BACP Therapy Today March 2022 by Think Publishing

Cover

MARCH 2022 | VOLUME 33 | ISSUE 2 THERAPY TODAY

VERSION

Therapy created the space I needed to accept myself

REPRO OP

Page 36

SUBS ART PRODUCTION CLIENT

MARCH 2022 | VOLUME 33 | ISSUE 2

You can knock... Why counselling is still largely inaccessible to disabled people

but you can’t come in

Hope and healing after collective trauma // When labels can be liberating Getting back to therapy basics // Individualism and the person-centred approach

BLACK YELLOW MAGENTA CYAN

91BAPMAR22100.pgs 09.02.2022 12:39

Contents, 1 VERSION

Contents March 2022

REPRO OP

Upfront

SUBS

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

Main features

CLIENT

‘Collective trauma events are opportunities to face our collective shadow and undergo post-traumatic growth’ Jelena Watkins (‘In the shelter of each other’, pages 30–35)

Regulars

It changed my life My practice Talking point The bookshelf Dilemmas Analyse me

On the cover..

The big issue

How can we make counselling more accessible for disabled clients? asks Catherine Jackson (pages 20–24)

Opportunities

COVER IMAGE: KIRSTEN SHIEL

PRODUCTION

SHUTTERSTOCK

ART

The big issue Catherine Jackson explores the many barriers to disabled people accessing counselling 'We need more faith that therapy works' Counsellors need to understand how their work changes lives, say Matt Wotton and Graham Johnston In the shelter of each other Jelena Watkins and Helena Lewis describe how community-based groupwork can promote healing, connectedness and hope after collective trauma When labels are liberating Be wary of undermining neurodivergent clients’ need for a label, warns Kathy Carter Only human In the face of climate collapse, therapists must hold on to the belief that human beings are not inherently destructive, writes Becky Seale

Classified, mini ads, recruitment, CPD

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

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

5 6 10 11 12 16 17 18

20 26 30

38 42

36 45 46 48 50 74

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

MARCH 2022

91BAPMAR22101.pgs 09.02.2022 12:45

VERSION

From the Editor

REPRO OP

SUBS ART

more faith that therapy works’ I still have days on page 26. The importance of professional when my mind questions confidence is also a thread running whether what I do actually through our ‘Big issue’ feature this issue, which explores why counselling makes any difference… remains largely inaccessible to clients with disabilities, even though so many What comes with of us now offer online therapy. It may experience is the ability feel ethical to turn down a client with to hold tight and not attach disabilities if you feel the work is beyond your competence, but what too much significance to that can mean for the client is a series those thoughts of rejections – we can’t assume that ‘other therapists’ out there are better qualified and will pick up the work. The experiences of the clients interviewed by Catherine Jackson make for shocking reading, but their stories need to be told. It is important that we educate ourselves about the challenges disabled people face living in a society set up for the non-disabled, but what all the disabled people interviewed said they want from therapy is ultimately what we aim to offer every client – a safe, non-judgmental space to explore what is going on for them. See page 20 for the report. As ever, I hope there is something in this issue that supports your practice – do send your feedback 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

COVER IMAGE: KIRSTEN SHIEL

CLIENT

WILL AMLOT

PRODUCTION

hy is it so hard to hold on to the conviction that therapy works? Despite more than a decade of practice I still have days when my mind questions whether what I do actually makes any difference, usually after a session that has felt disjointed or disconnected. But what comes with experience is the ability to hold tight and not attach too much significance to those thoughts. And, thankfully, it’s never long before I experience the ultimate antidote to doubt – a session where there is no question that the work is making a difference to the client’s life. As Matt Wotton and Graham Johnston point out in their ‘Opinion’ piece in this issue, therapy can be hard and slow, and even Freud yearned for it to be quicker. When doubts set in it’s easy to assume training in a new ‘add on’ is the answer. But, as the authors argue, by succumbing to therapy fads, we risk diluting our offering. They recommend basing CPD on client presentations, rather than feeling pressured to train in the latest technique. Of course, refreshing your skill set can be re-energising and it’s one of the many factors that can give a therapy career longevity – my own long-term plan is to pivot my practice by training in couples therapy. But before we pivot, is it better to pause and reconnect with the basics of therapy? As the authors point out, it’s the strength of the therapeutic alliance that changes lives, not any particular technique. You can find ‘We need

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

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

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

MARCH 2022

91BAPMAR22102.pgs 03.02.2022 12:27

Welcome, 1

Welcome

VERSION

News round-up

Our monthly digest of news, updates and events REPRO OP SUBS

FROM THE CEO Ella Henderson

ART PRODUCTION CLIENT

As you may know, we are developing our Equality, Diversity and Inclusion (EDI) strategy, and have begun taking steps to improve accessibility to accreditation. A new Learning and Disability Consultant, Dr Jen Remnant, has been commissioned to provide specialist guidance and expert knowledge in support of this process. You can read more about this work and the further work of our accreditation team on page 8. Our policy team are making strides to ensure the skills of our members are reflected in government strategies across the four nations of the United Kingdom this year. For the Northern Ireland Assembly elections in May, we hope that all parties will adopt our four policy ambitions in their manifestos, so that the need for improved investment and access to counselling and psychotherapy will be fully recognised. We would also like to see the Scottish Government commit to ensuring counselling is included in its new expansion of mental health support through GP settings. You can read more about this important work on page 9. Finally, I’m thrilled for two of our members, who have been awarded royal honours. It’s really wonderful to see recognition of our members at such a prestigious level and my heartfelt congratulations go out to Edith Fleck and Pete Barty on their achievements.

Hadyn Williams BACP CEO

Nicola Roberts

Craig David

Celebrities join NHS mental health campaign Girls Aloud star Nicola Roberts and award-winning singer-songwriter Laura Mvula spoke about the impact of therapy on their lives as they helped launch a new NHS mental health campaign. They were joined by other performers, Craig David, Max George and Ella Henderson, in a video reciting lyrics to The Beatles’ classic song ‘Help!’, as part of a campaign encouraging people struggling with their mental health to access talking therapies. Laura said of her personal experience of therapy: ‘It did so much for

my emotional wellbeing just to know that someone was truly caring for me on a regular basis. It helped me see that things are temporary and, however bad and permanent your situation feels, reaching out and sharing with someone you can trust is so important. It’s OK to ask for help – everybody needs it.’ Nicola added: ‘It’s about saying this is what is happening to me, it’s not my fault, but my happiness matters and I’m going to put my hand up and say I need some help. I wouldn’t be where I am now without therapy.’

Matt Smith-Lilley, our Policy and Engagement Lead (Mental Health), welcomed the campaign but called for government action to help meet the demand for services. He says: ‘The Government needs to invest more in counselling and psychotherapy and recognise the vast, largely untapped potential of the existing counselling and psychotherapy workforce. We’ll continue to campaign on behalf of our members and the public for more investment in therapy, for more choice and for greater access.’

NICE guidelines update We’ve submitted our response to the consultation on the National Institute for Health and Care Excellence (NICE) draft guideline for treatment of adults with depression. We’ve welcomed the improved focus on client choice and the recommendation that all psychological therapies should be considered as firstline treatments for depression. But we’ve raised serious concerns about how the guideline was put together and how relevant research was not considered. We’re also unhappy with how treatment options are ranked, the inconsistent use of the word ‘counselling’, and that longerterm psychological therapies are not recognised in the guideline. Our Head of

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

Laura Mvula

MARCH 2022

Research, Dr Clare Symons, says, ‘This has been an incredibly important consultation to respond to because recommendations in the guideline have a direct impact on the treatments offered for depression and whether counselling and psychotherapy are made available. While we welcome an increased focus on choice, a long-standing ask by BACP, we remain concerned that failings in the development of the guideline have downplayed and downgraded the existing evidence of the positive impact of counselling and psychotherapy on people’s lives. Thank you to all our members and academic researchers who contributed to our consultation response.’ The updated NICE guideline is to be published in May.

News, 1

mInutes with… Sabine Maltby

Sabine Maltby BACP Course and Service Accreditation Officer

to leave and live my own, independent life.

Describe your role at BACP:

I am one of three Course and Service Accreditation officers within the Professional Standards department. I am the first point of contact for anybody wishing to apply for course accreditation and look after 95 accredited courses, co-ordinating their annual renewal process and dealing with queries. I also work closely with the accreditation assessors to co-ordinate their work allocation. What’s the best thing about working at BACP? It is coming up to

12 years now that I have been working at BACP and I think the fact that I have stayed for so long shows what a great place to work it is! The best thing is definitely the people and how passionate everyone is about their job. What gets you up in the morning?

I am very much an early bird and I love the peace and quiet first thing. I certainly appreciate it now that my children have grown up and fled the nest! A big coffee and half an hour in bed with my book before getting up is sacred, plus running four times a week. What advice would you give to your younger self? Stay

financially independent. I felt trapped in an unhappy marriage for quite a few years before I had the courage and the means

Best advice you’ve been given?

This hasn’t been given to me personally, but it is one of my favourite Oscar Wilde quotes: ‘Be yourself, everyone else is already taken.’ What was the last book you read?

I have just started The Century Trilogy by Ken Follett, recommended by both my brothers. The first one in the series is called Fall of Giants and is set in World War I. What’s your go-to karaoke song?

I really can’t sing and don’t do karaoke for that reason, but if I did, it would have to be ‘There is a Light that Never Goes Out’ by The Smiths. Your proudest achievement? My boys, Tommy and Henry (23 and 20), and the fact that they have turned out to be such nice young men – even if I do say so myself! On a sporting level, I completed a half Ironman in 6.5 hours (a long time ago now).

What would you like to achieve over the next year?

I am hoping to run the Yorkshire Three Peaks in October – it’s my dream to move to Yorkshire in the future.

PROFESSIONAL CONDUCT

Huge congratulations go to two of our members who received recognition in the Queen’s Birthday Honours and New Year’s Honours list. Edith Fleck (top) has been appointed MBE in recognition of her services to the community in Northern Ireland. Edith runs Serenity Counselling in Lisburn, which was named Counselling Service of the Year in the Prestige Awards, and hopes her award will help to raise the profile of counselling. Meanwhile, Pete Barty (above) received the British Empire Medal in September 2021 for his services to charity and the local community. Pete’s recognition comes after he raised more than £25,000 for Macmillan Cancer Support and Harbour Cancer Support since being diagnosed with cancer in 2009. If you were named in the New Year’s Honours, or you know of a member who was, please let us know at media@bacp.co.uk

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

THERAPY TODAY

Honours for BACP members

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

MARCH 2022

91BAPMAR22103.pgs 09.02.2022 17:00

VERSION REPRO OP SUBS

Members in the media Friendship, body image, perfectionism and underthinking are just some of the subjects our members have been talking about to the media.

ART PRODUCTION CLIENT

BACP Vice President Julia Samuel spoke to The Sunday Times for a feature on increasing awareness and take-up of counselling and psychotherapy in the UK. • Arabella Russell was featured in The Sunday Telegraph in an article exploring how partners look after each other when they’re ill. Nicola Vanlint shared advice with Yahoo! News on how to fix a drifted friendship or let one go. Metro spoke to Lina Mookerjee about how friendships have changed during lockdown. Lina also talked to the Press Association (PA) about the impact of lockdowns on older people’s mental health and how to support them, for an article that was syndicated in regional newspapers. Ruth Micallef • talked to Stylist magazine about body image, perfectionism and making peace with your body. She was also interviewed for a separate article exploring emotional eating and how it affects your nutritional and mental health. Stylist also spoke to Nia Charpentier for an article looking at underthinkers and the reasons for underthinking, and to Vasia Toxavidi for a feature on why people share their secrets and private thoughts online. Sharing crying selfies online and on social media was the focus of a HuffPost article that featured comments from Natasha Page. HuffPost also spoke to Stefan Walters • for a feature on finding the right partner, while Philip Karahassan discussed the end of a romantic relationship and how to deal with it in an article syndicated by the PA. The PA also shared expert comment from Philip and • Indira Chima about why almost two in five people are planning to quit their job this year. Lara Waycot spoke to Refinery 29 for a feature on why people felt emotionally detached from 2021. Lara also contributed to an article offering advice to people anxious about returning to ‘normal life’ post COVID, which was syndicated by the PA. Andrew Harvey was interviewed on BBC Radio Nottingham about New Year’s resolutions. Time Out London shared tips from Louise Tyler on how to feel good on so-called ‘Blue Monday’.

Accreditation accessibility As part of the Equality, Diversity and Inclusion (EDI) work being undertaken at BACP, a specialist consultant has been commissioned who has knowledge and experience of providing specialist guidance, support and reasonable adjustments to improve accessibility for people who are neurodivergent, or have learning differences or disabilities. Dr Jen Remnant is currently working on ways to make the accreditation process more accessible to all, and will produce a report with recommendations for us to take forward. These recommendations will help to inform best practice and identify any additional actions that BACP could take to increase accessibility to accreditation that haven’t yet been identified. The accreditation team are also preparing to launch a new individual accreditation online form. The form is being created to help improve the experience of applying for accreditation and will help address your feedback to make the application process more straightforward. In January we also held focus groups with staff and students to review our course accreditation criteria. The project aims to embed awareness and understanding of EDI into courses from the point of recruitment through to student experience, the competence of trainers and the students’ competence to work with diverse client groups. Another project starting this year includes a review of the accredited service criteria to ensure services are addressing accessibility issues for marginalised client groups, developing an inclusive and diverse workforce and supporting the development of their practitioners so they are equipped to work with diverse communities. Along with this we’ve appointed some new accreditation assessors to assist in processing the many applications we receive, and we hope this will see a reduction in accreditation waiting times.

Free CPD for members Are you making full use of our Good Practice in Action (GPiA) resources? These are designed to support members in meeting their commitments under the Ethical Framework. All GPiA resources are based on current research and evidence and cover a variety of topics. They’re regularly reviewed by member-led focus groups and experts in the field to ensure they’re up to date and relevant for practitioners working today. They are included in your membership fee, and reviewing a GPiA counts as CPD, so if you haven’t made use of one recently, take a look at what is available at www.bacp.co.uk/gpia

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

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

News, 2

News round-up

Working for you

● We’ve been collaborating with the Royal Agricultural Benevolent Institution (RABI) to help launch a new counselling service for farm workers and their families. The service will provide much-needed counselling support to rural communities. Suzy Deeley, RABI’s Head of Partnerships, said the new service will complement existing schemes: ‘All of the counsellors providing support have been selected for a combination of their clinical expertise and their background, engagement or interest in farming and rural communities. It’s vital they have an understanding of the complex challenges farming people face. Ongoing counsellor training will ensure farming people are properly supported when they face issues impacting the sector.’ Kris Ambler, our Workforce Lead, says, ‘We’re pleased to be able to support RABI in addressing the mental health challenges experienced by our vital, but often overlooked, rural workforce. Collaborative work of this kind demonstrates our commitment to social value and helps our members access new, paid employment

opportunities.’ For more information, email kris.ambler@bacp.co.uk ● We’ve been working with the Northern Ireland Counselling Forum (NICF) on a manifesto for May’s Northern Ireland Assembly elections, calling on all the parties to adopt four policy ambitions – to secure the £1.2 billion shortfall in the Mental Health Strategy’s Funding Plan; to use the counselling and psychotherapy workforce in Northern Ireland; to commit to long-term funding of the Healthy Happy Minds therapeutic and counselling service, and to ensure consistent access to quality and culturally sensitive services at a community level throughout Northern Ireland. Steve Mulligan, our Four Nations Lead, says, ‘We’ll be reaching out to BACP and NICF members in advance of the election to help us raise the profile of counselling and psychotherapy with election candidates.’ ● We’re calling on the Scottish Government to ensure counselling is part of new mental health support being made available through GP surgeries. The Scottish

THERAPY TODAY

Government announced significant new investment in GP mental health services during a debate in the Scottish Parliament. Under the new system, support from a range of professionals will be available through GP surgeries, such as mental health nurses, psychologists, peer support workers, occupational therapists and link workers, and we want to ensure counselling and psychotherapy are part of the provision. Services will also connect to community support, such as addiction services, food banks and benefit support, through a link worker dedicated to each GP practice. Funding is expected to amount to more than £100 million by the end of this Parliament, substantially increasing the mental health workforce and transforming how support is delivered. Steve Mulligan, our Four Nations Lead, says: ‘We welcome this announcement, which reflects a call we made in our 2021 Scottish Manifesto for investment in primary care to improve access to counselling across Scotland’s communities. While we note the official statement listed a small number of professions who could form part of these new multidisciplinary teams, we’re urgently seeking assurance from Scottish Government that counsellors and psychotherapists are part of the offer.’

Championing professional standards As part of our ongoing strategy to raise awareness of the training and skills of registered therapists, our Deputy Chief Executive and Chief Professional Standards Officer Fiona Ballantine Dykes contributed to a BBC Radio 4 programme that focused on how to find a registered, qualified therapist. Fiona was interviewed for a feature on BBC Radio 4’s flagship consumer programme, You and Yours. The piece on therapy in the programme was prompted by us raising concerns in a recent BBC documentary about how vulnerable people are being exploited by unqualified therapists. ‘It’s deeply disturbing because of the vulnerability of people seeking help,’ Fiona said. She spoke about how she found unqualified people offering a range of mental health ‘miracle cures’ when she’d searched online: ‘We’d like to help people navigate that by being clear about where they can find people who are qualified.’ She highlighted the need for people to look for a therapist who is on a Professional Standards Authority (PSA) accredited register, such as ours. We will continue to campaign and work on this throughout the year.

MARCH 2022

91BAPMAR22104.pgs 03.02.2022 12:29

REPRO OP SUBS

Exploring suicidal risks with clients

ART PRODUCTION CLIENT

Clients will often first make reference to suicide through metaphor, or allude to it. They may use phrases such as ‘I want to get out of people’s way’, or ‘It would be better if I wasn’t around anymore’. In context, such phrases often mean suicidal thinking, but this may not be immediately clear. The task for the therapist is to check in with the client to understand what they mean. For many, a typical fear is that, by asking about suicide, it might put the thought into the client’s mind, where it didn’t exist before. However, there is no researched evidence to support this fear. Rather, it provides the client with an opportunity to talk about suicide and for the therapist to explore, in more detail, the level of risk. A new resource explores the importance of asking clients explicitly about suicide, and what might happen in the therapeutic process if suicide is

Join our Research Conference

not asked about. The resource features Dr Andrew Reeves working with a client who presents with suicidal ideation part way through their latest session. You’ll watch two examples demonstrating the different approaches Andrew takes to pick up on the client’s reference to suicidal thoughts. The aim is to help you to build confidence and capacity to engage more actively with suicide potential and to move beyond a ‘risk factor’ approach when working with clients. This resource, which is underpinned by the Good Practice in Action resource Working with suicidal clients in the counselling professions (GPiA 042), is free for all members. See www.bacp.co.uk/cpd/ exploring-suicidal-risk-with-clients

Staying Connected in Scotland Don’t miss our next Staying Connected event, which takes place online on Monday 14 March and focuses on issues important to our members living in Scotland. Two presentations will focus on these issues and a further presentation will be delivered on a general CPD theme. There’s also the opportunity for you to watch dedicated two-minute platforms from our staff and divisional volunteers and join various

breakout sessions on different themes to network with peers. This event is free for all our members to attend and includes access to a live chatroom and the option to submit questions to presenters during live Q&As. If you’ve missed the event, you can catch up with the on-demand service. For more information and to book, see www.bacp.co.uk/events/osc1403 -bacp-staying-connected-scotland

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

SHUTTERSTOCK

This year’s Research Conference, ‘Striving for equality, diversity and inclusion in research, practice and policy’, is co-partnered with Abertay University. The conference is returning as a hybrid event on Thursday 19 and Friday 20 May 2022, with the opportunity to attend in person at the venue in Dundee or online via two dedicated live streams. There will be three keynote presentations, along with research papers, lightning talks, poster presentations and symposia. In-person delegates will also have the opportunity to join a networking dinner on the evening of Thursday 19 May, and attend discussions and methods workshops. Online delegates can network virtually with peers, send questions to presenters and listen to dedicated interviews between presenters and the studio hosts facilitating the day. Both in-person and online delegates will be able to catch up on any content they miss on the day by viewing the on-demand service, until August 2022. For more information and to book, see www.bacp.co.uk/events

MARCH 2022

91BAPMAR22105.pgs 09.02.2022 15:09

BACP Events/CPD, 1

VERSION

BACP events and CPD

From the Board, 1

VERSION

From the Board

REPRO OP

‘We must establish in clean, concise terms what we do and how we do it’

SUBS ART PRODUCTION CLIENT

As with anyone joining a board of trustees, my hope in 2020 was to find a way to support BACP in any way that I could, and over the past year I have been lucky enough to be able to draw on my experiences of working with the NHS and in therapist education. I settled on a career in academia in my early 40s, and currently head a department of health sciences in a modern university. This role brings with it an understanding of how healthcare works in the UK, and in tandem, brings the cultural differences between physical and mental healthcare into sharp relief. Knowing the strengths and shortcomings of an institution of which I am exceptionally fond has aided my role on the BACP Board. I am someone who hopes to ensure we are a nation where ‘there is no health without mental health’. I have been involved both in the development of an evidence base for the effectiveness of counselling and in our conversations with the health service in England and Scotland (my professional stomping ground) around how to resolve the ongoing mental health crisis. What is most significant to me is that the counselling and psychotherapy professions are on the cusp. For most people, therapy would be the first choice of intervention for mental health support, but in our health service, it is only one of a range of interventions offered. Recent changes to the NICE guidelines in England have moved in our favour, suggesting that talking therapies should be considered before medication for depression. For the therapist community (many of whom have worked with or for the NHS) this is an optimistic sign that has been a long time coming, BACP has responded to the news by recognising the progress made, but also highlighting the need to listen to what people are saying, to examine what is making a difference in practice, and to allow professionals with the capacity and competence to help to make the difference in our society.

To most therapists, the question of competence is a familiar one. Few practitioners require such a level of self-awareness and self-scrutiny as is seen in our profession. To undertake our roles, we constantly ask ourselves ‘Are we good enough?’ and ‘Are we doing enough for our clients?’, and usually we can respond with clarity and purpose. As a profession, we are being asked similar questions. When we fight to ensure our members are paid appropriately for their work and to have their expertise recognised, we are asked what can therapists do, and to what extent can they make a difference. If we are not careful, our response can revert to the language of medically significant outcomes: a significant drop on the depression inventory over a fixed time, perhaps, or an alleviation in waiting times for more ‘serious’ mental health problems. The frustration for me is that these conversations do little to illustrate what counsellors and psychotherapists actually do every day. In practice, our work is complex and unique. We enhance our knowledge by incorporating all available information,

Kate Smith

Trustee, BACP Board of Governors

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

remaining open to ways of knowing – whether that’s the lived experience of clients or theoretical understandings about human nature – and we do this in the face of the limited scope and the tacit understandings infused within healthcare around what helps and how to judge quality and effectiveness. What we are in need of is a way of translating what we do in a way that is understandable but not diminishing, and I believe that our current development of the Scope of Practice and Education (SCoPEd) framework has the potential to do this. What started as a way of ensuring standardisation across training and practice has evolved into a tool that will hopefully allow us to remove the vagaries of understanding in terms of what therapists can do, and show how we make a difference each and every day. I am aware that SCoPEd is like no other topic when it comes to eliciting wide-ranging perspectives, and this tells me something important about how we value what we do and what we want for society and for ourselves. As someone who espouses pluralism from a philosophical stance and as a practitioner, I know that lack of consensus is a natural state, and I welcome these voices. I am proud, too, to belong to a profession where the purpose, application and effect of what we do is hotly debated in research and discussion, and believe this in itself has helped hone and direct the progress of the work. It is, however, a balance, and we also need to ensure we progress beyond a debate that may never be resolved. We must at some point establish in clean, concise terms what we do and how we do it, not simply for our own sake but to enable us to converse with those who tend to misunderstand or undervalue what therapists do. It’s my belief that this is a crucial step towards achieving parity of esteem for mental health with physical health and promoting talking therapy in all its various forms as a first choice of treatment in the NHS. ■

MARCH 2022

91BAPMAR22106.pgs 03.02.2022 12:32

VERSION REPRO OP

Reactions

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

Your feedback on Therapy Today articles

necessarily those of BACP or Therapy Today’s editorial team

SUBS ART PRODUCTION CLIENT

When stepped is not best

Working behind bars

Three years ago, I was employed as a high intensity therapist (HIT) in a male prison local to me. Along with two counsellor colleagues I helped set up an IAPT service, using our counselling skills, aligned with the Ethical LETTER Framework. The prison offers a unique setting OF THE MONTH where people live in a constant state of struggle for survival, where any form of vulnerability will be seen as weakness. Therefore, creating a space where these men could let themselves be vulnerable could appear impossible. However, within six months, our team were across the prison, offering one-to-one counselling and CBT-focused groups. When I first walked the wings, the men were mistrusting, but in response I offered consistency, unconditional positive regard, genuineness and authenticity. Most of us have experienced these core conditions at some stage of our lives, yet these men have not. Schools, police, social services, parents, partners, the prison system – most social structures have never offered safety to these men. Thus, one can imagine the powerful effect counsellors’ core conditions can have with prisoners. From my experience, these men are by far one of the most psychologically minded demographics I have ever worked with. After a year and a half of some of the most profound counselling sessions of my career, politics changed our beloved counselling service. The ‘stepped’ model was brought in, and I was no longer deemed qualified to be a HIT and was dropped to the level of psychological wellbeing practitioner (PWP), offering CBT-based interventions. All the prisoners wanted was to share their trauma with someone, and attempt a journey of trust and opening up, and I was being pressured to respond with ‘thought challenging’ or to talk about ‘worry time’. After reading ‘Working behind bars’ (Therapy Today, December 2021/January 2022), I was optimistic for the counselling and psychotherapy professions to take notice of the prisoners behind the brick walls. Reading it, I felt a sense of change and recognition – however, I know very well that, when I enter the prison on Monday, it will be a very different story. Unfortunately, counselling is reducing rapidly in prisons, with many counselling contracts being outbid by big organisations bringing in IAPT services. These men are almost programmed to believe that help will not turn up, or that they are a lost cause. Counselling is the only boundaried discipline where that damaging belief can be challenged with weekly sessions. In addition, counsellors are trained and experienced in delivering a healthy therapeutic relationship, where they are able to contain their client’s traumatic narrative, which is often the first healthy relationship prisoners have experienced. This is the ethos of a counsellor, not a ‘HIT’ or ‘PWP’. Spending the majority of my working days on the wings, it is clear to me and other professionals in the prison that prisoners are crying out for counselling. Prisoners want counselling, prison staff want the prisoners to be counselled and the counsellors want to counsel prisoners. Yet counselling is being pulled away from a setting where it is needed the most. Name and email address supplied

Having read ‘Working behind bars’, it seems that nothing has changed since my article, ‘Inside story: working in a women’s prison’, was published in Therapy Today in April 2014, except the involvement of IAPT. I chose to work in a prison because I wanted to find out how person-centred therapy could be relevant and effective in a prison setting where structured/manualised approaches were the norm. My experience was that it emphatically is both relevant and effective. Managed and stepped approaches are vulnerable to being experienced by prisoners as being out of the same drawer as the prison system, where you get regulated and controlled to within an inch of your life. I worked for a small charity based in the prison alongside but not part of the system. The empathic, respectful, clientdirected approach that we offered – despite the tension with the prison protocols that we were often faced with – was a powerful experience for many prisoners, and it was possible to build deeply empathic therapeutic relationships in such an extremely non-facilitative environment. It’s emotionally demanding and it’s not for everyone – the suffering in prisons is hard to bear. One counsellor left because they could not cope with the number of times a day that you lock and unlock gates and doors. When I worked there, I was having about eight hours’ supervision a month in different settings. The TV drama Time understated the horror of prison. A close friend who was recently released after three years described worse. Our prison system should be a source of national shame. Acute levels of psychological distress are pervasive and inadequately attended to. Prisoners deserve and need greater choice than psychologybased manualised, stepped care. John Fletcher MBACP (Accred)

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

I am the team lead for a counselling service, Choice 4 Change (C4C), originally set up in HMP Holloway to work with women

facing issues of child separation and child/ pregnancy loss, which is an abiding theme in prison. When HMP Holloway closed in 2015, the service was moved to HMP Downview and HMP Bronzefield in Surrey. We are a small staff team of three BACP registered counsellors and we also offer placements to trainee counsellors or qualified counsellors who wish to gain further experience. Currently we have seven volunteer counsellors. We are privileged to be able to offer clients a counselling contract of up to 26 weeks of therapy, which allows time to build up a strong working relationship and to work safely with issues of trauma related to the loss of their children and beyond. What is evident from the work that we offer is the huge need for counselling services at the prisons. For the women we reach, the loss of their children and how this is impacted by their own experience of childhood attachments and trauma is a significant part of the work we do with them. Working in a person-centred and psychodynamic way allows clients to grieve their losses and find a greater understanding of themselves, increasing their self-awareness and self-acceptance and building self-esteem and self-belief. These are significant building blocks in facilitating their ability to change. Many of these women who contact us have had their children taken into care, and many of their children have been subsequently adopted. As you can imagine, this is an area of enormous pain and distress for both the mother and her children. This is where we are facing a challenge in being able to offer the help that is required. The law in England states that, for a counsellor to work with issues of adoption, including the birth parents, they need to be trained and registered with Ofsted as an Adoption Support Agency (ASA). We have been unable to access training up to now, due to a huge gap in appropriate training and an oversubscription with the very few training providers. As the law currently

One of the biggest challenges as a person-centred therapist has been the issue of power. The power imbalance is inescapable, and I continue to work to understand what it means to offer brief person-centred counselling in this environment

stands, our hands are tied, as without the training and registration we are unable to offer the necessary support to the women. Often they have turned to drugs and crime as a dysfunctional way of dealing with the unprocessed and unresolved pain from their past. An inability to access any support at this point only serves to reinforce their destructive behaviour cycle. I am in the process of writing to Ofsted and my local MP, but I wonder what else is being done to address the red tape and wider considerations around this particular law. I am not politically minded but I am therapeutically minded, and I am lobbying from this perspective. If Therapy Today readers have any experience or insight into addressing this issue, I would be very interested in hearing from them. Dee Thornton, Team Lead, Choice for Change (C4C) Editor’s note: We will be covering the issue of adoption and Ofsted regulation in the April Therapy Today ‘Dilemmas’ section. I have been on a placement in a men’s prison for 10 months now. My experience so far has been very positive – it is a very challenging environment, but it is also incredibly rewarding work. Working in a team and with support from a very experienced supervisor has been critical – I have been very careful in considering my competence to work with clients, depending on the complexity of their needs. The possibility of transfer of prisoners is ever present; I have found Barrie Hopwood’s

THERAPY TODAY

advice to treat every session as if it is your last particularly helpful in thinking about how to manage this uncertainty.1 One of the biggest challenges as a person-centred therapist has been the issue of power. The power imbalance is inescapable, and I continue to work to understand what it means to offer brief person-centred counselling in this environment. I have to manage my own feelings of powerlessness in the prison environment and work with each client to develop an empathic relationship. Without exception, the clients I have worked with to date have experienced significant childhood trauma, underlining, I feel, the importance of counselling services in prisons working as part of the wider mental health service. Lesley Harding, trainee psychotherapist REFERENCE

1. Hopwood B. Treat every session as if it’s your last one – person-centred counselling with young people in a young offenders’ institution. In Tudor K (ed). Brief person-centred therapies. London: Sage; 2008.

I previously worked in a prison, recruited as a counsellor into an embedded NHS service provided by counsellors. When I started, the service offered exactly what the residents needed – a safe, confidential space to explore their trauma, complex PTSD, childhood abuse, emotions and the life they had led. I felt and still feel humble that all those that I counselled felt they were able to do this. The years spent counselling in that prison will remain with me forever. However, as the service grew and expanded across other establishments, the flexibility, needs of the residents and what actually worked dwindled. Instead, psycho-education sessions were pushed, along with the stepped approach, meaning the residents had to fit into the IAPT model rather than get what they needed, going against what I, as a counsellor, was trained to do. The agenda became a tickbox one, focused on collecting the statistics needed to keep the contract.

MARCH 2022

91BAPMAR22107.pgs 03.02.2022 12:34

Reactions, 1

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

VERSION REPRO OP

Reactions

Email your views on Therapy Today articles (500 words max) to therapytoday@ thinkpublishing.co.uk

Your feedback on Therapy Today articles

SUBS ART PRODUCTION

I was then told that, although I was a qualified counsellor, I would need to attend an IAPT psychological wellbeing practitioner (PWP) course to continue within the service as a practitioner. I knew the IAPT path was not for me, so I left with a heavy heart and the gutwrenching feeling that I had left the prisoners with a service that no longer met their needs. I was excited to read ‘Working behind bars’ (Therapy Today, December 2021/January 2022), to see how counselling could be offered to those whose lives are filled with so much trauma, pain, sadness and despair. Reading it, however, just confirmed how far we have to go. Unless counselling services are offered funding and more resources to provide services in prisons, big organisations with structured models will win. Name and email address supplied

CLIENT

I was very interested in your article ‘Working behind bars’ (Therapy Today, December 2021/ January 2022). A former probation officer, I now teach on the Professional Qualification in Probation (PQiP) at Sheffield Hallam University and am also a trainee counsellor. I am pleased to see the attention paid to counselling in prison work. Counsellors in prisons are much needed; the role also needs to be paid and valued. However, I would go further than this – I would like to see the involvement of counsellors throughout the penal system. Often the probation service is not talked about as a site for counselling. I am pleased to say that trauma-informed approaches are being embraced in probation practice. There is a strong tradition, culture and value attached to rehabilitative work in probation. Further to this, it is a core aim of the Probation Service and statutory obligation of sentencing. There are approximately 82,000 people in prison and 260,000 people on probation in the UK. I am reminded of the Alinsky parable, and maybe focusing our attention only on counselling in prison fails to see what is happening further upriver before custodial sentences are imposed. Andrew Fowler MBACP, trainee counsellor

Having read ‘Working behind bars’, we absolutely know that therapy does have a place, and a very important place, in addressing the mental health crisis in our prisons. At Clear Counselling Ltd, our team of 20 counsellors has been working within the Warwickshire and West Mercia probation offices and justice centres for the past eight years. We cover every scenario and work with dual and multiple diagnoses. When inspected by HMIP, Clear Counselling was described as ‘exceptional’. We have spoken at length with prisons such as HMP Hewell, HMP Onley and HMP Swinfen Hall, and have delivered talks to Hereford magistrates about the issues of revolving-door clients and ‘what to do with them’; as your article states, there are a lot of unmet needs. When working with clients on probation, a common theme of comment was, ‘I wish we could have had this in prison.’ Despite the Government saying there would be more money available for mental health services, our experience is that this is not the case. With the unification of probation this year, our contract for providing counselling to offenders was significantly reduced. In our experience, the biggest barriers to continuing this work in custody or the community is budget, general red tape and, most recently, COVID restrictions. Michelle Mikulsky MBACP and Mary Hutchings MBACP, Clear Counselling Ltd I was interested to read your article about counselling in prisons. One aspect of the work that is hardly ever addressed is erotic transference. If the prisoners are male and heterosexual and the practitioners are female, it’s worth remembering that these men may not have been in the presence of a woman for a long time, let alone in a one-to-one situation. Erotic transference may be conscious or unconscious. The practitioner could also be the object of sexual fantasies, both in and out of the session. Even if it is not acknowledged,

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

she needs to be aware of the possibility of erotic transference and work with it. The other possible transference is that of the mother. The real mother may have been loving and generous or withholding and punishing (Melanie Klein’s good breast/bad breast). There is ample space in the work for fantasies and projections, both positive and negative. In the countertransference, the practitioner just needs to be a good-enough mother who can manage the client’s feelings of hate, rage, despair, loss, longing and unrealistic expectations. By being a stable, reliable, calm mother figure who tolerates and survives attacks or expressions of great need, she will build trust and the client can find healing. I believe these transferential issues can occur not just in the long term but in just one session. I also feel that, in an ideal world, this kind of work should be undertaken by experienced practitioners, as opposed to trainees, however good their supervision. Carol Martin-Sperry Fellow BACP

Autism diagnosis I was interested to read the responses to the dilemma about whether it is appropriate for a therapist to suggest a client gets assessed for autism (‘Dilemmas’, Therapy Today, February 2022). As a counsellor in private practice and for an IAPT service, in recent years, I have become much more aware of the incidence of adult clients who do appear to

An effective therapist needs to be congruent, so ignoring their nagging thoughts is not a good idea – it’s definitely something to take to supervision. But equally, coming straight out with unpacked ideas is not a good idea

have autistic spectrum traits but, because they are generally ‘able’, have not been diagnosed, and yet have, of course, struggled in many areas of their lives. This has largely been males but is increasingly females too. The dilemma is if and how to share my thoughts around this. I generally wait for some sort of opening, such as the client mentioning a relative who has a diagnosis or very obvious traits, or I might say something like, ‘It occurs to me that some of the ways you seem to think and act are similar to autistic spectrum traits. Has that possibility ever occurred to you?’ Sometimes I am met with bemusement or blankness, in which case I simply say, ‘Don’t worry about it, I could be wrong and it’s not a big deal either way.’ But most often, they tell me that they have suspected it, or that a family member has suggested it about them. Sadly, a significant number have mentioned it to a GP who has dismissed them, saying they are too ‘high functioning’ for that, that a diagnosis is a waste of time because there is no ‘cure’ for autism, or even accusing them of ‘wanting a label’. The sense of understanding that diagnosis can bring, both for the individual and often for their partners or family members, is easily overlooked. Amber Middlemiss MBACP (Accred) The therapist featured in February’s ‘Dilemma’ (‘Should we tell a client if we suspect they may be autistic?’ Therapy Today, February 2022) is making gross assumptions about their client. Their client has not disclosed beliefs about the possibility of being autistic, only that they feel their brain works differently to others. This could mean a million things and, as the client has brought this into the therapy room, I would be inclined to explore it with them. How do they feel their brain works differently? What does this mean to them? A feeling that my brain works differently to me might mean something very different to someone else. It sounds like the therapist has jumped to a conclusion about their client, and has jumped further to find a practical solution. This comes across as the therapist wanting to rescue their client and might be coming from a state of

wanting to find a quick solution, to feel good about themselves. An effective therapist needs to be congruent, so ignoring their nagging thoughts is not a good idea – it’s definitely something to take to supervision. But equally, coming straight out with unpacked ideas is not a good idea. As counsellors we need to explore our thoughts and find out where they originate from and how any information we share with a client can benefit them. Jude Hutchinson, trainee counsellor

Learning from Narcissus Duncan Barford’s article, ‘Narcissism – the therapist’s friend?’ (Therapy Today December 2021/January 2022), was a good read for me, as I have an interest in Greek mythology and its connection to modern-day psychotherapy. The idea that narcissism, or love of the ‘self ’, is a good thing in therapy (as part of the healing process) is laudable, but somehow misses some of the crucial narrative for me. Freud used the story to explain his own theories about how the mind operates, but the subtle meaning behind the story is easily missed. Greek myths were not only communicated to help us consider what it is to be human, but also to give moral and ethical guidance to our lives through the use of symbolism. In the original story, Narcissus grows into a handsome young man and, at some point, Echo (a mountain nymph) falls in love with him, but Narcissus rejects her advances and so Echo takes her own life. When Nemesis (an aspect of Aphrodite and therefore an aspect of love) hears of this, she seeks revenge and tricks Narcissus into falling in love with his reflection when he drinks from a pool of water. But, crucially, he doesn’t know it’s his own reflection, just the face of a beautiful person. Narcissus falls in love with an image of beauty, not really himself. Narcissus eventually realises his love will never be reciprocated and also takes his own life, thus the moral of the story is not only a

THERAPY TODAY

cautionary tale about being overly selfinterested, but more about teaching us to have empathy for others and be able to imagine what it’s like to have our love rejected. Narcissus was not prideful or arrogant, just a good-looking young man hunting in the woods of ancient Greece. But his story was used to demonstrate how a lack of self-awareness is less than desirable in life. It could also be interpreted as an analogy of coming face to face with our ‘self ’, or seeing the reflection of what we portray to the world. In time, the allegorical meaning is overlooked and we end up with a Freudian ‘narcissist’, but the original story of Narcissus is not the definition of a character. Such ethical dilemmas are still relevant – the right to autonomy and the right to say no in a relationship. However, the myth of Narcissus teaches us there are always consequences to our actions, and that desire comes quickly but love isn’t easy to hold on to. The use of allegory as a form of teaching can help us see through the eyes of Echo and gain an empathic understanding of how much it hurts to have our love rejected – the crushing futility of giving our love to someone, never to be returned. The myth helps us feel the vengeance, sadness, sorrow and loss of the characters and facilitates empathic understanding, rather than providing a label to pin onto someone. Nick Beesley MBACP (Accred)

MARCH 2022

91BAPMAR22108.pgs 03.02.2022 12:34

Reactions, 2

To the Editor

VERSION REPRO OP

Obituaries, 1

Obituaries Lesley Gray

SUBS ART PRODUCTION CLIENT

Lesley Gray, a proud member of BACP, died aged 65 on 15 October 2021. After a career in banking Lesley began her training in 1997, gaining her master’s degree in counselling from Durham University in 2004. She had found her calling in every sense of the word. Following placements in both primary care and occupational health, she was an ideal candidate to apply for the role of Staff Counsellor at County Durham and Darlington Foundation Trust. Appointing Lesley was the easiest and best decision I ever made, and in 2003 she made the move to Darlington Memorial Hospital, where she built an excellent reputation with clients and colleagues alike. One of my best memories of Lesley was the day I witnessed her bouncing round the office, having just been awarded her BACP accreditation. She later went on to qualify in individual and group supervision. In 2010 Lesley began training as an IAPT high-intensity therapist. This meant more night-time studying at the dining room table, but as ever, Lesley gave it her all and qualified two years later. She worked in IAPT for eight years and, while there, was first diagnosed with cancer. It is a measure of her value to the service that they supported her through her treatment and, in return, she went back to work and threw herself into her job, covering the west of Northumberland. Lesley’s husband, Robert, and family were her life, as was her faith. As a Christian, Lesley had spent a life caring for others long before she began working as a counsellor. In 2018 she retired to spend more time with her ever-growing family of grandchildren and her first great-grandchild, and also to look after her mum, who is in her 90s. The arrival of lockdown was a blow for Lesley – she was a sociable person and had to shield, along with her husband. Cruelly, as life

began to open up in the summer of 2021, she discovered that her cancer had returned and, sadly, she died eight weeks later. Lesley, a much-loved and respected friend and colleague, will be missed by all who knew her. Kath Egdell and Sue Orr, former colleagues and friends

warmth, kindness, compassion, professionalism and sense of humour will be truly missed by all. Paul René, course director, Redlands Counselling and Training, and friend

Stuart Rose

Dr Aaron Beck passed away peacefully aged 100 on 1 November 2021 at his home in Philadelphia. He was a unique human being who spent his life working tirelessly in the service of mental health, creating a global community of therapists that inspired thousands. Yet his career did not take off till his 60s, and when most are thinking of retiring, he worked for 40 more years in a field dedicated to helping others. He continued to work right to the end. Dr Beck founded the non-profit Beck Institute with his daughter, Judith Beck, in 1994. It is from this institute that many projects grew, providing a solid foundation for researchers worldwide to create a scientific awareness and methodology for CBT. It has also been a source of wonderful friendships and professional connections. I never met Dr Beck but attended his memorial online and listened to speakers talk of his humour, humility, kindness, drive and enthusiasm for helping others. Many spoke of his trust in humankind, always looking for perspectives to explain behaviour and thought processes. I am grateful for CBT both personally and professionally. The model developed by Dr Aaron T Beck continues to help me grow, as well as providing me with a wonderful career. Rest in peace. Elaine Davies MBACP (Snr Accred), lecturer at Coventry University and counsellor and supervisor in private practice

Stuart Rose MBACP (Accred) died peacefully in his garden aged 71 on 5 November 2021. I first met Stuart more than 10 years ago. He had been recommended to me by a colleague who knew I was looking for a suitable tutor for a CBT course. I instantly knew Stuart was the right person for the role. He had the professional credentials but, just as importantly, he also had a warmth and friendliness, coupled with a quick wit. Originally trained in the person-centred approach before becoming a CBT therapist and a chartered psychologist, Stuart had accredited member status with both BACP and BABCP. Following that meeting, Stuart went on to design and deliver a Level 5 Diploma in CBT. Stuart was always popular with students, who appreciated his encouragement, support and willingness to pass on his experience. During his time as a tutor Stuart kept up to date with developments in CBT and had a particular interest in mindfulness and compassionfocused therapy, designing and delivering CPD workshops. As well as teaching, Stuart worked in the NHS and ran his own private practice for clients and supervisees, based in West Dorset. He was always modest – as colleagues we would often learn from a student that Stuart had had an article published in a professional journal, rather than from Stuart himself. His

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

Dr Aaron T Beck

MARCH 2022

91BAPMAR22109.pgs 03.02.2022 12:36

REPRO OP

From the Editorial Board, 1

‘Imagine if we didn’t have to do therapy in the way we think we have to’

SUBS ART PRODUCTION CLIENT

Imagine if there was a way in that gave us and our clients a bit more room. In spring 2020 I started to wonder whether a book of conversations with friends and colleagues might inspire, challenge, mirror and support some of the conversations and reflections we have with clients and between peers and supervisors, to enrich our work, whoever we find ourselves working with. As a queer psychotherapist working predominantly with lesbian, gay, bisexual, trans, non-binary, intersex and queeridentified (LGBTIQ+) clients, I couldn’t find many up-to-date reflections in textbooks or papers on some of the dilemmas I face in the therapy room. I have great supervision and peer support, but I craved more breadth and complexity in the literature that helps us to learn and grow. A ‘queer press’ journalist before I trained as a therapist, I wondered if combining these passions might yield something useful for therapists who work with what the culture calls ‘difference’, and even those who don’t. In most institutional therapy trainings, the texts and the framework support the dominant ideologies that assume we are white, heterosexual, middle class, monogamous and cis. So-called difference from these assumed categories is considered as a learning add-on and that we must learn about ‘others’ instead of understanding that we exist in and navigate a multiplicity of cultures from a mixture of these intersectional axes. Further, a lack of awareness about our own positionality can sometimes mean that we trap the client in our own necessarily limited frame of reference. When I approached a publisher with my book proposal, Queering Psychotherapy: non-normative insights for everybody, I explained how the life-shaping conversations we have with queer clients often come from the queer and decolonising philosophies that would underpin it. The conversations would reject the notion of the therapeutic ‘expert’

and the contributors would have a range of professional and lived experiences to offer and share. Their insights would refashion the limitations of how we are taught about each other and those who are often othered. In her chapter, Dr Gail Lewis notes some of the ways that black lesbian poet and author Audre Lorde’s ideas seem to echo the work of white heterosexual male psychoanalyst Wilfred Bion. I re-read Lorde’s essay ‘Poetry is not a luxury’,1 and was struck by the therapeutic message in her description of poetry. Reflecting on the form as a revelatory ‘distillation of experience’ that makes it possible to ‘give name to the nameless so it can be thought’, Lorde’s words sound not dissimilar to what white psychoanalyst Christopher Bollas conceived with his ‘unthought known’ or the exploration of what we unconsciously learn of the object world as infants and how we can harness it in the service of our psyches.

Jane Czyzselska

Therapy Today Editorial Advisory Board Jane Czyzselska is a psychotherapist in private practice. Queering Psychotherapy: non-normative insights for everybody will be published by Karnac Books in October 2022 (pre-order from www.karnacbooks.com).

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

It wasn’t the first time I had felt that Lorde’s words convey something vitally important about how we can examine and regulate our emotions. So, it’s not only poetry that is a vital place for self-reflection and understanding, as I believe therapy can also be, but also intersectional, black lesbian feminist and queer perspectives that can bring richness to our profession; a richness that often goes unacknowledged or is even rejected as ‘too political’, as if the therapy encounter is a politics-free space. In my own personal therapy journey, I have been fortunate to work with therapists whose ability to see and hold me as a queer and gender non-conforming person has been deeply reparative. I don’t often read about my lived experience in therapy literature or feel seen in trainings, unless they’re specifically LGBTIQ+, and in a culture that tends not to acknowledge the various kinds of violence visited on those from marginalised communities, it has felt incredibly meaningful when therapists have acknowledged the harm of homophobic, lesbophobic and transphobic microaggressions. Examples of this include the therapist who generously disclosed her experience of lesbophobia, and in so doing communicated, ‘Yes, this really does happen, I know the pain of this and it’s not OK.’ And the therapist who has accompanied me on my gender journey, from cis to non-binary, learning a new language along the way, open, accepting and non-pathologising. Therapy gold. These kinds of conversations with LGBTIQ+ clients can be world changing. And, despite three decades in queer community, after each of the conversations with my co-contributors I came away with numerous positionalities and orientations from which to work with clients. We can often think we know enough, and that we have the world tied down, but in a changing world, shouldn’t our learning be a constantly moving thing?

1. Lorde A. Poetry is not a luxury. (Essay, first published 1985). In Lorde A. Sister outsider. London: Penguin; 2019.

VERSION

From the Editorial Board

MARCH 2022

91BAPMAR22110.pgs 03.02.2022 12:37

VERSION

The month

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

Photography

PRODUCTION CLIENT

Ingrid Pollard is renowned for using portrait and landscape photography to question our relationship with the natural world and to interrogate social constructs such as Britishness, race, sexuality and identity. This first retrospective of her career to date includes the ‘Pastoral Interlude’ series from 1987 – hand-tinted photographs depicting black people in rural settings such as the Lake District, challenging the stereotype of black people as primarily associated with urban environments. Pollard works across a variety of techniques – photography, printmaking, drawing and installation – and the exhibition includes two new works – a film that meditates on the human body as it moves through space and time, and a triptych of dynamic sculptures. ‘Carbon Slowly Turning’ is at the Milton Keynes Gallery from 12 March until 29 May (www.mkgallery.org).

In Couples Therapy, we see US psychoanalyst Dr Orna Guralnik work with four real-life New York-based couples, interspersed with sessions with her supervisor (or ‘clinical advisor’ as she’s labelled in the programme). It’s so stylishly filmed you could mistake it for a scripted drama, but it’s also realistic – there are no clever resolutions to sessions, and sometimes Guralnik stumbles to articulate what she wants to say. Over the course of the series, we see her gently but persistently dig below the surface to unearth the source of challenging behaviour. We meet a man who thinks his wife should know when he needs a glass of water before he does, and a woman who can’t accept that it’s unreasonable to call her partner at work 20 times a day. If you missed it on BBC2 earlier this year, seasons one and two (eight episodes each) are available to download now on BBC iPlayer.

Back to nature • In her memoir, A Line Above the Sky: on mountains and motherhood, poet Helen Mort explores the thrill of climbing, the climber’s relationship with the natural world, the complex allure of risk and – after she becomes a mother – whether that will, and should, change. (Ebury Press, out 24 March)

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

• Birds and Us explores the relationship between birdlife and humankind over 12 millennia, revealing how birds have captured our imaginations and informed both culture and science. Award-winning writer and ornithologist Tim Birkhead reveals our mutual history with birds. (Viking, out 3 March)

MARCH 2022

• Tending to a garden builds our sense of connectedness, not just to the earth, but to the whole ecosystem, opening our eyes to the matrix between all life, writes horticulturalist Jack Wallington. His guide to building a garden from scratch is also a visual treat. (Laurence King, out 3 March)

BBC

Carbon Slowly Turning

COUPLES THERAPY

Books

ART

SUBS

Catch-up

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

TRUE NORTH/BBC

Film

COLIN THOMAS

Theatre

THE ANIMAL KINGDOM Set in a family therapy room, The Animal Kingdom, scripted by Ruby Thomas, maps the evolving dynamic between four family members and their therapist in an inpatient setting. Award-winning playwright Thomas grew up absorbing the language of therapy through her psychotherapist mother and says, ‘There is something inherently theatrical about therapy, sharing the conflicts of life with someone helping you to pull them apart and understand them.’ Having experienced the power of ‘being listened to without judgment’ in her own therapy and 10 years as a Samaritans volunteer, she says, ‘I ultimately want to leave the audience with hope and faith in the value of openness.’ At London’s Hampstead Theatre until 26 March. www.hampsteadtheatre.com

Gypsy Queen George Ward left his Romani Gypsy community in Darlington after coming out as gay at 18. A former mental health nurse, he went on to create his drag queen alter ego Cherry Valentine, based on ‘Traveller women’s fabulousness’, and became a contestant on RuPaul’s Drag Race UK. In this documentary, he charts his journey to reconnection with his Gypsy roots. As part of the documentary, he meets therapist and BACP member Tyler Hatwell, the founder of Traveller Pride, and has a session with psychosexual therapist Silva Neves. ‘[There’s] a whole new world of people out and proud in the Traveller community,’ says Ward. ‘Why do people pretend it doesn’t exist?’ First shown on BBC3, Gypsy Queen: Cherry Valentine is available now on BBC iPlayer. Podcast picks

Ideas and insights • We have to keep meeting our edge and then softening, to survive when living with uncertainty, says Buddhist teacher Tara Brach in ‘Resilience and Wisdom’, a recent episode of her longrunning podcast of interviews and meditations. www. tarabrach.com/ resilience-wisdomuncertain-world

THERAPY TODAY

• We live in a world where our wants can often be met on demand, but do we pay enough attention to what is driving our desire? asks psychotherapist and writer Philippa Perry in this three-part series of interviews. Consumed by Desire, first broadcast on Radio 4, is now available on BBC Sounds.

• Is our everyday consciousness formed by our daily ingestion of caffeine? This is just one of the intriguing ideas discussed by writers Michael Pollan and Katherine May in episode four of Future of Hope. This new series on Krista Tippett’s ‘On Being’ podcast is focused on remaking our lives post-Covid. www.onbeing.org

MARCH 2022

91BAPMAR22111.pgs 09.02.2022 15:06

VERSION

Catherine Jackson asks why counselling is still largely inaccessible to disabled people

SUBS ART

PRODUCTION CLIENT

n estimated one in five people in the UK are disabled. So, on average, all counsellors and psychotherapists are likely to be contacted by a disabled person seeking therapy at some point in their working lives, all things being equal. Which they are not. As any person with a disabling condition will tell you, the barriers to goods, services, spaces and opportunities that non-disabled people regard as an automatic right are myriad, physical and psychological, and often insurmountable. And counselling and psychotherapy are right up there on the list. A random search of the BACP directory (for counsellors who work with, say, depression) produces 11,000 practitioners; put in a request for those who say they work with ‘disability’ and it drops to 4,000; search for the term ‘disabled access’ and it drops to 1,900. On the Counselling Directory, it’s very similar – within a 20-mile radius of central London, there are 5,000 practitioners who say they work with depression; 2,000 specify disability, and 452 say they can offer wheelchair access (the BACP directory currently doesn’t offer a search filter for this, but BACP is working on it). Outside London (Birmingham, for example), the figures are 454 for depression; 212 for disability and 64 with wheelchair access. This is a very imprecise way of searching for counsellors who offer an accessible service to disabled people, but it is all that is available to the average disabled person who is setting out on what many experience as a gruelling, distressing and sometimes hopeless quest. One such is Ashley Cox. He is 25, blind since birth, and hit national newspaper headlines back in 2019 when he wrote an article describing his struggles to find

a private therapist who would work with him:1 ‘Having no idea where to start, I ventured into an online counselling directory and picked a profile at random. I repeated this process eight times, but each time was rejected. In every case the rejection related to the disability… The reactions varied. Most were courteous enough to state their uncertainty in handling the disability as a reason, yet were unwilling to proceed anyway, despite assurances that we could work together. Some were patronising, downright rude, or suddenly had no space available, while one simply hung up without another word.’ Sadly, when I contacted him recently, matters had not improved. He found a therapist, eventually, back in 2019, but she could only offer seven sessions. They were incredibly helpful, and put him on a sounder footing to manage the psychological issues that had previously led him to the point of considering ending his life, he says. But when he started searching again this year, he met with a similar reaction, only more so. ‘Six months down the line, I wanted more therapy. I tried someone who was recommended but we weren’t a good match. So I went back to the directory. There are 187 therapists listed in my local area and so far I’m 56 in. I keep a spreadsheet to track the responses. None of them so far seem to want me as a client.’ And, he says, 83% have ticked the ‘disability’ box on the list of their areas of specialist practice: ‘To be honest, I’ve noticed most therapists just tick all the boxes, so I don’t even look at them as criteria any more.’ Katy Evans, who has cerebral palsy and uses a wheelchair, reported a similar story in a blog in December last year on the BACP website:2 ‘A directory search for local in-person therapy generated 505 therapists but when I filtered for wheelchair

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

accessible therapists, just 141 remained, less than 30%. In fact, most directories didn’t have wheelchair access in their filters. My experience isn’t unique. I know one wheelchair user whose search result threw up just four accessible therapists,’ she writes. When I spoke to her in January, she had had 120 rejections, but not all because of lack of wheelchair access. The rejections themselves make things worse, she points out. Most people seek therapy when they are very vulnerable anyway: ‘I have attachment trauma from my early life and it plays into that. And I’ve not had a good relationship with NHS mental health services – they deem me “too complex”, so whenever a therapist tells me no, it ignites all that again. And it’s frustrating as it’s something I cannot change. I can’t just get up and walk.’

Access and attitudes The Equality Act 2010 does not provide an automatic right to access. Service providers are legally obliged to provide ‘reasonable access’ to goods, premises and services, but it is the provider, not the disabled person, who gets to say what is ‘reasonable’. Cost, practicability and lack of resources are all good reasons to say no, whether you are a lone practitioner working from home or for a charity or independent organisation. Public services, such as the NHS, would of course have a tougher time claiming any of these reasons as exemptions. But, as Evans points out, it isn’t just getting into the building and counselling room; it’s the journey there too. ‘So much labour goes into getting there, negotiating the barriers, organising personal assistants (PAs), accessing public transport. Sometimes I feel mentally drained and exhausted before I’ve even got there, and I don’t think that’s fully understood.’

KIRSTEN SHIEL

REPRO OP

You can knock...

could identify it better than I could, and I really need for that to be challenged. Society is inherently ableist. It’s set up for non-disabled people and we are expected to fit ourselves into that, and when we can’t do that, we can feel a lot of shame, that we should be able to do this, we shouldn’t be a burden. But she was really able to recognise that, whereas a lot of other therapists see me in the wheelchair, see my condition but don’t go beyond that. And, to be honest,’ she says, ‘it’s the social barriers and attitudes that are a bigger problem to me than my impairment.’ Essentially, what she is describing is the social model of disability. Josh Hepple, who also has cerebral palsy and spoke about his views on counselling and disability at the 2021 BACP AGM, summarises it thus: ‘Cerebral palsy is my impairment. Impairment is the medical condition. Disability is a social construct. I am either a disabled man or a man with

but you can’t come in And, of course, it’s not just about physical access. As many disabled people will tell you, having got into the building, there are numerous other non-physical barriers that stop or discourage them from getting any further. Cost (many disabled people are unable to work fulltime so may be on a low income) is a big one as regards private therapy, but no less mountainous are the attitudes and understanding of therapy organisations and individual therapists. Ticking the box for disability on the BACP online directory is no guarantee that the premises and procedures are accessible and that the therapists are equipped to work successfully with a disabled person. At present, holding BACP accreditation does not mean an individual or organisation can be compelled or even encouraged to do what is needed to make this happen. Steve Rattray, who is blind and a BACP senior accredited therapist who works with and has used counselling services, says he would rather individuals and organisations just said so, if they aren’t accessible. ‘What

I’ve experienced is they say “Yes, not a problem,” but they’ve not got a clue. And if I raise it, it’s “Thank you for letting us know, we will see if we can change things,” and nothing happens.’

Boundaries and defences Lack of basic knowledge and understanding about the impact of being disabled (and all the different kinds of impairments, including hidden ones, chronic pain and long-term and intermittent conditions) are widespread. Says Evans: ‘I did see a therapist who specialised in disability, the only one with that background, and it was very different. She could identify with the social barriers and internalised ableism. Sometimes she

‘The social barriers and attitudes are a bigger problem to me than my impairment’ THERAPY TODAY

an impairment. It’s far more powerful to say disabled man as that describes it as an act of disablement by the society and environment we inhabit.’ Says Evans: ‘Often, I’ve felt like I am educating the therapist – it’s more than just telling them my history. It’s like I am training them, and it’s in my therapy hour – I am paying for that, and meantime I’m not getting the support I need.’ Professional rules and practices can, ironically, present another major barrier and knowledge gap. Evans says: ‘I’ve met some therapists who didn’t want to do a home visit because they said they’d been advised it would transgress their professional boundaries.’ Third-party involvement is also an issue where therapists frequently fall short, says Mel Halacre, a psychotherapist, director of the disability support organisation Spokz People CIC, and author of BACP’s good practice resource on working with disability:3 ‘There is a lack of awareness around the involvement of third parties. We aren’t trained to consider their

MARCH 2022

91BAPMAR22112.pgs 03.02.2022 12:40

The Big Issue, 1

The In bigfocus issue

VERSION REPRO OP SUBS ART PRODUCTION CLIENT

involvement at all, but you have to because of the closer relationships disabled people have with parents, professionals, PAs, the NHS, social services and so forth. If you want the therapy to be helpful, you have to involve them. ‘What if a client’s parent stops bringing them to therapy because they don’t like that their child is getting more assertive? If I know there is some third-party involvement – for example, with a parent or PA – I will ask the client if it would be helpful to involve them in some way, perhaps with group sessions at the beginning to talk everybody through the change process, or I might offer them some therapy, if the client consents. But some therapists say no, it’s breaking boundaries, and won’t do it.’ But therapists who do liaise with third parties can get that very wrong too: ‘At the end of the session, I can feel like I am a child being handed over to another adult,’ says Evans. ‘I’ve had some therapists who tell the PA how the session went, which is totally inappropriate. One said, “Oh it was a good session today and next week we are talking about boundaries,” and that was awkward because it was my difficulties asserting my boundaries around the PA that I wanted to talk about!’ The therapist’s own conscious and unconscious fears, prejudices and biases are another barrier. But prejudice is natural, says Mel Halacre, and she cites Brian Watermeyer’s work: ‘As humans, difference is something we find hard.’4 ‘We all have prejudices and act them out,’ she says. ‘But a lot of therapists struggle when faced with the anger of the disabled person. A lot of our consultancy and training work at Spokz People is about helping therapists understand the social model and where the anger is coming from, as well as becoming more comfortable with their own relationship with disability. The therapist’s job is to validate that anger because it’s an accumulation of all the negative experiences in disabled people’s lives. If you only see disability as a medical issue, it just stops at that person. ‘Joy Oliver’s research5 has shown us that what most disabled people struggle with emotionally is not the disability but the psychological impact. It’s the segregation, the continual assessments

‘Practitioners should have training so the client doesn’t have to educate them’ from government bodies that don’t liaise with each other, and people’s attitudes. What they need is a therapist who understands all that and can say, “Yes it’s OK. I understand you’ve been silenced and here is a space where you can voice that anger and you are not going to be silenced.” Difference makes us all uncomfortable, disabled and non-disabled therapists and clients alike, but we can learn to sit with and work through that discomfort for the benefit of our clients.’ Says Evans, ‘When I ask therapists how they will work with my disability experience, many individualise it and explain how they would help me change my thinking to overcome my difficulties. This won’t change the reality that inaccessibility and ableism are everywhere. I want someone to hear my anger that so often gets silenced and sit alongside me in the injustice.’ Ideally practitioners should have training so the client doesn’t effectively have to educate them at their own expense. ‘If you do feel out of your depth, the best thing is to own it,’ says Halacre. ‘At least you are being open and frank, and you can either continue to work together at a reduced fee or say honestly that you need to get trained first and refer them to someone else – although that’s a challenge because there are so few.’

Pushed away and silenced Something that many disabled people stress is that their coming for therapy doesn’t have to be all about their disability, and frequently it isn’t. Steve Rattray says that what he needed from a therapist when his fading sight was really impacting on him was, yes, help with overcoming the barriers it raised, but also help with finding himself again, when so much of his identity (work, hobbies, relationships) had been stripped away. ‘Losing my sight

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

opened up so many questions for me about the rest of my life. It took me a good two or three years to find the actual person I was again and to come to terms with it.’ Josh Hepple, who has a background in law and is an active volunteer at his local Samaritans branch, says: ‘I think it’s important to separate out the actual therapy. I talk a lot about anger and disempowerment in my therapy sessions. Cerebral palsy does mean I have to rely a lot on other people, and so of course disability has a part in it, but that feeling of disempowerment and how to process it and not let it mess up your health and relations with the people around you, that is universal, not to do with being disabled. Everyone brings their own stuff to therapy and so, disabled or not, the therapeutic process should remain quite similar – or that is the theory anyway!’ He does a lot of consultancy work on access for arts venues and events, including the Edinburgh Festival, as well as charities and other organisations. ‘In my experience, and it applies to private therapists too, those who want to be accessible will find a way, and those who don’t care about equality won’t do anything, whatever you tell them. I think it needs more stick than carrot now, which is sad. But someone who wasn’t prepared to make the effort probably wouldn’t be the best therapist for disabled clients anyway,’ he points out. Another response that really annoys him is what, in the disability world, is called ‘inspiration porn’. Essentially, it’s when able-bodied people get off on how ‘brave’, ‘courageous’, ‘extraordinary’ and ‘wonderful’ disabled people are to do something that would be much less remarkable if they weren’t disabled. ‘Give me three practical take-aways that you will implement; don’t just listen to me, feel good about yourself and then never think about it again,’ Hepple says. Halacre understands much of these reactions as being driven by fear. ‘Anybody can become disabled just like that – it triggers fear that it could happen to you one day,’ she says. ‘That leads to pushaways: either a refusal to take on disabled clients, or a refusal to sit with the reality of

what the client is saying – “I need to see that you are OK so that I know I will be OK if it happens to me.” And that silences the disabled person from sharing their anger and sadness.’ Perhaps those most frequently silenced by the medical profession are people with chronic, long-term ‘hidden’ illnesses and impairments, such as chronic fatigue syndrome, endometriosis, lupus and fibromyalgia. Thalia Joyner had scoliosis as a child and was subjected to traumatising, intrusive surgery in her early teens. She then suffered further spinal injuries in a motorbike accident and, 10 years later, having forged a career and had a child, lost mobility in both legs again that triggered a spiral downwards, and she was unable to walk for many years. She has since retrained and works as a therapist. Socalled medically unexplained symptoms are most doctors’ nightmare; they defy their expertise. What gets overlooked are the impacts on the person themselves. ‘There is a lot of medical gaslighting and professional gaslighting,’ Joyner says. ‘Trust is absolutely vital with any client but especially with this client group. By the time they get to counselling, it’s often very far down a long and painful road. If counsellors have an understanding and experience of working with these conditions, it could empower the client on their journey. People will have gone through the mill of the medical professions and been told it’s all in their head; they’ll come feeling they must be mad, and it takes a lot of courage then to go into a therapy room. It’s so important to believe the client’s experience. They’ve had so much judgment in their lives.’

Disabled counsellors Might it be preferable if all disabled people could access therapy from a disabled counsellor? First, that is unlikely, given current availability, and the barriers to disabled people accessing training (another story, needing an article of its own). According to BACP’s 2021 member survey, some 11% of its members are disabled. But, anyway, it’s the relationship that matters, surely? Shouldn’t disabled people have the same right to access the same breadth of choice as a non-disabled

‘I TRY TO COME ACROSS AS HUMAN AND FALLIBLE’ Vicki Sherry was a police officer before multiple sclerosis brought her career to an abrupt halt, and she retrained as a counsellor. What she, as a client, would want from a therapist is simple, she says: ‘Congruence, honesty and a clear description of what the therapist can offer. I ask potential clients how they are going to get here, and I explain about parking and access and where the room is and access to the toilet. That can lower their anxiety straight away. If they need a drink, I can offer that. That should be how it is for any client, but it will be that much more important for disabled clients. I tell them I need to know what they need so they can get the most from these sessions and that, even though I am disabled, I don’t profess to be the expert on their life.’

person? Why should every disabled person want a disabled therapist? This is, essentially, what all the disabled people I spoke to felt. Yes, there can be advantages if your therapist is also disabled and so understands what you are experiencing on a daily basis and why it might cause psychological distress. You don’t have to waste (pay for) valuable therapy time explaining. And yet, as Josh Hepple points out, ‘disabled or not, the relationship is with the therapist. To me, what is important is whether the therapist is competent or not and if they are someone I can relate to therapeutically. I don’t even know if my therapist is disabled but that is not my concern. He is just very good at what he does.’ Oliver Ward sits in both chairs, as a disabled client and a disabled therapist. He retrained as a counsellor after he had to leave his job in banking, when he was affected by a degenerative condition that means he now uses a wheelchair, and set up in private practice offering accessible online counselling – which, he points out, most counsellors are now doing because of COVID. He does not think that only

‘I can’t assume I automatically understand what someone else is going through’ THERAPY TODAY

a disabled counsellor can work with disabled clients. ‘That would be like saying you have to have experienced domestic violence yourself to work with survivors of domestic abuse,’ he argues. And there is a danger for the therapeutic process in a client’s assumption that their disabled therapist will ‘know what they mean’ automatically because they too have had that experience. ‘Some disabled clients may think that, because I am also disabled, I must know what they are going through, but we are all individual. I can’t assume I automatically understand someone else’s experience. It’s easy to get into a situation where the client says, “You know what I mean”, and the therapist just says, “Yeah, yeah”. It closes down further exploration.’ For Joyner, it’s an ethical issue: ‘It is instilled in counsellors that it is not ethical to work with certain clients if you don’t have the training, experience and knowledge. I understand the theory about Rogers’ six conditions and unconditional positive regard, but would you work with a client with an eating disorder or trauma, say, based just on the conditions? The relationship is important, that is where the change and the magic is, but you need the knowledge and wider understanding to deliver the ingredients. To work ethically, therapists need specialist training, in case congruence and empathy manifest as pity.’ Specialist knowledge is particularly key for Deaf people who use British Sign Language (BSL) and need a sign

MARCH 2022

91BAPMAR22113.pgs 03.02.2022 12:41

The Big Issue, 2

The big issue

The Big Issue, 3

The big issue VERSION REPRO OP SUBS ART PRODUCTION CLIENT

language interpreter if the therapist isn’t BSL proficient. Victoria Nelson is a qualified psychotherapist who was born profoundly deaf (she also now has a cochlear implant) and was brought up orally. She wasn’t able to learn sign language until she was in her late teens. She knows very few therapists who can sign fluently enough to practise without an interpreter, and only a couple of profoundly deaf qualified psychotherapists. She set up an awardwinning therapy service, Deaf4Deaf, when she qualified as a counsellor in 2016, which brought together a team of signing therapists all over the UK to offer therapy to Deaf people. She is now in the process of establishing a new organisation, SoundMind-UK, which will specialise in a wider range of disabilities and offer therapy with therapists with those conditions. ‘The idea is that we specialise in shared lived experience,’ she says. She argues that it is necessary for a therapist to have personal experience – certainly for Deaf people: ‘It’s not just the language, it’s the cultural understanding. A Deaf therapist will understand about the oral tradition and BSL – a hearing therapist won’t get that cultural nuance, which matters, especially in couples therapy when the couple are from different traditions. Deaf people say they have to explain things to the hearing therapist before they can get on to what they came to therapy about. I don’t ask Deaf clients about their deafness – it might come out through the therapy, and if it is an issue we can deal with it, but we can work on what they are bringing immediately.’

Can do better

So, how can the counselling profession do better? Josh Hepple would like to see BACP actively encourage private counsellors to ensure they offer accessible premises. He also thinks therapists should include more provision in their contracts for disabled people around issues like cancellations, lateness, missed sessions and other traditional ‘boundary breakers’. He’d also encourage therapists to pause and reflect before they tick – or don’t tick – the ‘disability’ box. Katy Evans gives a very simple example of flexible, creative thinking: ‘Take a video

‘Take a video of your venue and let clients decide if they can manage it’ of your venue and let clients decide if they can manage it, rather than just tell them they can’t. Clients know their capability better than you do.’ She also encourages flexibility and being imaginative: ‘I know a lot of therapists work from home and are limited by where they live and that can’t be helped, but I do think some thinking outside the box is needed. I met with one therapist in the park and we did therapy that way.’ More training in the impact of being disabled would help, says Ashley Cox. ‘I’ve done sessions with local counselling colleagues, going into colleges and talking to diploma students. I think people are too afraid to ask questions in case they say the wrong thing or say something that’s politically incorrect. Sometimes we need to ask those questions to learn. If we don’t talk to each other, we’ll never learn. If sighted society doesn’t talk to me, you’ll never learn about my disability.’ Mel Halacre wholeheartedly agrees that there isn’t enough disability training. Spokz People has just launched an online platform for people needing therapeutic support, with interactive psycho-education programmes and a peer support community (www.spokzpeople.org.uk/ register). It will be launching an online training hub and networking/peer support platform for therapists later this spring. Another networking initiative, the Disability Psychological Practitioners Network, is already up and running on Facebook. Halacre, along with Steve Rattray, is on BACP’s Equality, Diversity and Inclusion Task and Finish Group, which is working on improving BACP’s responses across all the ‘equalities’ groups. Areas the group is focusing on include training, mentoring, placements and supervision, accreditation, events and CPD. It will also be revisiting the Good Practice in Action resources, Halacre says, and the online directory, to consider

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

how access can be best described and communicated to potential clients. In essence, this is a social justice issue, says John Barton, who has Parkinson’s and is a practising psychotherapist and a member of the Therapy Today Editorial Advisory Board: ‘Disability is not a pathology. If you are a therapist, you presumably believe in human potential, and support, empathy and compassion. On what grounds do you turn disabled people away? What are you afraid of? You may have to change your therapeutic frame slightly, or your boundaries, but so what? Get over yourself. This is about ordinary humanity.’ In short, before you tick the disability box, ask yourself: ‘What do I know about disability, and about myself?’ • We would love to hear your experiences – if you have adapted your room/service to make it more accessible, tell us what that involved. If you took on disabled clients for the first time since working remotely during the pandemic, what have you learned from the experience? Has any specific training or CPD been helpful? If you have turned down enquiries from disabled people, what stops you accepting this work? Have you as a disabled person had a successful experience of therapy? Email us at therapytoday@thinkpublishing.co.uk REFERENCES 1. Cox A. I needed mental health support but eight therapists rejected me for being blind. Metro 2019; 30 June. bit.ly/3nSMQ9X 2. Evans K. Getting into the room is the first hurdle. [Blog] BACP 2021; 7 December. bit.ly/3rL1DEy 3. BACP. Working with disability across the counselling professions. GPaCP 007. Lutterworth: BACP; 2020. bit.ly/3tLScrg 4. Watermeyer B. Towards a contextual psychology of disablism. New York: Routledge; 2013. 5. Oliver J. Counselling disabled people: a counsellor’s perspective. Disability & Society 1995; 10 (3): 261–280.

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

MARCH 2022

91BAPMAR22114.pgs 03.02.2022 12:41

VERSION REPRO OP

‘We need more faith that therapy works’

SUBS ART PRODUCTION CLIENT

BLACK YELLOW MAGENTA CYAN

Therapy fads undermine our profession – we need to go back to basics and understand how counselling changes lives, say Matt Wotton and Graham Johnston

GARY WATERS/IKON IMAGES

t’s hard to know where to start when describing just how effective therapy is. Maybe with the multiple studies showing that changes brought about by therapy are visible via brain imaging.1 Or maybe with the fact that the overall effect size for therapy is larger than the success rate for flu vaccines and heart surgery.2 Perhaps the most important fact of all is that more than three-quarters of people who have therapy are emotionally better off than those who don’t.2 Those findings have been established by thousands of clinical trials over more than four decades – trials using exactly the same methodology as that used to test medical treatments. So we can be absolutely categorical when we say that counselling and psychotherapy have a success rate just as high as the majority of treatments for physical illnesses3 and often have a substantially larger effect size than many medical or surgical procedures.4 And, of course, behind the percentages and effect sizes are real people who feel better as a consequence of having therapy. Those improvements show up in the number of hours slept per night or the number of days spent panic free. In one study, clients with anorexia weighed, on average, 40kg before therapy. After 12 months of therapy, on average they weighed more than 48kg.5 Therapy can literally be the difference between life and death. We also know this from our own, often life-changing experience of therapy. And now, as therapists and counsellors ourselves, we see these same kinds of changes in our clients. Evidence of this sort is anecdotal, but is also borne out by large-scale surveys. Seventy-six per cent of those who’ve had therapy or counselling would recommend it to friends and family, according to a recent BACP survey.6 An earlier large-scale consumer survey in the US found that, of the people feeling ‘fairly poor’ at the outset, an incredible 92% reported feeling ‘very good’, ‘good’ or at least ‘so-so’ at the end of therapy.7 So therapy works. Indeed, that’s the reason for the radical expansion of mental health provision in the UK. Whatever you think of

the limitations of the Improving Access to Psychological Therapies (IAPT) NHS initiative, Britain now leads the world in spending on psychological services. And the number of people receiving treatment each year will reach 1.9 million by 2024. Before we get too carried away, that is still only a quarter of the number of people suffering from anxiety or depression.8 But the key point is this – services have been expanded because therapy is proved to reduce distress. Therapy works. And it’s not just CBT that works. As the architects of IAPT say, ‘CBT may be the most widely researched form of psychological therapy… but there are many others, which have proved equally effective for some conditions’.3 That’s why the National Institute for Health and Care Excellence (NICE), which produces evidence-based guidance for the NHS, also recommends family and couples therapy, short-term psychodynamic therapy, personcentred experiential therapy for mild to moderate depression, motivational interviewing for substance dependency, and interpersonal therapy, alongside CBT.

● Helping clients become more aware of what

causes their difficulties – standing back to see the wood for the trees, and/or zooming in to see the detail, as it really is. ● Encouraging clients to engage in ‘corrective experiences’ – helping them connect with thoughts and feelings they tend to avoid, and encouraging them to do things differently to learn something new or unexpected. ● Practising ongoing reality testing by putting all of the above together to create a virtuous circle to help clients notice when they’re on autopilot; pause and reflect; do something differently; note the results, and apply that learning. Using a framework like this allows clients to begin to change the thoughts, feelings and habits of a lifetime. As we know, even small but consistent changes can make a remarkable difference over time. At its best, therapy helps us experience more meaning, more contentment and more fulfilment – to self-actualise, in the language of the humanistic tradition. In short, counselling changes lives.

So how does therapy work?

Knowing the research

The reason all these different types of therapy are effective is due, in part, to what all good therapy has in common.9 Drawing on this finding, and summing up 40 years of research, Goldfried suggests that all effective therapy works according to five evidence-based, broad principles of change, listed below:10 ● Promoting clients’ hope and expectation that therapy can help – most of the time, for most people, with most problems, therapy is effective at relieving distress. ● Establishing a good working relationship – a good therapeutic alliance is the foundation for change, which means agreement on the goals and methods of therapy.

BACP’s Ethical Framework requires practitioners to ‘work to professional standards’ by keeping knowledge up to date and ourselves informed of relevant research (‘Our commitment to clients’, point 2b; ‘Working to professional standards’, point 14b).11 Knowing how, why and to what extent therapy works is a requirement for one simple reason – it protects and benefits our clients. You wouldn’t give people with diabetes a medicine that hadn’t been tested and proven to be effective. By the same logic, we shouldn’t give people with depression or anxiety psychological treatments that are of no proven value. And the problem is we have so many models of therapy – the most common estimate is

‘At its best, therapy helps us experience more meaning, more contentment and more fulfilment – to self-actualise’ THERAPY TODAY

MARCH 2022

91BAPMAR22115.pgs 03.02.2022 13:47

Opinion, 1

Opinion

VERSION REPRO OP

nearly 500!12 Some are short-lived fads – past-life therapy, rebirthing and primal scream therapy to name a few. Nevertheless, we still have far too many therapies that are unsubstantiated by research and therefore have no proven value. Even some incredibly well-known therapies have very limited academic support. Let’s take a look at two of the most popular – EMDR and polyvagal theory. The evidence base for each may surprise you.

SUBS

EMDR

ART PRODUCTION GARY WATERS/IKON IMAGES

CLIENT

Eye movement desensitisation and reprocessing therapy (EMDR) invites clients to focus on traumatic memories while simultaneously moving their eyes from side to side. Proponents of the treatment argue that bilateral eye movement stimulation while thinking about the traumatic memory somehow changes the way that the memory is stored in the brain, and thereby reduces or eliminates distress. However, long-standing criticisms of EMDR have now settled into an academic consensus that eye movements are unnecessary, and that the effect obtained is solely the result of exposure, a technique borrowed from CBT. In CBT-based exposure, the client is invited to gradually confront the feared stimulus in order to learn that trauma reminders, however unpleasant, are not harmful, and that we are quite capable of tolerating the temporary distress they cause. Head-to-head clinical trials consistently show exposure-based CBT to be more effective than EMDR. This isn’t new information either. The data indicating ‘no significant benefit because of eye movements’ is 20 years old.13 This same finding was also reported by Mick Cooper in 2008, in his excellent book, Essential Research Findings in Counselling and Psychotherapy: the facts are friendly, where he sums up the evidence for therapy more generally.14 There is some nuance here because research has found that EMDR works better than doing nothing and is probably better than just supportive listening.15 The creators of IAPT conclude that this is because EMDR is actually a form of CBT by another name, albeit in

slightly less effective form.9 But the key point is this – NICE recommends exposure-based CBT, and only suggests providers ‘consider’ EMDR, if the client has a preference for it. In truth, this is a modest-to-weak endorsement. And the scientific status of EMDR is still best summarised by McNally, who wrote more than 20 years ago: ‘What is effective in EMDR is not new, and what is new is not effective.’16

Polyvagal theory

Polyvagal theory describes the way trauma supposedly affects the autonomic nervous system – the part of the nervous system that regulates heart rate, blood pressure, respiration, digestion and sexual arousal. Polyvagal theory has been lauded by big-name therapists. Despite this, mainstream neuroscientific research suggests that some of its main premises are unlikely to be true. For example, research has found that the dorsal branch of the vagus has little effect on heart rate, and that the ventral vagal system is not a unique adaptation in mammals. There is an excellent summary of the research in a short, non-technical blog post by US psychologist Dr Shin Shin Tang.17 But perhaps the main criticism is this – while the vagus nerve, which extends from the brainstem to the heart, lungs and stomach, plays a role in transmitting signals between the brain and the rest of the body (a fact established long before the emergence of polyvagal theory), there is no evidence to suggest that it has any control over fear responses. Critics therefore suggest that polyvagal theory has not

‘We need to be clear that practising and promoting ideas that are untested or lack evidence can and do produce harm’ THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

been able to shed additional light on what is already better explained by attachment theory, research on emotional self-regulation or existing psychological stress models. Inevitably, this is a technical subject, and most therapists will need to defer to experts in this area. Paul Grossman, Research Director at the University Hospital Basel, says he debunked polyvagal theory more than a decade ago.18 By 2017 his paper had been cited more than 500 times, without ‘a single serious attempt to rebut his argument’.19 He has since invited proponents of polyvagal theory to defend the idea on a prominent academic forum. Despite being viewed more than 17,000 times, there has been no serious defence of polyvagal theory. Grossman concludes that polyvagal theory is simply not seen as worthy of serious debate by those working in academic psychology. For some, that information will be bitterly disappointing, perhaps even shocking. Others may prefer not to believe it. Dr Tang, summarising the evidence in this area, wrote that she felt like the Grinch who stole Christmas.17 But we need to be clear that practising and promoting ideas that are untested or lack evidence can and do produce harm, not least by depriving clients of scarce time and money, and by diverting them from evidence-based treatments that do exist. And before we get too downcast, we should remind ourselves of the sheer weight of evidence in support of therapy practised according to the well-established principles of change, outlined above. We already have a solution that works.

The slow road

So what accounts for the continued popularity of untested and novel therapies? First, not enough of us know the research. Second, publishers and training providers aggressively promote new ideas – they are lucrative, after all. And third, and perhaps most importantly, therapy is hard and slow, and we are seduced by promises to make it quicker. We look for breakthrough treatments because we care about our clients’ distress and because therapy can often feel like a trudge. Freud first bemoaned how time-consuming therapy was nearly 100 years ago, and therapists have been echoing that sentiment ever since. In truth, we are, in part, looking for a miracle cure. But we’ve got to curb that impulse. As behavioural scientist Professor Katy Milkman outlines in her recent bestselling book on habit

change,20 change is possible but not easy, and the barriers to change have to be overcome via tailored strategies and interventions. So we’ve got to accept that therapy is often hard and sometimes slow, just as we’ve got to accept that it doesn’t always work for everybody. If 76% of people would recommend therapy to family and friends, that means 24% wouldn’t. If nearly eight in 10 people feel better after therapy, two in 10 don’t. Research also suggests that significant numbers of clients drop out of therapy21 and a small number even deteriorate.22 But most of the time, for most people, with most problems, therapy helps. That’s by far the most likely outcome. Nearly 80% of people get better, and the numbers are even higher for those treated for specific conditions such as panic and social phobia.23

Seven keys of effective work

So, with that in mind, let’s conclude with seven practical ways to sharpen our practice and avoid magical thinking: 1. Stick to the basics – we have decades of consistent research findings that underpin the basic principles of therapy. Goldfried’s framework11 is simple, memorable and underpinned by research. Don’t be seduced by new ideas. If it sounds too good to be true, it probably is. 2. Use supervision to be honest about the clinical problems you face and get to the heart of the issue. Be honest and ensure supervision isn’t too comfortable or cosy. Bring what you routinely struggle with or where you get stuck. 3. When considering CPD, don’t be afraid to go back to basics. Chances are you don’t need a new technique. When athletes plateau or suffer a loss of form, they deconstruct and refine existing techniques and/or they seek marginal gains. They seldom try a brand new technique or switch sports! 4. Consider CPD that goes further into your existing way of working. Going deeper may be more beneficial than qualifying in the latest ‘add-on’, which may well be difficult to incorporate into your practice. Chopping and changing styles, techniques or approaches is confusing – for you and your clients. 5. Match CPD to your actual clinical problems. Take a reflective approach and use supervision to identify any knowledge gaps or development needs, then choose your CPD accordingly. 6. Accommodate your clients’ preferences. Rather than adding on a new technique, you

may need to shift your approach to suit your client. You can’t reinvent yourself, but we can all be ourselves with more skill. If you can’t accommodate their preference, then refer on. 7. Change happens slowly – there is no miracle pill or magic cure. Expect the work to be hard sometimes; stay the course and work it through. Shortcuts and hacks are mostly overhyped fads; don’t feel you have to follow the crowd just because others are training in or promoting them. Therapy has never been more important in public life. Roughly a third of families in the UK include someone who is mentally ill. A third of us are expected to experience mental illness at some point in our lives. In developed countries, the World Health Organisation estimates that mental illness accounts for nearly 40% of all illness (stroke, cancer, heart disease, lung disease and diabetes together account for less than 20%).24 Mental ill health is arguably Britain’s biggest social problem. Our work is critical. Practitioners need to be able to describe the core principles of change and keep clients safe from the harm inherent in ‘miracle’ cures or unevidenced therapies. We should be sceptical of anything inconsistent with mainstream scientific knowledge, and we shouldn’t practise anything we don’t understand or can’t explain. We don’t need to. Therapy is a powerful solution to human distress. It is backed by decades of research. It is enough.

About the authors Matt Wotton MBACP is a psychotherapist and executive coach. He is Chair of The Bowlby Centre, the UK’s leading training institution in attachment-based psychotherapy. He has more than two decades of experience in forensic mental health in the criminal justice system, in operations, coaching leaders and advising ministers. He is co-founder and director of the London Centre for Applied Psychology (www.lcap.co.uk). Graham Johnston is a UKCP registered psychotherapist and Director of Policy at The Bowlby Centre. Prior to training as a therapist, he spent two decades as an adviser and operational lead for the UK Government, specialising in home affairs. He is co-founder and director of LCAP.

THERAPY TODAY

REFERENCES 1. Linden D. How psychotherapy changes the brain – the contribution of functional neuroimaging. Molecular Psychiatry 2006; 11: 528–538. 2. Lemma A et al. Brief dynamic interpersonal therapy: a clinician’s guide. Oxford: Oxford University Press; 2011. 3. Layard R, Clark DM. Thrive: the power of psychological therapy. London: Penguin; 2014. 4. Carr A. The effectiveness of psychotherapy – a review of research prepared for the Irish Council for Psychotherapy. Dublin: ICP; 2007. 5. Eisler I et al. Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. Journal of Child Psychology and Psychiatry 2000; 41(6): 727–736. 6. BACP. Counselling changes lives: public perception survey. Lutterworth: BACP; 2019. www.bacp. co.uk/about-us/about-bacp/public-perceptionsurvey-2019 7. Seligman ME. The effectiveness of psychotherapy – the consumer reports study. American Psychologist 1995; 50(12): 965–974. 8. Clark DM. IAPT at 10: achievements and challenges. [Blog]. NHS England. 13 February 2019. bit.ly/3zjUaQe 9. Wampold BE. How important are the common factors in psychotherapy? An update. World Psychiatry 2015; 14(3): 270–277. 10. Goldfried M, Eubanks CF. A principle-based approach to psychotherapy integration. In: Norcross J, Goldfried M (eds). Handbook of psychotherapy integration (3rd ed). Oxford: Oxford University Press; 2019. 11. BACP. Ethical framework for the counselling professions. Lutterworth: BACP; 2018. 12. Cooper M. How different are the different therapies? [Blog]. Mick Cooper Training and Consultancy; 3 February 2020. bit.ly/3mU2xgp 13. Davidson PR, Parker KCH. Eye movement desensitization and reprocessing (EMDR): a meta-analysis. Journal of Consulting and Clinical Psychology 2001; 69(2): 305–316. 14. Cooper M. Essential research findings in counselling and psychotherapy: the facts are friendly. London: Sage; 2008. 15. Arkowitz H, Lilienfeld SO. EMDR: taking a closer look. [Online]. The Scientific American: 1 August 2012. bit.ly/3zpehwr 16. McNally RJ. On eye movements and animal magnetism: a reply to Greenwald’s defense of EMDR. Journal of Anxiety Disorders 1999; 13: 617–620. 17. Tang SS. RIP polyvagal theory. [Blog]. 14 August 2021. bit.ly/3pNJeqY 18. Grossman P, Taylor EW. Toward understanding respiratory sinus arrhythmia: relations to cardiac vagal tone, evolution and biobehavioral functions. Biological Psychology 2007; 74(2): 263–285. 19. Grossman P. After 20 years of ‘polyvagal’ hypotheses, is there any direct evidence for the first 3 premises that form the foundation of the polyvagal conjectures? [Blog]. 18 January 2016. bit.ly/3Hnt1ii 20. Milkman K. How to change: the science of getting from where you are to where you want to be. London: Vermilion; 2021. 21. Wierzbicki M, Pekarik G. A meta-analysis of psychotherapy dropout. Professional Psychology: Research and Practice 1993; 24(2): 190–195. 22. Lambert MJ. Outcome in psychotherapy: the past and important advances. Psychotherapy 2013; 50(1): 42–51. 23. Roth A, Fonagy P. What works for whom: a critical review of psychotherapy research (2nd ed). New York: Guilford Press; 2005. 24. Layard R, Clark DM. Why more psychological therapy would cost nothing. Frontiers of Psychology 2015; 6: 1713.

MARCH 2022

91BAPMAR22116.pgs 03.02.2022 13:47

Opinion, 2

Opinion

VERSION REPRO OP

IN THE SHELTER OF EACH OTHER

SUBS

Community-based group interventions can promote healing, connectedness and hope after collective trauma, say Jelena Watkins and Helena Lewis

PRODUCTION

SHUTTERSTOCK

ART

n the UK, mental health services set up in the aftermath of terrorist attacks have historically focused on individual interventions for post-traumatic stress disorder (PTSD) and other trauma-related ‘disorders’. While prompt provision of these is crucial for some, so are broader group and community interventions for many. Terror attacks rupture both individual worlds and collective identities, so require both individual and collective responses. The Manchester Attack Support Group

CLIENT

BLACK YELLOW MAGENTA CYAN

Programme (MASGP), established to support those directly affected by the Manchester Arena terror attack in 2017, is an example of a collective approach, achieved through the delivery of a facilitated, peer support programme. It provided long-term psychological and social benefits to those directly affected. Yet such collective interventions curiously remain peripheral in much post-disaster planning for psychosocial recovery. This article shares reflections and learnings from this support group

programme from the perspectives of the co-creator/clinical lead (Jelena) and one of the facilitators (Helena). It does so to demonstrate how communitybased group interventions following collective trauma can promote healing, connectedness and hope, and to argue for fully integrating these into future disaster planning, response and recovery.

Peer support More than 14,000 children, young people and their parents attended the

22 May 2017 Ariana Grande concert at Manchester Arena. As they were exiting afterwards, a home-made bomb exploded, killing 22 people, including children as young as eight, and injuring hundreds of others. It was the UK’s deadliest terror attack since the 7 July 2005 London bombings. In the aftermath, various mental health interventions were implemented to ameliorate the widespread and profound suffering from this horrific attack. The NHS Manchester Resilience Hub, for example, regularly screened those affected for symptoms of trauma and referred on individuals who needed specialist therapy. To complement and enhance individual clinical interventions, the communitybased support group programme was created. This network of regional, professionally facilitated peer support groups was initially funded for two years, but during the pandemic lockdown the funding was extended for a third year. During a transitional phase, the formation of a self-managed network was

encouraged and supported through mentoring newly emerged leaders and by running joint events for all groups. This programme was initiated and managed by two individuals with both personal and professional experience of disaster – Dr Anne Eyre, a sociologist and Hillsborough disaster survivor, and Jelena Watkins, a trauma psychotherapist and a 9/11 bereaved family member. They applied learning from their own experience of participating in support groups but also from delivery of postdisaster support group initiatives over 20 years, including the British Red Cross Tsunami Support Network (2004-2005) and Paris Attack Support Group (20152017). They brought together a team of

‘It’s in the shelter of each other that the people live’ Irish proverb

facilitators, mainly psychotherapists, who held a safe space for the regular group meetings. The programme was therefore infused with the philosophy of peer support and lived experience integrated with professional expertise and facilitation. Initially working with Manchester City Council on developing the permanent memorial to the attack, the project leaders subsequently proposed a programme of peer support groups, based on international best practice. In June 2018 it gained approval. The We Love Manchester Emergency Fund provided funding, and Manchester City Council would oversee it.

Outreach Outreach began immediately after the project approval, with Greater Manchester Police and the Manchester Resilience Hub sharing our information with those on their bereaved and witness list. Within 24 hours, there were more than 60 registrations. Initial reasons for interest included parents wanting to hear how others were coping with their children’s trauma, and indeed their own; people feeling alone and

91BAPMAR22117.pgs 09.02.2022 14:58

Counselling Changes Lives, 1

Counselling changes lives

VERSION REPRO OP SUBS ART PRODUCTION CLIENT

isolated, and some who were particularly struggling around the first anniversary, which made them aware of their alienation from family and friends’ expectations regarding ‘moving on’ and how profoundly affected they still were. Group formation considerations included location and individual circumstances, such as bereaved, survivor or responder (formal or spontaneous helpers on the night). Initial sensitive grouping in relatively cohesive groups can mitigate inter-cohort conflict, as can anticipating, discussing and mediating tensions and disagreements early. Such tensions can be compounded by differing treatment from authorities, charitable bodies and the general public, which brings validation to some and unintended invalidation to others. July and August 2018 involved outreach, preparing facilitators and organising venues across several northern UK cities. Groups started meeting in September 2018, with 12 peer support groups in regional hubs – Glasgow, Durham, Preston, Bolton, Leeds (two groups), Manchester (three groups) and Liverpool (two groups). A telephone support group catered for those living more remotely. Two short-term groups for young people were also established. Separately to the programme but reporting to the programme co-ordinator, the Resilience Hub also ran family days and young people’s workshops.

Our approach Although these are support groups and not therapy groups, based on the programme leader’s professional and personal experience, they understood the complexity and level of skill needed to

‘Collective trauma events are opportunities to face our collective shadow and undergo posttraumatic growth’

deliver them. Therefore, they decided that all the facilitators had to be fully qualified and experienced psychotherapists or psychologists. Most had previously attended ‘Working Therapeutically in the Aftermath of Disasters’ training, designed by Jelena and run before the Arena attack. Most were also familiar and comfortable with working in the community. In our approach, we posited that terrorism and other collective traumas differ from individual trauma in specific ways. Mental health services often inadequately address contextual specifics of collective trauma overall, despite individuals’ traumatic experience being situated within a traumatised society. Notably, then, societal coping responses impact individuals in both helpful and harmful ways. For example, an initial post-attack surge in solidarity and social cohesion generally helps those directly affected, but it is short lived. Longer-term, disasters tend to bring to the surface aspects of the ‘collective shadow’ of the particular society, which could include the underlying hostilities, injustice and inequality. Those directly affected may experience others’ very polarised views or be used for political gains, with media fascination amplifying these. Collective trauma events are nevertheless opportunities for society to face their collective shadow, engage with what is unveiled and, ultimately, undergo post-traumatic growth.1 For some individuals, recovering from the trauma of terrorism may involve gaining new meaning by becoming agents of social change. Additionally, our approach incorporated Hobfoll and colleagues’2 internationally agreed principles for post-disaster psychosocial interventions – promotion of safety, calm, connectedness, efficacy (self and community) and hope. Of primary importance for peer support is connectedness, although the rest of the principles must be appropriately present for connectedness to happen. Finally, we adopted a phase-based approach to trauma recovery, based on Judith Herman’s seminal writings,3 with the phases being, first, establishing safety; then remembering and mourning, and,

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

finally, re-engaging with meaning and returning to society. Using this for group trauma recovery, we applied the work of Mendelsohn et al4 regarding initially creating homogenous groups with low-conflict tolerance and high cohesion to create safety, then building slowly towards heterogeneous groups with higher conflict tolerance and a stigmatising greater sense of community.

Group themes Regular group meetings commenced in September 2018 and took place roughly once every six weeks. Although each group had, as expected, its unique dynamic and focus, there were some themes that were dominant and recurring. Some of these were specific to particular groups (for example, the bereaved, or those with physical injuries) and others were more universal.

1. Safety and belonging The main themes were safety and belonging, which pivoted around people’s natural inclination towards, and need for, connection with others who have shared a common experience. We see this as a fundamental factor in why the groups became a place where many people felt seen and understood. Longing for connection with others who share the same life experience is not unique to terrorism and disasters. There are, however, some specifics for terrorism – these experiences are relatively rare so individuals affected are unlikely to have someone in their circle who has been through an attack, hence the greater need to connect with others. Not only is the same incident a shared, common experience, but so too are what come in the aftermath, in terms of criminal trials, public inquiries and other legal processes. A potential pitfall of this is that it creates an ‘us and them’ mentality – that anyone without direct experience of the attack will, by default, be a ‘nonunderstander’. This is not always helpful for individuals sustaining connection in the wider world and during longer-term recovery. From the start, we planned to merge the groups so that, as they became larger, less homogenous and more

‘The groups became a safe container and a holding ground where the feelings could remain alive but not overwhelming’

Some of these losses were temporary and some were not, and we could give many examples of how, over the course of the groups, these losses were expressed. Although the groups could not resolve these feelings, they did become a safe container and a holding ground where the feelings could remain alive but not overwhelming and, in some cases, be transformed into something more manageable.

3. A portal to therapy diverse, people would continue their recovery in a wider setting, hopefully leading to a sustainable and meaningful engagement in society. The transitions from the small groups to co-existing in a wider context was managed in a measured and safe way. One example of this is when we brought together the injured group with the group made up of responders. This came about through a request from both these groups. Those who were physically injured wanted an opportunity to thank those who helped them and those who had acted in the service of the injured wanted an opportunity to meet them again in person. This meeting served different purposes. It was important for filling in gaps in people’s narratives and also for being able to show gratitude. It was not so much about the actual injured person meeting the actual responder but the opportunity to meet someone who represented that figure. This relates back to Herman and colleagues’ theories around the need to make meaningful connections with an increasingly broader community

2. Loss It is hard to find the right words to express the severity and complexity of loss and give this subject the weight it deserves. Although loss may be an obvious theme following such an event, the ways in which it was experienced were not always obvious or visible. These included loss of life of loved ones, of relationships due to broken connections that were heightened by the trauma, of romance, of memory, of joy in live music and other activities, of faith, of confidence, of work, of income, of identity and of structure.

For some, peer support groups are less stigmatising than personal therapy and act as a way in to access other support such as one-to-one talking therapy. We observed that people who were initially hesitant about therapy were motivated by other group members reporting positive outcomes and that members encouraged each other to start therapy. There is a different value in what people hear from peers as opposed to non-peers (in this case, facilitators) and we noted that, even when we suggested therapy or other interventions, it was more likely to be taken up as a result of peer encouragement and peers’ experience. The experience of being mutually alongside each other helped individuals not only to hear the suggestions differently but also to be more likely to act on them. We see this as further evidence of the need to integrate peer support groups with other mental health interventions. However, we must emphasise that this is not to say any one approach is better than the others. Some individuals will choose certain means of support over others; indeed, some avenues of support will be more relevant and appropriate, depending on the timing, needs and context.

4. Information sharing The groups also became a vehicle for sharing information about anniversary commemorations, the criminal trial, the public inquiry, upcoming TV programmes and media requests. In the context of support groups such as these, this plays an important role because having access to information is not only important at the time but also enables access to it in the future. Information can engender

THERAPY TODAY

empowerment, validation, choice and a sense of being included in what is influential. It is therefore another factor that helps the individual feel emotionally supported. We found that, very quickly, most groups created their own complementary online discussion groups (for example, via Facebook or WhatsApp) to connect and share information outside of the facilitated groups. We found that information from certain authorities was not always disseminated consistently and this could result in some people having access to information or services that others did not. Peers sharing this through their own generated channels helped alleviate this disparity.

5. Entitlement and hierarchies When tragic events happen, one of the ways we try to make sense of it is by attempting to understand what’s happening for others who were also affected. Inevitably this sets up some comparative thinking, which can help us keep perspective, but can also be unhelpful and maintain pre-existing beliefs about not deserving help, for example, or minimising our vulnerability. We have already mentioned the notion of hierarchies, and this got played out in subtle and complex ways in our programme. Among those who survived the attack without injury to their physical selves, there was a prevalent difficulty in allowing themselves to fully acknowledge their trauma, as this was seen against a backdrop of ‘I know I’ve had it so easy compared with...’ We also saw the reverse of this – people minimising the needs of others who they perceived as having lesser losses. This sense of entitlement is not only subjective; it is often also reflected and reinforced through the ensuing public processes, such as who gets financially compensated and, if so, by how much, or who gets invited to the anniversary services, which were limited to a certain cohort of those affected by the attack. When external and systemic discrepancies are reflected financially and socially, they inevitably impact the psychological experiences people are left with.

MARCH 2022

91BAPMAR22118.pgs 09.02.2022 15:41

Counselling Changes Lives, 2

Counselling changes lives

VERSION REPRO OP SUBS

It’s important to acknowledge the complexity of this issue and to recognise the need to validate people with less obvious losses while also recognising there are inherent and profound differences in the experience of loss. This dilemma was part of our thinking from the outset in how best to organise the separate cohorts, and often led the thinking on the ways forward – for example, in managing the safe merging of the groups.

6. Impact on relationships

ART PRODUCTION CLIENT

Any trauma can be a threat to relationships, but what is specific in the kind of trauma discussed here is the public context, and the additional complexities that this brings in relation to organisational systems and processes, the media interest and narratives, and the distribution of financial support and compensation. The ways these influence individuals, couples and broader familial relationships can often cause friction, sometimes leading to more shattered, damaged relationships, although also sometimes leading to closer, more intimate relationships. One of the ways we observed this to be particularly relevant was the impact on relationships between mothers and daughters. In our groups, both were represented. We had young women who had attended the concert independently and who felt guilty about burdening their mothers if they were to share how they were feeling and what they were struggling with. Conversely, there were women who attended the event to escort or collect their daughters, but felt unable to give time and attention to processing their own trauma because of their instinct to focus on their daughters’ needs.

‘Facilitators also needed to mediate in order to preserve a calm space, necessary for working with trauma’

What was created therefore was a parallel process whereby both the mothers and daughters had strong feelings of needing to protect the other from their own painful feelings. What the groups provided was the reparative opportunity to listen to the ‘other’ and to share their own feelings; both to provide the other side of the story and to hear it.

Facilitator dilemmas It was important to us from the outset to have a clear distinction that we were working as facilitators within the context of a support group and not a therapy group. For some practitioners, this was a comfortable and familiar transition; for others, depending on modality and values, it required a conscious re-shifting. In our approach, we believe that the purpose of a post-disaster support group is to aid coping with the common situation brought about by the impact of the disaster on participants’ lives. This coping is nurtured and fortified through mutual validation, normalising and sharing information. Although there are many different types of therapy groups, their purpose tends to be a broader inner change rather than a particular situation, and the focus is on changing entrenched, problematic thoughts and behaviours, which members of a support group do not necessarily sign up for. Maintaining this boundary was paramount for the support groups, despite some facilitators sometimes feeling restricted and therapeutically frustrated. For example, expressed emotions or beliefs that perhaps indicated unresolved earlier history were not explored, as they might have been within a therapeutic setting, as this was not the facilitator’s role, although the facilitators provided referral to therapy services where appropriate. Facilitators also needed to mediate rather than explore conflict (which would be more appropriate for a therapy group) in order to preserve a calm space, necessary for working with trauma. At times, though, managing conflict without it being ‘available as material’ proved tricky. Terrorism can shatter social and community cohesion but also polarise

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

those affected. As facilitators and project leaders, we had to reconcile our professional values and programme goals with preserving the freedom for participants to express conflicting values. When an individual’s world order is so fundamentally broken, it is possible that their need for survival may fuel prejudices or extreme thinking. In our groups, we observed that this dilemma was resolved through the group’s repair – that, by other group members responding to and challenging certain viewpoints, individuals were able to review and adjust their thinking. This was able to happen because of a peer (equal) questioning, as opposed to a facilitator-participant dialogue, which always carries some innate inequality.

Managing exposure to traumatic material One of the ways we needed to manage different needs was with regard to allowing people to tell their stories while at the same time protecting themselves or others from being retraumatised. We spoke about this in the group ground rules and agreed concrete strategies if individuals felt any account was too explicit. We also reiterated and modelled the need for pacing so that people’s stories, views or information were shared in a way that was appropriate. Most of the time we found the groups regulated themselves, but there were also times when someone’s intention to share may have been experienced by another as close to ‘spilling over’. At these points, we needed to be firm in intervening and in finding ways to respect one person’s need to share (to be witnessed) while also respecting another one’s need to withhold (to be protected). In retrospect, we learned that a clear and structured check-in at each session, and agreeing as part of the ground rules that facilitators had permission to interrupt (when done in service of the group), were factors that supported our achieving this delicate balance.

Endings and new beginnings Initially the groups ran separately, and in the later stages of the programme we also

‘It is in the broader context of human connectedness that the healing can take place following collective trauma’ brought them all together. We ran numerous workshops for this collective group after the small groups had been brought to a managed close. One workshop, focusing on establishing peer-based, independent support groups, resulted in the initiation of the new self-managed network, the Manchester Arena Support Network, which now provides support by and for its peer members. This network demonstrates the potential for the sustainability of support groups. When the scaffolding of our professionally managed support group programme is gradually dismantled, their own mutual structure can remain in place over the long term. Of course, not everyone chose to remain involved with others over the longer term. Some participants chose to be part of the new network, others continued to meet in other ways, such as in Facebook groups for their own small regional group, and some chose to continue the journey on their own. During the final evaluation process for the programme, members were asked, ‘Would you recommend this programme for someone in the future?’ One hundred per cent of respondents replied that they would. In line with the findings of an ongoing process of feedback and review throughout the delivery of the programme, this reinforced the value of our approach and a strong sense that we provided something that matched people’s needs, wants and expectations.

Recommendations We believe facilitated peer support group programmes should be seen as an essential ingredient of post-disaster

services. Our programme delivered an effective complement and enhancement to more targeted, specialist therapy post-disaster and to more informal, spontaneous, unregulated forms of peer support. Furthermore, the kind of programme described here is both cost-effective and adaptable (and, indeed, has been adapted by the programme leaders) for addressing psychosocial impacts following other types of disaster and collective tragedy. It is also particularly appropriate for addressing the sorts of needs arising from complex politico-legal processes that often play out following mass-fatality incidents. Such programmes also increase the potential for the foundation of wellgrounded peer support networks, which are self-sustaining long after formal support has ended. Based on our learnings from this programme, our three key recommendations are: 1) Emergency planning and response mechanisms following collective trauma events should include provisions for the timely delivery of facilitated peer support programmes along the lines of the Manchester Attack Support Group Programme. 2) Peer support groups should be facilitated by fully qualified, experienced and registered psychotherapists, counsellors or psychologists, additionally trained in disaster response, due to the complexities involved in the work. In line with the NICE guidelines for PTSD,5 the peer support group facilitators need to be in ongoing training and supervision. Also, they should be appropriately contracted and recompensed for the work. 3) The delivery of such a post-disaster support group programme needs to fully integrate peer support philosophy. This means that at least some key people with lived experience are influential in the design and monitoring of the project. In this case, the project leaders fell into this category and, in addition, we invited guest speakers to all our group gatherings who had survived or been bereaved by terrorist attacks. In this way we engaged those with previous

THERAPY TODAY

experience of collective trauma in active roles as advisers and guest speakers and, where appropriately qualified, as group facilitators and programme leaders. It is in the broader context of human connectedness (‘In the shelter of each other’) that the healing can take place when there has been shattering through collective trauma. ■

About the authors Jelena Watkins is a psychotherapist in private practice, a co-founder of the Centre for Collective Trauma, an advisory panel member of the EU Centre of Expertise for Victims of Terrorism, and a founder member of September 11 UK Families Support Group. www.jelenawatkins.com Helena Lewis is an integrative arts psychotherapist and EMDR therapist. She currently works in private practice as well as offering trauma counselling within the emergency services and charity sector. She is also the founder of On Route, a network of practitioners bringing together psychological, physical and social wellbeing. www.helenalewis.co.uk

REFERENCES

1. Tedeschi RG, Calhoun LG. Trauma and transformation: growth in the aftermath of suffering. California: Sage; 1995. 2. Hobfoll S et al. Five essential elements of immediate and mid-term mass trauma intervention: empirical evidence. Psychiatry 2007; 70(4): 283–315. 3. Herman J. Trauma and recovery. New York: Basic Books; 2015. 4. Mendelsohn M et al. The trauma recovery group: a guide for practitioners. New York: Guilford Press; 2011. 5. National Institute for Health and Care Excellence. Post-traumatic stress disorder: NICE guideline NG116 [online]. 5 December 2018. www.nice.org.uk/guidance/ng116

MARCH 2022

91BAPMAR22119.pgs 09.02.2022 14:58

Counselling Changes Lives, 3

Counselling changes lives

It changed my life, 1

It changed my life VERSION REPRO OP

‘Therapy created the space I needed to accept myself’

SUBS

ART PRODUCTION SHUTTERSTOCK

CLIENT

n April 2015, I moved back home to Hounslow to look after my dad. I’d left seven years previously, after sixth form and years of struggling with both my parents’ divorce and my sexuality. Following a classic gay narrative, I dyed my hair, got facial piercings and moved to Brighton, where I later discovered a word and a world that would change my life – transgender. But now my dad needed help. He was living with pulmonary fibrosis, a terminal lung disease that was starting to impact his life. I was thrown back into a brown town and confronted with the Muslim culture I left behind. I started to see a therapist who was also South Asian and my therapy focused heavily on my relationships at the time, but I was sparing with what I shared about my childhood and family. At the time, my family were struggling with my transness and I didn’t need to feel any more cultural rejection, so I kept this part of my identity to myself. I was visibly gender non-conforming and presented as androgynous, but my therapist never asked and I never told. Hidden in plain sight. I don’t think there was anything she could have done to make me feel comfortable. I’ve spoken to other queer friends of colour who also have the same feelings – white therapists will understand our queerness but not our brownness, and therapists of colour will understand our brownness but not our queerness. I know it doesn’t help me to think this way, but I do carry the fears of being a queer, brown, trans person in society with me into the therapy room. Therapy is not a neutral space and the risk assessment I carry in the world outside is similar to the one I carry with all my therapists. Which part of me is safe and understood here? How much do I need to justify myself before I can express myself? Two years later, after I started my master’s in psychotherapy, I had to find a therapist from a list of university-approved therapists. Without personal recommendations or much of a choice, I changed tactic and put my cards on the table in an email: ‘I’m looking for a therapist who has worked with trans and gender non-conforming clients before, or who identifies as a feminist.’ I got a reply from a cis, white

therapist and, after our first conversation, I was relieved that I could bring this complexity somewhere and didn’t have to question later whether she understood my experience of gender or what trans meant. I was ready to start unpacking this. But what actually became the focus of my therapy was a part of me that was the hardest to accept. ‘I’m his primary carer,’ I said, reluctantly, in one of our early sessions. Over the last three years of my dad’s life, his health deteriorated quickly. He was diagnosed with dementia and the reality of this added strain to our relationship, as well as the many others I had in my life. I kept a lot to myself, and therapy became the weekly spot where I could drop some of it off. I found myself feeling angry in a way that I haven’t felt before. Every now and then, my therapist would reflect how hard I found it to accept what was happening. I didn’t understand why I would ever accept what was happening – the difficulties, the frustrations and the inevitable. My therapist gently brought knowledge of caregivers and information that might help me. Looking back, I think her regarding me as a carer was one of the ways in which I accepted myself as one. This new identity gave validity to my experience and made me accept that what I was experiencing was different from my peers and colleagues. I could accept my anger and this new emotional landscape. And I could accept this new role in my dad’s life and his new role in mine. Speaking about my relationship with my dad actually brought a lot of my identity into the therapeutic room. Through everyday interactions from visiting the mosque with Dad for the first time since transitioning to being treated like a father and son when we were in public, my gender, race, religion and faith were all brought into therapy. The difficult conversations and segmenting parts of my identity felt long behind me, as my therapist and I had a connection where I deeply felt she was on my side and by my side. Part of this meant she would get it wrong or misjudge, but her empathy and presence would never falter. It affected me most when I was least sure of myself. But therapy helped me work with what was present, and that created the space I needed to accept myself.

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

About the author Sabah Choudrey is a reluctant activist, proud trans youth worker, speaker, writer and psychotherapist in training. Their new book, Supporting Trans People of Colour: how to make your practice inclusive (Jessica Kingsley Publishers), is out now.

MARCH 2022

91BAPMAR22120.pgs 03.02.2022 12:55

VERSION REPRO OP

When labels are liberating

SUBS

Therapists should be wary of undermining neurodivergent clients’ need for a label, says Kathy Carter

ART

PRODUCTION

n recent years, we’ve seen an increase in people identifying as autistic and embracing a neurodivergent identity. While there is also an increasing number of therapists who identify as neurodivergent, most autistic or neurodivergent clients end up working with neurotypical therapists. So as a profession, educating ourselves about clients’ diverse needs and offering a neurodiversityaffirming environment are key. As a member of several autistic support networks, I have come across many fellow autistics who have felt misunderstood, dismissed or undermined when they sought therapy. In this article, I outline best practice to ethically support neurodivergent clients with the environment and therapeutic relationship they need in order to flourish.

CLIENT SHUTTERSTOCK

Defining neurodiversity

A good starting point is an understanding of what is classed as ‘neurodiversity’. Neurodiversity indicates a range of neurologies within a population, as in biodiversity. Those not fitting within the normative ‘neuro’ majority are considered neurodivergent; their brains have different neural pathways. Neurodivergence describes brains, sensory systems and behavioural traits that are different to the ‘typical’ majority. Most people are neurotypical, also known as the predominant neurotype, as their brains function and process information in the way society expects. However, the word neurodiversity tends to be misused and applied to a person, not a population. There’s no singular definition of who is included under the neurodivergent umbrella. Some healthcare clinicians, outside of the counselling sphere, may separate ‘clinical’ from ‘applied’ neurodivergence. Applied

neurodiversity refers to difficulties in skill application such as reading, as may be experienced by a client with dyslexia. Clinical neurodiversity relates to difficulties in communication: for example, those associated with autism. Acquired neurodiversity relates to conditions linked to illness or injury, such as a stroke injury. As examples from a longer list, autistic folks and those with ADHD (often called ADHD-ers), and people with issues such as sensory processing disorder and dyspraxia may identify as neurodivergent. Clients with epilepsy and even personality disorders may also identify as neurodivergent. Here I will focus on autism, although the aspects covered within this article relate to just about any client falling under the neurodivergent umbrella, most of whom will experience regulatory challenges.

What is autism?

The term autism spectrum disorder, or ASD, widely used under the medical model, is discouraged by many folks within the autism community. While autistic people definitely have an individual spectrum of autistic experience and support needs, there’s no linear journey from being more or less autistic, which is how the spectrum is often interpreted – hence, ‘spectrum’ can be confusing. Many autistic clients will have been immersed in a medical narrative in the course of diagnosis, with words such as deficit and

‘I don’t do labels…’

As therapists, we’re ethically bound to promote client autonomy and self-governance. The profession upholds the value that gender and sexual identities are equal, for example. However, there is some way to go in terms of therapists recognising neurodivergent identities as equal to neurotypical identities. To explore this further, let’s consider an area of confusion within the neurodiversity narrative – labels. Across talking therapies, social care and education, there’s a growing disparity in viewpoints concerning stereotyping. It may surprise you to know, for example, that the neurodiversity movement is in many ways pro-labelling, if labelling means identifying an individual’s support needs, respecting diagnosis and self-definition, and honouring an individual’s authenticity. For many neurodiversity-informed folks, a therapist saying that ‘they don’t support labels’ is a red flag that indicates they may not support personal autonomy if it doesn’t meet their own world views. A counsellor or psychotherapist may not want to compartmentalise an aspect of a client (for example, the client’s ‘autisticness’) because they don’t want to ‘other’ them. But this may

‘For many neurodiversity-informed folks, a therapist saying that “they don’t support labels” is a red flag that indicates they may not support personal autonomy’ THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

disability applied to them. Helping them find a more positive narrative in the form of difference and uniqueness can help bolster conditions of worth.1

MARCH 2022

Otherness or belonging

This viewpoint of recognising non-normative diagnoses (or clients’ self-identification) as a ‘flat stereotype’ leads teachers, counsellors, psychotherapists, parents and many individuals to follow the premise that we shouldn’t label someone (for example, as ‘autistic’), as it doesn’t define them. But in fearing that we may ‘other’ a client, we may not recognise that this sense of otherness also represents belonging, especially when someone is marginalised. We all know that a psychological sense of fitting in, plus social support from a community, reduces the risk factors for loneliness and depression; therefore, belonging to a ‘tribe’ can be far from limiting. One client, Ben,* explains that rather

INTERSECTIONALITY AND GENDER DIVERGENCE

be ignoring client autonomy. One client, Elle,* was told by her therapist, ‘I don’t do labels’, when Elle tried to discuss the possibility of being autistic: ‘I ended up seeking a diagnosis without telling my therapist, because she had dismissively said, “Nooo, you don’t seem autistic,” when I’d spoken about it.’ There is an outdated belief that autism is a mainly male experience – Baron-Cohen originally proposed the ‘extreme male brain theory’, which suggests that female brains tend to socialise, male brains tend to systemise, and males are more likely to be autistic.2 While it is recognised that autistic males and females do present differently (acknowledging that female autistic neurology is not based on assigned gender), the extreme male brain theory is increasingly challenged. At present, autism is underdiagnosed in individuals assigned female at birth and in gender-fluid and non-binary people, people

from ethnic minorities and people in lower socioeconomic groups. Another autistic client, Carla,* was told by her therapist: ‘I don’t want you to be limited by your autism.’ ‘As if my limitations are just a matter of mindset!’ said Carla, with irritation. ‘It’s like you finally have an explanation for things, then [a therapist] dismisses it under the guise of not wanting it to “limit you”.’ This professional wariness of naming clients’ presentations and identities for fear of ‘putting the client into a box’ and stereotyping them is not uncommon. Psychologist and author Lucy Foulkes recently wrote in a newspaper article: ‘When you use a label to describe someone, you can turn a multi-faceted... character into a flat stereotype.’3 This is certainly one viewpoint; however, it is important that neurotypical therapists are not deciding on behalf of their client what is stereotyping and what is respecting autistic identity.

THERAPY TODAY

Intersectionality recognises the interconnected categorisation of marginalised groups, such as race, ethnicity, gender identity, ability and neurology. There are especially interesting connections where neuro and gender divergence are concerned. There are clearly elevated rates of autism in transgender and genderdiverse individuals (although identifying statistics will always be complex); it’s thought that up to six per cent of transgender and gender-diverse adults could be autistic.4 Generally, however, research into autism and its prevalence in gender-minority and non-binary adults is limited. Because only a selection of individuals within a population attends therapy, and as those in marginalised groups may need support most, due to minority stress, key elements of intersectionality may condense within a client base. Counsellor Steph Callaghan has a 100% neurodivergent caseload, and says that within that figure, at least 40% of her client base at any time also identifies as gender diverse. ‘It’s paramount that counsellors wanting to focus on neurodivergent work have some knowledge of gender diversity,’ she says.

MARCH 2022

91BAPMAR22121.pgs 03.02.2022 12:47

Presenting Issues, 1

Presenting issues

Presenting issues VERSION REPRO OP SUBS

than defining and limiting them, a diagnosis ‘expands who I am, not restricts it’. It seems that neurodivergence is not yet widely regarded as a human rights issue like race, physical ability and gender diversity. Great steps are being made to educate individuals in all walks of life about racism, ableism and sexual orientation discrimination. Yet, neurodivergent folks are rarely afforded the same viewpoints by professionals; the same emphasis is not given to valuing a client’s culture (for example, autistic culture), and respecting their sense of belonging to a marginalised community.

Person-first language ART PRODUCTION CLIENT

The premise that autism doesn’t define that person extends to unhelpful language used by many therapists. As an example, person-first language, which is decreasing in popularity, describes the client ‘Jane’ as ‘having autism’. This is because ‘her autism’, in the eyes of the therapist, doesn’t define her if, for example, she’s also a mother and a teacher. But what if Jane is also black? She wouldn’t be described as ‘having blackness’ – and being a black mother does define her. And what if Jane were blind? Would she ‘have blindness’? No one would suggest that being blind would not affect and steer Jane’s perceptions of the world and how she navigates it. Thus, identityfirst language – such as ‘Jane is autistic; Jane is black; Jane is blind’ – is widely preferred by the neurodivergent community (although not exclusively! Therapists should always check their client’s preference). By using identity-first language and not imposing our own world view of neurodivergence on a client (for example, the dreaded ‘You don’t look autistic’, or ‘We’re all a little bit autistic, aren’t we?’), counsellors and psychotherapists can truly support neurodivergent clients on their therapeutic journeys. Alison Jones is a neurodivergent, person-centred counsellor specialising in neurodiversity, anxiety and trauma. She reminds us that our ethically advised openness to clients’ self-definition should also extend to clients self-identifying as neurodivergent without a formal diagnosis. ‘Knowing you are neurodivergent and having it confirmed via a diagnosis are often very different things. A diagnosis can be a huge part of a person’s identity, but there are ripples with work, family and friends that

KEY TENETS OF THE AUTISTIC EXPERIENCE Communication differences. Autistic folk commonly experience alexithymia – trouble finding words to express feelings.5 They may also experience apraxia of speech and situational mutism. Therapists should not assume they have a ‘neurotypical’ method of communication. Co-existing conditions. Autistic clients are statistically more likely to experience conditions such as depression, behavioural and anxiety disorders, self-harm and suicide.1 Contributing factors include the ‘double-empathy problem’ and the impact of masking (see below); lack of social support; difficulties with recognising and regulating emotional experiences; sensory sensitivities and executive functioning challenges causing distress, and the effects of minority stress. Eating disorders are also increasingly linked with autism:6,7 it’s estimated around 20% of people with anorexia could be autistic.8 There’s a proposed ‘bidirectional’ relationship between epilepsy and autism. Autistic children are at higher risk of developing epilepsy, and autistic children with intellectual disability are at most risk.9 Double-empathy problem. Coined by Damian Milton, the double-empathy problem identifies communication breakdowns between autistic and non-autistic

challenge one’s core. Clients can feel frustrated and not enough, leading to masking [putting on a front to appear more neurotypical] and feeling ashamed. It is therefore important not to dismiss a client’s self-definition with patronising tropes such as “We’re all a little bit autistic, aren’t we?”’ Alison says.

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

people as caused by both parties’ difficulties in understanding.10 It challenges the theory of ‘impaired mind’ – the limited ability to infer the intentions or feelings of others that is supposedly experienced by autistic people. This theory is now widely criticised.11

MARCH 2022

Empathy. Therapists should not assume a lack of empathy in autistic clients and instead could explore how empathy is processed and expressed by the client. Autistic people may activate their mirror neuron system differently, perhaps linked to a lack of ability to imitate others.12 One theory suggests that autism may be a hyper-arousal of neural microcircuits, causing hyper-perception, hyper-attention, hyper-memory and hyper-emotionality (known as ‘Intense World Theory’).13 Facial language. Autistic folk may exhibit different vocal prosody and unsynchronised (with conversation partner) facial expressions. For therapists, it may take time to get to know the client and not assume a neurotypical viewpoint of how clients should process and display emotions. Autistic clients may also avoid eye contact. This is neurological: enforced eye contact may result in ‘aberrant activation of their subcortical pathway, linked to fear response’.14

Steph Callaghan, a therapist specialising in creative, holistic counselling and trauma therapy, agrees that counsellors must help clients embrace their neurodivergence, even if it is self-identified. ‘As an autistic person, I have been personally told by a therapist: “We don’t do labels in this room.” I found it very hurtful.

Presenting Issues, 2

Masking. This is creating a more outwardly neurotypical ‘front’ to fit in, also called camouflaging. It’s a coping mechanism for neurodivergent clients. The mask can only truly come off in the therapy room when the therapist offers a secure base and a trustworthy space. Burnout or severe fatigue in neurodivergent people is often linked to masking; it can lead to problems with emotional regulation or negative self-soothing, such as with drugs or alcohol. Monotropism. This term refers to interest-based minds, commonly experienced by autistic individuals. Such brains quickly use up processing resources, so it is harder to change tack, and autistic folk often have special interests. Within the therapy room, working with clients’ special interests can help embed the therapeutic relationship. Stimming. Short for selfstimulating behaviour, stimming can include movements like finger-flicking, hair twirling or repetitive sensory activities like stroking a texture. Rhythmic behaviours help manage overwhelming external stimuli and mood. Many autistic individuals experience unregulated nervous systems, finding themselves stuck in a heightened or overstimulated flight state. In the therapy room, under the neurodiversity paradigm, social judgments of stimming may be explored, and stims should not be discouraged.

functioning’ or ‘low functioning’ is now considered unhelpful, as it generally decries the individual’s struggles or strengths. It is better to name co-existing conditions that increase their support needs. Likewise, while people diagnosed with ‘Asperger syndrome’ may still identify with this diagnosis, it’s now considered a controversial term, not least because of Hans Asperger’s involvement in the Nazi eugenicist programme. A final note on stereotyping and labelling: as therapists, a good way to check the appropriateness of our stance is to check our privilege. Do we have lived experience of neurodivergence (other than being a parent or partner of a neurodivergent person)? If not, then it isn’t our place to decide whether or not neurodivergence defines a client, or otherwise. Of course, for every case where a therapist has misjudged their therapeutic narrative, there are many more who have got it right, whether by instinct or thanks to training or self-education. When therapy is truly diversity affirming, it can be a life-changing experience for autistic clients, helping us make sense of situations, relationships and experiences we have found challenging, and develop a stronger sense of self and pride in our identity. * Clients’ names and identifiable details have been changed.

Further information The National Autistic Society and Mind recently launched a free good practice guide to help mental health professionals adapt talking therapies for autistic adults and children. Available from www.autism.org.uk

About the author

Having an autism and ADHD diagnosis later in life was hugely validating – it is not a label for me, it is a way of being. Neurodivergent clients have a difference in the way they think and communicate, not a deficit,’ she says. Not all labels are helpful, however. Describing an autistic client as ‘high

Kathy Carter MBACP is a neurodiversity advocate with a diagnosis of autism. She is a therapist, cognitive hypnotherapist and writer, and is the Therapy Today Editorial Advisory Board advisor on autism.

THERAPY TODAY

REFERENCES 1. Cromar L. A literature review exploring the efficacy of personcentred counselling for autistic people. [Online] bit.ly/3qPzOdW 2. Baron-Cohen S. The extreme male brain theory of autism. Trends in Cognitive Sciences 2002; 6(6): 248–254. 3. Foulkes L. The big idea: Is it your personality, or a disorder? The Guardian 2021; 18 October. 4. Warrier V et al. Elevated rates of autism, other neurodevelopmental and psychiatric diagnoses, and autistic traits in transgender and gender-diverse individuals. Nature Communications 2020; 11(1). 5. Poquérusse J et al. Alexithymia and autism spectrum disorder: a complex relationship. Frontiers in Psychology 2018; 9: 1196. 6. Råstam M. Eating disturbances in autism spectrum disorders with focus on adolescent and adult years. Clinical Neuropsychiatry: Journal of Treatment Evaluation 2008; 5(1): 31–42. 7. Brede J et al. ‘For me, the anorexia is just a symptom, and the cause is the autism’: investigating restrictive eating disorders in autistic women. Journal of Autism and Developmental Disorders 2020; 50(12): 4280–4296. 8. Wentz E et al. Childhood onset neuropsychiatric disorders in adult eating disorder patients. European Child & Adolescent Psychiatry 2005; 14(8): 431–437. 9. Scott RC, Tuchman R. Epilepsy and autism spectrum disorders – relatively related. Neurology 2016; 87(2): 130–131. 10. Milton D. On the ontological status of autism: the ‘double empathy problem’. Disability & Society 2012; 27(6): 883–887. 11. Gernsbacher et al. Empirical failures of the claim that autistic people lack a theory of mind. Archives of Scientific Psychology 2019; 7(1): 102–118. 12. Chan M, Han Y. Differential mirror neuron system (MNS) activation during action observation with and without social-emotional components in autism: a meta-analysis of neuroimaging studies. Molecular Autism 2020; 11(72). 13. Markram K, Markram H. The intense world theory – a unifying theory of the neurobiology of autism. Frontiers in Human Neuroscience 2010; 4(224). 14. Hadjikhani N et al. Look me in the eyes: constraining gaze in the eye-region provokes abnormally high subcortical activation in autism. Scientific Reports 2017; 7(3163).

MARCH 2022

91BAPMAR22122.pgs 03.02.2022 12:47

VERSION REPRO OP SUBS

Only human

ART

Therapists must believe that human beings are not inevitably or inherently destructive, says Becky Seale

PRODUCTION CLIENT SHUTTERSTOCK

n the recent article ‘Breaking the climate bubble’,1 Linda Aspey asked whether, if we agree that climate change is the greatest existential threat we face, we are colluding with clients’ denial if we don’t bring it into the therapy room. In response, some members highlighted the difficulties for practitioners who

feel it goes against the principles of personcentred practice for a therapist to bring it up unless the client does. This is not the only challenge for personcentred therapists who are environmentally aware. It could also be argued that the humanistic approach, with its emphasis on

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

the individual, is at the root of the behaviours that are driving environmental collapse. Do environmentally conscious person-centred practitioners need to challenge the idea of the primacy of the individual, as the late Bernie Neville suggested, because it perpetuates a world view that divorces, separates and elevates

us from the environment to which we are so inextricably entwined?2 If it is our ‘speciesism’, or exaggerated sense of narcissistic entitlement as human beings, that drives environmental destruction, as psychoanalyst and climate specialist Sally Weintrobe argues,3 then are we, as person-centred practitioners, at risk of encouraging this? Or is this a simplification and misunderstanding, as Art Bohart says, of an approach that sees the ‘self’ within a wider social and relational context?4

Boiling frogs Former US vice president Al Gore, in his 2006 documentary An Inconvenient Truth,6 used the metaphor of boiling frogs who don’t notice the increasing temperature in slowly heated water to describe the human response to ecological breakdown. Human beings live on a different timescale to the planet – rapid changes in ecological terms might not feel fast for us from our individual perspectives. It’s perhaps hard to make sense of what it means for the planet to be 1.5 degrees warmer than in pre-industrial times, and hard to notice the impact of these changes on our everyday lives. If we are lucky enough for our homes not to have been in danger from flooding or wildfires over the past few years, and not to have faced local food shortages, it can be easy to ignore that these things are happening to many others in the world. Media reporting only goes so far; for every report on an environmental catastrophe, there is a cheery weatherperson delighting in the fact that we are having an unusually warm spring. Like the frogs in their pot of warming water, we have to look beyond our immediate environment to truly understand what is going on.

Selfishness

The main psychological root of ecological breakdown, Weintrobe suggests, is a human propensity for selfishness or lack of care;3 a notion echoed by Pope Francis, who also blamed human selfishness for environmental destruction in his 2015 encyclical letter.7 But what does this mean for person-centred therapists who trust in the actualising tendency as a generally prosocial and co-operative way of being in the world and a fundamental premise of the approach? For those who are environmentally aware, guilt and shame in the face of environmental destruction can be a powerful response.

There is increasing evidence, however, that supports the person-centred view that human beings are not inevitably or inherently destructive. Psychologist Steven Pinker provides much evidence to argue that human beings and societies are becoming far less violent as they develop.8 The historian Rutger Bregman also makes a strong case against inherent selfishness in relation to environmental destruction in his bestselling book Humankind: a hopeful history.9 Despite living in a ‘culture of uncare’, it would seem that many human beings do care deeply, as recent studies, including Caroline Hickman’s groundbreaking global study of 10,000 young people, have shown.10, 11 From a person-centred perspective, recent research by Awa Ottiger and Stephen Joseph at the University of Nottingham, which aimed to assess the empirical validity of Carl Rogers’ vision of the authentic person to be ecologically minded, suggests that, rather than it being inevitable for human beings to mistreat the natural environment, destructive behaviour is a result of incongruence – in other words, a distortion of our intrinsic way of being in the world.12 The authors believe there is evidence to suggest that the more congruent someone is, the more ecologically sensitive they will be, and that our inherent instinct is to show caring awareness for our natural environment rather than exploit it from selfishness and greed. So it could be argued that, by helping clients live more congruent lives, therapists are also helping to protect the planet.

Power and agency But how do we deal with feelings of ‘ecoparalysis’ often experienced by clients in response to the climate crisis?13 Fostering a sense of agency and self-direction is an important part of a person-centred philosophy, and yet, in the face of environmental issues, we have to deal with a sense of utter powerlessness. Personally, I have felt an expectation in relation to environmental issues throughout my life

‘A person-centred perspective that puts the onus on an individual to change may only reinforce a sense of powerlessness, hopelessness and guilt’ THERAPY TODAY

that the onus is on me to change, and that if I change certain behaviours, I can elicit the change needed to halt climate breakdown. After years of recycling, not flying, not eating meat, eating locally produced food, driving an electric vehicle, opting for cloth nappies for my babies and giving money to environmental charities, only to find that the planet is still facing disaster, I feel overwhelmed by a sense of powerlessness and guilt, rather than any sense of agency. A perspective that puts the onus on an individual to change rather than the culture or society to do so may only reinforce a sense of powerlessness, hopelessness and guilt when it comes to climate change. For person-centred practitioners, therefore, as with issues such as sexism and racism, it is critical to acknowledge the impact of structural power in society, which affects individual agency, and recognise the wider context of the work we do.

Congruence and eco-empathy For Weintrobe, denial, emotional avoidance and wishful thinking are key psychological issues to address as we face climate and ecological breakdown.14 From my perspective as a personcentred practitioner, however, I question how useful these concepts are, both for me and for those seeking therapy. My feeling is that this kind of language implies an objective judgment of another person’s experience, rather than an empathic understanding. Viewing human beings as fundamentally flawed and weak in the face of their greed and selfish impulses creates a cycle of blame, shame and guilt – emotions that person-centred practitioners seek to alleviate in their clients. My experience echoes Ottiger and Joseph’s findings that the more congruent someone is, the more ecologically aware they will be.12 In person-centred theory, greater congruence develops the more an individual accepts themselves and their phenomenological experience. In therapy, it is a therapist’s ability to convey genuine acceptance through empathic understanding of the experience of others that enables a client’s self-acceptance. Viewing clients with complete respect or with unconditional positive regard is the unique and revolutionary feature of the person-centred approach, and nurturing a view of human beings as fundamentally trustworthy rather than selfish may be key in climate psychology.15

MARCH 2022

91BAPMAR22123.pgs 03.02.2022 12:50

Best Practice, 1

Best practice

Best Practice, 2

Best practice VERSION

Worthlessness

REPRO OP SUBS ART PRODUCTION CLIENT

Strong evidence suggests that consumerist culture and the endless cycle of using precious resources to make goods that are bought, sold and quickly thrown away are key contributors to climate change. We know that the atmosphere is filling with carbon dioxide and other warming gases, and the seas and land are being filled with plastics that will take centuries to disappear. If we accept that the plundering of the planet’s resources is a direct result of human action, then it’s worth considering what is driving us to over-consume to catastrophic extremes. In 1999, US economist Juliet Schor coined the term ‘competitive consumption’.16 The psychological and sociological roots of over-consumption, she argued, lie in the desire to ‘keep up’ with our neighbours and to have what others have. There is also much evidence for the impact of inequality and unfairness within societies on mental health and wellbeing, which further drives the desire to consume and own more material goods.17 From a person-centred perspective, the notion of consuming to keep up with others would point to feelings of being less worthy than others. Therefore, it could be argued that feelings of worthlessness in an unequal world are driving the environmental crisis, rather than any sense of the selfishness and ‘narcissistic entitlement’ of human beings. Understanding and recognising climate psychology in this way may facilitate an understanding and compassionate empathy for ourselves, our clients and our fellow human beings. Many of our clients may be feeling guilt, shame, selfblame, powerlessness, hopelessness, grief or despair about their personal role in creating the climate catastrophe. We counsellors have an opportunity to support our clients to process these feelings, so they are in a better place to care for the unique wonder that is this planet. We are all affected by climate and ecological breakdown, and it seems imperative that we find a way to stay grounded and don’t

‘It is important to recognise that the depth of feeling our clients may have about these issues is not a pathology’

overindulge our fears so we can remain present for our clients. As the writer and activist Alastair McIntosh says, ‘Irrespective of what is or isn’t happening in the Arctic, a methane bomb goes off inside the mind.’18 He argues we need to be cautious and seek to find a balance between doom and gloom and climate denial.

Self-care and competence

There are many things that we therapists can do to support ourselves for work in this area. They include regaining a sense of agency and community by joining others involved in activism or engaging in conversations through climate cafés. Buddhist and deep ecology scholar Joanna Macy’s project, the Work that Reconnects Network (www.workthatreconnects.org), is one example of a powerful process that provides a safe and supportive structure for addressing feelings about ecological breakdown. I believe we have an ethical duty to demonstrate competence in working with our clients by communicating an empathic understanding that holds and supports them in their emotional struggles. Competence in this area includes managing our own emotional and behavioural responses to environmental issues. This is an ongoing process, but if, as counsellors, we are able to keep a bit of a space within ourselves through remaining open to our own fears, anxieties and feelings of grief, then we may in some way be able to hold clients in a truly person-centred space while they process feelings about the climate emergency. As a person-centred counsellor, I aim to understand my client rather than to educate or explain how they are in the world. I am not asking clients to become more environmentally aware or to consider the ways their actions might be harmful to the planet, and I would not raise the subject unless the client brings it into the room. But I do listen to my clients with an awareness that the climate and environmental crisis will inevitably be having an impact on them. As Neville put it, the counsellor who attends fully to the client as a whole will be listening not only to their private pain but also to the pain of the species and the plight of the world.2 Some clients will come to counselling to directly explore their responses to the climate emergency, and it is important to recognise that the depth of feeling our clients may have about these issues is not a pathology, but an indication of their congruence.

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

About the author Becky Seale MBACP (Snr Accred) is a lecturer in counselling on a BACP accredited and university-validated course at Coleg Sir Gâr in South Wales. She is also a supervisor and counsellor in private practice, and a member of the Person-Centred Association Environmental and Climate Crisis Working Group.

REFERENCES 1. Aspey L. Breaking the climate bubble. Therapy Today 2021; 32(9) 2. Neville B. The life of things: therapy and the soul of the world. Ross-on-Wye: PCCS Books; 2012. 3. Weintrobe S. Moral injury, the culture of uncare and the climate bubble. Journal of Social Work Practice 2020; 34(4): 351–362. 4. Bohart A. The actualising person. In: Cooper M et al (eds). The handbook of personcentred psychotherapy and counselling (2nd ed). Basingstoke: Palgrave MacMillan; 2013 (pp84–108). 5. Cooper M, Bohart A. Experiential and phenomenological foundations. In: Cooper M et al (eds). The handbook of person-centred psychotherapy and counselling (2nd ed). Basingstoke: Palgrave MacMillan; 2013 (pp102–117). 6. Guggenheim D (dir). An inconvenient truth. Paramount; 2006. 7. Francis. Laudato si’ of the Holy Father Francis on care for our common home. Vatican; 2015. bit.ly/3FmS7wb 8. Pinker S. The better angels of our nature: why violence has declined. New York: Viking; 2011. 9. Bregman R. Humankind: sa hopeful history. London: Bloomsbury; 2020. 10. Andı S, Painter J. How people access news about climate change. [Online]. Oxford: Reuters Institute; 2020. 11. Hickman C et al. Climate anxiety in children and young people and their beliefs about government responses to climate change: a global survey. Lancet Planetary Health 2021; 5(12): e863-e873. 12. Ottiger AS, Joseph S. From ego-centred to eco-centred: an investigation of the association between authenticity and ecological sensitivity. Person-Centred & Experiential Psychotherapies 2021; 20(2): 139–151. 13. Blair L. Ecopsychology and the person-centred approach: exploring the relationship. Counselling Psychology Review 2011; 26: 43–52. 14. Weintrobe S. The psychological roots of the climate crisis. London: Bloomsbury; 2021. 15. Freire E. Unconditional positive regard: the distinctive feature of client-centred therapy. In: Bozarth J, Wilkins P (eds). Unconditional positive regard. Rogers’ therapeutic conditions: evolution, theory and practice (vol 3). Ross-on-Wye: PCCS Books; 2001. 16. Schor J. The overspent American: why we want what we don’t need. New York: Harper Collins; 1999. 17. Wilkinson R, Pickett K. The spirit level. London: Bloomsbury; 2009. 18. McIntosh A. Riders on the storm, Edinburgh: Birlinn; 2020.

MARCH 2022

91BAPMAR22124.pgs 03.02.2022 12:50

VERSION REPRO OP

‘We give clients the tools they need to look after their own mental health’

SUBS

ART PRODUCTION SHUTTERSTOCK

CLIENT

ike many services dependent on grant funding, The Empowerment Group counselling charity uses outcome measures to demonstrate results and effectiveness. But for founder and CEO Kunlé Oyedeji, what’s just as important – although harder to measure – is the ripple effect that benefits the communities around each client. ‘We chose the name “empowerment” because we believe in giving clients the tools they need not only to look after their own mental health but also to inform their interactions with others. Better relationships and communication can change family dynamics and particularly impact children and young people. We were also aware of the power of word of mouth, and of clients talking with friends and family about the benefits of counselling and getting support, helping to break down taboos and the culture of silence around mental health,’ he says. The aim of The Empowerment Group is simply to provide affordable, culturally appropriate counselling for black and minority ethnic people. ‘There are so many odds against BME people – lack of employment and low educational attainment, lower standards of living and income, and of course, racism. It’s important for the black community to be empowered in so many ways, to not focus on these odds, but rather to focus on carving out their own path, with the support of others who can identify with their struggle as well,’ says Oyedeji. Oyedeji is also a pastor of a London church, with a background in the charity sector, who was inspired to set up The Empowerment Group during the 2020 lockdown, in response to community need and the lack of culturally appropriate counselling. ‘I looked at my skills in the charity sector [in management, fundraising and project delivery], and thought of how I could combine those skills by reaching out to counsellors I knew, and what we could do together to empower one another to then empower our people to grow in mental wellbeing, to become strong, confident and manage their day-to-day challenges, and build them up to maintain good mental health and stability long term,’ he says. ‘Our focus was to build a team of qualified counsellors

and source funding so that we could pay them, while offering affordable sessions for clients.’ There are now 14 BACP or UKCP registered counsellors on board. Clients self-refer by filling in an application form on the website. Initially, counsellors were allocated to applicants but now clients can self-select who they would like to see from a list of profiles. ‘Giving clients that autonomy has made a big difference to client engagement,’ says Oyedeji. Clients receive 10 sessions, with the option to carry on the work as a private client of the counsellor if desired: ‘That does happen in some instances, but most clients see results they are happy with in 10 sessions. Sometimes, it’s just about getting a new perspective on a situation and helping a client realise they have the inner resources they need to manage their challenges.’ All sessions are online, which opens up the service nationwide. The application criteria are wide – the service is open to all black and minority ethnic adults in the UK – although a number of places have been ring-fenced for those on benefits or low incomes. Not surprisingly, demand has been high, but the service aims to place successful applicants with a counsellor within two weeks. Approximately 200 clients were seen during the first year of operation. ‘One of the memorable highlights for me was our service connecting with a young woman who was feeling suicidal. She had 10 sessions of counselling, which left her with a new focus and determination to give back to the community by working with young people with mental health challenges. Clients like her also then become informal ambassadors for The Empowerment Group, by talking about the part that we played in supporting their life,’ says Oyedeji. Although the charity was originally planned as a short-term response to the pandemic, there has been no let-up in demand, so the service has now become an ongoing project. Reliance on grants means the pressure is on to keep funding coming in, but Oyedeji is passionate about keeping it going: ‘Every time we work with an individual we are potentially also reaching a pool of other people that they interact with, and that makes it worth it.’ • For more information, see www.theempowermentgroup.co.uk

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

About the author Kunlé Oyedeji is the founder and CEO of The Empowerment Group, a counselling charity and organisational member of BACP providing culturally appropriate counselling for black and minority ethnic adults.

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

MARCH 2022

91BAPMAR22125.pgs 03.02.2022 13:00

My Practice, 1

My practice

VERSION REPRO OP

Making contact

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

How can we ensure potential clients find us?

SUBS

‘I try to put myself in the place of a person who is looking’

ART PRODUCTION CLIENT

New clients mostly reach me through my BACP directory listing, or after reading more about me on my website. I’ve thought carefully about how I describe my approach online. For me, the focus of what a prospective client reads should not be about my qualifications or my understanding of the psychodynamic process. Instead, I try to put myself in the place of a person who is looking for a therapist; to speak to how they might be feeling about starting therapy and what they can expect when they get in touch with me. I currently maintain a caseload of around 15 clients a week, which I think is enough for me for now as I work three days a week in private practice. When I can’t take on a new client, I refer them on via several groups of psychodynamic practitioners I belong to – it’s reassuring that I can put them in touch with a trusted colleague. Several years ago, I tried Google Ads, but found it expensive and time-consuming to maintain, with little demonstrable benefit. I avoid social media for similar reasons. Even though it’s free to use, I don’t think the amount of time you need to spend to be visible is worth it. More importantly, it feels like the wrong space to appear as a therapist – I prefer the idea of a potential client having got far enough in their thinking to be looking for a therapist on a register such as BACP’s.

‘Self-promotion is a difficult process for a therapist’ I have found that, ultimately, the most effective way to find clients is by having a website that communicates my therapeutic approach and the experience of working with me. This is achieved directly, through pages on my background, philosophy and practice, and symbolically through pictures. I think self-promotion is a difficult process for a therapist. Marketing ourselves does not come naturally, and it needs to be done ethically and sensitively. However, it is worth the struggle, as it leads to better therapist-client fits. When I began my private practice, clients found me in the same way they do now – through referrals, private insurance lists and therapy directory listings. However, it was not until I put more time into my website that I started getting long-term clients, who were consistently well-matched to my approach. Since the therapeutic alliance is one of the best predictors of outcomes of therapy, I believe strongly in the importance of communicating what I offer that is different from other therapists, from the very first click on my website. By putting work into creating an honest portrayal, I believe that therapists start off the therapeutic relationship with an element of authenticity and trust. At the start of my practice, I was nervous to share anything unconventional about myself and my work. For example, I also have a background in anthropology that I worried might confuse clients. Over time, I’ve learned that such details are precisely what draw clients to me and add to the richness of our work together. Comfort Shields, psychodynamic and humanistic psychotherapist

Mike Toller, psychotherapist and coach in private practice

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

‘Client influx can change very quickly’ Most of my referrals come through the directories and word of mouth. I have thought about using Google Ads in quieter periods, but I have never done it. It can occasionally be challenging when I finish working with a few clients at around the same time and that coincides with sparse new enquiries. I try to keep calm and to focus on CPD courses during these periods. I have learned that the client influx can change very quickly. I can go from having a half full to an extremely full practice in the space of a month. Therefore, it is important to hold my boundaries around days off, amount of clients per day and the types of issues I am willing to work with. Clients can find me in varied, unusual ways. For example, once I met an elderly Brazilian lady on the London Underground as I gave her my seat. As I am also Brazilian, we started to chat, exchanged names and she added me on Facebook. This all happened while I was still studying. As soon as I graduated and posted this update on Facebook, she messaged me and wanted to start therapy. Of course we agreed on unfriending each other on Facebook in order to keep healthy boundaries. Marina Lorenzato, psychosynthesis therapist in private practice

MARCH 2022

Talking Point, 1

Talking point

Most of my private clients come to me by word of mouth. I was very fortunate, initially, to be offered paid work with both the organisations with which I had been on placement. This provided a useful springboard. Almost immediately, I was asked if I would also take private clients. After a discussion with my supervisor, once I felt I was ready, I started in private practice, while continuing to work at the school and the community project with which I started. Today, this a balance I maintain. Over the years, I have also written columns about mental and emotional health for various local publications and then been contacted by individuals who have read an article that resonated and want to work with me. I have a website, social media presence and a blog, but tend to use them to support my work rather than recruit new clients. I have never advertised or joined any directory. As well as being a member of BACP, I am also a member of the Association of Christian Counsellors, and some clients have contacted me via that route. In those cases, people are looking specifically to include a spiritual or transcendent element in the counselling process that is rooted in Christian beliefs and ethics. They specifically want to work with someone whose world view they know matches their own, whereas usually I set my own beliefs to one side in client work.

ELLY WALTON/IKON IMAGES

‘Targeting a niche audience has been most effective’ Successful self-promotion does not necessarily come naturally to every therapist. However, it is essential to attract a steady stream of prospective clients. In my personal experience, I have found that establishing a specialist interest and targeting a niche audience has been most effective. If you try to market yourself to everyone, the expression ‘jack of all trades, master of none’ springs to mind. A previous career in marketing was certainly beneficial when it came to identifying my key audience. Nonetheless, after qualifying, I spent time learning how to best promote my fledgling private practice via YouTube tutorials created by well-established practitioners. This helped me tailor my messaging for prospective clients when building my website and registering with online counselling directories. Today, the directories generate the bulk of my enquiries, with some performing better than others. I have found sustaining a presence across several is good for ensuring search engine results. Furthermore, having my own website linked to the directories offers an extra level of professionalism, as well as a further opportunity to explain how I work as a practitioner. And as my private practice has become more established, word of mouth and colleague referrals have also become a great source of prospective clients (although I have to be mindful of any referrals who have a direct relationship with existing or previous clients!). James McWilliams, counsellor and psychotherapist for LGBTQ+ clients

THERAPY TODAY

Lucy Beney, integrative psychotherapist working with adults and young people

THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN

‘I have never advertised or joined any directory’

MARCH 2022

91BAPMAR22126.pgs 03.02.2022 13:43

VERSION

The bookshelf

REPRO OP

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

SUBS ART PRODUCTION REVIEWS COMPILED BY JEANINE CONNOR

CLIENT

Skewed to the Right: sport, mental health and vulnerability Amy Izycky (Phoenix, £25.99)

The Pluralistic Therapy Primer: a concise introduction Kate Smith and Ani de la Prida (PCCS Books, £12.99)

Sexual Addiction: psychoanalytic concepts and the art of supervision Vamik D Volkan (Phoenix, £17.99)

It’s always a good sign when your marginalia consist largely of thick black lines and scribbles of ‘Yes!’, which is what I found myself doing on so many pages of this book. An exploration of the liminal space where sporting achievement and mental ill health are uncomfortable bedfellows, this book feels long overdue. The central argument is that the traits needed to be a great athlete are often the same traits that could lead to mental ill health. Izycky is both a clinical psychologist and psychodynamic psychotherapist, so is curious about the relational developmental origins of certain traits often exhibited by elite athletes. We hear about Freud, Winnicott and Bowlby, and how childhood family dynamics can shape the athlete’s story; how athletes develop a template for a way of being that could be seen as obsessive or abusive but is validated and culturally accepted in elite sport. The explorations of different sporting worlds, particularly horse racing and rowing, are fascinating and astonishing – and not in a good way. There is a chapter devoted to injury and retirement, where an athlete has to face the complete upheaval of their identity and everything they have built their life around – a process very much like grieving. The coach–athlete relationship is explored, with a curiosity around the dynamics and an appeal for athletes to be treated as respected adults rather than commodities. Izycky asks difficult questions, explores paradoxes, isn’t afraid to draw a conclusion where it’s warranted but is equally comfortable to sit with notknowing. She writes with clarity, explaining key concepts and addressing issues that appertain far beyond the sports field alone. Nick Campion is an integrative psychotherapist in Derby

I found this book informative and challenging. For those who haven’t encountered pluralistic therapy, it is a way of approaching therapy that puts the client in the driving seat. The basis of the approach is a principled, ethical set of assumptions. This leads to a flexible, client-sensitive approach, which does not assume any particular style of therapy. It does not matter what your favoured modality is, you can be a pluralistic therapist if you share the assumptions. Following on from a description of the principles, the two chapters that made the most impact on me were on the collaborative relationship and the process of pluralistic therapy. The pluralistic approach sees ‘the collaborative relationship as the foundation of practice’. Being fundamentally collaborative has significant implications for practice, which are outlined. In the chapter on the process, the authors describe the concepts of goals, tasks and methods and the use of formulation and feedback. It is difficult to do justice to this material in just one chapter, but I came away with an understanding of how it might work. At 102 pages, the book gives a condensed but comprehensive introduction to the approach. However, do not expect a great deal of explanation or discussion. I would have liked more case examples and there is also no real discussion of problems that might arise when using different ideas and techniques from different modalities. The challenging part for me about this book is that, although I agree with the principles, I also realise how demanding it might be to be true to those principles in practice. Andy Wilson is a counsellor and supervisor working in Cardiff

Although this book is intended to explore facets of supervision within the psychosexual fields, the author does not forget the client’s importance in the relationships presented. Volkan shows great confidence in the concepts explored, which include the idea of twinning within sibling relationships and how therapeutic play may be used to understand the client’s mental conflicts. Given the locus of the book, concepts of compulsive sexual behaviours are explored in detail. As with many recent publications, related discussion of social isolation is also addressed. There is a robust roundness to the cases presented, which provides honest accounting and discussion of related concepts. The author’s approach and style result in a clear explanation of the key points while maintaining interest for the reader. This is not a dry read and is best suited to reading from cover to cover. I found myself pausing many times to consider how the supervisor and supervisee may have used other modalities, such as person-centred theory, solution-focused therapy, or cognitive behavioural therapy. For those training in psychodynamic theory, this could be a useful resource, and it may also be of equal use to those with an interest in the person-centred approach to counselling, as it could be used as a potential reference to compare and contrast approaches to psychosexual therapy and client materials. This is an enjoyable read and a good starting point to delve deeper into the concepts offered within. I found Volkan’s book to be a good addition to my library. If I have a criticism, it is that I would have liked the book to be longer, but this did not diminish my enjoyment. Beverly Neeson is a student member of BACP

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

The Bookshelf, 1

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

Waking Dreams: imagination in psychotherapy and everyday life Allan Frater (Transpersonal Press, £19.99)

What Lies Beneath: how organisations really work Ajit Menon and Trevor Hough (Phoenix, £19.99)

Sad Little Men: private schools and the ruin of England Richard Beard (Harvill Secker, £16.99)

The title of this book intrigued me, but also took me out of my comfort zone. I wasn’t sure what to expect. This book balances complex theory with examples of working with clients and using imagination in therapy. As well as being a guide to using this approach in client work, the author invites us to join him on a journey that could lead to a different way of thinking and being. We’re probably all curious about what our dreams mean, and professionally we may use a psychoanalytical approach to dreamwork, but in this book the author is challenging us with what I felt was a deep philosophical and spiritual approach to life as we experience it. As children, we more often live in our imaginations, and that’s generally acceptable. But as adults, we’re encouraged to grow up and think rationally about life. This is the essence of the author’s challenge: ‘The conventional view does not like to think of normal, everyday life as an imagined one.’ That phrase is at once both straightforward and profound. I think this book is best read slowly and carefully. There is plenty of historical information describing the dawn of enlightenment as well as the development of Freud’s psychoanalytical method. We are introduced to the approach of Roberto Assagioli, who shifted away from psychoanalysis to develop his own style of psychosynthesis. The author comments on how the mysticism at that time was largely hidden because of the need for empirical science to be ‘proven’. In a sense, the essence of the book is summed up in the closing sentence: ‘May you notice and follow novel images into an ever-richer, story-filled, and enchanted life.’ Joanna Burridge is an integrative counsellor and spiritual accompanier

The authors work in organisational development, using human relations and behavioural science theories and framework, to help organisations, leaders and individuals develop, adapt and problem-solve in order to survive and thrive. The book uses the metaphor of the iceberg to describe what happens in organisations. It is only possible to see a fraction of what is happening above the waterline – business strategy, systems, structure and metrics. What is often unseen are the relational and cultural dynamics that occur below the waterline. Menon and Hough are more interested in what happens within and around the organisation, so they focus on individual and group dynamics, which are often hidden and unconscious in the system. They look at the cultural dimensions, the norms and beliefs that impact the organisation and its performance. Each chapter tells of one of the consultant’s experiences working with a client, often around the themes of succession or transition. Each one is set in a different country, so we get a glimpse of the cultural diversity providing the backdrop against which the stories unfold. At the end of each chapter, the consultants meet to scrutinise each other’s progress in a peer supervision format. They offer each other feedback, based on psychotherapeutic principles, which enables them to overcome blockages or gain perspective, so that the consultant can return with a refined strategy for that piece of work. This book is a fun read and intends to inspire those who work in and with organisations to take up some of these ideas and especially to try the peer supervision model to help gain insight. It is short and punchy, and left me curious to read more on the subject. Mel Kinross is a counsellor and supervisor

The title of this brilliant book says it all. Within its pages, it confirms that boarding schools keep ex-boarders immature and blighted by loss and the nation stuck in an anachronistic class structure, and turn out disastrously duplicitous leaders. I have written about these issues over the past 30odd years, but here, Beard’s breathtaking personal account of the British habit of institutionalising elite children captures all the nuances and subtleties of the boarder’s undoing and its lasting legacy into adulthood. Sent away at eight, as if ‘abducted by aliens’, ‘sad and alone’, to a world based on threats and fear, where ‘toughness is the price of survival’, Beard seems to be exorcising the experience from his psyche, while warning parents against what is still considered by some to be the top choice in British education. His new book is not Beard’s usual novel-writing – neither fiction nor theory. It should be compulsory reading for therapists unfamiliar with the curious double-binds that affect the ex-boarder (being both privileged and abandoned, both of the establishment and abused by it). They will learn a lot. The novelist now lives a mile away from the muscular public school he attended, and walks its grounds anonymously, since naming the normalised neglect is still taboo. This is why Sad Little Men was slated by many unreconstructed ex-boarder reviewers in the mainstream media. It has taken a very long time for the therapy profession to get it too, but finally, with greater understanding of trauma and attachment issues, things are moving on. Ex-boarders are among the fastest-growing client group in the country, so I think it behoves all therapists to understand boarding school syndrome. Nick Duffell is a psychotherapist and psychohistorian

THERAPY TODAY

MARCH 2022

91BAPMAR22127.pgs 03.02.2022 14:49

Dilemmas VERSION REPRO OP

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

SUBS

SHOULD A SUPERVISEE BE CHALLENGED FOR NOT BEING HONEST?

ART

I am an experienced supervisor, and I suspect that one of my supervisees is not being totally honest in supervision. They never admit to making ‘mistakes’, or even any weaknesses or possible areas for development. I think that they may not be reporting some client work for fear of being judged, but whenever I challenge them over this, they deny it. Because I can only work with what they choose to bring, I’m not sure what to do about this.

PRODUCTION

Stephen Hitchcock, BACP’s Ethics Consultant, replies: In our training as

PATRICK GEORGE/IKON IMAGES

CLIENT

therapists, we probably reflected on the issue of selectivity in our practice. We acknowledge that we cannot respond to everything a client says, and are necessarily selective in what we choose to say, what to empathise with, what to question, what to pick up on and what to let pass by without comment. Our choices might well determine the direction of the therapy, and even the outcome. But what seems to be less frequently discussed is how much responsibility we have as supervisees in deciding what to take to supervision – which clients to select, how much of ourselves to bring, whether to report apparent ‘successes’ or to confess to ‘getting it wrong’ sometimes. Supervisees actually hold a lot of power! As supervisors cannot directly observe their supervisees at work (which would be inappropriate), they do have to rely on what they are told by their supervisees, and on the supervisee’s openness and honesty. Hopefully a trusting supervisory relationship is established in which supervisees feel safe enough to bring their whole selves, including their ‘mistakes’. As stated in the Ethical Framework (Good Practice, points 60–61), ‘Supervision is essential to how practitioners sustain good practice throughout their working life. Supervision provides practitioners with regular and ongoing opportunities to reflect in depth about all aspects of their practice in order to work as

effectively, safely and ethically as possible. Supervision also sustains the personal resourcefulness required to undertake the work… This requires adequate levels of privacy, safety and containment for the supervisee to undertake this work.’ Supervision is not personal therapy and it is not friendship, but a supervisor might need to help a new supervisee to work out where the boundaries lie and to demonstrate what it is. Note the respective responsibilities of supervisor and supervisee as set out in Good Practice, point 72: ‘Supervisees have a responsibility to be open and honest in supervision and to draw attention to any significant difficulties or challenges that they may be facing in their work with clients. Supervisors are responsible for providing opportunities for their supervisees to discuss any of their practice-related difficulties without blame or unjustified criticism and, when appropriate, to support their supervisees in taking positive actions to resolve difficulties.’ The Good Practice in Action resource Monitoring the supervisory relationship from the supervisor’s perspective makes clear that ‘It is the supervisor… who is responsible for managing the conscious and unconscious dynamics of the supervisory and triadic (client, practitioner, supervisor) relationships.’ If you suspect that information is being withheld by your supervisee, maybe the first step is self-examination. Ask yourself if you are

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

creating a safe enough space for open exploration. Are you being harsh or unreasonably critical? Do you feel this way generally, or just in relation to this particular supervisee? What might this supervisee be afraid of? Do they feel threatened, or fear being judged, or rejected, or complained against? Have you been overemphasising the ‘normative’ function of supervision, while neglecting the ‘formative’ or ‘restorative’?1 Your own supervision or consultancy would be an obvious place for honest reflection. The next step might be to share such questions with the supervisee and explore them together. What are they expecting from supervision? Has their past experience of supervision felt more like case-reporting or line management, rather than welcoming a wider discussion around personal impact, resilience or self-care, for example? Is supervision perceived as ‘policing’ rather than collaborative enquiry? Was it made clear at the initial contracting stage that there’s a place for challenge as well as support in supervision, and has the balance become skewed? Is a parallel process being worked out, reflecting the supervisee/client relationship or your relationship with your own supervisor? Is the supervisee withholding client information because of overlapping boundaries (whether yours or theirs)? Are your theoretical ways of working sufficiently compatible? What does the supervisee most need from supervision at this time? Has there been a lack of clarity or misunderstanding about responsibility for the client work? Note our requirement, in Good Practice, point 65, to give careful consideration to ‘the undertaking of key responsibilities for clients and how these responsibilities are allocated between the supervisor, supervisee and any line manager or others with responsibilities for the service provided’. It is possible that supervision has become rather stale and predictable so a review could be timely, as part of a regular review process. Ideally supervision is a place to be free to play with different ideas and be curious about what’s going on, for both supervisee and clients. It should be motivating and confidence-building, empowering the supervisee to leave with renewed energy and enthusiasm. If the supervisee is able to admit to being withholding, could they be encouraged to say why? Perhaps they feel inadequate, fearing criticism or judgment or being shamed. Or maybe they are

Dilemmas, 1

Ideally supervision is a place to be free to play with different ideas and be curious about what’s going on, for both supervisee and clients

too guarded about not straying into personal therapy, or not trusting you to manage that boundary effectively. Some supervisors, either regularly or periodically, put this question directly to their supervisees: ‘What are you not telling me?’ Or, ‘What about the clients you have not presented recently?’ That in itself could inject new life into the supervisory relationship. If all else fails, then perhaps it needs to be acknowledged that the arrangement simply isn’t working. If it has become unsatisfying for you as the supervisor, then the same could be true for the supervisee, and the time may have come to work towards an ending. After all, not everyone

‘clicks’ with their supervisor. Supervision is an essential element of your professional practice and ‘relies on a mutually trusting and collegial relationship in order to succeed’ (GPiA 008 How to choose a supervisor). It would be disappointing, though, if the opportunity to learn from this experience was missed, and you and your supervisee just moved on to repeat the same pattern in the next supervisory relationship. In limiting what we take to supervision, we are limiting the help that our supervisors can give us. It is better for supervisees, and ultimately for our clients, if nothing is regarded as off limits, and that we trust our supervisor to do the containing or the signposting.

THERAPY TODAY

REFERENCE 1. Inskipp F, Proctor B. Making the most of supervision (Part 1). Twickenham: Cascade; 2001.

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.

MARCH 2022

91BAPMAR22128.pgs 03.02.2022 13:46

Dilemmas VERSION

READER RESPONSES REPRO OP

‘It seems they lack what is aptly called “professional intimacy”’

SUBS ART PRODUCTION CLIENT

I would love to sit in on a supervision session with these two practitioners and see what’s really going on between them! My guess is that they are too much ‘in role’ and have never made good contact as ordinary human beings. I imagine them each adhering to their own form of ‘proper’ professional etiquette, or something unduly constraining like that, which has meant that doubts and fears about the supervision process – along with its playful curiosities and excitements – have been suppressed. In other words, they’ve avoided being vulnerable with each other. It seems they lack what is aptly called ‘professional intimacy’. Can we be honest without showing our vulnerability? I don’t think so. Can a supervisor reveal their own vulnerability to a supervisee in the service of the work? Absolutely. I’ve been fortunate to have experienced this in various ways with my own supervisors. For example, when I was a novice counsellor, it was an oddly benign shock when my supervisor told me that they once repeatedly and embarrassingly called a client by the wrong name. As a beginner, I’d assumed that highly experienced therapists like my wise and wonderful supervisor would never do such a thing. But the more significant learning was hearing from my supervisor about how carefully and constructively they discussed the mistake with the client, and how these lapses can be used – despite the apparent threat to trust and respect – to strengthen the therapeutic alliance. In deliberately stepping off the pedestal I’d put them on, my supervisor taught me two key things – first, no matter how ethically well-tuned and knowledgeable we are, we all screw up sometimes, and second, bringing to supervision the stories of our mistakes and mishaps is beneficial for everyone concerned, not only the clients. Exploring the errors of our ways is how we build our authentic caselore – the accumulated tales of what really happens in our practice, not what the textbooks tell us is supposed to happen. The supervisee in the description sounds like someone giving a polished impression of what they think they should be. As a supervisor, when I see a supervisee performing in this way, I gently shift the focus of the dialogue so that

I get to know more about the person behind the persona. Without taking up a lot of time and space, I’ll consciously bring in more of myself too. I see it as the supervisor’s responsibility to the supervisee to be ready and willing to show the strings and wires behind the scenes, so to speak. A well-trained supervisor knows how to do this with confidence. The authoritative transparency of the supervisor is, in my view, crucial to creating a setting where honesty and plain speaking take centre stage. If the supervisee can’t or won’t go there, despite the supervisor showing the way and offering specific encouragement and generous feedback, it’s probably time to bring the contract to a close. Jim Holloway MBACP (Snr Accred) is a counsellor and supervisor in private practice

‘Gentle challenge is part of the process’ What does totally honest look like? Is it possible and how will I know? These would be the first questions I’d ask myself. My style of supervising is based on relationship and trust. Where needed, I recommend that supervisees write things down between sessions so they don’t get forgotten about with the passage of time. I suggest supervisees bring, for example, anything that has made them feel unsettled or embarrassed, any achievements, safeguarding issues, and ‘how might you approach this’ questions. Also to bring clients who haven’t been thought about for a while, and ethical dilemmas, even if they don’t feel like issues. How do they experience the client? What’s the unconscious communication? Is any of their own material evoked? Are there any similarities or differences to explore? How’s our relationship? My very first supervisor urged our newly formed group to be brave enough to bring

My very first supervisor urged our group to be brave enough to bring things we were least proud of. It has stood me in good stead – it means I can take absolutely anything into supervision

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

MARCH 2022

things we were least proud of. It has stood me in good stead – it means I can take absolutely anything into supervision for discussion and I aim to foster this for my supervisees. If I felt the supervisee was not being honest, I would explore that with them in relation to the client work presented. I would ask myself if this feeling was new in our space together or if it had been there throughout our work. If I felt it was more about their work generally, I would encourage open discussion around how they prepare for supervision. I would invite exploration around mistakes, but be mindful of shame: for some people in oppressed groups and/or within some family structures there is a culture of needing not to show mistakes, as they are seen as weakness, so I would investigate carefully. I might enquire what might help them to feel safer, aware that, just because I am intending to provide a safe space, this won’t automatically make it feel safe for the supervisee. I’d enquire if they need me to do more or less of something to facilitate wider and more helpful discussions about their work. I’d invite a deeper investigation into the dynamics within supervision and whether it might be beneficial for the supervisee to explore their feelings in personal therapy. Clearly we need the supervisory relationship to feel safe enough to make ourselves vulnerable, and for our defences to enable this. Gentle challenge is part of the process. If we can allow ourselves to explore why we did/didn’t do or say something with the client at the heart of our work, we become more autonomous, accountable and consciously competent, and encounter a richer supervision experience. For example, at the end of a session, a client requested to switch from weekly to fortnightly sessions. The supervisee immediately agreed and arranged the next date. I invited the supervisee to think about what prompted the immediate decision. How else might they have responded? Would they still make the same decision now, having had time to think it through? This discussion was less about right and wrong decisions and more about self-awareness. If I became aware that a supervisee was wilfully withholding details of malpractice I would encourage open dialogue. Depending on the outcome, we would potentially find ourselves in a time of personal development, both individually and collectively, and/or

Dilemmas, 2

one or both of us might feel the need to bring about an ending to our work. I would discuss this in my own supervision/consultation before making any firm decisions. Luan Baines-Ball MBACP (Snr Accred) (they/them) is a counsellor, psychotherapist and supervisor in private practice

‘Being examined does not facilitate openness’ My take on honesty in supervision has developed from an early experience of its perils. I call it the ‘cake incident’. At my first ever training placement, a client presented me with a large cake, saying that they found baking very therapeutic. After a moment’s hesitation, I said that I would enjoy a slice after lunch and then leave it for all the counsellors to share. My client nodded happily. I had a nagging doubt about doing this and thought it could be a good topic for my course group supervision. I admit I hoped that the cake might hint at a good therapeutic alliance. So I was shocked when I was admonished about boundaries, ethics and professionalism. I left the room feeling shaken, with what seemed like strange ideas ringing in my ears, such as my client was putting something of them inside of me; that the power dynamic sounded off, and that I couldn’t trust that the cake was OK to eat. I felt humiliated and ashamed that I’d done something terribly wrong, when thinking I was doing well. I feared that I might fail the module and resolved to be more careful in future. I mulled it over and over because forcing my client to carry their cake back home felt wrong too, and could have caused therapeutic harm. What exactly should I have said and done? I eventually decided to take it to my placement supervision the following week. This supervisor had a different view. She thought I’d acted with my client’s best interests at heart and liked that I’d left the cake at the placement for colleagues to share. She used my story to discuss gifts in therapy in general with the group. It was a thought-provoking and useful learning experience. What did I learn from this, apart from to be careful around gifts? I learned that different supervisors have different styles, rules and opinions. I learned that supervision is most helpful when you feel safe enough to bring the whole truth, but that some contexts don’t feel completely safe and being examined does not facilitate openness.

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. Here is a selection:  How to choose a supervisor (counsellors) (GPiA 008)  How to choose a supervisor for your service (GPiA 009)  Monitoring the supervisory relationship from the supervisor’s perspective (GPiA 010)  Monitoring the supervisory relationship from the supervisee’s perspective (GPiA 011)

As a supervisor now, I am still informed by those early experiences. I promote honesty in supervision by demonstrating that I prize it. On my website, I emphasise my collaborative style, saying that ‘I work in an open and non-judgmental way as I want supervisees to feel secure and confident’. I use the ‘normative, formative and restorative supervision model’ that Stephen Hitchcock mentions, to ask my supervisees to plot their supervision needs as they see them on the three axes of the triangle and discuss where they feel I can help most. I ask about previous experiences of supervision, good and bad, and

 Supervision within the counselling professions in England, Northern Ireland and Wales (GPiA 032)  Introduction to supervision in the counselling professions (members) (GPiA 054)  Accountability and candour within the counselling professions (GPiA 073 and 113)  Ethical mindfulness in supervision and training (GPiA 084)

when I hear accounts that sound quite harsh I re-emphasise my stance that one gets most from supervision when you bring your biggest challenges. I say I am there to help them through their toughest moments, not to hear success stories, even though I love those too. If I suspect I’m not getting the whole picture, I will probe for it. Perhaps I’ll suggest that the next session should only be about their difficulties. I might also tell them about the cake incident. Rachel Shattock Dawson MBACP is an integrative psychotherapist and supervisor and consultant editor for Therapy Today

HOW WOULD YOU RESPOND? Can I end with a client because I don’t like them? I am struggling to like one of my clients. They are frequently late for their appointments, with no apology or explanation, and they seem quite distracted in sessions. What’s worse is that I find myself questioning their integrity. Sometimes I refer back to something they have said in a previous session, and they deny ever having said it, and this throws me completely. I really don’t wish to work with them any more, yet I fear it could be damaging to them to bring the work to an end. Also, I’m mindful of our commitment to ‘make clients our primary concern’, so does this mean I have no choice but to stick with them? 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.

THERAPY TODAY

MARCH 2022

91BAPMAR22129.pgs 09.02.2022 14:53

VERSION

What do you do for self-care/to relax? I run,

practise yoga, spend time with friends. During the lockdowns, I took up an old hobby of crocheting and started learning to paint.

me Analyse

SUBS

SHUTTERSTOCK

REPRO OP

Marilyn Gulland speaks for herself

ART

What motivated you to become a therapist? Being a parent, and

trying to understand how and why patterns of behaviour and relating are passed down through generations, irrespective of their benefit.

PRODUCTION

Do you have a specialist field of practice? I work in private practice,

CLIENT

with intensive short-term dynamic psychotherapy (ISTDP), which is an accelerated form of experiential psychodynamic psychotherapy. It involves operating as a feedback loop on the moment-by-moment process that occurs between therapist and client and within the client. It is often a novel experience for the client to pay such minute attention to themselves, their anxiety, bodily reactions and feelings. The process helps clients to gain insights that might otherwise be hard to access, and to gain understanding of the way they might be maintaining their suffering. It is incredibly challenging and intense, but I love it because it is dynamic, positive and compassionate. What have you learned about yourself since becoming a therapist? That I have an enduring

desire to learn and that there is so much I do not know. In particular, it has been incredible to experience the wealth of difference and diversity in humanity as I have learned to listen and attune to each client with devoted moment-to-moment curiosity, compassion and care.

What do you find challenging about being a therapist? Watching

a client choose to continue their suffering for whatever reason, rather than to work towards the change they also really long for.

And what do you find most rewarding? Seeing the deep change

that ISTDP can bring and watching clients leave feeling freer, braver and more hopeful about their future, often having courageously faced the hard and sometimes fear-inducing feelings inside them. How do clients find you? Mostly

through referrals within the ISTDP community. I often get referred clients who for various reasons have had previous failed therapies.

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

For therapeutic reading, I often recommend Adult Children of Emotionally Immature Parents: how to heal from distant, rejecting, or self-involved parents by Lindsay Gibson, a US-based clinical psychologist. It can help clients to see themselves in the context of their family of origin, including how they might be repeating patterns of relating with adult siblings. It’s easy to read and jargon free, making it accessible and helpful. For pleasure, the novel A Fine Balance by Rohinton Mistry – the work of a master storyteller. It

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

takes you on an emotionally charged journey of human relationships steeped in struggle and suffering, while also holding onto the hope of humanity and human relations. What are you most proud of achieving? Raising children who

are (mostly) able to tell me how they honestly feel, and even that, I know, I cannot take full credit for.

Where would you like to be in five years’ time? Right here!

The pandemic has provided me with a wonderful opportunity to slow down and practise mindful contentment. I feel blessed to be able to do work I believe in and love, and particularly at a pace that means it does not feel like work. What gives your life meaning?

My faith as a practising Christian, with its core message of love as a healing force.

About Marilyn Now: I work online and in central London offering weekly or block therapy sessions for treatmentresistant depression, anxiety, relational difficulties and also medically unexplained symptoms that might have emotional roots. Once was: A solicitor – I studied law at Durham University and practised in the City for many years. And this is a cheat answer, because I still consult as a solicitor on an ad hoc basis, but I am grateful not to have to work at it full time. First paid job: Administrative assistant for a haulage company in Basel, Switzerland.

Who is your psychotherapy (or counselling) hero(ine)? Each

and every one of my teachers and supervisors who have taught me with kindness, curiosity and humility. What would people be surprised to find out about you? I am a

published novelist. I wrote two novels set in Ghana during the recent history. I abandoned my third novel, and do not imagine that I will resume writing it, but you never know.

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

MARCH 2022

91BAPMAR22130.pgs 03.02.2022 13:06

Analyse Me, 1

The questionnaire