month on-demand service to catch up on any content you miss during the live event. To book, see www.bacp.co.uk/events

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Most of us will have experienced times when our voices have been dismissed, ignored or even silenced

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It may not always be intentional, as we can tune people out without realising. This was known as the ‘cocktail party’ effect, first described by the aptly named cognitive scientist Colin Cherry in the 1950s – a time when drinks at smart gatherings often came with a sweet maraschino cherry on a stick!

These days it is more often referred to as selective hearing: the ability to tune into certain conversations in a crowd of people while filtering out others.

While this is a helpful and sometimes necessary attribute, it may also keep us from hearing those voices we do not recognise as being important, useful or relevant to us. This can be the case whether we regard ourselves as being part of the mainstream or a minority, as we each identify headlines and narratives that have particular meaning for us.

For me it has sometimes felt like being lost in a howling storm and falling silent as the winds of other people’s opinions and emotions rage around me. I want to hold on to that feeling so I am less likely to impose a similar experience on others.

Nobody should be silenced simply to ensure that others’ voices can be heard.

However, there are times when we need to offer a platform to particular groups or individuals so that what they have to say can be appreciated and understood. This is not an easy balance to maintain but if we can dial down the background noise we may be able to hear, and attend to, the sometimes discordant voices that are often asking the most challenging questions.

Social media platforms built around public conversations have allowed many people a degree of inclusion formerly denied to them, and the opportunity to publicly express support or dissatisfaction around a prevailing

viewpoint. This is a rich and diverse seam of information, and to maximise the benefit we need to be particularly sensitive to the voices within the subtext as well as the context. For me, this is about focusing on the quality of the conversation, rather than the quantity, along with an acceptance of the fundamental right of each of us to be heard and believed.

Many of the concerns continuing to be expressed around the Scope of Practice and Education (SCoPEd) framework are that a hierarchy of competences is being created that will privilege one voice over another.

While there may be differing opinions about the validity of this viewpoint, not to attend to it directly and consistently risks falling into the same behaviour that some people are most concerned about.

Research is clearly an important element in the ongoing development of the profession, but can be another area where certain voices can seem to have become privileged.

Michael Golding

Deputy Chair, BACP Board of Trustees

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Highlighting particular academic viewpoints can create a false impression of a shift in the way we think about our practice, which then risks creating a disconnection for those who might disagree.

There is always the risk of a dominant discourse drowning out alternative views, and we need to remain sensitive to our own enthusiasms taking over and tuning out the dissenting voice. All members’ voices need to be heard and we need to continue to be very careful about choosing when, or if, we prioritise one over another.

One of our priorities as a Board this year is to continue our work on promoting equality, diversity and inclusion (EDI), both within BACP and also the profession as a whole.

A mainstay of any EDI strategy is ensuring all voices are valued and particularly that no one voice dominates the discourse. This requires sometimes stepping out of the space to see what dynamic patterns are emerging, while also being willing to step into the space and immerse ourselves fully in the complexity of difference.

While there is comfort in listening to voices we agree with, there is often more to be learned by attending to those that are harder to hear. As practitioners, we are experienced in having difficult conversations.

By continuously challenging prevailing perceptions and assumptions, we create a dynamic space for bold and courageous conversations to take place.

Social media is like a modern version of the cocktail party, with its cacophony of differing voices, emotions and viewpoints.

It is important we are able to take the time to tune into each of them and to maintain the balance between the comfort of consensus and the creative tension of dynamic discord.■

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in human relationships, we also need to acknowledge that tackling climate change is hugely complex – it cannot be broken down into ‘goodies’ and ‘baddies’ as simply as some would wish. Above all, we need to signpost hope among the hand wringing.

Lucy Beney MBACP, integrative counsellor

Climate crisis

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I wanted to thank Linda Aspey for raising an issue that almost seems to be a taboo subject – certainly a topic that the counselling community appears reticent to address (‘Breaking out of the climate bubble’, Therapy Today, November 2021). I am currently a counselling trainee, and having brought up your article in my weekly group ‘check-in’, I am feeling rather on my own with this.

Of course, I understand that many people simply can’t deal with the enormity of climate change and many, like me, are genuinely and deeply concerned about it but don’t know how to begin to respond. But I am wondering how equipped I will feel, coming out of a training course in an environment where CO2 emissions continue to soar, despite David Attenborough outlining the need for collective action within five years if we are to avert annihilation. How equipped will I feel as a therapist? How much credibility will there be for a profession that appears not to be engaging with the ‘elephant in the room’, given the woeful lack of climate crisis- informed conferences, training courses, CPD or supervision? I can appreciate that, as Linda points out, there is still anxiety and uncertainty about how to professionally integrate the impact of climate change into therapeutic work. However, if we don’t willingly face the reality of climate change now – individually and as a profession – then we will be forced to face it very soon.

Ana Pollard MBACP, trainee student I found that the coverage of climate change in the November edition of Therapy Today lacked acknowledgment of the benefits to humanity of the development that has brought us to this point – or indeed, humanity’s documented success in tackling environmental and other challenges.

Maslow teaches that unless our basic needs are met, we lack the inclination to reflect on more abstract things. The modern globalised world is providing those basics for more people in more places than ever

before. Having lived for almost two decades in the developing world, I cannot feel shame or guilt at seeing living standards rise beyond recognition during that time – along with an awareness of the adverse consequences of that progress. These are problems that will be solved, both locally and more widely, with time and technology – not knee-jerk activism, which only tells one side of the story.

As a species, we are remarkably good at adaptation and innovation. We have survived millennia of wars, plagues, invasions, migrations, natural disasters – and, indeed, earlier climate change. In these islands, our forebears enjoyed balmy tropical conditions several thousand years ago, having returned here after the earlier Ice Age. As therapists, we know that change is difficult – and many resist it – but sometimes we have to accept it.

We cannot go back, so we have to go forward.

I work with a lot of teenagers, many of whom have deep-rooted issues stemming from the collapse of family and community, as we have traditionally understood it. A few have mentioned concern over climate change, but tragically most tie their worth as human beings to the acquisition of ever more stuff.

When given the chance of a new phone and fast fashion, climate change concerns go on the back burner.

We all need to play our part, to live as sustainably as possible, but as therapists we also need to foster hope, the possibility of transformation and a different future. Just as we frequently discuss the complexity of being human and the difficulties involved

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Thank you so much for dedicating the November 2021 issue of Therapy Today to breaking the silence on climate change. I also very much appreciated BACP Chair Natalie Bailey including in her column (‘From the Chair’, Therapy Today, November 2021) BACP’s position statement on peaceful protest, something I have been hoping to understand since I first applied for student membership of BACP six months ago. I was arrested at an Extinction Rebellion protest in October 2019, and subsequently convicted (I later successfully appealed). I feel strongly that this action was necessary and ethical, and sad that it felt like a barrier to my entering BACP – it took more than six months for me to be able to join and become an active member.

I am currently a second-year student on a Level 4 diploma in integrative counselling, and have had an extremely difficult time achieving conversation with my tutor and fellow students on the climate emergency.

This is despite me bringing up my own feelings regularly, and appealing on the basis of how much time has been given to processing Brexit and COVID-19 in comparison. I used the November issue of Therapy Today to help instigate 40 minutes of discussion on climate anxiety, which I found very useful.

Research shows that young people around the world are deeply distressed by government and adults’ inaction on the climate emergency.1 Social and racial trauma are deeply interwoven with this, and this is where I think therapists have a huge opportunity to contribute.

By acknowledging clients’ feelings and building resilience, we can help process deep emotions and empower clients to face this

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existential crisis. However, in order to hold others, we must prepare ourselves, research the facts, and work hard to acknowledge our own feelings too.

Sophie Broadbent MBACP, trainee counsellor REFERENCE

1. Hickman C et al. Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. The Lancet Planetary Health 2021; 5(12): E863–E873.

It was interesting to see the focus on the climate crisis in the November issue and to read contributions from various people.

There is no doubt that humans are having an increasingly negative impact on the fragile and finite resources of planet earth. However, I was somewhat concerned by Linda Aspey’s suggestion in ‘Breaking out of the climate bubble’ that we are potentially colluding with clients if we don’t bring the topic into the counselling room. I feel that we are in danger here of imposing our own agendas on our clients. Our job is to tune in to the client’s current point of reference and gently expand awareness into new perspectives. Many who are suffering in their personal lives and are just surviving psychologically from day to day are simply not able to engage with bigger political issues, and it would be quite wrong, in my view, to burden them further. An individual has already confided in me how a school has been giving so much information to her five-year-old about the climate crisis that it has upset her child. It is our job as parents to protect our children from ‘adult’ information that is too much for them to bear.

It is also our job as therapists to honour the fragility of our clients and travel at their pace.

As clients begin to take more responsibility for their own lives, they will become more able to engage with the bigger issues globally.

I believe that it’s for them to decide when they feel ready, not for the therapist.

Jennie Cummings-Knight MBACP, MA, PGCE, FHEA

How much credibility will there be for a profession that appears not to be engaging with the ‘elephant in the room’, given the woeful lack of climate crisis-informed conferences, training courses, CPD or supervision?

Thank you Linda Aspey for challenging us to speak out about the climate emergency (‘Breaking out of the climate bubble’, Therapy Today, November 2021). I agree that, as a profession, we have not engaged with the implications of the emergency for us personally and as therapists. There are times when I have been shocked at the lack of knowledge and awareness there is around this topic, as if it were something that does not or will not affect us and our loved ones in our lifetime.

As a supervisor and tutor on a BACP accredited course, I feel it is important to raise awareness within the profession so that we can better support others as the effects of the emergency become more apparent.

I am keen to network with others, having been involved in Extinction Rebellion over the past few years, and this year joined the Person Centred Association’s working group on the environment and climate crisis. As a next step, I’d like to see the creation of a BACP special interest group or division devoted to the environmental and climate crisis.

Becky Seale MBACP (Snr Accred)

Gliding not coasting Matt Wotton and Graham Johnston’s ‘Embracing challenge in therapy’ (Therapy Today, November 2021) seems to make explicit a growing trend in the therapeutic world to take a pop at person-centred counselling for not being sufficiently challenging or effective.

Having worked as a person-centred counsellor in the NHS for 20 years, I don’t think that this is paranoia on my part. As counsellors are being replaced by a variety of other modalities in the NHS, calling oneself ‘person-centred’ seems to be seen as a starting point for many integrative counsellors, rather than a valid approach in itself.

The article refers to various studies to conclude that most clients want a ‘directive approach’ that is ‘active, structured and educational’. It goes on to say that therapists whose training is grounded in person-centred theory may ‘focus on offering a safe space,

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and being accepting and non-judgmental’ but that the finding above suggests that is ‘not enough’, since this safe space does not involve challenge or direction setting.

There is not enough space here for me to defend person-centred theory in detail, but I feel that this article is somehow missing the point altogether. This approach has the relationship between client and therapist at its very heart, so the counselling could only be passive or neutral if this is how both participants were by nature (which may or may not be a good fit, according to client preference). I, for example, am someone who is quite direct and who likes to challenge myself and others. Although I do not impose a structured cognitive framework on my clients, in order to cover all bases I hold one firmly in my own mind. I also do not think it is inherently non-person-centred to offer information if I feel it might help my client, or to question whether or not it would be helpful for a therapeutic relationship to have more direction.

I am aware that my approach is much more ‘active’ than it was 20 years ago, but I do not see this as meaning I am no longer person-centred. I believe instead that I have developed the capacity to be more present and congruent in my therapeutic relationships.

Person-centred counselling is actually far from passive, and trying to connect with another person at a deep level without imposing an external structure is supremely challenging. Maybe it looks as though, like ducks, we are gliding along (or ‘coasting’, according to this article) with the frantic paddling going on unseen, underneath the water.

Jess Ketteringham, NHS counsellor ‘Embracing challenge in therapy’ (Therapy Today, November 2021) offers a good starting point for anyone wishing to reflect on their own practice. I related closely to the dilemma of challenging a client whose sessions bring bread to our tables. I was recently placed in a position where parents were urging the young person to end the work, while both I and my client knew

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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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we had more to explore together. Discussing this with the parents, I was very conscious of this underlying anxiety many of us in private practice experience, where we somehow feel that we have to work harder to convey our professional argument so it is perceived for what it is (a reflective, evidence-based clinical decision) rather than a financial venture.

When it comes to clients themselves, the article reminded me of the many discussions I had in supervision during my training. As a trainee, negative transference was possibly the most challenging learning curve. At first glance, it emotionally contradicts the very reason we chose to become therapists – our wish to help. However, this, if one is not reflective and open to constructive criticism, can quickly turn into a wish to be the ‘good object’, as Klein would put it, with none of the ambivalence that is crucial to an integrated emotional development. If anything, working solely in positive transference (without dismissing its central place in therapy) places us at risk of reinforcing unhealthy, unconscious splits.

From a psychodynamic perspective, I see what the authors call ‘challenge’ as accepting to be the recipient of negative projections.

Only through this can we truly become what Bion termed the ‘container’ for our clients’ most painful thoughts and feelings. Unless we welcome such projections, we cannot digest them on their behalf and return them in a manageable enough form to allow for their reintegration as part of the client’s inner self.

Despite how strongly I share the authors’ belief in the need to challenge clients, I am very cautious of doing so too early in the work.

I was rather viscerally taken by the authors’ reference to Kerner’s work. Such an approach may be valid and efficient where clients require low-level, cognitive behavioural interventions, but I see it as important to highlight how counter-effective this would be in a psychodynamic framework, where challenges are presented in the form of interpretations. These should remain minimal during the assessment and should only be shared in a timely and sensitive manner

throughout an intervention. Safety and containment in the therapeutic alliance must be the precursors of any type of challenge when offering more intensive, in-depth therapy.

This is also key to any trauma recovery work.

While psychodynamic thinking is very cautious of self-disclosures, I really liked the reference to Lewis Aron’s work where the therapist found a healthy compromise, inviting mentalisation and promoting therapeutic alliance.

Florence Nadaud MBACP, children, adolescents and families psychodynamic psychotherapist in private practice I just wanted to say how much I enjoyed the November issue of Therapy Today in general and ‘Embracing challenge in therapy’ in particular. This article resonated a great deal and also provided a good range of relevant approaches to the subject matter. I thought the authors’ exploration of the interplay between counsellor discomfort with client preference was spot on. I also liked the article because it was succinct and not too long, thus being one I will return to as a valuable tool for my practice.

More articles like this please! Thanks again for the excellent magazine.

Martin Bulpitt, counsellor In their article ‘Embracing challenge in therapy’ (Therapy Today, November 2021), Matt Wotton and Graham Johnston argue that the main areas required for change in therapy are specific goals, structure, a directive/active approach, and

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that therapy should be educational, challenging and in line with what clients say that they want. As a solution-focused (SF) specialist practitioner, I am of the view that SF has much to offer in the development of these practices.

In relation to what the client wants, an SF session opens with the question, ‘What are your best hopes?’, thus immediately orienting towards a preferred future and what the client hopes to achieve.

Rather than specific goals, the SF approach has evolved to elicit a rich description of the client’s preferred future and signs of that already happening. This allows for the broader possibility of noticing progress in areas that may be overlooked in the more linear goalsetting approach. It also allows for flexibility as things move and change. Second and subsequent sessions frequently start by asking, ‘What is better?’

I would describe SF as directional, rather than directive. The direction is determined by the clients’ best hopes. Our job is to elicit, and then co-operate with, their well-described future preferences.

SF is always educational, although not, perhaps, in the conventional ‘teaching skills’ sense of the word. An SF therapist adopts a ‘not knowing, always on the way to understanding’ approach, placing the client as consultant in their own experiences and learning from them.

In the process, the client comes to recognise what they already know, but often hadn’t realised. This realisation can often be built on by suggesting that the client simply does more of what they are already doing.

The SF approach is, by its very nature, challenging. Being asked questions based on genuine curiosity requires clients to think and work hard. Further enquiries about how they have coped and how they did things helps them to change their thinking and allows them to recognise their successes and abilities. It is common for clients to leave the room feeling uplifted and hopeful, and to return for their second session in a much better place.

Bryan Thornton MBACP (Accred), solution-focused practitioner, trainer and supervisor

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Francesca Inskipp died at home on 24 July 2021 aged 100. Throughout her professional life, she had an exceptional ability to work co-operatively in groups and partnerships. Four of us who worked closely with her have co-operated, as she would have liked, in celebrating her legacy.

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Brigid Proctor: Francesca and I met in 1973, on the way to the first Standing Conference for the Advancement of Counselling (SCAC), from which the British Association for Counselling (BAC, now BACP) emerged. As trainers, we both became actively involved in BAC’s struggle to agree individual accreditation criteria. Francesca was a member of the training and accreditation committees and of the supervisor recognition team. She became an early Fellow.

In the late 1980s, we developed our shared interest in the purpose and practice of supervision. Supervisees on counselling courses had revealed that many supervisors lacked clarity of task, variety and basic skills. A ferment of activity ensued, from which various models began to emerge. Francesca and I called our generic version ‘The Art, Craft and Tasks of Counselling Supervision’. We created two self-study workbooks for supervisees and intending supervisors (Making the Most of Supervision and Becoming a Supervisor, both published by Cascade Publications), which we used as a basis for our Cascade residential diploma courses. A former student, who later inherited the courses when we retired, wrote of Francesca: ‘She was always learning, always curious, immensely kind and just a little bit scary!’ We continued to accept invitations to run workshops from all over the UK. Francesca thought valuing a person was core – she had worked hard to learn to withhold judgment. She succeeded. Amazingly, I can never remember an altercation with her – she disliked arguing and had ingenious ways of diverting without avoiding the issue.

In her 70s, she joined a three-year psychosynthesis course as a student. She valued it highly (and offered advice on how to meet their requirements for university accreditation!).

She also studied several units of an Open

University literature degree, was a member of two book groups and wrote poetry: ‘The sun is up and getting bold, Time to paint my toenails gold.’ weipke@yahoo.com Charlotte Sills: We four met with Francesca in the wonderful Supervisor Development Group that met over many years. She was loving, challenging, iconoclastic, appreciative, humorous and surprising.

I met her in a different way later when Sage, the publisher, asked her to be the series editor of its ‘Skills in…’ series – a welcome addition to the literature, with its focus on how to apply different therapeutic approaches effectively. Phil Joyce and I wrote the book on Skills in Gestalt Counselling and Psychotherapy. Francesca was a really helpful editor. Her input was minimal and mainly took the form of encouragement and appreciation. Where she did make suggestions, they were without exception useful and supportive, pointing out areas where we might elaborate or simplify. Even well into her 90s, as we prepared the fourth edition of the book, she continued to read the revisions and show her interest and encouragement. contact@charlottesills.co.uk Hazel Johns: Francesca undertook at the University of Keele one of the first courses in the UK to offer one-year, full-time training for school counsellors. After working briefly as a training officer with youth workers, she was appointed in 1973 to the new Centre for Studies in Counselling,

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set up by Hans Hoxter at the then North East London Polytechnic (now University of East London) to train teachers and careers officers alongside each other. I joined her in 1975 and, with Hans and Peter Heaviside, we ran diploma courses and developed short courses for helping professionals. Francesca’s gifts of endless curiosity and fascination for new ideas prompted us to visit counsellor education centres in the US, then import and adapt much of value, especially the skills-based work of American educators such as Gerard Egan and Susan Gilmore, despite resistance from some quarters. By invitation, she and I wrote and recorded for BBC Radio 4 two eight-programme series called Principles of Counselling (the BBC’s choice of title), using extracts of counselling dialogue recorded by some of our current students. This was productively used by many organisations and individuals. Francesca was brilliant at making contacts, and modelled energy, enthusiasm and commitment to students, influencing several of us who moved on to develop significant training centres elsewhere. hazeljohns10@gmail.com Penny Henderson: In the 1980s, Francesca was invited to write a distance-learning text on counselling skills for the National Extension College. Despite widespread doubt that it was possible to teach interpersonal skills this way, she produced a lively package of written materials supported by audio recordings of vignettes. This package, which we piloted in Cambridge, sold well and was used by many groups as a resource for ‘Introduction to Counselling Skills’ courses in further education and by individual trainers.

She was a regular attender and contributor at the extraordinary Standing Conference for the Advancement of Training and Supervision (SCATS), a lively co-operative annual exchange for trainers and supervisors. Later, she also regularly attended and contributed to the British Association for Supervision Practice and Research (BASPR) conference for supervisors.

Throughout her long career, Francesca was a remarkable contributor to the development of counselling, training, supervision and BACP. ph286@cam.ac.uk

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1. Gladwell M. Blink: The power of thinking without thinking. London: Penguin; 2006. 2. Said E. Orientalism. London: Penguin; 1978. 3. Yalom ID. Love’s executioner and other tales of psychotherapy.

New York: Basic Books; 2012. 4. www.poetryfoundation.org/articles/69384/selections-from-keatss-letters 5. Eliot TS. East Coker. In: The Four Quartets. London: Faber & Faber; 2001.

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‘You can either be right, or you can be open’ Humans and chimpanzees are 98.8% the same, genetically. If we’re that similar to chimpanzees – who, for all their brilliance, have never managed to deliver a compelling webinar or offer a cogent opinion on, say, EMDR – imagine how similar we are to each other.

In all the most important ways, you are actually just like some random human on the other side of the world, your arch enemy, a neighbour, a client who sits before you, weeping over an ancient, lost hurt. You are just like me.

And yet there is nobody else quite like you.

Only you were born into your body, at that time, to those people, in that place; only you have had your complex web of relationships, encounters and experiences. You are a one-off prism that refracts and casts a unique light on what it is to be human.

So who are you? Friend or foe?

What do we say after we say hello?

Our survival has depended on a certain level of anxiety, vigilance and distrust towards the unknown, and an affiliation with the safety of the known – this has been our evolutionary process. We navigate through life with the help of what Malcolm Gladwell describes as ‘thin-slicing’,1 in which we use our senses, our experience and our beliefs to process a given situation very quickly, largely unconsciously, and take action. Yet so often the red warning light flashes completely unnecessarily. The results of such bad intelligence can be devastating, especially when poor light, adrenaline and police firearms are involved. Thin-slicing draws heavily on groupthink – social identity theory suggests that we categorise members of a group as being all the same.

Since time immemorial, people who have power have deemed groups of people who do not to be ‘different’ – and usually inferior.

Edward Said called this ‘Orientalism’.2 Sometimes it is done wittingly – the British empire was built on a savage belief in its own, white supremacy atop a human caste system that was solidified and exploited in order to ‘divide and rule’.

Marginalised groups seeking justice are often successful in presenting a united front in demanding change, but when identity politics becomes too dogmatic, inward-looking and sectarian, it can paradoxically reinforce the very barriers it seeks to abolish. I identify as a ‘person with a disability’ – not a ‘disabled person’, which the social model mandates. Black History Month, the Paralympics, Pride – these are a step forward from exclusion, but they are essentially segregationist and would not be necessary in a truly inclusive society.

Psychotherapy, of course, is meant to build bridges, but it too is not immune from unwittingly reinforcing walls – Orientalism isn’t always conscious. Is our profession, for example, person-centred or white personcentred? In England, if you’re black, you are four times more likely to be sectioned than if you’re white. Or how about disability? Such clients can

Dr John Barton MBACP (Accred)

Therapy Today Editorial Advisory Board

Dr John Barton MBACP (Accred) is a member of Therapy Today’s Editorial Advisory Board. He is a therapist in private practice specialising in working with life challenges, including disease, disability and death. His new book, The Humanity Test, will be published later this year by PCCS Books.

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sometimes struggle to find a therapist who will take them on, and when they do they sometimes report feeling pitied, patronised or pressured to conform to the therapist’s assumptions of what is normal. The worst word in our language might be ‘invalid’.

How much do we question our own biases and prejudices? Do we tell ourselves that our approach, modality, research method, our way of being a therapist, is the right one, that our brilliant interventions and interpretations are surely correct? Do we indiscriminately reduce, label and pigeonhole clients with CORE scores, simplistic models and clinical diagnoses that are, perhaps, little more than adjectives dressed up and repackaged as nouns? (As Yalom observes: ‘Even the most liberal system of psychiatric nomenclature does violence to the being of another.’3) We tell ourselves we know. And when we do this – what the poet Keats called ‘irritable reaching after fact and reason’ 4 – we perhaps stop listening, and talking therapy becomes telling therapy, and ‘being with’ becomes ‘doing unto’. The therapist exerts power; the client shrinks. My supervisor, Mark Gullidge, once said to me: ‘You can either be right, or you can be open.’ Or, in the mournful words of TS Eliot: ‘The only wisdom we can hope to acquire/ Is the wisdom of humility: humility is endless.

The houses are all gone under the sea.’5 We must question ourselves, and what we think we know about humans. We must be like fish trying to understand the concept of water. We must be xenophiles. We should know about and be sensitive to the struggles and history of disadvantaged groups, but we must assume nothing about the person before us.

Spinelli says therapists should aspire to be un-knowing – as opposed to ‘unknowing’. We should be pluralist, integrative, flexible, perhaps creating what Jung described as a new therapy with each client.

As WH Auden says in his poem ‘As I Walked Out One Evening’: ‘You shall love your crooked neighbour/With your crooked heart.’

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Exhibition

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Kayleigh Llewellyn’s Cardiff-set comedy drama tackles with wit and wisdom heavyweight social issues, including teenage struggles with sexuality, bullying and parental mental illness, as we follow protagonist Bethan’s final years at school. Originally shown on BBC3, the recently released series two of the award-winning In My Skin is available for catch-up now on iPlayer.

Life stories • In The Gift of a Radio: my childhood and other trainwrecks, Justin Webb, presenter of the R4 Today programme, shares with dark humour his dysfunctional childhood coloured by parental mental illness and a Quaker boarding school.

(Demy Octavo, 10 Feb)

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IN MY SKIN There’s still time to see this unique exhibition that will appeal to cat and cartoon lovers alike. Louis Wain (1860–1939) was an illustrator specialising in animals and countryside scenes, but he became best known for his anthropomorphised caricatures of cats. These were originally inspired by a stray cat, Peter, who was a comfort to Wain and his wife when she was dying of breast cancer. Sadly, and ironically, he ended his life in a series of lunatic asylums, diagnosed with schizophrenia, believed to be brought on by toxoplasmosis, which is caused by a parasite commonly found in cat faeces. To mark the release of the biopic The Electrical Life of Louis Wain, starring (inevitably) Benedict Cumberbatch as the eccentric artist, Bethlem Museum in south London is showing many of Wain’s cat drawings in all their vitality and satirical wit.

Ends 14 April. bit.ly/3esD2yp

• Award-winning disability advocate and TV presenter Sophie Morgan, paralysed from the chest down after crashing her car at age 18, describes her remarkable journey from despair to hope and resilience in Driving Forwards. (Sphere, 17 March)

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• After the sudden death of her brother, journalist Christina Patterson looks back at her childhood and unpicks the lasting impact of her older sister’s schizophrenia diagnosis in the beautifully written Outside, the Sky is Blue.

(Tinder Press, 17 Feb)

The Month, 1 Know of an event that would interest Therapy Today readers?

Email therapytoday@thinkpublishing.co.uk

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HOW TO REST WELL In today’s industrial world, work is active, productive, acclaimed and rewarded, and rest is… passive and pointless ‘downtime’. We’ve got it wrong, argues Alex Soojung-Kim Pang in this contribution to the Psyche digital magazine. Pang is the founder of Strategy and Rest, a Silicon Valley-based consulting company that helps companies design and implement four-day working weeks. ‘Good rest is not idleness,’ he argues.

‘The most restorative forms of rest are active, not passive.

Further, rest is a skill: with practice, you can learn to get better at it, and to get more out of it. So I believe we should not regard work and rest as opposites, but partners… You won’t fully flourish unless you master both work and rest.’ He goes on to offer nine steps towards making our downtime truly restorative – and sleeping is only one small part of it. bit.ly/3FjdxLs

Turning Red The story of a little girl who turns into a giant red panda when she gets angry sounds… irresistible! Move over, Hulk, Panda-Grrrl is coming! Mei Lee is a sassy, confident 13-year-old Chinese-Canadian girl who wakes one day (admittedly after a bit of a bad dream about ancestors and stuff), stumbles into the bathroom and finds, looking back from a mirror, a huge, red-and-white, hairy face. Seemingly, it is a trait inherited from her Chinese ancestors. From then on, this animation from the Disney/ Pixar studio just gets more and more fun. It’s a sweet but powerful metaphor for adolescence, the crisis of confidence and body image sparked by hormonal changes, and the choices we face between staying the perfect, dutiful little daughter or owning and inhabiting one’s emerging adult self and body. It’s also a warming celebration of the importance of friends (‘I always wanted a tail,’ remarks one). Unleash the panda within! Turning Red is promised for general release from 11 March.

Podcast picks

Therapist talk • BACP member and CYP specialist Melanie Light features in episode three of A Good Divorce, Rachel Oakes’ exploration of the possibility of an amicable divorce. With Melanie, she discusses ways that parents can tell children that they are divorcing.

On Apple Podcasts.

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• In episode eight of How We Care, BACP accredited member Elizabeth Turp and co-host Paul Gaunt discuss the courage of the person-centred approach. Episode four explores the benefits of being a mindful professional. See https://how-we-care. simplecast.com

• Therapy Today contributors Matt Wotton MBACP and Graham Johnston join relationship therapist Andrew G Marshall in episode 53 of his The Meaningful Life podcast to discuss what we really mean by boundaries in relationships. www. andrewgmarshall. com/podcasts

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Catherine Jackson explores how social media and public presence are shaping the therapeutic professions

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ocial trends and technological developments have made little impact on the fundamental theories and practice of psychotherapy and counselling since they emerged at the turn of the 19th century. Concerned as they are with universal human nature and experience, and using non-medical and non-technical tools and relational skills, why would they change? But the arrival of digital technology and social media has, arguably, cracked open the black box of the therapeutic relationship. Our increasingly psychologised world is becoming more emotionally literate; TV and video channels are proving a very effective public health medium, and reality shows attract seemingly insatiable audiences with their exposés of the most and least attractive aspects of human nature and how we conduct our relationships.

And social media has given individual practitioners a global platform to promote and explain themselves and what they offer. Many have seized these opportunities with enthusiasm; younger generations of therapists don’t think twice about having a visible and vocal presence on Twitter, Facebook and Instagram. But is this for better or for worse? What are the benefits of opening the black box of the therapeutic relationship for therapy, for therapists, for their clients, and for human relationships in general? Do clients gain from their therapist having a public persona?

Captured on screen Relationship psychotherapist and broadcaster Anjula Mutanda was one of the pioneers in popularising psychology on our television screens. A psychological on-screen expert to the Big Brother series when it first broadcast in 2000, she has a

string of shows and series about human relationships on her CV, including the recent Sex Tape, on Channel 4, where she works on-screen with couples experiencing difficulties in their sexual relationships. Alongside, she has built a successful practice as a psychotherapist (she is a senior accredited member of BACP and Fellow of the NCS), and was recently appointed President of Relate.

Mutanda sees the two roles, public and private therapist, as complementing each other. The TV work is an opportunity to bring therapy to a much wider audience: ‘It is education first, delivered in a relatable, informative and hopefully engaging way,’ she says. She reckons Freud would have seized the opportunities that the broadcast and digital media offer: ‘He was a bit of a rock star and pioneer in his own time, and I think he wanted his work to be known about.’ Her TV work is an effective way to deliver public mental health: ‘Not everyone can afford therapy or access it, and TV and social media can be great spaces for explaining what we do, and maybe even helping some people to go on to get appropriate help for themselves.’

Of course, her media presence does impact on her work with clients, she says.

Sometimes a client will come having watched her apparently achieve miracles with someone in one single episode of Sex Tape: ‘The intention of television relationship shows is to be transformative and show a person’s journey to achieve their personal goals. This can also sometimes come across as a bit like magic.

You have an hour’s show in which there appears to be an instant transformation.

You see a couple at the beginning struggling with their relationship and, by the end, they are in a better place. So sometimes potential clients might think that you can achieve such outcomes quickly

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and that you can deliver this for them. So, I am very transparent about this aspect, and start by saying TV is a very different medium, it’s more of an action-based, coaching relationship, and a therapeutic relationship is a very different journey. On the other hand, a client in pain might have initially contacted me because they’ve seen my work on TV, and they just want me to roll my sleeves up and get on with my job.’

Psychotherapist, writer and broadcaster Philippa Perry gave up her private therapy practice when her writing and television career took off, after the publication of her first book, Couch Fiction. ‘I took a year’s sabbatical to promote the book, and I was so enjoying talking to rooms full of people who weren’t colleagues, talking to the general public about therapy and how it can help, that I felt I was doing more good that way,’ she says.

‘These days, I see myself more as a therapy outreach worker. I write about therapy, and I hope that, by so doing, I can pass on some of the great things about it that people can use to help themselves.’

Nothing to hide For the traditional psychoanalytic or psychodynamic practitioner, to have any kind of identity that might contaminate the transference is theoretical anathema.

Freud deliberately sat at the head of the couch so his patients could not see him

JOHN HOLCROFT/IKON IMAGES

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(although, it is also said that he didn’t like his patients looking at him). Brett Kahr, psychoanalyst and author of numerous books, including Coffee with Freud, is regularly invited to give a professional opinion on broadcast media. He is an unashamed advocate for the therapist as a ‘blank screen’, he says – but less because he worries about the transference and more because he believes his total focus in the therapy room needs to be on his client.

‘I do strongly adhere to the notion that the psychological practitioner must ensure at all times that the patient or client receives 100%, if not 1,000%, of our attention, and I think to turn the narrative in any way towards oneself as practitioner has the potential to threaten that extraordinary, unusual focus,’ he believes.

Freud, of course, was the first person to foreground the patient’s narrative, rather than that of the practitioner, he points out: ‘Doctors were the ones who got to say what was wrong with you. I don’t think it is appreciated enough that Freud was the first to reverse those roles when he said, “I don’t know what is wrong with you, why don’t you tell me and I will listen.” Not only that, but he put his chair behind the patient so the patient could really be the star of the show, the centre of attention.

‘The American relational school has championed the potential benefits of self-disclosure, and that may be the case.

It depends on the nature of the disclosure.

If you disclose something about yourself, you always run the risk of overtaking the narrative, or provoking envy or competition or making the patient feel displaced.

‘For me the essential elements of therapy are showing up reliably, keeping everything about the patient’s life in the archive of your memory so they know you are really listening, and helping them unravel the complexity of the secrets of their unconscious. By focusing on all those, one does not need to self-disclose.’

Psychotherapist, writer and CEO of the international psychology hub Stillpoint Spaces in central London, Aaron Balick

‘These days, I see myself more as a therapy outreach worker’ Philippa Perry Therapist, author, broadcaster and agony aunt was one of the first in the profession to explore the impact of social media, in his book The Psychodynamics of Social Networking, published in 2013. He has no truck with the notion of the ‘blank screen’ therapist, as he explains in a recent blog.1 ‘The therapist’s values assert themselves, whether they are explicit or implicit,’ he argues. ‘Neutrality is never really neutral: it is rather a reproduction of normative cultural constructs prevalent at any given time…’ He points out that the idea of neutrality was created in the early 20th century, when psychotherapy was largely delivered by white middle-class analysts to patients not so dissimilar from themselves.

Practice according to those rules in today’s multicultural society is simply no longer fit for purpose: ‘For anyone who experiences themselves as different from conventional norms (and the vast majority of us do), being in a neutral therapeutic space is more likely to feel like oppression than care,’ he writes.

It is, he argues, even more of a fallacy to attempt to maintain the fiction of the blank screen and therapist neutrality in today’s world, and potentially unhelpful to the client: ‘Every relationship is messing with the transference because every relationship is now contaminated by what people find out about each other on social media or by googling. So, to pretend you can have a protected space that is separate from the relational spaces we are all occupying doesn’t make sense,’

‘TV and social media can be great spaces for explaining what we do’ Anjula Mutanda TV therapist and President of Relate

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he says. ‘By assuming that the therapeutic relationship can be somehow pure from the contamination of people being or even looking online, are you preparing your clients for the actual world we live in?

Shouldn’t we accept that is reality and work with that reality?’

But that doesn’t necessarily mean the therapist should disregard the potential impact of their social media presence and personal disclosures on their clients and potential clients, he says. Balick uses social media but ‘it is my professional persona that is deployed across them, and I am always aware that any client, past, present or future, can see anything I post’.

In the early days, use of social media was widely frowned upon within the psychological therapy professions – and still is to an extent among the older generations. ‘I didn’t come into this profession to be a monk. I think therapists should allow themselves to participate or not participate as they see fit, and accept the realistic consequences,’ says Balick.

‘For younger people who see no evidence of their therapist online, there will equally be an effect and a consequence – the client may be curious about that, or the therapist might not even get the business.

People want to know about who they are consulting these days before they engage with a therapist. That doesn’t mean the therapist has to have a social media presence or should not; it just means they have to ask themselves some questions about the consequences of either, and come up with some answers, and be prepared for the consequences of whatever choice they make.’

Selling yourself Balick highlights a crucial point for counsellors and therapists today: many clients, and especially younger ones, look for a therapist online – and not necessarily even on an online directory such as those provided by the professional associations. Coach and psychotherapist Charlotte Braithwaite, co-founder of the Network for Younger

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Counsellors and Psychotherapists (NYCP), calculates that some 40–50% of her clients find her, find out what they can about her and contact her entirely through Instagram. ‘They find me through hashtags like mental health, trauma and recovery.

They say they really liked a post I did on trauma responses, or they went to their GP who offered them antidepressants and then they found me on Instagram, and what I said made them feel I would get them – the self-awareness resonates. They feel a level of being understood just through the content I share,’ she says.

Social media isn’t necessarily good or bad, it’s a tool, she believes. ‘It’s about how it’s used. Yet I do still have a residual sense that I am doing something wrong when I use it!’ She deliberately chooses to make use of herself on her website and through her social media posts, but she is also very selective and deliberate in considering the ethics of her choices about what she says. ‘For me, social media is a great storytelling platform. My clients who have found me through social media have resonated with the stories I tell. They are psychoeducational; they’re not stories about me, my life, who I am – they’re more stories about situations that clients or potential clients may relate to. I’ve done a few podcasts or interviews where I have talked about how I came to be a psychotherapist – about my own trauma experiences in childhood that came back at me in adolescence, and how my own experience of going to counselling inspired me to become a psychotherapist.

But I am very mindful of what I choose to disclose, as I am with my individual clients, and that what I share publicly is of benefit to people who read it. I constantly ask myself, is it that I just want to be seen and heard? In which case, I should take it to my own therapy.’

But she, like Balick, thinks the notion of the blank screen is outdated, and even retraumatising for some clients.

‘I originally trained psychodynamically and I found it really limiting. Then I discovered

‘People want to know about who they are consulting these days before they engage with a therapist’ Aaron Balick Psychotherapist and author psychosynthesis – to me it’s very relational, relatable. If you are moved by what the client is saying, you don’t need to be afraid to shed a tear. I find it is far more healing with clients to show humanness – if only to say, if I were in that position, I’d feel the same. There is a whole space between selfdisclosure and blank screen – it isn’t saying “this happened to me too”; it’s being able to call on personal experience to humanise the therapy relationship. One client said to me, “I’d never trust a pilot who hadn’t been a passenger.” I thought that was a very creative metaphor for describing that we are human too; clients need to know where we are coming from.’

Philippa Perry puts it more bluntly: ‘Just sitting behind a client isn’t going to do it! We do good therapy by having a good working alliance, a connection.

Moments of inclusion are what make good therapy, not being clever by recognising the transference a client makes. I can remember asking clients what helped them the most, and people would say, “It was that time you touched my arm just as I was leaving, I felt so much care.”

Seven years of training and what made the difference was I touched their arm – and I shouldn’t have done it anyway! Nobody has ever said to me, “It was when you helped me realise I was seeing my mother in every female boss I had”.’

Charlotte Braithwaite challenges the suggestion that the stories on social media that resonate with and bring clients to her could influence and even obstruct exploration of the client’s own stories. ‘That can happen in any situation. For me, what matters is that something has resonated, something I have posted has helped them reach out, has made them believe I will get them. The presenting problem is rarely

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exactly the presenting problem in any client contact. I will use it as a starting point but it won’t direct where we go from there.’

For NYCP co-founder Ali Xavier, social media allows her to reach a particular type of client. She posts about her own life – her personal juggling to manage a life as a practising therapist and mother of young children – but does so carefully and selectively: ‘My main client base is mothers with young children. Last week, my daughter was ill and off nursery, and I had to spend some of the morning rescheduling my day. I shared a photo of me in my garden and posted a comment about how I had had to reframe my thinking to see this as an opportunity to spend time with my daughter when she was sick. I had some positive comments back about the helpfulness of reframing unexpected circumstances. Social media can be a helpful therapeutic tool and a gateway to reach clients who may relate to what I’m posting.

‘The challenge with that kind of post is if, say, a client came to a session and said she’d seen my daughter was unwell and how was she? My response would be to acknowledge her kindness, give her a contained response and gently move the focus back to her. I am conscious that I have to be prepared for a response to whatever I post, and I am aware of the need not to occupy that therapeutic space.

‘To me, my use of social media feels enough, and not too much. Most of my social media content is reflections about topical and relevant issues, but I supplement this occasionally with narratives that show me as a person too.

But what I share is a small part of me, not the whole part. And I have noticed that the posts that feature me get far more attention and feedback – that is what people are more interested in, the person. I am a working woman, balancing motherhood with a job – that is where the synergy comes from and so I become a more relatable therapist.’

She is alert to the risk of shared assumptions: ‘Some clients do say, “As you’ll know, as a working mother…” but I tend not to pick that up with a response, so the dialogue stays focused on their experience. Equally, one client said of a

post I shared about pandemic parenting: “You normalised struggle, and I didn’t want to see anyone who would judge me.”

Sharing a small part of my story seemingly gave her permission to acknowledge her own struggles and engage with therapy. If there is a therapeutic intent or benefit to what I am sharing and it doesn’t compromise my wellbeing or that of others, then I am happy to share.’

Both Xavier and Braithwaite say that professional networking is also enhanced by social media, and particularly during the past two years of lockdown. ‘I have built some lovely connections with other therapists on social media,’ says Xavier. She’s also taken part in professional panel discussions and debates where she’s contributed on mental health and therapy. ‘For me professionally, social media provides an opportunity to build some good professional connections and provides another route in for clients.

I wonder if in a few years website directories will still be the main route for clients to access therapy?’

Therapist as brand Catherine Asta doesn’t use online directories at all to advertise her services – simply her own website and Instagram, and broadcast and published media opportunities. As her website states, her clients are mostly women. In her posts and published columns, and in the 12-minute weekly slot she had for three years on local radio, where she took calls from listeners and talked about mental health, she is ‘open when I feel I need to be – I weave in parts of my own story and the adversity I have faced in life. I’m an advocate of narrative psychology as a theoretical perspective. I believe our stories become the lights of hope on someone else’s dark runway.’

She has no qualms about describing herself as a ‘brand’ and uses social media as a platform to build a community around that brand. ‘I am a brand. This is me. I may not be everyone’s

cup of tea, but people have a feel for who they are coming to see before they step through my virtual door. When I set up my therapy practice six years ago, I set out to do something different, to create a space where collectively I could start to normalise some of the stigma around talking about mental health. I deliberately aim to empower women to believe that, just because this is where they are now, it isn’t necessarily where they are going to end up – there’s some hope.’

It is, she argues, important to build a sense of relatability and common ground with those who might benefit from therapy with her. ‘I put myself in my clients’ position, and I’d want to work with someone who had a shared understanding of what was happening to me. So I attract women who have experience of some of the things that have happened to me.

I have experienced a lot in my 42 years and it’s all part of how I work. I am working class, from a very dysfunctional family, I’ve been a young single parent and now have my own blended family, and I have faced my own mental health struggles.

I am a wounded healer; I work from a very compassion-focused perspective.

I take my own experience and bring that compassion into the therapy room. I am not immune to adversities in life, and I think it’s important to be able to say that – to say my life isn’t perfect, I am only human.

‘This morning I went into the local café for breakfast and a woman stopped me and said, “I follow you on Instagram and every single post is a post about my life.

You make me feel like I have someone by my side.” It’s about feeling that you are not alone. I show up every day on social media, talking about things that matter in a collective sense. These are

‘If you disclose something about yourself, you run the risk of overtaking the narrative’ Brett Kahr Psychotherapist, author and broadcaster

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not individual stories; I post about things that many women are experiencing or have experienced and think they are the only person in the world with those problems, and I bring in my own experience, thoughts, values and feelings too. Instagram has progressed from somewhere to post pretty holiday pictures to a journal where women in the demographic I work with go every day to feel connected. I am not associated with any other bodies, other than my professional associations, and I don’t work with EAPs. The majority of people who come to me either come from word of mouth or say they’ve been following me on Instagram for many years and, at the point at which something went wrong and their life began to fall apart, I was the first person they thought of who they wanted to speak to.’

And sharing aspects of her own story online and on social media is very different from self-disclosure in the therapy room, she emphasises. ‘It’s less that the selfdisclosure happens in the therapy room and more that it has already come before they even find me. In the therapy room, I might share things when I think it will help the client’s understanding to know that I know what it feels like, but I always caveat it as something that I think might be relevant and help, and follow up by stressing this is their unique experience.’

Wounded healer The concept of the ‘wounded healer’ is very strong within the counselling profession; many if not most counsellors and therapists came to the profession through their own experience of therapy and its potency to heal emotional trauma.

But Anjula Mutanda sees dangers there.

‘My personal rule is I will talk publicly about what I have worked on and healed from.

I give a lot of talks on multigenerational trauma, for instance. But I won’t talk about a crisis that might be happening now.

I’ll talk about what happened to me in childhood in the context of how therapy helped me, and I’ll talk about it in terms of the work I’ve done on myself and what I’ve found helpful.

‘In the therapy room, self-disclosure in my opinion has to be appropriate and

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relevant to the client and used skilfully as a tool in the therapeutic process. It is something that I will also explore with my clinical supervisor if I am uncertain whether disclosure would be helpful or not. For me, talking about something that you are in the middle of means you are likely to get in the way of the client and their process.

You are no longer in a therapist–client relationship; you have crossed the line and blurred the boundaries.’

And, she says, she works hard to maintain those clear boundaries between her public, professional and personal lives: ‘I don’t, for example, post anything that involves my daughter unless she agrees, and even then, it is only in relation to wider newsworthy issues and campaigns. I am always thinking about how my clients might feel and what they do and don’t need to know about me.

When is it relevant? When does it matter?

When do we step aside? These are things I am always thinking about as a professional.’

Says Philippa Perry: ‘The thing about putting yourself out there is that you will put off some people, and I think a lot of therapists are frightened of doing that. But if you don’t put yourself out there you won’t engage those people, and there’s always going to be some seed that falls on stony ground. I think it’s good if you put people off when you aren’t the therapist for them.

‘Social media is part of life now and if you aren’t on it, it is saying as much about you as if you are. Therapists should at least have a shop window online to show clients who they are, and I don’t mean pictures of some stones or a pretty sunset. That just says you’re a cliché. Clients need to be able to see who they are going to be in a therapy relationship with.’

Identity politics One area where self-disclosure can, arguably, be hugely beneficial is in making therapy more accessible to people from highly marginalised and minoritised groups who may assume (or fear) that it isn’t for them or that the therapist will be critical of or even hostile towards them

or attempt to ‘cure’ a fundamental aspect of themselves that deviates from mainstream social norms. This is where Karen Pollock believes it is important for a counsellor or therapist to be upfront and open, and where having a social media presence that speaks to these beliefs and personal lifestyle can be very useful in engaging clients.

Pollock offers counselling to sexually minoritised groups such as sex workers, people from the LGBTQI communities and people with less usual sexual practices, such as kink. ‘I have thought about this a lot.

I decided people need to know I am safe, that if they come to me I’m not going to judge them because they’re kinky or a sex worker, and the only way to do that is to talk openly about these things. Social media is wonderful for reaching hard-to-reach clients. People have been hurt by therapists who didn’t understand them or made assumptions about what they needed or what they were. So I do talk very openly about controversial things like trans rights or my views on conversion therapy. Clients who contact me can be confident that they won’t get a negative experience of therapy, because I am totally upfront about these matters. And I very much hope clients do see what I write and post about myself – we all have a personal brand, whether we like it or not. That is what social media has done.

My personal brand is out there. The idea of neutrality is a myth. I probably go further into not being neutral than most others, and it’s OK if some people think I’m not the therapist for them – it’s just a shame when I think they might really benefit.’

Pollock also points out that every therapist comes to the work with a history.

Pollock was publicly politically active as a queer person in their previous career; it isn’t hard for a potential client to find that out. ‘I couldn’t remove my identities and

‘I believe our stories become the lights of hope on someone else’s dark runway’ Catherine Asta Psychotherapist and media contributor

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didn’t want to – the evidence base tells us it helps the client build a therapeutic relationship, and there were identities I couldn’t not disclose because of stuff about me that was already public knowledge,’ Pollock says.

But they are very careful to separate that public exposure from self-disclosure in the counselling room: ‘Research shows that the “we” self-disclosure is very important for minoritised people. To say “we” is a self-disclosure if the therapist says it in the counselling room, but it’s very broad, very gentle and doesn’t take up much space; it just helps the client feel more understood.

The use of “I” takes up space. When you use “I”, you are turning the attention on yourself and you are revealing something about yourself; you are making yourself very vulnerable and you have to be sure the client can take whatever you give, and you are centring the therapy on them. It has to be done so cautiously – it’s their space.’

Another potential danger of selfdisclosure of this kind with a client is that the counselling or therapy becomes a kind of echo chamber, Pollock says. ‘When I qualified, I enrolled on the Pink Therapy two-year diploma. If all you have is lived experience, you can do good sympathy and understanding, but that’s not therapy.

Therapists have to be able to stand back and see the bigger picture, as well as focus in and talk about the minutiae of life.

You really need to ensure that you aren’t just trauma-bonding. Most people need more structure to what they are doing.

Supervision is vital for everyone, but if you are working at the edges where you are bringing more of your self, even if it’s only the gentle “we” disclosure, you have to have a supervisor who will challenge you on it – is that for you or in the interests of your client?

‘And you need a supervisor who understands the tension. I bear in mind what Dominic Davies at Pink Therapy says, that the huge risk for LGBT therapists working with LGBT clients is that the clients can become their community. That’s not OK. We can’t nourish ourselves with our clients as “our people” – you need to find another forum to do that in, outside your therapy work. It’s hard because we bring all of our self and heart to our work, but the

client can’t be the way we express that.’

Aaron Balick has also explored the complexities around this issue. ‘If you come from any minoritised background, you may well be more comfortable having therapy with someone who shares that experience with you. I can understand why many clients make that choice. On the other hand, that doesn’t guarantee that the therapist is better able to understand you,’ he says. ‘In fact, a therapist can be so identified with their own experience that it can inhibit the clarity with which they can be fully present for the different experience of their client.’

A gay man, he chooses not to identify himself professionally as a ‘gay therapist’.

‘Gay is certainly a part of my personal identity, but only a part, and certainly not a foregrounded part of my professional identity. I think these days we are seeing a proliferation of identity categories, and the danger is that a single identity category can become the whole self-identification.

When you think about the Jungian idea of individuation, the identification of a part of one’s self as the whole can be limiting. In recent decades there has been a broadening of how we understand the spectrum of experience – as there has been with diagnostic categories. While identity categories are important, most of them also have features of generalised human experience. The idea in critical psychiatry and post-modernism was not that we would have a thousand categories to identify wholly with, but that we would realise that we share various degrees of these categories with others.

‘For example, one may have an anxiety disorder but one doesn’t have to identify as one’s anxiety disorder – that can fix an identity in ways that make it difficult to move on, grow and change.’

Policing the profession BACP has published several pieces of guidance on using social media, pointing members to the ethical principles that are relevant to social media presence

‘We all have a personal brand, whether we like it or not’ Karen Pollack Therapist specialising in sexually minoritised groups and usage. Says Stephen Hitchcock, BACP Ethics Consultant: ‘The main areas of relevance in the Ethical Framework are primacy of the client, respect for colleagues, client confidentiality, therapist self-care and not bringing the profession into disrepute, and our guidelines on maintaining the boundary between personal and professional presence on social media. It’s about having an awareness of the consequences and being prepared for them. You need to have a plan to deal with your clients’ responses to your social media presence.’

BACP doesn’t currently collect data on professional conduct complaints relating to social media, although this may change following its current review of areas that are frequently reported and where more guidance may be needed.

One area where respect for colleagues arguably gets thrown out of the window is in the sometimes very heated debates on social media about BACP’s policies and proposed initiatives, such as SCoPEd. Former Chair Andrew Reeves spoke powerfully and passionately at his final AGM about the personal abuse and attack he received from members on Twitter.

For a case to be raised, someone has to make a formal complaint through BACP’s professional conduct process, and it may be that those who are subject to attack from their colleagues don’t want to go through that process. However, there could be an argument that it shows disrespect for colleagues and could bring the professional into disrepute if the critical comments are on a public forum, like Twitter.

Says Adam Pollard, BACP’s interim Chief Operations and Membership Officer: ‘We expect all our members to use their professional judgment and to apply the principles and values of the

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Ethical Framework when using social media. At the heart of this is a need to respect other people and their opinions.

We’ve highlighted the importance of this to members through our social media guidance, community guidelines and Good Practice in Action resources. Our conduct process focuses on protecting the public and is centred around the therapist– client relationship. We assess complaints about members’ social media activities on this basis and, where appropriate, we’ll act to protect the public and the reputation of the profession.’

Balick sees these public displays of intra-professional disagreement and attack as typical of the polarity of opinion and intensity of expression that social media encourages. Social media is not an arena that encourages nuance, he says, and some of the professional disagreements are better worked through elsewhere.

‘I like the fact that therapists are out there, vocal and accessible as human beings, in the same way as others are. I also understand that social media offers a voice to those who might not otherwise have one. However, therapists occupy an important position with regard to how their profession is perceived by the public.

They also have a duty of care to both their clients and the public at large. Ideally, I think it’s important that therapists model ways of relating that demonstrate mutual respect and avoid ad hominem attacks.

Therapists should be cognisant of the fact that they occupy a public role that also represents the profession at large, and it’s important to be mindful of how we express ourselves publicly when doing so in a professional capacity.’

1. https://blog.stillpoint.org/the-myth-of-the-therapist-as-a-blank-screen-normativity-masquerading-as-neutrality

About the author Catherine Jackson is a freelance journalist specialising in counselling and mental health.

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s a psychiatrist, which is what I was for more than 30 years, I’ve helped many people to recover. I’m also a professor, an expert in my field, who has written numerous books and papers about mental health. However, all that knowledge has not made me any better at managing my own mental health. That is still something I struggle with daily. Indeed, in my experience, the one question that health professionals rarely ask, but really ought to, must be: ‘How do you get through the day?’

Those of us who, like me, are troubled by life problems and unresolved psychological conflicts have to find our own ways of living with our emotions. Many of us have ‘residual’ symptoms of depression and anxiety, which wax and wane from when we get out of bed in the morning through hours of

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being, doing, feeling and interacting before getting back under the duvet. Surviving this daily experience is central to the process of recovery. I’m still working on the task of getting through the day on my own and adopting a healthier lifestyle.

Soon after I retired from work, three years ago, I set about finding a home in Orkney, the archipelago off the north coast of Scotland. I say ‘I’ even though I am married and have been for more than 20 years, but my husband John was still committed to a life in the south. We were staying together on holiday, only a mile away, when this cottage came up for sale. Described as a low, white, rendered cottage in the solicitor’s particulars, it is situated in a shallow valley in the centre of the largest island of the Orkney archipelago, which is confusingly called the mainland. It has an uneven flagstone path along the front and side and a lawn, fenced off from the neighbouring field.

It’s not a traditional cottage. If it weren’t sturdily built, the wind that blows from the west straight into the front door and my ‘study’ window would demolish it. My nearest neighbour lives in a new house with a windmill two fields away, and at each of the points of the compass there are tumbled collections of farm buildings to be seen in the distance. My friend lives in one of these, a quarter of a mile down the road. In the summer, her cows in the next field cluster around the fence, with their calves, watching in fascination as I hang the washing on the line. In winter their bellows echo around the valley.

There are few trees in Orkney and a scrub of willow is my only shield from the west wind.

Cutting it back for the view may have been a mistake, but it was worth it to catch sight of the purple grey mass that is Hoy, the

only really mountainous place on Orkney. If I cannot see water, I must be able to see a hill.

The house was built around the end of the 19th century as a but-and-ben, a simple Scots two-room cottage, and was probably a farmhand’s home, as it stands on a plot at the corner of a field. Each generation of residents has extended it: a kitchen at the back, a loft room, and, finally, a wonderful airy lounge where the byre was once attached to a side wall. It was this room, with its two frontfacing windows, a door opening directly into the garden and skylights through which huge shafts of sunlight split the soft warm air, that seduced me into buying. It took me almost a year to make it habitable, travelling up and down from Yorkshire.

The previous owners had decided they would prefer to live in Spain – a decision I soon understood rather too well. My

budget extended to fixing the heating, the kitchen and the bathroom, but getting the house waterproofed was more challenging.

Facing west, it gets the full blast of the horizontal rain that Scotland is famed for – the combination of gale-force wind and water. Woken by a storm one night, I stepped barefoot into a huge puddle of water that had been forced around the edges of the glass panes in the newly fitted front door.

‘A porch – that’s what you need,’ the joiner told me. ‘But won’t the water simply soak the porch then?’ I asked. He shrugged. There’s a price for living here.

Keeping my mind on track is essential as I am alone most of the time. It’s a great place to practise the skills of allowing the boxes labelled ‘difficult thoughts’ to pass along the conveyor belt of my mind without having to unpack and ruminate over them. If I allow a worry to take over my mind here, it’s quite difficult to elude it. My mood soon begins to spiral downwards.

Everyone’s experience of what we call depression is different. For me, mood is paramount. Working and rushing around, I was probably less aware of it, yet my mood is a key part of my ‘being in the world’.

It’s the lens through which I see what is happening around me, and its qualities colour, clarify or distort the ways I think about myself, the world and the future.

It is like the Hall of Mirrors in the seaside fairground where my father worked; it warps reflections. Sometimes I was amused by my reflection in the mirrors; other times it horrified me. I’ve come to see that ‘mood’

is what must be managed if I am to reclaim my life.

Mood is more than simply ‘feelings’ or ‘emotion’. It’s a longer-lasting state of mind that encompasses all thinking. It can transform how events are viewed and change yesterday’s great opportunity into tomorrow’s disaster in the making. We aren’t always aware of our mood, but the people around us often are.

My boss for many years, a professor in the university, had a notoriously changeable mood. ‘Be careful what you ask him about today,’ his secretary would warn me as I waited in silence outside his office; ‘He’s really grumpy.’ As I entered the room, he would, at best, greet me with an air of irritation, telling me with a grimace, ‘Whatever you want, I doubt I can help you.’

Other times it might be, ‘Go away and come back when you’ve something useful to say.’

But then, another day, the atmosphere would be quite different, and everyone would know. The secretaries in the outer office would be chatting away, basking in the glow of good humour emanating from within. He would put his head around the door and call, ‘Come in, come in, what can I do for you? Sit down and tell me all about it.’

Mood is not only the spectacles we wear but the overcoat we show to the outside world. Our mood is both us and yet not us.

I cannot manage without my glasses, although I know, rationally, that if I could will myself to change them, the world wouldn’t look as bad. Tomorrow, things may appear differently through them: brighter, sparkling

‘Mood is more than simply “feelings”or “emotion”.

It can transform how events are viewed and change yesterday’s great opportunity into tomorrow’s disaster in the making’

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Experience

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‘In caring for others, we don’t consider how it might be hazardous to both our physical and mental health’

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and full of hope. When we’re feeling positive, even the most boring things can seem worth doing. Mood balances on a knife edge and can change within the space of a few hours, but then it can remain stable for months.

Another problem for me is the ‘timekeeper’ with his stopwatch, sitting somewhere in my head, usually insisting on what should be achieved each hour of the day. This is something I often observed in my patients.

I don’t set myself a raft of impossible goals on paper any more, although I have done.

Revising for my final examinations at university, my obsessional planning got out of control to such an extent that I spent more time revising the plan than the knowledge.

That timekeeper still measures out my day, and if I don’t start something at the beginning of an hour, it can be difficult to start until another hour is up. I get stuck. I’ve lived with this problem all my life, and I know I’m not alone in so doing, but now I’m more aware.

The danger is in counting away the hours of our lives.

Writing here, now, lifting my head every so often to watch the clouds scud across the sky outside my window, my mood is bright. It’s much easier to be alone now than when I have been severely depressed. Last year, during a very low ebb, there was a period when I would spend hours waiting to get out of bed, only to feel so exhausted that nothing meaningful or productive was possible. Even reading a book was beyond me. To simply keep going and not give up hope, I make myself set a few simple goals to maintain a daily routine: getting out of bed, washing, eating, eventually venturing outside for a walk.

‘I feel so guilty about you taking care of me all the time when you have enough to cope with already,’ I would say to John, trying not to blame myself and descend further into a spiral of guilt.

My psychiatrist thinks, because it is clearly stated at the top of every letter he writes to my GP, who sends me a copy, that I have a recurrent depressive illness. Almost every word of that last sentence is contested.

Everyone has opinions on mental health and illness: ‘experts’ who have studied it; people who have experienced it and are called ‘experts by experience’; those who have never suffered from it or know anyone who has, yet still have strong views. They all seem to know what you should do to ‘get better’ and ‘recover’, which generally means returning to your ‘old’ self. Many do, though some, like me, have persisting symptoms or relapse from time to time.

They wouldn’t dream of offering advice to a heart attack survivor or someone with a broken leg. They don’t understand that what they call ‘depression’ may only be the unhappy feelings they can usually shake off.

So… you can do that too. Yes? You would think that, after all the therapy I have had in my life, I might have taken the controller in my head to one side by now, punched him (I always think of him as male) in the face and told him to f**k off.

Sometimes I can do just that. There are times when I can almost forget that he is still there and others when it feels like he will never leave me. Most of the time I am somewhere in between. I know that the need to be doing the ‘right’ thing is to do with seeking approval from others and is a very powerful driver. We can become very self-critical because of the way others have criticised us in childhood, and that can lead to fear, anxiety and depression later in life. Along with these can come feelings of shame about what others think of us.

Changing how we live our lives is hard, and recovery certainly cannot depend on achieving the ‘gold star’ of always doing the right thing. More likely it has to do with recognising that it isn’t always necessary. Our need for perfection in living a ‘disciplined life’ can sometimes be more to do with our inner controller than needing to please those around us by working at ‘being healthy’.

Sometimes I shelter from the storms of life for days on end, like the hare outside my kitchen window, keeping my head down

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until it seems safe to venture out again, concentrating on surviving and simply ‘being’.

I cannot help the feeling that time is passing increasingly quickly, and the hours are getting fewer as I count them. I try to learn how to make every day seem a little longer and begin to work my way down what is left on my bucket list of life. I’m thinking of everything I wanted to do when I had enough time, everything and everyone I promised I would make space for when I returned to work.

Carl Jung was right about ‘wounded healers’. In caring for others, we try to deal with the damaged, unresolved issues of our early lives. We don’t consider how the simple act of ‘helping people’ might be hazardous to both our physical and mental health when practised with perfectionist fervour. Being a psychiatrist licensed me to take care of others while trying (and eventually failing) to suppress my own needs for love and care, which had been partially met by my father but, more or less, denied by my mother.

I have always felt like an imposter who is about to be found out. One way to recover from depression is to simply keep going, not to retreat from life. If I act better, it does help me to feel better too.

I always thought there would be a future time when I would be able to cope with life, but in Orkney my future has arrived. It is here, and now.

• This is an edited

extract from Finding True North: the healing power of place by Linda Gask (Sandstone).

About the author Linda Gask is Emerita Professor of Primary Care Psychiatry at the University of Manchester. Now retired, she lives on Orkney and writes a mental health blog, Patching the Soul. www.lindagask.com

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‘Medication gives me the fight I need to do weekly talking therapy’

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efore the pandemic, I was on antidepressants, working on getting slowly better from an eating disorder, managing depression and anxiety and the voices that yell or chatter – depending on the day – telling me I’m a failure, that I should stop breathing, that my friends and family hate me.

Taking my meds significantly reduces the stretches of time I spend stagnant, gripped by blackness and staring at my bedroom ceiling. They give me the fight I need to do weekly talking therapy, which in turn gives me the fight to get on with the job of living.

However, the pandemic unsteadied me, as it did everyone. The bad voices became clearer and louder as the world became more viscous, confusing and frightening. I barely slept, and when I did, my dreams started to seep into my reality. My mind was fraying.

My therapist referred me to a psychiatrist, who suggested an additional medication. ‘But I want to reduce my meds, not take more,’ I said. ‘Why?’ was his exasperated reply. No matter how irrational I knew this was, I somehow felt that I should.

I have suffered with mental ill health since childhood, not helped by a period of homelessness at a young age, and have been on and off antidepressants since I was a teenager. By the time I was admitted to the Maudsley Hospital’s eating disorders unit in London in 2018 at the age of 32, my feelings about meds were raw. About six months before, I had been misdiagnosed by a psychiatrist and prescribed the maximum dose of a mood-stabilising medication with some uncomfortable side effects that took me a full year to come off. The psychiatrist at the Maudsley helped me taper off and encouraged me to try antidepressants, which I eventually agreed to after a serious episode of low mood.

By this time, I had been in treatment for around eight months, part of which was weekly one-to-one therapy with a therapist who was also a clinical psychologist. Being able to discuss my medication with my therapist was a novel but enormously helpful part of my treatment. I could talk about previous side effects and concerns, and was monitored closely.

I had agency, choice and professionals around me who cared about me getting better.

I still see this same therapist weekly, now at a private clinic. Having this continuity of care has been vital for me. And so I trusted my therapist when, during the pandemic, things took a turn and she believed a referral to a psychiatrist was needed. The therapeutic toolkit we had been building together to keep certain thoughts and behaviours at bay was not enough for the more hostile and frightening turn they had taken.

My psychiatrist suggested a few different types of medication that would work with my antidepressants to help with the insomnia and heightened anxiety and what he called the ‘leaking’ between reality and fantasy – something extra to patch the frayed edges.

The difference became obvious in just a few weeks.

I slept better at night, I felt the warmth of the sun on my face, I knew when I was awake. I was out of bed and dressed and back on the ground.

There is so much stigma around medication, which only flourishes when patients are not listened to, are fobbed off or left to flounder with just a prescription and no follow-up – as I was for most of my adult life.

A lack of psychological support undermines the good work that medication can do. And, in the very worst of cases, it costs lives.

I do not believe my mental illness stems from a ‘chemical imbalance’; I believe it is due to a complex mix of social, cultural and internal factors that made me feel very unsafe and frightened in the world. This cannot be solved with drugs. It has been alleviated by years of hard work in therapy, accompanied by a long slog of learning self-care and compassion. The act of eating when you are anorexic and taking care of yourself when you think you are worthless are, at times, exhausting. Add to that external life factors – grief, injury, hurt, pain, instability – and that precarious balance of being well wobbles. It is in these times that I have found medication a helpful additional tool in keeping me well, sane and alive.

I do wonder what my life would have looked like had my eating disorder been picked up when it first manifested in childhood, and had I had the therapeutic support from the beginning. Would I still need medication? I cannot say. But I do know that I can only start from where I am right now. And from that place, today, the medication allows me a bit of a break when doing the work is hard.

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About the author Jenny Stevens is a journalist who has written about her experiences of mental ill health and an eating disorder for The Guardian, where she is a commissioning editor.

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It changed my life

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Snapshots and self-reflection

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Photographs can be used as catalysts to enhance communication and insight during therapy sessions, says Paola Borella hen I started my therapeutic journey years ago, my counsellor suggested that I carry a photograph of my younger self as a way of connecting with my inner child. The process brought up a flurry of emotions and memories within me, but it also brought out parts of me that had been suppressed for years. I remember the power of one photograph in particular and the way I felt I could connect with it. The image showed me dancing, with a smile on my face – it captured my vibrant side. Over the years, the little dancer in me emerged, and I will always be grateful for the part that photograph played in my personal growth.

Later on my therapeutic journey, I instinctively started the process of taking self-portraits when I felt the urge, often during emotional times. Photography has been one of my personal interests since childhood, capturing what I see and how a scene can change so quickly in a split second. I guess it could be seen as a form of mindfulness as it allows us to fully be in the present moment and embrace our surroundings, noticing the way that blossom delicately dances among the leaves and pirouettes to the ground, or how the crystal-like waves shimmer under the pale moonlight. Many of these memories and scenes remain in my mind, but when captured through the lens, they help me to relive some wonderful moments and process the memories associated with that particular time in my life.

A photograph can be seen as a mere snapshot of a personal moment, but it can also be much deeper than that, depending on the way one approaches it. As the celebrated US photographer Diane Arbus put it, ‘A picture is a secret about a secret, the more it tells you the less you know.’ A photograph that looks ordinary to us may trigger memories in someone else. I believe that a simple

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photograph has the power to transport us back in time and access a path to our unconscious, helping us release repressed emotions and heal through our resulting selfexploration. Photography is a powerful form of communication, without the need to utter a single word.

My self-portraits would sometimes capture me crying and looking quite distressed, and I would somehow feel comforted that I could creatively tap into my emotions without having to say how I felt. But the images were always powerful, raw and quite cathartic. I realise that I started to build trust in myself as I took the self-portraits. It allowed me to articulate my feelings in my own way and helped me become more self-aware. At the time, I wasn’t aware of the concept of phototherapy. Then I shared a blog post online, along with a self-portrait, and received a message from Judy Weiser, a US psychologist and phototherapy specialist,1 which inspired me to explore the process of phototherapy and its benefits.

Phototherapy Photographs were first used in therapy in the 1970s by health professionals in the US and eventually this became formalised as phototherapy. Phototherapy is not a psychotherapeutic modality but a series of techniques a therapist can use where the photograph is a tool. People’s personal snapshots are often used as catalysts to enhance communication and insight during therapy sessions. Weiser explains

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that using visual imagery helps bypass cognitive filters such as rationalisation and verbalisation and gives easier access to the unconscious. She has established five types of phototherapy techniques: photos taken by the client, photos taken of the client by other people, client self-portraits, client family albums and photo-projective interactions.2 There has been some limited research into the effectiveness of such techniques: Halkola found that photography in the therapeutic setting enables clients to express emotions, articulate feelings and be creative thus promoting self-awareness.3 Loewenthal reports that the application of photographs in clinical and therapeutic contexts has grown significantly in recent years.4 The use of photographs in counselling sessions could prove especially fruitful with younger clients. My experience of working with teenagers has shown that photography often naturally enters the therapy room, as they speak about taking frequent selfies and using social media to share their images with friends. The photographic image holds a particular power for young people – sharing images is seen as a way to connect with peers, but sharing images publicly is also fraught with danger of the images being misused, or of leading to cyberbullying. A study in 2017 found that frequently viewing selfies led to decreased self-esteem and decreased life satisfaction.5 In the book Enough As She Is, an 18-year-old girl says, ‘I don’t hate myself when I’m alone. I just hate myself in comparison to other people.’ 6

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New Ideas, 1

New ideas

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New ideas VERSION

Exploring the pressure to get ‘loads of likes’ on a photo can be a useful way to help teenagers reflect on their self-image and identity.

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Photos in counselling sessions

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I have found that clients of all ages will produce personal photographs during sessions without prompting, often to show me the people they are close to. As a result, I have felt more connected with the client. This has also acted as a springboard for experimenting with some phototherapy techniques in sessions. With teenagers, I have found it useful to suggest a ‘selfie journal’ that is purely for them and not for posting on social media. Some have found it challenging to not use filters or pout for the camera, but they have generally been willing to try. In counselling sessions, I have asked the client to produce one of the photographs and explore what they were feeling at the time and how they feel now, on looking at the image.

Often the words used to describe themselves have been negative, but it was rewarding to witness that change as the therapy progressed, their feelings about themselves changed and they developed a deeper sense of self-respect.

One client, Clara,* commented that she found the photo journal helped her to cope with stress and particularly difficult days. I’ve witnessed lots of emerging creativity as a result, and clients have found their own ways to express themselves, including photo collages, posters and a photo/art journal. It allows their personal interests to flourish and encourages them to feel proud of their creative endeavours, which takes the focus away from perfection and shows them they can look within for self-esteem.

Photographs from the past can also be very powerful and act as a catalyst in therapy. Anna* found a photograph of herself as a child and brought it to a session. She explained that seeing the photo had prompted a vivid dream, which she later discovered, from talking to a family member, reflected a true event that had been forgotten or repressed. I asked her to describe how the little girl in the photo felt: ‘Abandoned… unloved,’ was her reply.

Relationally, this helped us to explore her

lifelong issue of rejection and abandonment – a topic she had resisted for a long time. The photograph formed the basis of my client’s inner-child work and proved to be a powerful tool that challenged her to ultimately start loving herself.

Emma* was struggling with the feelings she had towards her mother, who had treated her cruelly and neglected her as a child. I was quite surprised when, during one session, she produced a photograph of her mother on her phone and said that she found it really difficult to look at it as she felt no connection with her at all. I still remember the vacant stare of the lady in the photo, looking off to the side. My client expressed her wish to delete the photo, which she did in our session. It felt like a powerful moment for her, as she was starting to realise that her mother no longer had control of her.

Deleting the photograph acted as a catalyst for her empowerment, and growth in self-respect and confidence.

changed to protect confidentiality REFERENCES

How self-portraits heal

Self-portraits have been an important form of self-expression and self-exploration throughout the centuries by many famous painters, such as Frida Kahlo and Vincent van Gogh. Like these artists, we can use the healing power of self-portraits to explore our inner struggles and heal from within. Self-portraits are a way for individuals to see themselves as they are, without any input from others, and they can be a very powerful tool for self-therapy and therapeutic interventions.

Weiser believes that issues connected with self-esteem, self-confidence and self-acceptance lie at the core of most clients’ problems, and therefore seeing themselves for themselves through self-portraits can be a very powerful and beneficial encounter.2 According to Nuñez, the photographic self-portrait gives the individual the possibility to shape their image according to their needs and desires, introducing the opportunity of self-reflection.7 From personal experience, I believe that selfportraits are a great form of expression and a way to build self-identity and channel emotions

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into art. Instead of capturing our surroundings, self-portraits enable us to capture what is within in a visual format.

Clearly, not all clients will take to the idea of self-portraits or sharing photographs in the counselling room, but there are other benefits that clients could gain from the practice of photography. The process of taking photographs has a meditative and calming effect, and exploring creativity through photography can bring great pleasure. For me, it turned into an expressive art form and a therapeutic hobby. Using photographs in therapy can help clients to reflect on topics that might otherwise be too difficult to articulate, such as traumatic experiences, bridging the gap between the past and present, and it can help clients to achieve perceptive states that result in healing and heightened self-awareness. * Clients’ names and identifiable details have been

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1. www.phototherapy-centre.com 2. Weiser J. Phototherapy techniques: exploring the secrets of personal snapshots and family albums (2nd ed).

Vancouver: PhotoTherapy Centre; 1999.

3. Halkola U. A photograph as a therapeutic experience. European Journal of Psychotherapy and Counselling 2009; 11(1): 21–33. 4. Loewenthal D. Introducing phototherapy and therapeutic photography in a digital age. Routledge: London; 2013. 5. Wang R et al. Let me take a selfie: exploring the psychological effects of posting and viewing selfies and groupies on social media. Telematics and Informatics 2017; 34 (4); 274-283.

6. Simmons R. Enough as she is: how to help girls move beyond impossible standards of success to live healthy, happy, and fulfilling lives. New York: HarperCollins; 2018. 7. Nuñez C. The self-portrait, a powerful tool for self-therapy. European Journal of Psychotherapy & Counselling 2009: 11: 51-61.

About the author Paola Borella MBACP is an integrative counsellor working in education alongside private practice. Her research interests include adoption, trauma and promoting young people’s mental health.

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1. Infant Feeding Survey – UK, 2010. NHS Digital 2012. www.digital.nhs.uk/data-and-information/publications/statistical/infant-feeding-survey/infant-feeding-survey-uk-2010

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specialise in working with clients experiencing infant-feeding guilt, having had my own experience of postnatal depression, partly triggered by feeding difficulties. Infant-feeding guilt or breastfeeding guilt are terms used to describe the complex emotions that some parents experience when they want to breastfeed their baby but have difficulties and subsequently opt for formula milk.

It’s called ‘guilt’ but inability to breastfeed also triggers a sense of loss, anxiety, depression, jealousy, disappointment, anger and shame. Both my personal and professional experience have taught me that it is useful to approach this as trauma and/or grief, especially when compounded by birth trauma or historical trauma from the person’s background.

The process of becoming a parent can often be considered both a physical and psychological trauma, involving loss, difficulties conceiving, challenges in pregnancy and compromised health of the baby.

To date, those accessing my service have been women, although I am aware that this issue may also affect trans men and non-binary clients. It is believed as many as 90% of mothers/birthing parents intend to breastfeed. However, despite these intentions, around half stop by six weeks, and only a very small percentage are still breastfeeding at six months.1 For some, it’s an informed choice – sometimes breastfeeding isn’t right for a family. But sometimes it’s just not possible – it isn’t always a case of ‘trying harder’. Sometimes there is little or no milk supply or severe pain on feeding, or it may have been hard to establish after a difficult birth or a history of abuse.

For others, breastfeeding may be causing severe sleep deprivation and impacting on the parents’ wellbeing. There can be many other reasons, including not wanting to feed the baby this way. As one mother said, ‘Breastfeeding and pumping were making me depressed and angry, feelings which I started to direct towards my baby because I was doing this for him.’

The profound sense of grief, anger and disillusionment at failing to breastfeed – especially

when parents feel they were not given the right support – can be difficult to explain or for others to understand. As one parent said: ‘I still struggle to think of this time and feeding.

I block the memories and still feel saddened and emotional by my experience.’

I chose to specialise in this area because I was aware that shame and fear of judgment can make it difficult for clients to talk about, reflect on and process their experience. Difficulties in breastfeeding may be triggered by a difficult birth experience, significantly contributing to the development of postnatal depression and anxiety.

Clients have described feeling triggered by seeing others breastfeeding, and may feel unable to attend baby classes and groups, so missing out on the protective effect of social contact.

Many clients who have experienced infantfeeding guilt – as well as other traumas surrounding the pregnancy and birth – experience hypervigilance and sleeping problems, which are common in the postnatal period but also distinct features of trauma.

I work with this by helping the client to better understand their experience, psychoeducation, encouraging connection with others and, if necessary, medication to shut down the body’s distressing anxiety responses, or perhaps a combination of all of these things.

There is no right way of working with this trauma, but what I have found is that all parents need to feel heard, and for their loss to be acknowledged. Above all, there is a need to validate and encourage – ‘You did what is best for you and your baby.’ Letting a client experience you as non-judgmental and providing a supportive, safe space to talk about how infant-feeding guilt may be impacting their life can be life-changing. Not being able to breastfeed is a legitimate loss and, as a profession, we have much to offer parents by validating their experiences and supporting them as they work through the impact.

Sarah Edge is a therapist working both remotely and in person from Sale, Manchester. She specialises in postpartum mental health, with a particular interest in supporting women in their emotional recovery from breastfeeding difficulties and infant-feeding guilt and trauma.

www.maternalmental healthmanual.com

• If you would like to share how you work in the ‘My practice’ column, email therapytoday@ thinkpublishing.co.uk

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The butterfly in the room

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Therapists need to be alert to the mental health effects of physically generated symptoms in clients, says Geraldine Marsh

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ay* drops into the client’s chair and apologises profusely for being late.

‘I’m lazy and slow’ is her opening sentence. She rubs her round face and runs a handkerchief across the back of her neck. Her doctor has diagnosed depression, she says, and has suggested antidepressants, but she’s already taking statins and HRT and isn’t keen.

Her daughter urged her to try counselling.

At the assessment, Kay lists her physical ailments on her swollen fingers – fatigue, irritable bowel syndrome, aches and pains, tiredness. I notice her looping back around, as if she’s forgotten what she’s told me: ‘Did I mention the tiredness?’ She rubs her eyes as she talks about her relationship. Her husband is sick of her not ‘pulling her weight’. She’s sure he’s disgusted by her middle-age spread. Her libido’s gone and she’s scared he’ll head off too, after 25 years of marriage.

At this point, she becomes emotional and I follow her need to understand the difficulties with her home life and her relationship. The session, topped by an assessment and tailed by our agreement to meet initially for eight sessions, comes to an end.

Depression. I underline the word, then draw a figure of eight, like wings. Something flickers in my peripheral vision, out of reach. Later, much later, I circle the error too.

Kay cancels the next session, apologises and sets up another. Five sessions go by and Kay is not getting any better. She becomes more confused, reiterating facts she’s already told me. Worse, she is paranoid that somebody is stalking her, that people are listening in on her phone calls. We talk it through and she agrees to speak to her GP. I call my supervisor to discuss Kay and doodle figures of eight in the margins, like wings.

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Missing clues There’s something I’m not understanding, some clue that I’ve missed. Kay’s paranoia stems from somewhere, so what are the origins of this burgeoning psychosis? I talk it through again in peer supervision, trawl through training notes, and even check past presentations of other clients for clues.

Kay doesn’t turn up for her next session. Her daughter, who had arranged the counselling, phones me and shares that her mother had some kind of episode in the shopping centre and security was called. The doctor re-ran some tests on her and…

I think, ‘She’s going to say they suspect psychosis. Paranoid schizophrenia perhaps.’

‘Borderline myxoedema,’ she says.

The butterfly lands. Myxoedema is caused by severe and untreated hypothyroidism, when an underactive thyroid gland does not produce enough hormones. It is rare, but still occurs.

I swallow hard and rub the scar on my throat.

My own butterfly-shaped thyroid gland only has one wing, following a partial thyroidectomy 20 years ago. I marvel that I’d noted my client’s mental and emotional symptoms – tiredness, lack of concentration, depression and confusion – and still hadn’t seen what was in front of me.

Admittedly, I couldn’t remember myxoedema being mentioned on my counselling training

Symptoms and treatment The thyroid is a butterfly-shaped gland at the base of the neck. Sometimes that butterfly stops (metaphorically) beating its wings – it’s estimated that one in 20 people in the UK1 have a thyroid condition that causes too little or too much thyroid hormone to be produced. Thyroid hormones play a role in the metabolism of all the body’s cells. In 90% of cases of hypothyroidism – underactive thyroid production – the cause is an autoimmune condition called Hashimoto’s disease.2 Often the first confirmation comes when a patient is told they have a raised level of thyroid stimulating hormone (TSH). Common treatment in this instance would be for a doctor or endocrinologist to prescribe the patient levothyroxine, a synthetic drug that mimics a naturally occurring hormone called thyroxine, often known as T4.

I had 20 years of lived experience with Hashimoto’s disease and the resulting hypothyroidism, yet I hadn’t seen the clues to my client’s condition that relate to my own life. I’d missed this, I thought, because my own physical symptoms are so enmeshed into my

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course 10 years previously, or how a case of acute hypothyroidism would present in the therapy room.

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emotions, feelings and mental states – my illness is so much part of me I can’t see the join.

Mind–body loop While myxoedema is thankfully rare, clients who have been diagnosed with a thyroid issue are often living with challenging physical symptoms that affect their mental state. For example, if thyroxine (T4) or triiodothyronine (T3) levels are low, a client may feel sluggish and fatigued and suffer brain fog and low energy. They can also feel depressed, and because physical energy is low, it can then be a struggle to function in everyday life. As a therapist, it would be easy to miss the physical symptom behind your client’s anger and frustration at themselves and their manifestation of low self-esteem.

In responding to a client’s cascade of unhappy feelings, we could be distracted by the resultant mental health effects of what could be physically generated symptoms.

Yet, like Alice in Wonderland nibbling the mushroom, if a client takes too much levothyroxine, or suffers from hyperthyroidism, they can feel sweaty, shaky and have heart palpitations. Again, these physical symptoms mirror anxiety responses and can also have therapists looking for mental causes of anxiety, rather than

understanding the interconnectedness of these physical symptoms and mental states.

The person can experience a mind-body feedback loop that keeps them locked into anxious feelings or depressed feelings because of the physiological changes. This doesn’t make anxiety any less real, just harder to separate out from the condition.

Also, because symptoms such as fatigue are generic, clients may be misdiagnosed with menopausal symptoms or depression. If there’s no blood test or diagnosis that a client can point to, then how would a therapist pick up this issue at assessment? Equally, a client who has had a blood test could still suffer symptoms if their levels of TSH and T4/T3 are deemed to be within what is considered the ‘normal’ range in the UK, which is considerably wider than those used by other countries.

Cause and effect?

What makes the presentation of depression or anxiety even more difficult to untangle from the effects on the body is that current research also indicates that early life stressors can affect hypothalamic-pituitary-adrenal (HPA) axis regulation.3 In other words, issues such as childhood trauma could increase a client’s likelihood of developing an autoimmune disease such as Hashimoto’s. However, in

contradiction to this, the British Thyroid Foundation advises emotional problems in this client group can be caused by the fluctuation of thyroid hormone.4 While there is medical research that identifies psychiatric symptoms linked to thyroid imbalances,5 this research does not detail the qualitative or subjective emotional states that clients may experience. Dayan and Panicker6 provide a good overview of existing research, but none is generated from the psychotherapy world, so unless a client’s presentation is extreme, how would a therapist pick up a potential issue? It may only be through a chance comment that they may realise their client is on levothyroxine or suffers from Hashimoto’s disease.

While reading Recovering with T3, a memoir by Paul Robinson,7 I was struck by the challenges he experienced in finding optimum physical and mental health through the normal medical channels. If clients are struggling to get a diagnosis and treatment from the medical profession, how will that affect the trust they put in us when they come to therapy?

Understanding needs What do we need to be aware of, in order to better understand the issues of this client group, given that levothyroxine is the third most common medicine prescribed in the UK? As hypothyroidism is deemed a common condition, clients often receive a prescription from their GP rather than a referral to an endocrinologist, and annual medication reviews are done by telephone or by a pharmacist. These factors can mean that the client is not fully conversant with how their feelings and moods can be affected by their fluctuating T4/T3 levels or medication. This is confirmed by discussions on thyroid-related health forums,8 where sufferers commonly describe struggling to find alleviation from a host of unresolved symptoms. Like people with chronic fatigue syndrome, clients with thyroid disorders often feel dismissed by mainstream medicine, and are left to find their own answers and support, which may include seeking therapy.

In supporting these clients, it feels vitally important to adopt a person-centred approach, to honour their unique difficulties and validate their experiences. I have thought about the questions I asked myself when

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I was diagnosed, which could offer some starting points. For example, how does it feel to have your body attack itself, to have some insidious assassin that you can’t see, hear or feel, destroy a part of you? Their body has let them down – do clients feel betrayed? I know this is how my disease left me feeling, as if I couldn’t really trust myself, particularly when I was revving with energy one day and utterly exhausted the next. It may mean we need to work practically with a client and help them create their own personalised care plan.

If they have varying energy levels, the work may involve moving around pieces of their life so that they can continue to work and invest in relationships and still maintain their health. Or it may prove beneficial to help the client find their voice, talk to their family or health professionals assertively and feel more empowered around their own recovery. It is definitely a case of one size of treatment not fitting all.

Some research suggests an element of permanence to a client’s psychological state due to its biological origin.9 If that is the case for certain clients, they may respond better to an acceptance and commitment therapy (ACT) approach – one that is focused on changing the client’s relationship to their feelings. CBT has a role to play too, in allowing a client to separate out how to manage their health, rather than becoming preoccupied with it. I am aware of my own tendency to dwell on symptoms and become overly focused on my health, even if at that point, I am actually fine. I once spent four hours researching the role of vitamin D in all its bioavailable forms, because it helps optimise levothyroxine’s conversion to T3.

Unlocking trauma

But there is also deeper work to explore with affected clients, as well as a need for further research within the psychotherapy community. For example, if there is a link between childhood trauma and dysfunction

of the HPA axis, then does the unlocking of trauma facilitate any physical changes? What happens to the intensity of symptoms if a client is emotionally happier?

I feel there is an urgent need for current medical research to be translated and disseminated to therapists in a relatable way.

Just as a perceived physical process such as polyvagal theory has been incorporated into the psychotherapy field, thereby giving therapists a way to work with clients therapeutically on a physical issue, a similar approach could be taken when explaining HPA axis and mental health connections. This knowledge could inform how we work with hypo/hyperthyroid clients in the future to improve their psychological outcomes.

And Kay? Her daughter called to let me know of her full recovery. Briefly I felt relief, then a great sadness at the thought of her struggling through those lost years of utter fatigue and misery.

I rub at the scar at the base of my neck and close my eyes. It’s not Kay’s image I see but my own mother’s round, swollen face, her eyebrows that peter out and thinned hair, all classic hypothyroid symptoms. Yet it wasn’t myxoedema my mother was diagnosed with.

Nearly 50 years ago, after long, slow years of deteriorating mental and physical health, my mother was diagnosed as having paranoid schizophrenia. No blood tests were ever ordered. I was 11 years old but, even as a child, I can remember thinking that something wasn’t right about that verdict. Through my early years, I had witnessed my mother struggling with fatigue and other chronic symptoms as her body shut down.

I am therefore left, a generation later, looping around figure eights, relieved that doctors picked up the condition in my client, Kay, yet at the same time, unsettled, knowing I will never be able to say for definite that my mother had suffered myxoedema. * Client’s name and identifiable details have been changed.

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REFERENCES 1. British Thyroid Foundation statistics. www.btf-thyroid.org/what-is-thyroiddisorder 2. Animo N. Autoimmunity and hypothyroidism. Baillieres Clinical Endocrinol Metabolism 1988; 2(3): 591-617. 3. Tofoli S et al. Early life stress, HPA axis and depression.

Psychology & Neuroscience 2011; 4(2). 4. British Thyroid Foundation.

Your guide to psychological symptoms and thyroid disorders.

Harrogate: BTF; 2018. www. btf-thyroid.org/psychologicalsymptoms-and-thyroid-disorders 5. Hall RC et al. Psychiatric manifestations of Hashimoto’s disease. Psychosomatics 1982; 23(4): 337-342 6. Dayan C, Panicker V. Hypothyroidism and depression.

European Thyroid Journal 2013; 2(3): 168–179. 7. Robinson P. Recovering with T3. Elephant in the Room Books; 2018. 8. www.thyroiduk.org 9. Wingenfeld K, Wolf O. HPA axis alterations in mental disorders: impact on memory and its relevance for therapeutic interventions. CNS Neuroscience and Therapeutics 2011; 17(6): 714–722.

About the author Geraldine Marsh MBACP is a psychodynamic counsellor working in private practice in south-east London. Her experiences of Hashimoto’s disease and ongoing hypothyroidism shape her interest in working with clients on the interconnectedness of physical health with mental health. www.blackheathcounselling.com

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hen Cecil* was five or six, his dad had terrible nightmares. He would wake up in the middle of the night, running up and down shouting and screaming, and Cecil would wake and start crying. His mum would come in and say, ‘It’s OK, Cecil, Daddy is just having dreams and bad nightmares.

Don’t worry, go back to sleep.’

That little boy is now in his 70s. He sought therapy after collapsing at Paddington station in London for no identifiable reason. And the nightmares that plagued his father, and many thousands of other fathers, were as a result of their time spent as prisoners of war during World War II. February 15 is the 80th anniversary of the Fall of Singapore, when, in 1942, following a ferocious battle, the British Armed Forces surrendered to the Japanese Army. Churchill called it the worst disaster and largest capitulation in British history. For the next three-anda-half years, the captured soldiers were used as slave labour on projects such as mining, laying out airport strips and building the Burma ‘Death’ Railway.

They suffered starvation, torture, disease, isolation and brutality, and almost a third of them died before freedom came on 15 August 1945.

When the men eventually returned home, in the autumn of 1945, three months after VE Day, there were few fanfares. These damaged men were expected to pick up their normal lives.

They were instructed that it might cause harm if they talked about their experiences. But, like Cecil’s father, they suffered from terrible nightmares, recurring diseases and the symptoms of what would now be recognised as post-traumatic stress disorder (PTSD).

Generational trauma Many who had married before the war returned to families who did not recognise them. Long-suffering wives had to find ways to help them adjust to civilian life again. My own father was one of these Far East prisoners of war,

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but I knew very little about all this. My father died of cancer in 1976, aged 65.

It was only after my mother’s death in 2011 that my brothers and I discovered plastic bags full of papers, drawings and even a diary, which my dad had brought home with him in 1945. He was a Church of England chaplain assigned to a territorial battalion of the Royal Northumberland Fusiliers, which had arrived in Singapore just days before the surrender. Initially, they were imprisoned in Changi, but a year later he was sent up-country to Kanchanaburi, beside the River Kwai in Thailand, to join the men who were building the Death Railway. He was appalled at the scene that met his eyes – thousands of young men starving to death and sick with tropical diseases such as beriberi, dysentery and malaria, and huge tropical ulcers. He asked the doctors in the ‘hospital’, which was no more than a series of bamboo huts, to let him know when any of the men were critically ill. He tried to be with them when they died and then gave them as dignified a burial as possible. He recorded in his diary that he buried more than 600 young men.

Like many others, my father never talked about his experiences but I have always felt haunted by something

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unknown and unknowable. To find out more about these critical years, I joined various Far East prisoners of war (FEPOW) organisations. When I went to a conference in Liverpool, I had a eureka moment – at last, I’d found ‘my people’.

They were all as obsessed as I was and eagerly exchanging information. Why were they so driven? I had a hunch that the trauma suffered by our fathers was passed on, raw and unprocessed, to the next generation – my generation. I began to ask around and discovered that there were many people who felt they were profoundly affected, and some of them had been scarred for life.

I decided to gather some interviews and so I put the word out on various websites. To my surprise, people were eager to tell their stories. These ‘children’ wanted to share their experience of living in a family where the horrors were unspoken, and in me they recognised someone who was similarly affected and understood and respected the depth of their feelings. I never revealed that I was a therapist because I was far too involved in their story to keep a therapeutic distance. But, even though I have 20 years’ experience of seeing clients, again and again I was struck by how alive their stories were, even 75 years later.

Flashbacks The most shocking of all was the experience of a doctor, Nigel.* His father, also a doctor, was tortured to death by the Kempetai (the Japanese secret police), accused of being a spy. Nigel has experienced flashbacks all his life,

‘I had a hunch that the trauma suffered by our fathers was passed on, raw and unprocessed, to the next generation – my generation’

based on information he has gathered about his dad’s experience. Sometimes they feature the methods of torture that were used on his father and, if the flashbacks occurred when he was doing a ward round, he said he would have to pause for a few moments before carrying on. According to DSM-5, ‘learning that the traumatic event(s) occurred to a close family member’ is a recognised stressor for PTSD.1 Charmaine’s* father is Eric Lomax, whose bestselling memoir, The Railway Man,2 was made into a film in 2014, starring Colin Firth. Eric was tortured almost to death after being discovered to have hidden parts of a radio.

Charmaine was profoundly affected by a childhood in which her father was locked in a world of his own and never spoke of his experiences for 50 years.

‘When I was a child, I hated my dad for the way he treated my mum,’ she said.

‘But as an adult, and a nurse, I was filled with compassion for what he’d been through as a human being.’ She had to work out how to understand the man who was a hero in everyone else’s eyes but who had exerted control and humiliation in so many different disguises over his wife and children: ‘Dad had been 50% physically present in our lives but 100% emotionally absent.’

Charmaine had depression growing up and a breakdown herself as an adult.

She then transitioned into counselling, following her retirement from nursing after 40 years of service, and now runs a counselling service in Edinburgh.

At least two other women I spoke to said that the pattern of their lives had been affected by their fathers’ trauma. One refused to get married and the other did not feel emotionally secure enough to have children.

Charmaine said she had found very helpful a passage in The Body Keeps the Score by Bessel van der Kolk: ‘Trauma affects not only those who are directly exposed to it, but also those around them. Soldiers returning home from combat may frighten their families with their rages and emotional absence. The wives of men who suffer from PTSD tend to become depressed and the children

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of depressed mothers are at risk of growing up insecure and anxious.’3 Janice* told me that her dad did not talk about his experiences, but sometimes references to what he’d been through would slip out. ‘He was doing his feet one day and he said to me, “Every toe on that foot has been broken.” I said, “When did that happen, Dad?” And he said, “Oh that was when I was in the jungle.” I thought he must have tripped over the roots of some trees. But I found out that they broke his feet, each and every toe, because he was caught trying to escape. That has haunted me all my life – who would do something like that to my dad? It caused me a lot of upset as a child. I can honestly say that until my 30s I was still being kept awake at night by thoughts that played through my mind.’

Unvoiced trauma Gerry’s* father suffered from PTSD and had a very short fuse. ‘Sometimes a car backfiring or a door slamming shut would be enough to trigger Dad, and you’d get the wrong end of a broomstick or something.’ Then he told me a powerful story. When he was a teenager, his father pushed his mother into a sideboard and she was hurt, and Gerry felt he had had enough. His father had gone out to meet a friend, so Gerry sat up into the small hours and when he came back Gerry challenged him and said, ‘Never do that again!’ But now, following research into his father’s years in captivity, which he only started five years after his father passed away in 1990, he lives with a punishing guilt that he faced down a man who had endured so much. He said he wishes his father was here today so he could hug him, hold him close and say, ‘Dad, I understand.’

Another man profoundly affected is Stephen.* When I met him at Southampton station, I asked if he was OK with the interview and he said, ‘The subject is in my mind continually, it never leaves. Even though my father did not talk about his experiences, without a doubt they overshadowed my childhood.

Dad had marks all over his body and we thought it was chicken pox, but it was cigarette stub marks. The war was always

around in his head.’ Stephen said, ‘Basically I had a breakdown. I was sent to see a psychotherapist and we went through all the family and he said, “Your main problem is your dad.” One day the therapist said, “When you come in next, I want you to draw a picture of how you feel.” And I drew a prison camp and I said, “That’s the tunnel there and that’s blocked off, there are guards there and I can’t get out.” I didn’t know what I was going to draw, it just came naturally, and this is where I am! I can’t escape from this.’

Judith Herman, in her book Trauma and Recovery,4 describes the power of the unvoiced trauma our fathers were holding: ‘The more the period of captivity is disavowed (however), the more this disconnected fragment of the past remains fully alive, with the immediate and present characteristics of traumatic memory.’

As I conducted my interviews, I increasingly felt that it was often the wives who quietly bore the brunt of their husbands’ PTSD. Meg Parkes,* whose mother was a doctor like her father, said, ‘Mum was such a wonderful influence in our lives, calm and patient. If Dad got cross, over-reacted to something we’d said or done, she would just quietly say his name in a tone that said, “Enough”.’

Meg said that another prisoner told her that her dad had once displeased a guard, who then kicked him so hard on the shin that he drew blood. Her dad simply looked the guard straight in the eye and did nothing. This started Meg thinking more about the effects of repressed rage on men like her father.

Meg has devoted herself to FEPOW research, writing books and organising exhibitions and conferences.

Resilience These stories are also a testament to human resilience and the importance of finding meaning in our experiences.

Those who could still practise their professions while captured, such as the medics and padres, seemed to fare better – my mother said that knowing they were desperately needed helped them to get through it. My own father’s

quiet faith ‘buoyed him up’, as he put it.

And I was surprised to read something he said in a chapter of a book called Beyond Hatred,5 published in 1969: ‘In spite of the grim and hungry times, it was the most wonderful time in my life.

For once and for three-and-a-half years, the thin veneer of civilisation had been stripped from men. After months of sheer degradation, gradually the spirit to care for each other revived, incredible kindness and self-sacrifice was in evidence. Under the strain of prison life, only one thing prevailed and that was strength of character. Only real goodness made any impact.’

But under torture, the first thing that gets broken is trust – trust in another human being because you have seen them commit such horrible things to a fellow human being, says Funda Kansu, counsellor and clinical team manager, who worked with torture victims through the charity Freedom from Torture, which has provided therapy and support since 1985. In therapy, she says she works first on their relationship with her.

When I asked Funda why the trauma might trigger violence in an otherwise gentle person, she explained that, under torture, horrible things are being done to you and you have no power: ‘That anger, that fear, the silent scream of “How dare you! If I had the power, I would defend myself” – that accumulated anger can start to flood out as an explosion.’

In Generation of Postmemory,6 Marianne Hirsch addresses the experience of Holocaust families, but I think her observations could also be applied to the families of these traumatised men. ‘Postmemory describes the relationship that the “generation after” bears to the personal, collective, and cultural trauma of those who came before… But these experiences were transmitted to them so deeply and affectively as to seem to constitute memories in their own right.’

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75 years on, it still carries an emotional charge powerful enough to affect our lives. I have published the 35 interviews I conducted in a book, Echoes of Captivity,7 and I believe their stories will resonate with many other people whose relatives have been involved in war zones.

A timely and poignant email from one of the interviewees has just pinged into my inbox: ‘I intend to pay a visit to a counsellor as you suggested, as the older I get, my father’s experience and my past in growing up are not getting any easier to live with. It still makes me very emotional, even though I always look forward and try not to dwell on the past.’ ■ * Interviewees and their families have given permission to share their stories.

About the author Louise Reynolds MBACP has worked as a couples counsellor and a psychotherapist for London Marriage Guidance, The Tavistock Centre, Relate and in private practice. She has also published four books about Far East prisoners of war in World War II.

REFERENCES

1. American Psychiatric Association.

Diagnostic and statistical manual of mental disorders (DSM-5). Exhibit 1.3-4: Diagnostic criteria for PTSD. Arlington, VA: APA; 2013.

2. Lomax E. The Railway Man. London: Vintage; 2014.

3. Van der Kolk B. The body keeps the score: mind, brain and body in the transformation of trauma. London: Penguin Books; 2015.

4. Herman J. Trauma and recovery: the aftermath of violence – from domestic abuse to political terror. New York: Basic Books; 1997.

5. Moir G (ed). Beyond hatred. Cambridge: The Lutterworth Press; 1969.

6. Hirsch M. The generation of postmemory: writing and visual culture after the Holocaust. New York: Columbia University Press; 2012.

7. Cordingly L (ed). Echoes of captivity. High Winds Publishing; 2020.

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s an ethnic minority, humanistic, integrative and creative supervisor of South Indian heritage, I have predominantly engaged in cross-cultural supervision, supervising white, British trainee counsellors. During my time supervising, I have often experienced a particular form of racial microaggression that has been described by Solórzano as ‘subtle automatic or unconscious insults, verbally, nonverbally expressed and directed toward people of colour’.2 These experiences have left me silent, puzzled and, at times, completely immobilised.

As a supervisor, I dismissed this perpetual discomfort for fear of jeopardising the supervisory relationship. I was ashamed to explore this unease in my own supervision.

I have been wondering if brushing off this ‘hot potato’ has been experienced by other supervisors and therapists of colour when engaging in cross-cultural work. Therefore, in sharing my reflective process, my rocky journey when working with microaggressions, I hope to be helpful to others.

Throughout this article, I describe my interactions with a supervisee, Tina.* I also offer my spontaneous responses and, later, report what might have been said, following further reflection.

Way of being My responses draw on person-centred theory, in particular the use of congruence. I am captivated by congruence, like a moth to a light. I feel it is less technique and more a profound way of being. I also believe it is the path to being visible in the supervisory relationship, especially when issues of power, diversity, difference and conflict come into play. Rogers defines congruence as ‘being dependably real and genuine’, communicated through psychological contact, empathy, presence and unconditional positive regard.3 Lambers states that supervision is a pivotal place to demonstrate congruence, ensuring ‘the process of supervision facilitates the therapist’s congruence to the client’.4 Tina: I’m worried about working with this next client.

RR: I can feel you getting smaller as you say this, somewhat restricted in your body.

‘It is through the depths of difference we make contact with ourselves and others’ Mark Nepo1 Tina: Yes, my shoulders feel frozen… The whole thing feels big, like I won’t know how to relate to her.

RR: Tell me more about this feeling of bigness.

Does this create some fear in you?

Being congruent begins with somatic selfawareness, noticing what is happening in one’s body. Drawing on Gendlin’s focusing, I offered my own visceral felt responses to Tina – the tightness in my chest, the struggle to gasp for air.5 My intent in sharing these reflections was to help Tina listen inwards.

RR: Tell me more about this feeling of bigness.

Does this create some fear in you?

Tina: Yes. She’s from Pakistan or Nigeria maybe.

RR: [Pause/silence] OK… [Pause] Tina: It’s fine. She’s just a person.

RR: [Pause] OK, I see. [Silence] Did my somatic responses relate to Tina’s fear of racial and/or cultural differences? As I pondered this, I noticed the stark physical differences between us – my dark brownness next to Tina’s chalk whiteness. I felt utterly exposed. Had I fallen through what Morris calls the ‘trap door of racism’, via the unexpected slip of the tongue?6 Was Tina subtly or overtly expressing her prejudices? I was full of doubt.

I’d lost my footing and my voice. As a result, a discomfort ensued between Tina and me.

Cain’s guidelines for congruence state that strong reactions may result from one’s own biases, blind spots or relationship challenges.7 I reluctantly acknowledged the strength of this internal collapse, how this moment touched my own experiences of being the other, the foreigner, hooking painfully into memories of migration and racism. I felt a riskiness now, with Tina, and distanced myself.

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conditions of worth coming into play. I have adapted this Rogerian term to include how my values and beliefs were shaped by the firstgeneration South Indian immigrant diaspora.

This was to suppress feelings of personal discomfort when being attacked, in order to survive living in a foreign country. As a result, I offered Tina a closed response, eliciting no further exploration.

Cultural self Avoiding these uncomfortable moments was a skill I’d honed throughout my life. Becoming ‘as good as white’ had been my modus operandi.

I was adept at sacrificing the culturally different parts of myself, prioritising the emotions and values of the dominant class over mine. How else could I be acceptable and palatable? Being incongruent with my cultural self was how I survived my psychotherapy training. I made the most visible part of me disappear so as not to ‘rock the otherwise untroubled boat’,8 as Taylor writes, or be scapegoated as difficult or angry. This incongruence, this playing at being invisible, was an adapted survival response, another acculturated condition of worth. This time, I internalised the messages from the dominant culture to not challenge. I was aware my avoidance was felt by Tina. In holding back, I was not only jeopardising the trust we had built together, but stunting Tina’s own cultural exploration and blurring the parameters of ethical practice.

How could I use this self-awareness to strengthen the relationship? I held the above experiences in my mind, this time without dismissal or shame. As a result, I felt compassion for these hurt parts of myself – they felt like small, unloved beings, left in the dark for too long. I could only observe them with tenderness. Guided by this self-empathy and positive self-regard, I noticed something softened in me. I began to feel open and curious to Tina’s lived experiences. My gaze shifted from anger, judgment and defensiveness to enquiry. I noticed my body relaxing, my breathing becoming steadier. Tina’s unique way of relating to the world would be informed by her own racialised conditions of worth – as Chantler describes, those societal values, beliefs and expectations that shape one’s self-image.9 For Tina, this might be her socially constructed identity related to her skin colour, her whiteness. With further thought, perhaps I could have responded differently:

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Hycner and Jacobs describe this position as offering presence, ‘turning away from the preoccupations of oneself and offering one’s whole being to the other’.10 Congruence was becoming my ally, supporting and challenging me to deepen my practice with self and other. I began to lean further into its meaning. How could I appear more fully in the relationship? How could I attend to the unspoken undercurrents? My supervisor’s words rang through my ears – if you take risks to be yourself, it will deepen the relationship.

I wanted to be more honest. Mearns and Thorne state that mindful self-disclosure, relevant to the supervisee’s concerns, can be a way of expressing congruence.11 With this in mind, earlier memories surfaced. I was a child when we arrived in England and I felt so utterly exposed and small. I was disconnected from the sounds, smells and sights of South India – I no longer saw the familiar bright colours, felt the continual warmth, saw women in saris. England was the first time I saw skirts and women’s legs. I remember a perpetual feeling of disorientation, desperately searching for familiarity and safety. However, the colour of my skin left me nowhere to hide.

I recall how fearful I was of the whiteness around me and the constant staring. The words of my parents ricocheted like bullets in my head: ‘Stay away from them’, ‘They have bad ways.’

Sharing your story Cornelius-White describes congruence as ‘involving an awareness of feelings, thoughts and stories about oneself. Stories influenced by cultural variables’.12 If I shared my story, perhaps it would give Tina permission to bring herself, her cultural stories, to the room?

I hoped, too, it would normalise prejudice, bias and confusion around difference.

I note here the difficulty I feel in verbalising these cultural stories. I gain clarity from Anthias’ view of identity, as being a process of belonging.13 Here, one’s sense of belonging or not belonging is held in a multitude of moments, differentiated by when and where they were formed. This has helped me explore my self-identity at different points of assimilation to England. From this view, supervisees can explore their cultural configurations of self14 – the many different cultural voices informing their self-identity, the contexts in which they emerged and the relationship with these aspects at different points in time.

I now see my diverse subjective experiences offering a rich and nourishing quality to supervisees, a bridge to different perspectives, creating further opportunities for cultural empathy. I also see it as my role as supervisor to normalise the ‘not knowing spaces’ without fear or shame. Another person’s frame of reference may simply be out of one’s experiencing. How can one truly step into the uniqueness of another’s multi-positional, intersectional (gender, sexuality, age, class, ability, spirituality, neurodiversity) frames of identity? Therefore, I would support Tina to make statements like, ‘I don’t know, it’s something I haven’t experienced, but I am interested.’ This ensures the client is the expert of their experience. My modelling of this in supervision would look like this: RR: Does this create some fear in you?

Tina: Yes. She’s from Pakistan, Nigeria….

RR: As a second-generation, Westernised South Indian therapist, my life is very different to yours. I really want to know what this situation means for you.

Still, a nagging discomfort persisted between myself and Tina. Rogers describes this as ‘something being twisted in the relationship’.15 It was Tina saying ‘she’s just a person’, and my collusion with it that I found irksome.

An impossible task One of the tasks of the supervisor is to help supervisees create their ethical antennae

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I was concerned about the ‘treating everyone as equal’ approach. As Turner states, we do not live in the same cultural container,16 thereby refuting Rogers’ ideal view that we do. This idea is problematic, serving to neutralise differences or locating difference as a burden and negative. This view of diversity further perpetuates the belief that power and privilege are equal. Neville declares that ‘if race is not on the table, then whose frame of reference is being used?’17 This can result in what I call ‘cultural gaslighting’. Stern describes the gaslight effect as a process of using power to deny one’s reality, memories and experiences.18 Here, the recipient feels unheard; they are doubting and letting go of their experiences to avoid conflict in the relationship. I believe that, whether this is done knowingly or not, it results in harm.

Clients, already vulnerable, are denied their reality in social and political structures. Sue states that ‘being unaware of the impact of whiteness, one remains part of the system that upholds an unjust racial hierarchy’.19 White privilege, a term originally coined in 1989 by McIntosh,20 describes the advantages of being in this specific racial group. This term, now in our collective conscious, needs continual raising and challenging. While feeling the injustice of white privilege, I realise my choice to collude and hide comes from a privileged position. I have access to education, resources and jobs. ‘Checking one’s privilege’ is essential for everyone – a fundamental factor to understanding oneself and the impact of other people’s privilege on us and our clients’ lives. Turner highlights how positions of privilege and otherness can intersect.21 Therefore, acknowledging one’s own fragility when exploring issues of difference is as important, leading to deeper personal and interpersonal growth.

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to ensure the distinctive lives of clients are not overlooked.22 But the challenge here is to balance the many supervisory roles of facilitator, therapist, teacher, gatekeeper and individual while offering congruent empathetic responses, without judgment and without conditions – an impossible task?

Tina needed to feel understood, accepted and supported to develop awareness of the boundaries of competency and ethics.

As I pondered the weight of this, my mind wandered to my relationship with this supervisee, a trainee I had known for nearly a year. Tina was deeply committed to the course and wanting to do the best for the client, but still feeling exposed and not good enough.

This care for Tina and her own developmental needs further dissipated my anger. I reflected on my own experience of welcoming with compassion my vulnerabilities and blocks. I wanted to offer this powerful, healing and transformative process to Tina. Therefore, I offered Tina positive empathy by highlighting her thoughtfulness. Also, I used meta-awareness (what is felt about being felt) by sharing why I think and feel a certain way to create further trust, safety and transparency. Finally, I maintained throughout a genuine belief in Tina’s capacity to find her own way.

This brief exchange with Tina had initially knocked me to the core. However, through deepening my understanding of congruence and how it related to my identity as a secondgeneration South Indian, person-centred supervisor, I finally found the myriad of responses I could have shared with her: Are you responding to my stepping back?

I think the root of my reaction is feeling uncomfortable with these words… mainly, because we are from different cultures. Can we talk about the different meanings these words may have?

I worry your statement might imply that you are overlooking the client’s colour and hence the unique experience related to this, like oppression. I hope this doesn’t come across as a criticism. I experience you as a thoughtful student.

I don’t know if you are aware or not – the colour of our skin will be linked to all kinds of privileges and feelings of difference. This will affect, in many ways, the power dynamic in the relationship with your client.

This is ethically important to look at, so we don’t say things unwittingly to make the client feel devalued, invalidated or misunderstood.

There’s a lot here to think about, and I’m wondering what’s happening for you? I’m sensing you feel vulnerable. I feel that, too.

I’d like to support you in these issues and in finding what you need. Can we start to explore this together?

So, to conclude, what has this experience confirmed for me about congruence?

Congruence begins with an honest relationship with self – seeing the unacknowledged, unaccepted parts of self.

Congruence is compassion for self and others – a process of unravelling, revealing, reclaiming, retelling. Congruence leads to new ideas and new ways of being.

Congruence cannot grow without core conditions. It can only be offered when the wider political, social, cultural, intersectional positional context is embraced.

Congruence is rooted within an ethical and competency frame. It means honesty when exploring issues of power, culture and difference in a relationship.

Congruence is emotionally demanding.

Congruence is reflecting, learning, growing, changing. I pledge to be more visible with supervisees – to seek support, to take risks and to trust. * The supervisee’s name and identifiable details have been changed.

About the author Rajita Rajeshwar is a humanistic and integrative psychotherapist and lecturer on the master’s in Counselling and Psychotherapy at Salford University. She is a psychodramatist, clinical supervisor, EMDR therapist, trainer and group therapist, as well as a neurodivergent human rights activist. rajita.rajeshwar@gmail.com

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REFERENCES 1. Nepo M. The endless practice of becoming who you were born to be.

New York: Atria; 2015. 2. Yosso T et al. Critical race theory, racial microaggressions, and campus racial climate for Latina/o undergraduates.

Harvard Educational Review 2009; 79(4): 659–691. 3. Rogers C. A way of being. Boston: Houghton Mifflin; 1980. 4. Cooper M. The handbook of person-centred psychotherapy and counselling. Basingstoke: Palgrave Macmillan; 2013. 5. Gendlin E. Focusing. New York: Bantam; 1978.

6. Morris W. Dumber than your average bear. New York: Grantland Press; 2015. 7. Cain D, Keenan K, Rubin S (eds). Humanistic psychotherapies: handbook of research and practice. Washington: American Psychological Association; 2016. 8. Taylor F. In Jackson C. Why we need to talk about race. Therapy Today 2018: (29)8. 9. Chantler K. From disconnection to connection: ‘race’, gender and the politics of therapy.

British Journal of Guidance & Counselling 2005; 33(2): 239–256.

10. Hycner R, Jacobs L. The healing relationship in Gestalt psychotherapy: a dialogic/self-psychology approach.

New York: Gestalt Journal Press; 1995.

11. Mearns D, Thorne B. Personcentred counselling in action. London: Sage; 1999. 12. Cornelius-White J. Person-centred multicultural counselling. Person-centred Practice 2003; 11(1): 3–11. 13. Anthias F. Where do I belong? Ethnicities 2002; 2(4): 491–514. 14. Mearns D, Thorne B. Person-centred therapy today: new frontiers in theory and practice.

London: Sage; 2000. 15. Rogers C (author), Kirschenbaum H, Henderson V (eds). The Carl Rogers reader.

London: Constable; 1990. 16. Turner D. Race and the core conditions.

Therapy Today 2020: (31)8.

17. Ponterotto J (ed). Handbook of multicultural counseling (3rd ed).

Washington: Sage; 2009. 18. Stern R. Identify ‘the gaslight effect’ and take back your reality! [Blog]. Psychology Today 2009; 19 March. bit.ly/3rzcKls 19. Sue DW. Race talk and the conspiracy of silence: understanding and facilitating difficult dialogues on race. John Wiley and Sons; 2015. psycnet.apa.org/record/ 201503150-000 20. McIntosh P. White privilege: unpacking the invisible knapsack. Peace and Freedom 1989: July/August. bit.ly/3Dbly3q 21. Turner D. Intersections of privilege and otherness in counselling and psychotherapy: mockingbird.

Abingdon: Routledge; 2021.

22. Carroll M. Effective supervision for the helping professions. London: Sage; 2014.

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Email therapytoday@ thinkpublishing.co.uk

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Making concessions

‘It was vital that I work through my feelings around fees’ Fees are a controversial issue for many reasons, not least because there is no standard fee structure, unlike for NHS doctors, nurses and psychologists, for example. When I qualified, I found asking for a fee uncomfortable as I had never done it before and wasn’t used to it. Discussing my fee with a potential client who was in psychic pain felt very uncomfortable for me. Attending workshops for therapists to help them explore their feelings around fees and money was very helpful, but the fact that these workshops exist is very telling. It was vital that I work through my feelings around fees in order to make a living. A therapist has the right to choose their fee and charge whatever they are comfortable with. After all, it is intrinsically linked with our own self-care, which is vital for us to do our work. I have a set fee but will negotiate on a case-by-case basis, always keeping in mind how I am feeling about my offering.

I offer concessions to low-income and unemployed workers and, since the pandemic, I include NHS workers. As the fee is part of the therapeutic frame, it is part of the work to discuss it with clients and I continue to explore my own feelings about it.

Gemma Levitas, psychotherapist and coach

Is it OK for some clients to pay less?

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I do not explicitly offer the availability of concessions on my website as I believe that this encourages clients to devalue their worth in terms of personal as well as financial investment in their treatment. However, where it is clear that the funding of long-term treatment is going to be problematic, I do endeavour to offer help, although I frequently feel this has an air of horse-trading about it – would we consider bargaining with a dentist or vet? (Perhaps we should!) Psychotherapy seems to be perceived differently to other professional services, with fees set somewhat ‘Setting my fee has always felt arbitrarily, varying between £20 and in like a personal decision’ excess of £100. My fees in London are necessarily at the top end due to the high As I charge on the lower end of the range (£45 per session), I already consider my fee concessionary, although on occasion cost of a West End presence, whereas I have listened to clients’ financial situations and offered to lower fees at my local practice on the coast it to £40. I also currently work at Newcastle University two days are more modestly set, and it is there a week on a permanent contract, which allows me to feel less that concessions are more frequently pressure, knowing that I have a guaranteed income. Setting my requested. I offered free sessions for key general rate at lower than £45 a session, however, would not be workers last year, but I did wonder how sustainable for me. On the very rare occasion when I have offered many clients actually needed the support sessions for less than £40, I regard this as a form of charitable work rather than part of my private practice. I am aware that, for some and would otherwise have paid for it. people, therapy at £40 or £45 a session is not accessible, in which When the free offer expired, virtually case I signpost to organisations that offer a low-cost or free service. all of them felt the need to continue Setting my fee has always felt like a personal decision based on was ‘unnecessary’. I believe that is the providing an accessible service while balancing my need to earn underlying point – clients have to value a sustainable income. However, I don’t feel in a position to judge themselves as much as they value their what other therapists charge their clients as I don’t know what their therapist, and the paradox is in enabling personal circumstances are, for example, their overheads, cost of training or the area that they practise in. the conflict between the two.

Dr Peter Finlay, psychodynamic psychotherapist in private practice

Genevieve Buee, therapist working with young people and adults

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Talking Point, 1

Talking point

I know that some practitioners believe it’s unconscionable when therapists do not provide low-cost counselling and I have also witnessed bullying in social media groups because of this. But I don’t believe we have the right to shame others for not offering low-cost therapy – not everyone is in a position to afford this. I worked for free throughout my training and I also did agency work for seven years after qualifying, where part of our caseload included low-cost therapy. Since last year, however, I have focused on full-fee work in private practice. I choose to work with clients who are professionals and have the ability to pay my fees. My services are in demand and my retention rate is high, which tells me my fees are appropriate for my clients. There are different ways of thinking about fee setting and there are a number of factors at play. But it starts with thinking about how many hours you wish to work and how many clients you have the emotional capacity to see in that time.

Taking into account your business costs, you can then work out the fee you need to set per session to earn the salary you would like. This is the approach I took when I wanted to cut down my working hours and it has been very successful – it’s about working smarter, not harder. I do not offer concessions as I am not a charity and I do not work for a charity, but my income tax supports public services and the more I earn, the more tax I contribute to the public purse to fund services, including NHS counselling.

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‘Mental health services should not come at the personal cost of therapists’ Coming from a social care background, I want to help make therapy more widely accessible. But as a private practitioner, I also recognise the need to feel secure in my ability to pay my bills, save for a pension, take sick leave, do my own therapy and take time off to rest. This puts prioritising my own self-care in tension with my social justice values – however, I cannot be a good therapist if I don’t put my own oxygen mask on first. I believe mental healthcare should be free to all, but that’s not the world we currently live in, and sacrificing my personal financial wellbeing won’t change that reality. I also believe that providing essential mental health services should not come at the personal cost of therapists, many of whom come from historically underpaid demographics, who are then often overworked and undervalued to the point of burnout. I am fortunate to be able to offer a proportion of my slots at a concessionary rate to those who self-assess as being unable to pay my full fee. I have committed to doing so not because I think it is my job to redress the imbalances in society, but because I have some privilege that others in my profession do not. I have the luxury of making that choice, but I would never judge or pressure others who choose not to.

Jen Bellanich (she/her), psychotherapist in private practice

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Indira Chima, therapist in private practice

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THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN

‘My services are in demand, which tells me my fees are appropriate’

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For exclusive publisher discount codes, see www.bacp.co.uk/membership/book-discounts Black Identities + White Therapies: race, respect + diversity Divine Charura and Colin Lago (eds) (PCCS Books, £23.99)

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This book aims to address the continued failure in therapy research and practice to address diversity in a meaningful way.

The gaps are first found in training course curricula – the lack of representation of non-Europeans in the theoretical canon, and the focus on the experiences and needs of 20th-century white clients.

Whether you are coming to this subject as a researcher, trainer, supervisor or practitioner, you will find essays that explore your situation as it currently is, with some explanations about how and why we have found ourselves here. Concepts discussed include colonisation, power, privilege, oppression, internalised and externalised racism, exclusion, trauma, shame, denial and micro and macroaggressions, all of which can be found in the wellintentioned world of therapy! But we are given ideas and inspiration for improvements too – the intention is to criticise but also to be creative and thoughtful as we go forward.

There are 19 essays covering a broad spectrum of experience and advice.

My favourite is a written conversation between ‘Cece’ and ‘Niall’, a black woman and a white man, where they talk about their experiences of their training courses, which have diversity at their centre. It is fictional, but you can start to imagine it.

Reading these texts as a white, middle-class woman was uncomfortable, and it is meant to be. But the intention is to encourage curiosity rather than shame. We are asked to consider our own assumptions, our internalised racism, our entitlement. I would recommend this book to everyone. I shall revisit, reread, use as a checklist, and try to understand some of the more complex concepts more fully.

Mel Kinross is a counsellor and supervisor

Trauma Healing in the Yoga Zone: a guide for mental health professionals, yoga therapists and teachers Joann Lutz (Handspring, £27.50) I approached this book as an experienced therapist, novice yogi and curious scholar.

The author has combined classical yoga, somatic psychotherapy and neuroscience to develop a nervous system-informed, trauma-sensitive yoga model (NITYA). The first two chapters explain the physiology and anatomy of the nervous system and the philosophies of yoga. Chapters three to eight introduce the practical elements of breath work, hatha postures, yoga nidra and meditation, and offer illustrations of how Lutz incorporates NITYA into therapy sessions with individuals and groups. Each chapter begins with a vignette introducing a client, and there is an extended case study in chapter six.

There is undoubtedly a place where yoga meets therapy, which is apparent in my practice of both and is evident throughout this book. For example, Lutz encourages the use of ‘invitational and interoceptive language’ to empower choice – ‘Would it be alright if?’ – and encourage connection with internal experiences – ‘How does it feel when?’

She also advocates starting where the client is, using language consciously and encouraging spontaneity, all of which feel familiar. The areas of unfamiliarity are interesting to consider.

Something that I think should be made explicit, and which isn’t, is that yoga therapy is a specialist discipline, requiring specialist training to develop specialist skills. The subtitle of this book implies that any mental health professional could add yoga to their repertoire of trauma healing, which I would caution against, just as I would caution against yoga instructors claiming to incorporate psychotherapy into their practice.

Jeanine Connor is a child and adolescent psychotherapist

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Timeless Grandiosity and Eroticized Contempt: technical challenges posed by cases of narcissism and perversion Michael Shoshani and Batya Shoshani (Phoenix, £30.99) Intrigued by the title and arresting cover image, I found much of practical use in this engaging book about working with hard-to-reach clients.

The first half of the book focuses on the clinical work of this Israeli husband-andwife duo, who are both experienced psychoanalysts. They define perversion broadly as a failure to mourn, think and love. I found the rich case illustrations extremely helpful, and in particular the well-chosen detail of the thoughts and feelings of the analyst as the dialogue progresses. I learned much from Michael Shoshani’s brave and perceptive analysis of what helps and what inhibits the client’s progress – for example, neglecting to recognise unprocessed material in himself. It takes courage to look at one’s own narcissistic and perverse parts, but, as the authors put it, ‘the first and foremost task of the therapist is to look inwards for similar psychic tissue’.

The second part of the book brings together ideas from literature, philosophy and cinema to show destructive narcissism in its wider context. Again, I found comfort in the Shoshanis’ humanising approach, their refusal to see the perverse as simply ‘out there’, rather than part of the spectrum of universal human experience.

‘Each of us carries a latent perverse nucleus... that can be awakened given the right seduction,’ they suggest.

When really stuck with a client, it is tempting to collapse into self-blame.

This book provides a refreshing alternative to that and will be a valuable resource for therapists and supervisors who are prepared to look carefully at countertransference and parallel process.

Jane Cooper is a former senior counsellor at the University of Cambridge

The Bookshelf, 1

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

Sexual Grounding Therapy: context, theory and practice Geoff Lamb (Routledge, £29.99) This bodywork model of therapy is presented in four parts: ‘Exploration’, ‘Comparison’, ‘Sexual grounding therapy’ and ‘Future perspective’. In chapter one of ‘Exploration’, Lamb succinctly and powerfully highlights psychological tensions created by attempts to separate cognition from human sexual nature, rather than honouring their natural integration of each other. He examines culture and religion as influencers of this separation. We are introduced to Willem Poppeliers, the founding theorist of sexual grounding therapy (SGT) and the two main points of why he developed it – lack of genital work in clinical settings and the need to engage more fully with transference and countertransference in the therapeutic dyad. By this stage, I was already challenged and engaged.

The ‘Comparison’ section offers in-depth insights on the lack of sexinclusive training in mainstream models of counselling and how, when it is included, there is an absence of sex-affirmative stances. This is a stimulating read with a healthy critique of how sex was and is seen in therapy models.

In section three, we are introduced to a new twist on the familiar stages of developmental theories. This stages model is logical and sensible, with in-depth chapters dedicated to each stage. Chapter six on puberty and adolescence deals with consent, and it is already influencing my work with younger clients. Each chapter offers something valuable, challenging and/or moving too.

The book’s conclusion addresses how difficult it is to access SGT training and therapy, due to cost and lack of trainers.

While some pathways to SGT’s future are offered, lamentably, it’s hard to see how such an exclusive model will survive.

Gavin Conn is an integrative counsellor

Psychological Roots of the Climate Crisis: neoliberal exceptionalism and the culture of uncare Sally Weintrobe (Bloomsbury Academic, £21.99) ‘As I looked out into the night sky across all those infinite stars, it made me realise how unimportant they are.’ Aptly introduced with this pithy quote from the late Peter Cook (satirical comedian/ actor), Weintrobe’s latest book explores the intersection of psychology with politics, economics, social frameworks, culture, leadership and mass media – a remarkable accomplishment – weaving in vivid examples and metaphors throughout.

Weintrobe believes that a tussle between two aspects of our inherent imagination (caring and uncaring) and encouragement by cultural forces (particularly under neoliberalism) has leaned us, especially in the global North, towards ‘business as usual’, permitting us to ignore the stark reality of the climate crisis. She argues that ‘exceptionalism’, which she sees as a rigid psychological mindset, is largely responsible for the climate crisis. People falsely believe that they are entitled to see themselves in idealised terms, to have whatever they want, dispense with moral and practical difficulties and live an apparently guilt-free, ignorant existence, as though only ‘their’ world matters.

Weintrobe urges for the reinstatement of our ‘frameworks of care’ (provided by a good-enough mother/carer and social support) to work through the damage to our environments, our societies and our minds, and challenge our narcissistic sense of entitlement with its healthier alternative, ‘lively entitlement’, which powers our will to act with greater care.

I found this book highly accessible, richly researched, fascinating and replenishing. It may not have all the answers but it offers a sense that all is not yet lost, if we take heed.

Linda Aspey is a counsellor, coach, facilitator, writer and climate change communicator

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Jung: an introduction Ann Casement (Phoenix, £21.99) Knowledge of Jung and his influence on modern psychotherapy has always felt like an important piece of the jigsaw that I was missing, so I was pleased to be able to review this book. However, although it is entitled ‘an introduction’, it feels as if a significant prior level of knowledge is assumed, making some parts of it quite dense, technical and – for this reader at least – difficult to grasp. I felt I needed an introduction to this introduction.

There can be no doubt about the author’s erudition – indeed, a couple of times she criticises other books on Jung for being theoretically lightweight, a criticism that could never be levelled at her. She covers key concepts and history, including Jung’s relationship with Freud, archetypes, the collective unconscious, the shadow, the numinous, anima/animus and individuation, and it is fascinating to catch glimpses of how Jung’s influence and ideas have formed the bedrock of some of our current psychotherapeutic theory and practice, especially in the object relations and broader developmental relational field.

The author herself is a huge presence throughout this book and there is a surprising amount of personal musings and diversions – especially around academic colleagues, their achievements and how much she enjoyed their company, their countries and their restaurants – that the book could do without. What could have transformed it is a glossary. The author goes to the trouble of italicising technical terms in the text but does not define them anywhere; a list of succinct definitions would have been invaluable. As I read the book, I was thinking that maybe I was expecting too much of it. I finished it thinking maybe it was expecting too much of me.

Nick Campion is an integrative psychotherapist in Derby

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OUR ETHICS TEAM AND THERAPY TODAY READERS CONSIDER THIS MONTH’S DILEMMA:

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SHOULD WE TELL A CLIENT THAT WE SUSPECT THEY MAY BE AUTISTIC?

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I have been seeing a client in their 40s for three sessions now, and I strongly suspect that they might be autistic. However, they have not used the word themselves, although they have talked about being aware their brain ‘works differently to other people’s’. I don’t want to cause offence, but I believe that the client might benefit from having an assessment. I’m not sure how long they would have to wait for a diagnosis, though, or what resources they could access even if they were diagnosed. Should I suggest that they see their GP, or refer them on to a specialist therapist, or just not say anything about it?

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dilemma for which there is no single answer, and it would be unwise to generalise. Each client deserves to be met as a unique individual, and the danger of stereotyping is that we can become patronising and disrespectful, setting ourselves up as expert or seeing the other as ‘less than’. Some clients would take exception to the word ‘disorder’ in the commonly used term ‘autism spectrum disorder’ (ASD), with the implication that something is wrong with them and that neurodivergence is a problem.

The trouble with any formal diagnosis is that we can focus on the label and miss the person.

Therapist Max Marnau, who has an autism diagnosis, says, ‘When you have met one autistic person, you have met one autistic person. We are just as varied as neurotypicals.’1 Even a seemingly innocent question such as ‘Have you ever considered being assessed?’ is bound to be interpreted by the client as ‘I think you should be’. So it is worth considering your motivation before broaching the subject, however tentatively. Seeing that this particular client has not mentioned autism, I wonder who would benefit from them seeking a diagnosis? If it is not an issue for your client, does it need to be an issue for you? Are you wondering whether it’s within your competence to work with a

person who may be neurodivergent, or whether it’s more ethical to refer them on for a diagnosis?

A diagnosis could be liberating – some people report feeling massively relieved on being formally diagnosed. It may allow a client to make sense of their way of being, help them secure appropriate support and expect ‘reasonable adjustments’ to be made in their workplace.

It may also be helpful and provide guidance for family members and those closest to your client.

As one client said of their diagnosis, ‘It came as a huge relief. For my whole life, I had felt I was different – life wouldn’t fall into place for me.’2 However, the diagnosis process itself can be time-consuming and stressful, with no certainty of a positive outcome. Even if an onward referral were to be made and a diagnosis given, there is no guarantee that appropriate resources would be made available. There could be a long waiting list, with a lengthy delay between assessment and diagnosis, and the cost of a private assessment could be prohibitive. A client in their 40s is less likely to be able to access support than a young person.

If you are feeling inadequate when confronted by possible neurodivergence, you may feel convinced your client would be better served by being referred on. But you could be the right person to help them, and your feeling of insecurity is simply reflecting theirs. It’s also

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worth bearing in mind that your speculation about your client’s autism may be of limited relevance to the actual issues they want to bring to therapy.

Undertaking some CPD in order to understand neurodivergence better might help you feel sufficiently confident to continue working with this client and seeing where the work takes you both. It will also help you assess whether you are working within your competence, one of our most important commitments under the Ethical Framework (‘Our commitment to clients’, points 1b and 2a, and Good Practice, point 13). A search on BACP’s CPD Hub and Learning Centre reveals a range of relevant resources. As Max Marnau says: ‘If I [with autism] can work with neurotypical clients, you can work with autists… We need each other’s different perspectives, our different languages, our different ways of being in the world.’

One avenue of exploration could be around how the client thinks their brain ‘works differently’. Allow them to explain to you what that is like. You might need to make a special effort to create a safe space, making explicit what you are doing and how you are working as you go along. You could do your level best to enter into their world, to try to experience it as they do, and to help them feel less isolated and ‘different’ in what can seem a lonely world.

It’s also worth bearing in mind Elaine Nicholson’s reminder that it is not our job as therapists to pathologise autism: ‘We are there to listen, to emotionally hold, to gently assist the client to progress through their inner turmoil and conflict so as to help them.’ 3 REFERENCES 1. Marnau M. Coming out as an autistic therapist.

Therapy Today 2021; 32(1): 26–29.

2. Turner R. My autism diagnosis changed everything. Therapy Today 2020; 31(4): 25.

3. Nicholson E. What to do when autism or Asperger’s is suspected in the client: to share or not to share? BACP Learning Centre resource. https://learningcentre.bacp.co.uk

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.

Dilemmas, 1

Seeing that this particular client has not mentioned autism, I wonder who would benefit from them seeking a diagnosis? If it is not an issue for your client, does it need to be an issue for you?

READER RESPONSES ‘A diagnosis can help us find self-compassion’

As an individual who is now diagnosed as autistic, but went through life (and therapy) without knowing, I would encourage you to gently broach the subject when the time is right, rather than not mention anything to the client.

I would say from personal experience that once you have the understanding that you’re autistic, it potentially changes so many aspects of the self – processing past experiences, making sense of co-existing issues like anxiety and depression, and simply shaping the way you identify as the human being you are now.

Because autism is widely considered by neurodiversity-affirming individuals to be a neurology and a difference – our way of seeing the world, rather than a set of deficits – a diagnosis can help us find self-compassion, if we currently experience being misunderstood, maligned and marginalised as a non-diagnosed or non-autistic-identifying person. The realisation that one is autistic can essentially

self-identify with whatever neurodivergence relates to them, and don’t feel they need a diagnosis, although they’d undoubtedly benefit from exploring what this neurodivergent identity means to them.

There are precious few resources available to diagnosed autistic adults, so they would be more likely to find support via local or online social groups, or private therapists. Feeling part of a tribe or community is a vital positive step for any marginalised individual.

Key aspects of the common autistic experience, such as sensory and nervous system dysregulation and sociocommunicative differences, could be gently explored in therapy to see what the client’s perceptions of their experience are. I feel it is a therapist’s duty to educate themselves about possible neurodivergencies in specific clients, like this one, so that collaborative discussions can be undertaken and an honest and strengths-based dialogue can be introduced, in order to help the client discover their identity and autonomy.

Kathy Carter, Therapy Today Editorial Advisory Board specialist in autism

help individuals ‘find themselves’ in a truly authentic way (although that personal journey of acceptance and processing may take some time!), especially if they’re able to work with a neurodiversity-affirming therapist.

Additionally, a lack of authenticity can lead to ‘masking’, a form of camouflaging (often subconscious) that one undertakes in order to ‘pass’ in life and appear typical. This comes at great cost to autists, in terms of their emotional, mental and physical health. For example, the charity MIND reports that 94% of autists have experienced anxiety, while 83% have experienced depression. Eight times more autistic folk report feeling lonely than do the rest of the population, a situation that of course is also linked to mental ill health.

Masking can even affect how an individual experiences and responds to therapy, and can vary between genders.

The waiting times for diagnosis in the UK can be lengthy (especially post-COVID), and the protocols for assessment do seem to vary within counties, and also between the four nations of the UK. A chat with the GP about the process in their locality would be a good first step. Some people are also happy to

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‘Autism is a fundamental part of a person’s self’ Don’t worry about referring at this early stage.

Treat this client as you would treat any other client. Pick up what they say. Reflect it back.

Listen. Respond. Get the feel of them. After three sessions, you barely know them.

Discover how they function, how their brain is different, what their experience of the world is. Ask them, ‘What do you make of that?’ If they say they feel like an alien, ask them what their planet looks like. Follow their lead.

Many non-autistic ‘specialist therapists’ are specialists in theory only; what they know is the medical model of autism – autism as a disorder, a deficiency, a collection of impairments.

That approach is inevitable in the diagnostic process, but it is unnecessary and potentially very damaging in therapy and in life. Those specialists may know more about autism from outside than you do, but they do not know your client, and they do not know about autism from inside, which is what you, and your client, are discovering.

As a counsellor you are there to facilitate your client’s self-discovery, to facilitate their being the self that they truly are; and autism is a fundamental part of a person’s self.

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If you have formed a therapeutic relationship and are working together, and after three sessions your client has already talked about their brain being different, then trust the process. You may find you don’t need to raise the question of autism; if it’s important to them, your client will do so themselves. But if, much later in the therapeutic process, it’s clear to you that you should, don’t worry about causing offence.

Autism is simply a different, and minority, cognitive and sensory processing style.

Your client may or may not decide to go for an official assessment. For some of us, it is enough to recognise that we are neurodivergent; for others, a diagnosis feels important, or may be useful in education, work or other aspects of life.

The choice is for your client, not for you.

I cannot overemphasise the importance of having done that work of self-discovery, of learning to prize one’s self before one faces the language of diagnoses, deficiencies, disorders, challenges and impairments of the diagnostic process; a GP is likely to have neither the time nor the understanding for that.

You will do that best by seeing their world from the vantage point of the client’s internal frame of reference, not that of your own theoretical expertise. Understanding autism from the autistic point of view may help, as you may pick up things that you would not otherwise notice; but it is more important to unlearn the stereotypes. If you are going to read or watch anything, choose something by autistic people, not by the non-autistic experts. There are plenty of books, articles and videos.

So when you begin to suspect that your client is autistic, don’t think, ‘Oh no, should I break the bad news to them, and if so, how?’; think, ‘Here is a chance for this person to discover something really essential about the self they truly are, to stop trying to be what they are not, and at last to play to their strengths.’

Max Marnau MBACP (Snr Accred), autistic person-centred counsellor and supervisor; founder of Autistic Counsellors and Psychotherapists Facebook group

‘Autism is not a condition to be cured’ Although it might seem sensible to encourage the client to see their GP to seek a formal diagnosis, I venture that, while it might be helpful for the therapist to know for sure, it would be too early for the client. For most autistic people I have known – including me – it takes a while to

explore the possibility of being autistic. There is the gathering of information as well as managing doubts and disbelief (‘Yes, OK, but am I fully autistic?’). And even once convinced, it takes time to get used to the idea and realise what this means (and has meant) about your life and experiences, past, present and future. It may feel more comfortable for the client to do at least some of this exploring first, before seeking a diagnosis themselves to ‘make it official’. And there are some autistic people who do not wish to have an official diagnosis because there is no disorder to diagnose. Autism is not a condition to be cured – an autistic person is a human with a different neurotype.

However, not saying anything about autism or neurodivergence is not the answer, as it could give the message that a difference in neurotype either does not exist, is not significant, or is something that is not important. In my experience of working with autistic clients, it is hugely significant. I think of it in this way – a person is not a neurotypical with autism, they are a person for whom many, many things are different as a result of being autistic in a neurotypical world. And these differences will not only be those they recount in the stories they tell in the therapy room – the injustices, traumatic experiences, shame, grief and defensive strategies. They will also be those in the actual interactions with the therapist, and in the process of therapy itself.

It would be lovely if, on suspecting a client has autism, a therapist could sensitively and in a nurturing way hold that client while they explore the possibility and progress with the journey ahead, at their own pace, rather than setting the agenda for them. If the client feels safe and supported to explore their neurodivergence, they will be more likely to go on to own a new identity and form better strategies of how to operate in the world based on that reality.

And it may be natural for the client to seek a life that is more fulfilling once things make

Not saying anything about autism or neurodivergence is not the answer, as it could give the message that a difference in neurotype either does not exist, is not significant, or is not important

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sense in a different way. That might mean, for the therapist, letting the client go when they need to find ‘their people’, which could well include an autistic therapist. My life has opened up in the past few years since finding a group of other autists like me – successfully independent, professional and sociable. Even though I have been a psychotherapist for 20 years, I’ve learned so much about life and myself from our talks. And it feels so good to feel the same things as other people, and to have had similar experiences. Autistic people do greatly benefit from being around other autists.

Vauna Beauvais, UKCP registered online therapist specialising in adults with autism and ADHD

‘A referral to a specialist may be appropriate’ Even without a mention of autism spectrum condition (ASC), a therapist noticing traits should nonetheless make suitable creative adjustments, in partnership with the client, allowing them to express and flourish. In addition, consistency provides predictability, making it easier for someone with ASC traits to maximise therapy. Of course, one size does not fit all – both neurodivergent and neurotypical people are on spectrums of differing needs.

As a neurodivergent counsellor, I am aware of the importance of a collaboratively agreed focus at assessment, along with a review point, to structure sessions. It helps to avoid a neurodivergent client feeling lost in the sea of exploration, adding more demands to the existing pressures of navigating therapy (a social situation). In therapy, clients may mask, or perform what they think may be required.

Incorporating a review provides a suitable juncture naturally leading into the possible causes for the initial concern, framed to delicately outline the possible reasons why this client’s brain ‘works differently from other people’s’. Potential additional questions could include: ‘What do you think could possibly be the reason for your brain working differently?’

‘How do you think these sessions have helped towards understanding your initial concern?’

Pursuing an assessment may not necessarily be the next step. Although you may feel the client would benefit, it is important to ascertain what they think would benefit them.

Researching autism together, psychoeducation and exploring how autism manifests specifically in the client’s life may be a better next step.

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Consider allowing the client freedom to explore subsequent steps at their own pace as this new information lands, to help them feel heard, understood, unashamed and accepted.

In my personal and professional experience, neurodivergent people often feel exhausted, judged and overwhelmed by continual daily demands. Hence I work creatively from a strengths-based model, with specific strategies tailored to that individual’s needs, drawing on their vast potential.

If a therapist feels ill-equipped, reading may prove to be helpful in the immediate term, but as with any presentation, the therapist should ensure they work within their competence as outlined in the Ethical Framework, otherwise a neurodivergent client’s experience of being misunderstood may be reinforced, perpetuating their anxiety. A referral to a counsellor with a specialism in neurodiversity may therefore be appropriate.

Iffat Shafiuddin MBACP (Accred) (she/her), counsellor working with children, young people and adults, clinical supervisor, manager and trainer

‘Be brave, be gentle and be sensitive’ I feel very strongly about this dilemma due to my own experience. When my son was 14, we realised that he probably had autism. I trod very gently when attempting to discuss with him the possibility of getting an assessment, but it led to a massive meltdown. I made a few more attempts over the years, but he could not take it from me.

As he was suffering badly with the anxiety and depression symptomatic of autism, I took my son to several different counsellors over the next seven years, desperately hoping that one of them would be able to form a strong enough therapeutic relationship with him to recognise (or at least suspect) ASD and be brave enough to bring it up. No one did.

Eventually, broken by pain and frustration, he reached the point where he was open to an assessment and was very quickly diagnosed on the NHS. This literally changed his life – it meant he could get the educational and financial support that he needed. It made things make sense to him and he is now comfortable with his neurodivergence. If one of those counsellors had done what I now do with my own clients, my son could have been saved many years of intense pain, shame and frustration.

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:  Safeguarding vulnerable adults within the counselling professions in England and Wales (GPiA 030)

 Equality, diversity and inclusion within the counselling professions (GPiA 062, 063 and 108)

 Ethical decision making in the context of the counselling professions (GPiA 044)

 Reasonable adjustments within the counselling professions (GPiA 080)

My personal experience has enabled me to spot the signs of autism, particularly in males, and if I see enough signs, I will very gently enquire about whether they had ever considered it while making it clear to them that I’m not an expert and could be wrong.

I work with adults and children and young people and have raised the question with clients from 12 to 59 years old without causing offence. No client or parent has ever had a problem with this. Most say that they were wondering about it themselves and would now arrange an assessment. Some said they ‘knew’ but didn’t feel the need for a diagnosis. Some wanted to explore the possibility and how they felt about it but not make it the main focus of their therapy.

For every client, it’s been like something inside just clicks, things suddenly make sense.

Perhaps they were like me, just waiting for

someone to say something. Perhaps by saying nothing we enforce within clients that it’s something so shameful that it should not be talked about.

As counsellors we can make an immeasurable difference to the lives of our clients who may be struggling with life because they are neurodivergent and trying to fit into a neurotypical world. So, if I see it, I say it, and I would encourage others to do the same. The dilemma writer asked three questions; here are my answers, based on my experience. Should they suggest the client see their GP? Yes. Should they refer them on to a specialist? If by that they mean a specialist autism counsellor, I’d say not unless the client asks them to. Should they say nothing about it? No! Be brave, be gentle and be sensitive.

Nicola Townsend MBACP, counsellor in private practice

HOW WOULD YOU RESPOND?

Can I work with a client on adoption issues when I’m not registered?

I have been seeing a client for 10 weeks, the presenting issue having been their relationship and ambivalence over whether to stay with their partner. Some way into the therapy, the client started to explore their feelings about being adopted and is considering trying to trace their birth family. This was not mentioned at the time I accepted the self-referral. I’m not registered with Ofsted as an adoption therapist, so I am unsure whether I can continue working with them, but it seems wrong if I am expected to ‘drop’ them at this stage, when the work is far from complete.

We welcome your responses to this upcoming dilemma. If you would like to contribute, please email the editor at therapytoday@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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What do you find challenging about being a therapist? Balance. Although I now

live in the UK, I work exclusively with clients in Guyana via online platforms, because of the great need for therapists back home.

This means I work with clients from 8pm to midnight (UK time), twice a week.

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What motivated you to become a therapist? I wanted to leave my

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world a little better than I found it, and I wanted to accompany others in their journey of healing. When I did my undergraduate studies at the Caribbean Nazarene College in Trinidad, I became fascinated with counselling and psychology and the transformative, healing power that lies in relationships. As I looked back at the various roles I’d held over the years, and as I thought about what I wanted to do with my life, I realised that a common thread for me was my ability to listen to people in distress and my trust in the human being’s capacity to heal.

Do you have a specialist field of practice? No – I work where the

relationship works.

What do you find most rewarding about the work? When clients raise

the ‘I think I’m ready to stop therapy now’ conversation, I feel joy that I still can’t capture in words. There’s something incredibly rewarding about witnessing the unfolding of a client’s trust in their own capacity to heal, survive and thrive. I love working myself out of a job!

What are you most proud of achieving? In 2016, I was awarded

a Chevening Scholarship, the UK Government’s prestigious scholarship programme for emerging leaders, to pursue my master’s at Keele

University. That experience continues to be an important highlight of my personal and professional development, which has led to meaningful outcomes, including setting up my private practice and now working at Keele as a lecturer.

What have you learned about yourself since becoming a therapist? That I can be just as kind

when saying ‘no’ as when saying ‘yes’.

How do clients find you?

Mostly via referrals, and my professional page on Facebook: @CollyCounselling.

Where would you like to be in five years’ time? I’d hope to be a

mommy, somewhere on my way to completing doctoral studies, and a published author of one of the books I’ve started writing. Maybe if I put it out there, I’ll look back some day and think, ‘Hey, I’ve actually done it!’

What book, blog or podcast do you recommend most often?

My husband and I co-host a podcast, My Wife is a Therapist, where we revisit conversations we’ve had, to highlight lessons we’ve learnt and are still learning, the realities of perpetual conflicts in marriage and tips for improving relationships. We combine the hilarity of drama with honest conversations and tips from a therapist. I think it’s great (but don’t take my word for it).

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What do you do for self-care/ to relax? I watch Gilmore Girls and

Friends on repeat, and Christmas movies on the Hallmark Channel throughout the year.

What gives your life meaning?

I can’t overemphasise how much my relationship with a God who loves me unconditionally keeps me grounded as a human and as a practitioner.

My trust in Christ as my friend and companion continues to confound my most overwhelming fears, insecurities and anxieties. On my worst days, I have a place where I am safe – where all that I am is embraced with a relentless passion. And on my best days, I have an assurance that I am sustained by a God who has given me everything I need to fulfil my purpose on the earth.

Who is your psychotherapy (or counselling) hero(ine)? I love the

work John Gottman and his wife Julie have done on understanding relationships. I think their research and ideas are simply outstanding. I’m wondering if there’s any chance they might read this – I’d love to meet them some day!

What would people be surprised to find out about you? I’ve still not

seen the film Black Panther. Don’t judge me! I prefer to give time for the hype around popular films to wane, so that I can have an authentic personal response.

About Kerese Now: Person-centred therapist (online), lecturer in counselling and psychotherapy at Keele University and podcast cohost of My Wife is a Therapist. www. mywifeisatherapist podcast.contactin.bio Once was: Client services and administration manager at a law firm.

I have also had many youth leader roles.

First paid job: As part of the Work Study internship programme for high schoolers in Guyana, I was attached to the National Insurance Scheme, where I learnt about state pensions and benefits.

I received a lovely stipend at the end, and suddenly understood all the adult fuss about payday – ka-ching!

Who would you like to answer the questionnaire?

Email your suggestions to therapytoday@ thinkpublishing.co.uk

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Analyse Me, 1

The questionnaire