Cover
SEPTEMBER 2021 | VOLUME 32 | ISSUE 7 THERAPY TODAY
VERSION
It turned out I didn’t really know how I felt about anything
REPRO OP
Page 27
SUBS ART
Understanding why clients drop out
PRODUCTION CLIENT
SEPTEMBER 2021, VOLUME 32, ISSUE 7
Improving counselling and psychotherapy for clients // The ethics of vaccination status Students’ experiences during the pandemic // Hybrid working – does it work?
BLACK YELLOW MAGENTA CYAN
91BAPSEP21127.pgs 09.08.2021 18:21
Contents, 1 VERSION
Contents September 2021
REPRO OP
Upfront
5 6 10 11 12 16 20
The big issue Catherine Jackson asks what new research tells us about effective counselling and psychotherapy Someone at the end of the line Rob Buttery describes how telephone counselling provided therapy for women in prison during the pandemic The power of reverie Marjorie Wittle looks to Wilfred Bion to help us understand the impact of the COVID crisis Understanding why clients drop out What to do when clients drop out of therapy? Frances Bernstein draws on her experience Hybrid working Sally Brown discusses how we can combine in-person and online working Articulating what we offer How do employers and commissioners think SCoPEd will help counsellors and psychotherapists become more employable?
22
It changed my life Talking point The bookshelf Dilemmas Analyse me
27 46 48 50 74
Classified, mini ads, recruitment, CPD
54
SUBS
Welcome News round-up CPD and events From the Chair Spotlight Reactions The month
Main features
CLIENT
Regulars
Rob Buttery (‘Someone at the end of the line’, pages 28-31)
Opportunities
On the cover..
Understanding why clients drop out
Frances Bernstein explores what clients may be communicating when they miss sessions (pages 35–37)
35 38 42
Company limited by guarantee 2175320 Registered in England & Wales. Registered Charity 298361
BACP Board and officers
Chair Natalie Bailey President David Weaver Governors Sekinat Adima, Michael Golding, 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
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
32
GIOVANNI SIMONCELLI
PRODUCTION
MILES WALKER
ART
‘On my first day I was told that, if you can hold clients in prison, you can hold clients anywhere’
28
3
Contact us by emailing: therapytoday@thinkpublishing.co.uk
SEPTEMBER 2021
91BAPSEP21128.pgs 09.08.2021 18:22
VERSION
From the Editor
I
REPRO OP
am delighted to introduce the new Editorial Advisory Board, the group of talented practitioners who have agreed to share their professional and personal experience to inform and shape the content of Therapy Today. Finding the right team wasn’t easy – I was seeking working practitioners, but also ‘experts’ in an area relating to diversity, with experience or an interest in writing and the publishing process. Part of the Advisory Board’s remit is to ensure that Therapy Today feels like an inclusive and welcoming place for all – I know we don’t always get it right but we are committed to listening and learning, and welcome the guidance that the Advisory Board will bring. You can read about them and their hopes for Therapy Today in the ‘Spotlight’ feature on pages 12-14. We also launch a new-look ‘Dilemmas’ section this issue, starting with a topic that has been the subject of much debate on social media – whether we can ask clients about their vaccination status. The section will now combine an in-depth answer from BACP’s Ethics team with responses from practitioners. We’ve tweaked this in response to feedback from members who missed the peer advice shared in a previous version of this section. I hope this new ‘hybrid’ approach will combine the best of both expert and member advice. Hybrid has become a bit of a buzzword of late – the future of working, we are told, is a hybrid or blended approach with both remote and in-person contact, which I explore in the ‘In practice’ feature this issue (see page 38). Like many practitioners, I’ll continue to offer online sessions as part of my practice alongside in-person work. Once I let go of the ‘it’s not the same’ thinking and assessed online and telephone sessions on their own merits, rather than how they compared with being in the room, I noticed a new quality of connection and the possibility of in-depth, focused communication. I was also struck by how quickly clients adapted and how the balance of power shifted slightly in clients’ favour – now they can take sessions in the comfort of their homes, without needing to
SUBS ART PRODUCTION CLIENT
travel. Many practitioners have noticed their client cancellation rate has gone down as a result. Of course, it’s not just transport issues that stop a client from attending a session. As Frances Bernstein explores in our cover feature this issue, sometimes the client is communicating something important when they don’t turn up. DNAs, as they’re often known, are frustrating, stalling the work and leaving us wondering if the client is OK, I know we don’t and what we might be missing or not always get it right but getting right. You can find ‘Understanding why clients drop out’ on page 35. we are committed to The pandemic is far from over. In ‘Talking point’ (pages 46-47), five students listening and learning, share their experiences of training during and welcome the the lockdowns. And in our ‘Counselling changes lives’ section, Rob Buttery guidance the describes his moving experience of setting up a telephone counselling service Advisory Board in a women’s prison during lockdown will bring (see page 28). I don’t have space to do justice to all the content of this issue, but I would like to draw your attention to our ‘Big issue’ feature. Catherine Jackson discusses research findings – new and old – on what makes a difference to client outcomes. Some of it is challenging, but all of it is important. And don’t miss the SCoPEd update, where we hear from employers and commissioners who believe SCoPEd will help make counsellors more employable (pages 42-45). As ever, your feedback – positive or otherwise – is always welcome. Do email your thoughts on any of the content to me at therapytoday@ thinkpublishing.co.uk Sally Brown Editor
COVER IMAGE: GIOVANNI SIMONCELLI
Contributing to Therapy Today We welcome submissions from practitioners. To submit, please send a paragraph synopsis of your proposed article to the editor at sally.brown@thinkpublishing.co.uk. Please note, we currently do not publish poetry. For further guidelines, see www.bacp.co.uk/bacp-journals/author-guidelines Editor Sally Brown e: sally.brown@thinkpublishing.co.uk Art Director George Walker Copy Editor Catherine Jackson Managing Editor Marion Thompson Consultant Editor Rachel Shattock Dawson Reviews Editor Jeanine Connor Production Director Justin Masters Client Engagement Director Rachel Walder Executive Director John Innes Commercial Partnerships Director Sonal Mistry d: 020 3771 7247 e: sonal.mistry@thinkpublishing.co.uk 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
5
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
SEPTEMBER 2021
91BAPSEP21129.pgs 11.08.2021 16:13
Welcome, 1
Welcome
VERSION
News round-up
Our monthly digest of news, updates and events REPRO OP
Working for you SUBS
FROM THE CEO
ART PRODUCTION CLIENT
At the time of writing, the UK Government has relaxed COVID-19 restrictions to reflect a more ‘normal’ way of life. Although for many of us this is a long-awaited change, we recognise that the past 18 months have been hugely challenging for all our members. We’ll continue to keep you updated with relevant guidance and support through what continues to be a very uncertain time. You can find our most recently updated guidance for England, Scotland, Wales and Northern Ireland on our website and, if you haven’t already, I’d encourage you to familiarise yourself with this information. We’re also continuing our commitment to provide regular updates on SCoPEd in these news pages. This month, we’ve gone back to its origins. We hope that, by exploring how we’ve arrived at today’s shared draft framework, we’ll provide clarity around questions some of our members have. You can read about the origins of SCoPEd on page 9. We also have an in-depth report on how employers and commissioners think SCoPEd will help counsellors and psychotherapists become more employable (pages 42-45). Our annual AGM takes place online on Friday 5 November and if you’d like to attend, you can book your place on our website. The AGM ballot paper voting opens in October and I’d encourage you to use your voice and vote to support your preferred candidate’s election to the BACP Board of Governors. It’s extremely important to have your say as our Governors represent you, our members, and they’re instrumental in delivering our organisational objectives, directly influencing our strategic direction and ensuring the best possible member experience. Finally, I’d like to extend my warmest congratulations to our former Chair, Andrew Reeves, who has recently received a full professorial title from the University of Chester. You can read more about Andrew’s well-deserved appointment on page 7. Hadyn Williams BACP CEO
■ We wrote to the Mental Health Minister, Nadine Dorries, and the Health and Social Care Committee to share the latest evidence on the availability and competence of counsellors trained to work with children and young people (CYP). It followed inaccurate comments made by Ms Dorries on social media regarding the counselling workforce for CYP and also given in verbal evidence to the committee. We also highlighted findings from our recent workforce survey indicating that around a third of our 58,000 members – approximately 19,000 counsellors – have undertaken specific training for working therapeutically with CYP. And we highlighted how our members could easily, efficiently and effectively meet the current demand and step into contracted work to alleviate the pressure on other services. ■ We welcomed an announcement of £4.2 million in funding for mental health counselling services in colleges and universities in Scotland. The allocation from the Scottish Funding Council was part of a four-year programme – which began in 2019 – to
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
6
provide more than 80 additional counsellors in further and higher education. Jo Holmes, our Children, Young People and Families Lead, said: ‘Equality of access for college and university students is a fantastic offer, ensuring no matter where a post-16 student studies, there exists no postcode lottery, with the counselling offer being universal.’ ■ We’re working with the Health Devolution Commission to ensure the new Health and Care Bill – which was published before the summer recess – has a positive impact on the mental health of communities. A key area of interest for us is the opportunity for the Bill to extend community-led counselling provision by enhancing the role of Integrated Care Systems to help provide more accessible support for people and communities most affected by the pandemic. We’ll be lobbying Government to achieve this important objective. To strengthen our lobbying on the Bill, we’ve joined the Health Devolution Commission, chaired by Andy Burnham, the Mayor of Greater Manchester and former Health Secretary. The Commission also includes a cross-party grouping of former Health Ministers.
SEPTEMBER 2021
■ We believe Northern Ireland’s ambitious new mental health strategy is an ‘important milestone’ and recognises the critical role counsellors and psychotherapists have in supporting the nation. The document sets out the strategic direction of mental health services in Northern Ireland for the next decade and calls on the Executive to ensure they’re adequately funded. It includes plans to ensure psychological therapies, including counselling, are more widely available and commits to investing in developing the workforce of counsellors and psychotherapists in Northern Ireland. We’ve been pleased to play an active role in the consultation that’s led to the strategy, calling for this increased investment and recognition of counselling. Earlier iterations failed to mention counselling and we’re glad this has been addressed following our representations. We were particularly grateful to work with many of our members, mental health partners, third sector counselling organisations, the Participation and Practice of Rights 123 GP campaigners and the University of Ulster to form our responses to the strategy, together with the Northern Ireland Counselling Forum.
News, 1
2
mInutes with… Steve Mulligan
Describe your role at BACP:
Do you have a guilty pleasure?
My role is to promote the profession to Governments, politicians, commissioners and partners across the four nations, grow opportunities for our members, and work to increase trust and recognition of the counselling profession.
I have a serious crisp habit.
What’s the best thing about working for BACP? To have met so
many hugely inspirational members in my work across the four nations. What gets you up in the morning?
The privilege of having a job that makes a difference to society.
Steve Mulligan BACP’s Four Nations Lead answers our ‘getting to know you’ column. Look out for other BACP staff members in upcoming issues.
Who is your hero? My dad, who
left school at 15 with no qualifications, worked tirelessly in the Labour movement to support and champion others and was a lifelong learner, and ended his career as a recognised legal specialist who never lost his core values. What was the last book you read?
Malachi O’Doherty, Fifty Years On: the troubles and the struggle for change in Northern Ireland. What’s your go-to karaoke song? ‘For Once in My Life’,
Tell us your proudest achievement?
by my namesake, Stevie Wonder.
Successfully lobbying with colleagues, members and partners for the Scottish Government to invest £80 million in counselling across all education settings.
What’s your favourite travel destination? Ronda
in Andalusia, where my wife and I got married.
What’s your biggest challenge?
Working to influence politicians who have widely different priorities and values is always a significant challenge, but so satisfying when you have a breakthrough! What’s the best advice you’ve been given? From my Glaswegian
dad – ‘We’re a’ Jock Tamson’s bairns’ – we’re all connected and collectivism and working together for the common good is in everyone’s interest.
What would you like to achieve over the next year?
My aims for the next 12 months are to ensure the profession is at the forefront of all government plans to rebuild after the pandemic; secure much more recognition for our members in Northern Ireland’s 10-year mental health strategy, and rapidly re-establish strong links with the new Governments in Wales and Scotland to ensure greater investment in counselling and psychotherapy.
PROFESSIONAL CONDUCT
It’s a great pleasure to announce that former BACP Chair Andrew Reeves has received a full professorial title from the University of Chester. Andrew joined the BACP Board of Governors in 2013 and was elected Chair in 2014, serving five years in the position. A professorial title is awarded to give public recognition to individuals who have achieved academic distinction and who have an outstanding record and reputation in a field relevant to the mission of the university. To be considered for a professorial appointment, candidates must evidence their academic citizenship and leadership, including evidencing high-quality leadership that contributes to the aims and objectives of the university and recognition of the activity beyond the university. Following this decision, Andrew’s full title is now Professor in the Counselling Professions and Mental Health. We hope you will join us in sending Andrew our warmest congratulations on such a welldeserved achievement.
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
Former BACP Chair Andrew Reeves receives professorial title
7
¢ BACP’s Professional Conduct Notices can be found at www.bacp.co.uk/professional-conduct-notices
SEPTEMBER 2021
91BAPSEP21130.pgs 11.08.2021 16:15
VERSION
News round-up
Our monthly digest of news, updates and events REPRO OP SUBS
The impact of COVID-19 on mental health
Members in the media
ART PRODUCTION CLIENT
• Louise Tyler joined Caroline Jesper, our Head of Professional Standards, and fellow members Cate Campbell and Denise Freeman • for a series of interviews on radio and television about the BACP Mindometer report and its findings. The interviews had a combined reach of almost 7.5 million people. Elsewhere, Fiona Ballantine Dykes contributed to an article in The Guardian about professional standards in therapy and the need for people to see a qualified therapist who is on a Professional Standards Authority register, such as ours. Denise Freeman shared her expertise from working with TV and film companies with newspapers in Scotland, discussing the mental health support that needed to be available for Love Island contestants. Rochelle Armstrong and Deone PayneJames • offered advice for people affected by the racist abuse of England footballers after the Euro 2020 final, while Kemi Omijeh discussed tackling racism in the workplace. • Caroline Plumer spoke to The Independent about how the England football team could use the disappointment of defeat in the Euro 2020 final to spur them on in the future, while Glenda Roberts spoke to the East Anglian Daily Times about problem gambling around the tournament. Jessica Mitchell • talked to GM Journal about how to support the mental health needs of people with cancer. The mental health impact of social media was discussed by Jennifer Park in Cosmopolitan, while the mental health benefits of running were highlighted by • William Pullen and Eve Menezes Cunningham in Stylist. If you are interested in becoming a BACP media spokesperson, email media@bacp.co.uk
■ Thank you to the 4,923 members who took part in our Mindometer survey, which found that more than half (51%) of our members think we’ll continue to see the impact of COVID-19 on people’s mental health for up to five years. A further third (36%) think the impact could last for more than five years, while 80% report demand for therapy means their service is either full or over capacity. ■ BACP Chair Natalie Bailey took to national radio to discuss the findings of the report and urge the Government to increase funding for counselling and psychotherapy to help meet the country’s mental health needs through the pandemic and beyond. Natalie told talkRADIO listeners that there’s been an increase in demand for therapy since the start of COVID-19 and called on the Government to put our members at the heart of the recovery. ■ Interviewed on The Week with Trisha on talkRADIO, Natalie
■ Our Chief Executive, Hadyn Williams, and BACP member Louise Tyler also contributed to an article on the Mindometer report in the Sunday Express. And Fiona Ballantine Dykes, our Deputy Chief Executive, spoke in a series of radio interviews, including LBC, BBC and Sky News radio. Fiona told LBC, ‘The survey produced interesting information that people are finding therapy more accessible because of the platforms it’s being delivered on. We’re seeing the possibility for greater access to therapy for more people.’ For the full report, go to www. bacp.co.uk/media/12035/bacpmindometer-report-2021.pdf
2021 AGM – ensure your voice is heard This year’s ballot paper voting opens on Monday 4 October and runs until 1pm on Friday 5 November, the day of our AGM. During this time, members can vote in favour or against all AGM voting items, including those resolutions and motions that gained enough support at the previous stage. All members eligible to vote will receive an email from Mi-Voice, who are managing the election process on our behalf. This email will include a voting link and a unique code. It’s important that you use your vote and have your say in this important process. The AGM will take place online on Friday 5 November and will include a review of BACP’s year, a live Q&A panel and keynote sessions. We’ll also formally announce our newly elected Governor. To attend this year’s AGM, book your place at www.bacp.co.uk/events/agm511-bacp-agm
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
said: ‘As a result of the pandemic, we’ve seen an increased demand. We’ve been calling on the Government for increased funding for mental health and also to include counsellors and psychotherapists as part of the solution. We have 58,000 members who are trained and ready to address these issues.’
8
SEPTEMBER 2021
News, 2
SCoPEd What are the origins of SCoPEd and how did we arrive at today’s shared draft framework? SCoPEd emerged in 2016 as part of a joint solution from BACP, BPC and UKCP to resolve existing challenges caused by the lack of a shared framework for professional standards when engaging with Governments, employers, clients and commissioners. No formal research was needed to identify these challenges – it was clear from the collective discussions with these important external stakeholders that this issue was, and still is, restricting opportunities for our members within the profession. The three partners, working together as the Collaboration for Counselling and Psychotherapy Professions (CCPP), agreed to use the Roth and Pilling methodology as the starting point for SCoPEd. However, when reviewing the available research literature, it became apparent that this methodology was not broad enough to capture all relevant information about training and practice standards. As a result, the collaboration has systematically and comprehensively reviewed existing standards, competences and practice standards associated with current training, membership and progression routes as sources of evidence to develop the first two iterations of the framework. Published standards and competences from other professional bodies, standards setting bodies, professional qualifications and relevant published competence frameworks were also analysed and included during the literature research. Alongside the first framework iteration, the SCoPEd partners produced a methodology document (November 2018), to describe how the work had been undertaken and to explain the process of member engagement and how and where feedback has been applied. This was updated with the release of the second framework iteration (SCoPEd methodology update, July 2020). The July
2020 methodology document shows how the Technical Group and Expert Reference Group (ERG) ensured that every item of feedback was reviewed and how each area of feedback was systematically considered to further develop the framework, while also remaining faithful to the available evidence. The document also includes details of ethical considerations and methodological limitations and information about the small group clarity check process by critical readers. This was undertaken to gain preliminary feedback about whether the revised framework successfully addressed concerns and member feedback, and whether the information had been presented in the clearest possible way. The expanded group of SCoPEd partners, including the Association of Christian Counsellors (ACC), Association of Child Psychotherapists (ACP), Human Givens Institute (HGI) and National Counselling Society (NCS), who joined in November 2020, is continuing to review and assess the evidence submitted after the publication of the most recent iteration of the framework and, where appropriate, make recommendations to the ERG for further changes. The aim is to agree a shared framework that maps existing evidence-based minimum training standards, knowledge and experience required for therapists working with adult clients. The final iteration of the shared SCoPEd framework is anticipated to be agreed by the end of 2021. It will then be up to individual bodies, including BACP, to decide whether and how to adopt it. The decision as to whether BACP will choose to adopt the framework will be made by BACP’s Board. To view the methodology documents and to find out more about SCoPEd, please visit www.bacp.co.uk/SCoPEd
THERAPY TODAY
9
Listening to our members So far, we’ve held five listening workshops and have asked those who attended or watched on-demand to complete a short survey to help us ensure they’re a benefit to members. Overall, many members agreed or strongly agreed that the content of the first three workshops was good – policy (80%), research (72%) and member experience (54%). Many members agreed or strongly agreed that the policy (57%) and research (50%) workshops helped them to feel listened to as a member. But slightly fewer members (40%) agreed or strongly agreed that the member experience workshop helped them to feel listened to. While most feedback has been largely positive, some members felt our panels haven’t always engaged with attendees enough, that we didn’t answer every question and at times our responses felt rehearsed. We are committed to taking the feedback on board and will be working hard to ensure a better balance between responding to pre-submitted and live questions at each of our future events. We also hope to interact more actively with attendees in the chat room. Thank you to everybody for joining the events and for your feedback. You can find full details of members’ feedback to the first three workshops at www.bacp.co.uk/news/newsfrom-bacp
SEPTEMBER 2021
91BAPSEP21131.pgs 11.08.2021 16:15
REPRO OP SUBS
CPD hub in the Learning Centre
ART PRODUCTION CLIENT
How does it feel to be bereaved during the pandemic, and have your loved one’s death presented as a statistic? Kathryn de Prudhoe’s powerful presentation, ‘The dehumanisation of the COVID-19 pandemic and my fight for justice’, draws on her personal experience to help you gain an understanding of the issues surrounding the reporting of COVID-19-related deaths in the UK, the dehumanisation of victims and the continual traumas suffered by victims’ families. Kathryn is a counsellor and psychotherapist who is active in the COVID-19 Bereaved Families for Justice campaign. To view this content, you can subscribe to the CPD hub for £25 a year, and access more than 300 hours of CPD
content and a personalised CPD certificate for your records. To find out more, see www.bacp.co.uk/cpdhub You can now find the CPD hub in the Learning Centre, BACP’s new home of learning. The Learning Centre also hosts a selection of free CPD resources, including the Therapy Today podcasts. You will receive a personalised CPD certificate following completion of each resource. The Learning Centre provides a free plan and log tool for you to use to plan your CPD at the start of your membership year and record CPD completed both inside and outside of the Learning Centre. For more information, see www.bacp.co.uk/learningcentre • Join our team of reviewers Want some CPD for free? Join our panel to review new CPD hub resources. You’ll also be helping us to ensure resources are accurate, relevant and accessible for members. For more information about this voluntary role, see www.bacp. co.uk/careers/work-with-bacp/onlinecpd-review-panel
Private Practice Conference There is still time to sign up for this year’s Private Practice Conference, ‘When words are not enough: using creative approaches to therapy’, which takes place online on Saturday 25 September. Highlights include keynote speaker Professor Helen OdellMiller OBE, Professor of Music Therapy and Director of the Cambridge Institute for Music Therapy Research at Anglia Ruskin University in Cambridge, whose research interests include music therapy, mental health and dementia. There will also be a second keynote speaker and six workshops on the theme of creativity, including supervision, dream compilation and metaphors. The day is dedicated to exploring creative approaches that help clients access and describe emotions and experiences in depth when words are not enough. Join us to explore ways that creativity can offer a different dimension to your private practice, as a form of expression and release and a way of creating space for healing and growth for both you and your clients. Speakers will join our hosts in the chat room for live question-and-answer sessions after their presentations, and workshops will span two strands so you can build your own flexible programme. It costs £25 to attend, which includes viewing the live stream on the day and the on-demand service for three months after the event. To book, see www.bacp.co.uk/events-and-resources/bacp-events
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
10
Working with children and young people’s online lives This one-day event will enable practitioners who specialise in children, young people and families to consider how they best approach and engage with children and young people’s online lives as part of everyday practice. Leading experts in the field of online safety will outline key concerns and considerations in keeping vulnerable children and young people as safe as possible online. BACP’s Children, Young People and Families Lead, Jo Holmes, is a member of the UK Council for Internet Safety Vulnerable Users Working Group, developing resources and training opportunities to support professionals working with children and young people. Jo and the chair of the group, Claire Levens, will host this event, which will highlight good practice considerations. This online event costs £35. To find out more, see www.bacp.co.uk/events
Presenters for events We’re looking for presenters to deliver new and thought-provoking content that will become a valuable CPD resource and feature topics we’ve not yet covered. We host events throughout the year and are actively looking for wider inspiration from members and non-members alike. If you, or someone you know, would be interested in delivering a presentation, please email us at events@bacp.co.uk
SEPTEMBER 2021
91BAPSEP21132.pgs 09.08.2021 18:18
BACP Events/CPD, 1
VERSION
BACP events and CPD
From the Chair, 1
VERSION
From the Chair
REPRO OP SUBS
The preparation for this year’s AGM (on 5 November) has been ongoing since the end of last year’s event
ART PRODUCTION CLIENT
Members will recall the last AGM was held remotely due to coronavirus lockdown measures. Although we were not able to meet in person, we were able to reach members who otherwise might not have been able to access the event and, as a result, we saw an increase in attendance and increased levels of voting. Despite lockdown restrictions easing, we are operating with caution, and this year the AGM will be a hybrid event, with BACP staff and Board members attending in person but members again invited to join online. I am looking forward to seeing many more of our events take on this hybrid format to add some variety to the purely online approach. I am sure I am not the only one who has found that the past 18 months of working remotely have presented many obstacles. When I set up in private practice, I made a decision not to practise from home as I valued separating my work and home life. Like many others, I’m now working from home and enjoying the convenience of not having to travel and being able to fit in other commitments. But I hadn’t bargained for this period to feel like such a stretch. It’s been nearly two years since I first became Chair, and I hadn’t imagined that most of my term so far would be spent chairing meetings, attending conferences and seminars and taking back-to-back video calls from the confines of my living room. Finding ways to form bonds without meeting the Governors who joined the Board last year has been remarkably similar to counselling clients online – effective, but different. At this year’s AGM, more new members will be joining, before some Board members have managed to meet in person.
Working relationally is an important aspect of the Board, so we value coming together to make collective decisions, such as deciding which resolutions and motions will go through to the AGM for members to vote on. Resolutions are legally binding and Board members devote considerable time and attention to deciding which resolutions to approve to move on to the support phase. The support phase is the period in the run-up to the AGM where members get to show support for the submissions they want to go through to the AGM. For a resolution to go through to the voting stage at the AGM, 5% of the membership must support it. If a resolution receives a majority vote at the AGM, it will be adopted by the Board.
Natalie Bailey
Chair, rd of Governors Boa BACP
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
11
Motions, which are not legally binding, require 0.01% of members’ support to move on to the support phase. If a motion receives a majority vote at the AGM, it will be brought to the Board for full discussion, and a decision made on whether it should be adopted. Once a member submits a resolution or motion, it is assessed by BACP officers to ensure it is in the correct format and to add any information the Board may require to make an informed decision. Each Trustee on the Board will receive the information ahead of the Board meeting so they can review the information and any legal advice. It is BACP Trustees alone who are eligible to vote on whether to accept a resolution or motion, and each submission is reviewed through a Trustee lens and our legal obligation to act in the best interests of the Association. This involves suspending personal opinion and assessing various factors, such as whether submissions meet our charitable objectives and align with BACP strategy. The preparation for the AGM is always a busy period in the BACP calendar. It involves a huge amount of work for BACP staff and for the Board, who volunteer their time. It’s also the time when members are most active. Resolutions and motions are a valuable way of engaging with members and offer an opportunity to present ideas to the Board for discussion. The window for members to show support for the resolutions and motions they want to go through to the voting stage at the AGM closes on 3 September. I would encourage all members to engage in the process and register to virtually attend the AGM in order to be able to vote.
SEPTEMBER 2021
91BAPSEP21133.pgs 09.08.2021 18:17
VERSION
Spotlight
REPRO OP SUBS
Meet the Editorial Advisory Board Introducing the practitioners who have joined the Therapy Today Editorial Advisory Board JOHN BARTON
ART PRODUCTION
About you: Carl Jung said the afternoon of life is a very different proposition from the morning. Volunteering for the Central London Samaritans was, for me, the high noon moment. Up to that point, I wanted to see the world – I had been working for glossy magazines, writing, editing, interviewing people, travelling a lot and living in the US. Since then, it is the mysterious interior landscapes of the human mind and soul that have beckoned. I am now a counselling psychologist and integrative psychotherapist in private practice. I work with all kinds of clients, many facing great transitions or existential challenges. The central topic in my doctoral thesis, an upcoming book and my life is disability – my ‘afternoon’ is guided by a pair of tough but transcendent teachers: two progressive neurological conditions.
PHOTOGRAPH OF JANE CZYSELSKA BY L+R
CLIENT
What you hope to bring: BACP members have such a wealth of personal and professional knowledge and experience and Therapy Today is a terrific, beautiful and accessible meeting place where we come to learn, contribute and join in the conversation. I hope to bring ideas, encouragement and constructive feedback to help maintain the magazine’s position as a beacon for the industry. I’m particularly interested in upholding a diversity of voices that includes that most different of differences – disability. What might people be surprised to learn about you? If I could have just
JANE CZYSELSKA
WHY AN EDITORIAL ADVISORY BOARD? Therapy Today aims to be the voice of members, but with 58,000, that’s no easy task. Sometimes, voices get overlooked or misrepresented. We believe in growing and learning from the experience of our members. We hope that setting up the Advisory Board will help us keep the content of Therapy Today relevant, helpful, appropriate and inclusive for all members. We are delighted to welcome our firstever team, who will bring both their professional and their lived experiences to Therapy Today.
shaved about a day off my finish time, I would have won the 2016 London Marathon. As it is, I came last. I walked the whole thing to raise money for Parkinson’s UK.
BACP members have such a wealth of personal and professional knowledge and experience and Therapy Today is a terrific, beautiful and accessible meeting place where we come to learn, contribute and join in the conversation THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
12
SEPTEMBER 2021
About you: I am a relational integrative psychotherapist and counsellor, and a writer. I graduated from The Minster Centre with a postgraduate diploma in integrative counselling and have been in private practice since 2014. I completed my master’s in integrative psychotherapy and counselling in 2017. As a practitioner and writer, and in life, I endeavour to engage with the harmful impacts of structural oppressions, and I work largely with LGBTIQ+ clients. From 2004–2017, I was the editor of DIVA (the magazine for LGBTIQ women and non-binary people) and was featured in The Independent on Sunday ‘Rainbow List’ of the most influential openly LGBT individuals in the UK. I recently helped to promote and wrote about the new English translation of the biography of Freud’s lesbian patient, The Story of Sidonie C. I am currently collaborating with clinicians from a range of modalities and lived experiences for a forthcoming book on queering psychotherapy. A paper based on my master’s dissertation – ‘The Truth That’s Denied: psychotherapy with LGBTIQ+ clients who identify as intersex’ – will be published in a forthcoming special issue of the Psychology of Sexualities Review on Intersex and Psychology in the UK. I am a trustee of The Relational School. What you hope to bring: I have been invited to pay attention to the LGBTIQ+ content in the magazine, and I hope to be able to increase intersectional representations from these communities and bring to greater
Spotlight, 1
Spotlight awareness how the liberation of queer and trans people benefits everyone. What might people be surprised to learn about you? My paternal grandmother had an affair with Freud’s lesbian patient in 1926, and my paternal grandfather married Melanie Klein’s housekeeper.
CHRISTA WELSH About you: My work as a consultant psychotherapist and author is centred on the lived experiences of black women of African ancestry, focusing on the interwoven strands of racialised embodiment and the tension of otherness to reveal other ways of knowing and knowledge production. My current PhD research combines autoethnography, attachment and trauma theories. I have been in private practice for more than 20 years. I was awarded a Winston Churchill Research Fellowship in recognition of my innovative teen-parenting and family development psychosocial educational projects. What you hope to bring: I hope to bring a British African-Caribbean culturally nuanced perspective that contributes to the ongoing dialogue around issues of mental health, wellbeing and, in particular, the psychological impact of transgenerational trauma perpetuated today by anti-blackness. As part of the ongoing dialogue, I will encourage insightful young and older voices through their writing to be part of the collective conversation. I welcome this opportunity to use my expertise as a psychotherapist and scholar to critically engage in providing constructive feedback towards the long-term development of Therapy Today. What might people be surprised to learn about you? My first degree was
in communications, and I used to work in project management in the voluntary and charity sector.
KATHY CARTER About you: I am a writer and author by trade, and I have worked in magazine publishing and PR. However, at the moment I am a busy BACP student, studying therapeutic counselling. As an autistic person (and member of a fully neurodivergent family!), I am really passionate about promoting neurodiversity, and am excited about the current developments in talking therapy concerning equality and diversity. It feels, however, as if there are still some misconceptions surrounding neurodivergent individuals, students and clients, and my personal belief is that the neurodiversity paradigm, which supports personal autonomy and the celebration of difference, goes a long way to bust these myths. I work closely with Thriving Autistic, a social enterprise offering various forms of therapy to autistic clients. The post-diagnostic (or self-identifying) process can be such a period of empowerment, and I enjoy helping people navigate this life stage. What you hope to bring: I am honoured to sit on the Advisory Board alongside such experienced individuals, and am enjoying
I hope to bring a British African-Caribbean culturally nuanced perspective… As part of the ongoing dialogue, I will encourage insightful young and older voices through their writing to be part of the collective conversation THERAPY TODAY
13
developing my own continued learning and allyhood in the process. We can learn so much from each other, and this collaboration deepens our understanding of intersectionality and minority stress, especially, for example, within the neurodiverse and gender-diverse communities, where there’s a significant crossover. As a late-diagnosed autistic person in a neurotypical world, I hope to bring my lived (and student!) experience to the table, and help spread the word about key elements of the autistic experience. These include the ‘double empathy’ problem; monotropism, which recognises and even celebrates interest-based brains, and the breaking down of unhelpful stereotypical viewpoints about autistic people and clients, especially concerning empathy, imagination and how neurodivergence defines individuals and shapes their identities. What might people be surprised to learn about you? I am also a cognitive hypnotherapist helping people deal with the symptoms of physical ailments.
DWIGHT TURNER About you: I am currently the course leader of the humanistic course in counselling and psychotherapy within the School of Humanities and Social Sciences at the University of Brighton, alongside which I lecture on the MSc course in counselling and psychotherapy. I am also a PhD supervisor at the doctoral college. I have also been a psychotherapist and supervisor in private practice since 2004, working online and in London. I completed my PhD in 2017, where my phenomenological and heuristic study used transpersonal and creative techniques such as visualisations, drawing and sand play work to explore the unconscious intersectional nature of privilege and otherness. What you hope to bring: With a wealth of knowledge and experience as a writer, as
SEPTEMBER 2021
91BAPSEP21134.pgs 09.08.2021 18:31
Spotlight, 2 VERSION
Spotlight
REPRO OP SUBS
an activist, and as an advocate for equity and change within the counselling and psychotherapy professions, my hope is to enhance the voices of the other within these pages, bringing forth the next generation of academic writers, and those who feel they have something important to say about the work we all do.
ART PRODUCTION
What might people be surprised to learn about you? I am an occasional athlete, and an absolute geek, and can often be found either pounding the concrete on the seafront near where I live or sitting in a café reading something non-academic (normally a graphic novel, or a fantasy epic), while drinking hot chocolate and eating cake.
LUAN BAINES-BALL (they/them)
CLIENT
About you: I have particular interest in the impact of early separation on adult relationships and working with people who identify as gender, sexual and/or relationship diverse. I provide clinical supervision and professional support to trainee, newly qualified and experienced counsellors, psychotherapists and allied health professionals. I am passionate about helping supervisees to explore how to make strong, defensible ethical decisions, providing an authentic space in supervision for LGBTQIA+ therapists and supervisors and to encourage us all within the profession to challenge our previously unexamined prejudices. I established Baines-Ball & Associates 10 years ago. We have a wonderfully diverse team of highly qualified and experienced therapists, all with different areas of interests and training backgrounds. While maintaining our individuality and autonomy, we work as a team, respectful of the different experiences we each bring.
What you hope to bring: I hope to bring to the Advisory Board knowledge and experience of working in a busy, established private practice, along with the additional lived experience of being a trans therapist in a world and profession where, at times, fear of the unknown and lack of understanding can generate huge disadvantages and unseen suffering. I am passionate about helping those in marginalised places to be witnessed as their authentic selves and for those in places of advantage to better understand the often unwitting impact on those without that advantage. What might people be surprised to learn about you? Self-care is vital for my capacity for resilience (though I don’t pretend to get it right all of the time!). When I am away from my clinical responsibilities I love to walk, camera in hand, in nature. Here, in this mindful activity, I find perspective, nourishment and a way to calm my busy mind.
JESSIE EMILION About you: I’m an accredited counsellor, psychotherapist, supervisor and trainer and am currently CAT lead psychotherapist in Southwark, with South London and Maudsley NHS Foundation Trust,
I am passionate about helping those in marginalised places to be witnessed as their authentic selves and for those in places of advantage to better understand the often unwitting impact on those without that advantage THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
14
and consultant supervisor to Greenwich Cruse. I have extensive experience of working in the NHS, both in primary and secondary care. I’m also undertaking a professional doctorate by public works on ‘Multiculturalism, Race, Intersectionality and Polyphonic Self: structural and societal positions’. I have had several papers published in journals and also I work as an independent consultant psychotherapist for several media companies, including the BBC and ITV, undertaking psychological assessments and providing aftercare. As a trained interpreter and bilingual therapist, I have worked with many refugee communities and third-sector organisations. I have a special interest in bilingualism, culture and race, and the impact of these constructs on the development of the self. I also teach on psychotherapy programmes in the UK, India and Malta. What you hope to bring: I hope to bring both my personal and professional qualities – my expertise in the field but also qualities such as creativity, compassion and fun. We learn more and do well when we are having fun. There is so much work to be done in addressing inequality, discrimination, power and privilege within mental health. With the pandemic and the Black Lives Matter movement, it is very clear that we need to address structural discrimination and close the gap in health inequalities, and I am committed to this. I am passionate about improving global mental health. It is important to recognise that prejudices, discrimination and oppression operate on many levels. I would love to see more articles in Therapy Today by clinicians from ethnic minority/marginalised backgrounds. It would be wonderful for BACP to lead on research on EDI matters, actively supporting clinicians from marginalised backgrounds to undertake such research projects. What might people be surprised to learn about you? I grew up by the beach but never learned to swim. And I love watching EastEnders.
SEPTEMBER 2021
91BAPSEP21135.pgs 09.08.2021 18:31
VERSION REPRO OP
Reactions
Email your views on Therapy Today articles to therapytoday@thinkpublishing.co.uk
Your feedback on Therapy Today articles
Men in therapy
SUBS ART PRODUCTION CLIENT
Thank you to Catherine Jackson for her timely, interesting and wellresearched article about men in therapy (‘Sometimes it’s hard to be a man’, Therapy Today, July/August LETTER OF THE 2021). So many important issues MONTH have been touched on that I wonder whether a whole issue of Therapy Today could be dedicated to exploring them further? Concerning the issue of the danger of trying to ‘feminise’ men – throughout my counselling training and in nearly every encounter I’ve had with other counsellors, I’ve been a minority or sole male in the group. As a result, it feels as if I’ve found my female voice in counselling, but struggle to find an equivalent male voice. And, of course, our male voices need nurturing, as do our female voices. This does need to start early. The number of times I counselled teenage males when they went to a funeral of a grandparent who may well have had more connection with them than their parents, and they were not allowed to show any emotion. It is not surprising that, for many teenage males, there is a code of not showing vulnerability in case someone puts the boot in! Yes, be aware that men often do communicate in different ways, valuing action and thinking. But living with feelings below an awareness threshold for much of their lives is neither healthy nor helpful. We men need to learn to bring our feelings into conscious awareness. Feelings are messages to us and we ignore them at our peril. That’s my female voice; what about my male voice? Where do banter, humour and problem-solving fit in? I so enjoy meeting other male counsellors but this does not happen very often. We need more male counsellors and more male supervisors with active female and male voices. Mike Trier MBACP (Accred), person-centred counsellor, supervisor and facilitator
Feminising men I had a visceral response to reading part of psychotherapist Sue Parker Hall’s contribution to the article ‘Sometimes it’s hard to be a man’ (‘The big issue’, Therapy Today, July/August 2021). First, let me say that I am a woman and Hall’s initial assertion that ‘counselling and psychotherapy try to force men into a particular mould that they innately do not fit’ really
rankled, as if our understanding of masculinity or what it means to be a man today is somehow not impacted by society and history and culturally constructed, as studies show it obviously is. As the article acknowledges, much of counselling and psychotherapeutic theory has been constructed by men and aimed at facilitating healing in both men and women. I, for one, can vouch that many male clients have needed to feel safe enough to get in touch
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
16
SEPTEMBER 2021
with feelings of pain and express vulnerability and tears in the sessions with me because they lack the space to share these parts of themselves with others in their everyday lives. Hall goes on to say, ‘I think there is a danger of feminising men, making them more like women…’ I really bristled at this, as I was wondering what is dangerous about femininity? Thinking in the binary terms of attributes being assigned to either masculine or feminine gender roles, Hall seems to be of the viewpoint that men don’t need to express their feelings or that the emotions that can be expressed are one dimensional, traditionally aggressive and competitive aspects of emotions, such as ‘healthy aggression’. Yet in the article that follows (‘It changed my life’), we hear how James O’Brien learned to get in touch with long-buried, painful feelings and developed self-compassion by expressing his ‘gentler side’ in therapy. Forgive me for the reminder that we are trying to move away from the traditional binary way of thinking about gender attributes. I believe it is perfectly feasible to suggest that we all exhibit feeling, thinking and action to a greater or lesser degree, whether we are male or female. Both men and women have the opportunity when they enter relational therapy to access parts of themselves they may have neglected, allowing their feelings to manifest as story (thinking) to be shared, thus changing and influencing future behaviour in a more healthy, holistic direction. Alicia Hobbs MBACP How should therapists view men and masculinity – as a problem to be fixed? Your article reflecting on the American Psychological Association’s Guidelines for Psychological Practice for Boys and Men makes this very relevant (‘The big issue’, Therapy Today, July/ August 2021). The APA guidelines are written within a framework that assumes an American academic feminist orthodoxy. The guidelines state that, although privilege has not applied to all boys and men in equal measure, in the aggregate, males experience a greater degree of social and economic power than girls and
I understand that straight, cis men are a group with many pressures and difficulties, which this article was intended to highlight. However, gay and trans men still suffer some of the worst oppression, especially in minority communities
women in a patriarchal society. Nobody, I would suggest, has an ‘aggregate’ as a client. Apart from the elite of our society – male and female – the majority of the populace, male or female, is simply not privileged. If so, is the very term ‘patriarchal’ an adequate description for a complex society? Is class, as opposed to gender, at least as significant, and quite possibly more so? It is a bizarre form of privilege, which results in more men being imprisoned for longer periods, being homeless, dying by suicide, dying of violence, suffering industrial accidents, and dying younger. The APA does report that many male users of counselling services felt an anti-male bias within the profession. Other investigations have identified systemic gender bias towards adult men in psychotherapy and in other helping services, such as domestic abuse shelters. I suggest that any man who is feeling stress and disruption in their life is likely to be reluctant to engage with an activity that they suspect of being anti-male. The lists of male norms given in this article are nearly all highly generalised, negative stereotypes – achievementfocused, anti-feminine, eschewal of the appearance of weakness, drive for adventure, risk and violence. These have been collectively referred to as ‘traditional masculinity ideology’ by the APA guidelines. Such ideas do exist and do sometimes cause great suffering. The problem lies in the unproven assertion that they are the defining feature of masculinity. Women are often extremely stoical in hiding their pains and worries from those for whom they care, soldiering on to protect their families. Men often verbally express their sorrows, resentments and frustrations and their unhappiness. We may do so in noisy rants but express them we do, sometimes incurring ‘zero tolerance’. The profession asks why men engage less with psychotherapy than women, even though they experience as much distress, and answers its own question by saying that men are socialised not to be in touch with their own feelings. Could it be that some attitudes within sectors of our profession may also be a factor? David Jones MBACP, MPhil Social Anthropology
I love your magazine but as a member of the LGBTQ+ community I found the article ‘Sometimes it’s hard to be a man’ (‘The big issue’, Therapy Today, July/August 2021) disappointing. The author referred to men who were assumed to be straight. The only reference to gay men was in quoted research that identified the ‘norms’ necessary to gain access to the ‘tribe of men’, including the need for ‘men’ to be disdainful of ‘homosexuals’. Gay men are men too. Yes, I understand that straight, cis men are a group with many pressures and difficulties, which this article was intended to highlight. However, gay and trans men still suffer some of the worst oppression, especially in minority communities. They deserved inclusion here. Catherine Cook, integrative psychotherapist
No mind needs fixing What an incredibly disappointing headline for the cover of your magazine – is the ‘male mind’ broken and in need of fixing? What is the ‘male mind’? The article itself is nuanced and interesting, but I would suggest a thought experiment to replace the word ‘male’ in the headline with ‘gay’, ‘black’, or ‘female’ and see if you are still comfortable running that headline as it stands. I wonder if my view of this headline might be shared by others and be part of the reason why many people are put off counselling? Paul Hayward MBACP (Accred), counsellor Editor’s response: The coverline ‘Fixing the male mind?’ was intended to question the idea that men need ‘fixing’ because they do not express their emotions in the same way as women, which was the argument explored in the article. It was linked to an illustration that was aimed at being arresting and provocative. I can now see, however, that the questioning approach was not overt enough to avoid it coming across as offensive, and apologise for causing that offence.
THERAPY TODAY
17
Therapy for neoliberalism? I would like to thank James Davies for the concise and sharp summaries he gave in his interview (‘The big interview’, Therapy Today, July/August 2021). There is knowledge, insight, courage and energy in his words. In my experience it is not only the NHS but employers in general that make mistakes in dealing with mental health. It is good that employers have started to recognise the impact that mental health issues have on their workforce. But as Dr Davies says, the neoliberal focus on individual choice obscures the reality of workplace culture and reinforces the notion that something is wrong with employees rather than with the organisation system itself. Companies do not acknowledge their contribution to the mental health of employees. I see this as arrogant, judgmental and potentially pathologising. In my experience, the support offered is superficial and includes a list of apps, mind tools and external sources of self-help support. This is part of the ill-thought-through approach Dr Davies talks about. Counselling is marketed as a ‘support at the most difficult of times’ (to quote one construction company’s website) and usually offered via employee assistance programmes (EAPs). It seems that the aim of outsourcing care by employing third parties through EAPs is to get people back to work rather than help people process ‘their’ difficulties. Any counsellor who does EAP work knows that the four to six sessions usually offered does not go far enough in caring for the employee’s needs. The forms at the end evaluate the client’s ability to live life on a scale of one to five, but not the likely reoccurrence of symptoms when they return to work. I wonder how many EAP therapists have the chance to give feedback on symptoms together with the cause of distress? It seems that the ‘liberal’ part of ‘neoliberal’ has made us victims of our own choices. Neoliberalism defines people as consumers whose democratic choices are best implemented by buying and selling. There is comprehensive research that links neoliberalism with current
SEPTEMBER 2021
91BAPSEP21136.pgs 09.08.2021 18:04
Reactions, 1
To the Editor
VERSION REPRO OP
Reactions
SUBS
epidemics of performance anxiety, depression, loneliness, self-harm and addiction, and Dr Davies’ interview makes great observations in this context. Some see psychotherapy as an inherent contradiction to neoliberal capitalism, while others see it as a key to spreading and underpinning neoliberal ideology. For readers of Therapy Today, it would have been very useful if Dr Davies shared his view on this point. Slavista Mirovic MBACP (Accred)
ART
Conversion therapy
PRODUCTION CLIENT
I agree with Dr Moon that the Memorandum of Understanding (MoU) on conversion therapy in the UK needs to be adopted into professional counselling and psychotherapy associations’ ethical frameworks or codes of practice (‘The big interview’, Therapy Today, June 2021). BACP’s Ethical Framework is already explicit on this (Good Practice, point 22e). There are further steps, however, that I think BACP should take to safeguard clients from this practice, not just among its own practitioners but also to protect anyone from unscrupulous therapists working outside of the signatory organisations to the MoU. As Dr Moon suggests, training on LGBTQ+ issues for student counsellors needs to be improved. I qualified in 2017 and my diversity training amounted to a couple of sessions on race and ethnicity and a dated book on the reading list that suggested people were gay due to a disordered inability to identify with their same-sex parent. Implicit in this was the notion that being gay was not normal and that psychotherapy might somehow resolve this. I hope such a view is no longer considered orthodox in our profession, but I think a greater awareness of LGBTQ+ issues in line with the Ethical Framework ought to be incorporated in BACP accredited training courses. I think BACP should go further, however. Unfortunately, the Government has delayed passing its long-promised bill to outlaw conversion therapy, claiming it must allow further consultation. Sadly, rather than apologise for conversion therapy in the past, some faith groups are now seeking to
demand that the Bill be watered down so they can continue to offer therapeutic services, contrary to BACP’s Ethical Framework and the MoU. Thankfully, they are meeting resistance from within their own community – the Bishop of Manchester, for example, recently challenged those holding such a view within Christian circles. I hope BACP will lend its voice to his in pressing the Government to outlaw conversion therapy completely in all its guises and do its part in ending a trauma that has been inflicted on LGBTQ+ people for far too long. Kevin Brant MBACP (Accred) It is important that Therapy Today has facilitated a debate as to whether or not the banning in law of conversion therapy is the right way to protect the needs of vulnerable clients. In his response to Dr Moon’s interview (‘The big interview’, Therapy Today, June 2021), Peter Jenkins states clearly why this law may not be the right way to proceed to protect the needs of vulnerable clients (‘Reactions’, Therapy Today, July/August 2021). I agree with Jenkins’ statement that ‘legislation needs to be based on an accurate survey of the extent of the problem if it is to be at all effective’. In addition to the Government’s 2018 LGBT survey, there have been many other studies and reports published in peer-reviewed journals that highlight the harm that can be inflicted on people who are afflicted with this form of ‘therapy’. Statements from religious leaders and organisations such as NHS England, the Human Rights Campaign and the Royal College of Psychiatrists similarly acknowledge harm from this form of intervention, as do membership organisations including BACP, NCS, BPS and UKCP. The idea that ‘there is no credible evidence that conversion therapy is practised on any significant scale in the UK’ is challenged by the 2017 LGBT in Britain Health Report published by Stonewall, which states that one in 20 of all people surveyed ‘has been pressured to access services to question or change their sexual orientation when accessing healthcare services’.1 I don’t foresee a ban on conversion therapy leading to a Section 28 type of situation and I
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
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
18
SEPTEMBER 2021
was surprised to see Jenkins make that link. I think a ban may encourage LGBTQ+ people to access therapy with heteronormative practitioners, knowing that they are legally protected from this form of harm. The idea that some practitioners may find working with LGBTQ+ people risky if there were some law in place banning the unethical, harmful practices outlined in Jenkins’ letter is interesting and may be worth exploring in supervision to consider harm in therapy more generally. I agree with Jenkins’ call for more CPD exploring these issues and I think this needs to go a step further and be incorporated into all core practitioner training. I work with counselling and psychotherapy trainees across different modalities and courses, and issues relating to race, gender and people within the LGBTQ+ community seem woefully under-represented. In my view, legislation banning unethical practice that has a long history of demonstrated harm would be most welcome. So the debate, I feel, is how we can incorporate working with these issues in core practitioner training. Andrew Smith MBACP, counsellor REFERENCE 1. Bachmann CL, Gooch B. LGBT in Britain Health Report. London: Stonewall; 2017. bit.ly/3ygqMJl
Calling out unsafe practice My interest was piqued by the column ‘To what extent is a supervisor responsible for a supervisee’s client work?’ (Therapy Today, July/ August 2021). In Dr Els van Ooijen’s response, in reference to a potential concern about a counsellor/ psychotherapist’s practice, she says: ‘If I am unwilling or unable to improve my practice, my supervisor may have to take this up with my employer and/or my professional organisation.’ This of course aligns with the Ethical Framework, Good Practice, point 11 (‘Putting clients first’): ‘We share a responsibility with all other members of our professions for the safety and wellbeing of all clients and their protection
The instinct being described of feeling unsafe is not something that needs justification, as it has a relevance in the real world and in the ways in which many women unfortunately have to act in order to protect themselves
from exploitation or unsafe practice. We will take action to prevent harm caused by practitioners to any client.’ I felt compelled to write on this point, having explored this concept thoroughly with a supervisee recently. To my knowledge, there is no avenue within BACP to raise an issue in respect of a qualified therapist’s potentially ‘unsafe’ or ‘concerning’ practice from a supervisory or peer perspective. As regards the scenario outlined in the article, I think it’s worth mentioning that where a therapist is not externally employed or accountable to an agency or other organisation, then in order to meet our ethical responsibilities to BACP, as mentioned above, the only route of ‘action’ available to us is via BACP’s complaints process. This was acknowledged to me in a thorough discussion with a member of BACP’s Ethics team. Debra Nash MBACP (Accred), person-centred counsellor and supervisor
Therapist safety I am concerned by the response to the letter titled ‘Presumed threat’ in a recent ‘Dilemmas’ article (‘Therapist safety’, Therapy Today, July/August 2021). A female counsellor was expressing her discomfort at the thought of being alone with an unknown male client in her own home. One element of the response was that the counsellor should question why she felt unsafe: ‘Was it just the gender difference? Why should difference in gender be a problem for you?’ The advice given was that, if it was purely the gender of the client, then this may be something to take not only to supervision but also to personal therapy. This seems to imply that a woman who is afraid to be alone in her house with an unknown man has something to work through, rather than it being an entirely reasonable and logical response to her experience of being a woman. From an early age, women learn to be wary or fearful of men through their knowledge of or direct experience of domestic violence, rape, sexual violence, femicide, physical
violence, sexual harassment and verbal abuse. This is not to say that some men do not also experience such assaults, but women’s experience is a systemic one. The United Nations has estimated that almost one in three women worldwide have been subjected to domestic violence and/or sexual violence at least once in their life. And this figure does not include sexual harassment.1 According to a recent Ofsted report, 79% of girls aged 13 and older had experienced a sexual assault of some kind, 68% had felt pressured to do sexual things that they did not want to, and 64% had been subjected to unwanted touching.2 Karen Smith, counselling student REFERENCES 1. Facts and figures: Ending violence against women. New York: UN Women; 2021. bit.ly/3ias5Ee 2. Review of sexual abuse in schools and colleges. Manchester: Ofsted; 2021. bit.ly/3A6qUvN
I wanted to write in response to the advice given in a recent ‘Dilemmas’ section (‘Therapist safety’, Therapy Today, July/August 2021). The first dilemma was from a female therapist who does not wish to see male clients in her home as she works alone. I felt the advice given implied that this impulse to protect herself was somehow unreasonable and discriminatory, and that the therapist in question should be examining within herself for her reason why she did not wish to be alone at home with a man who is a stranger to her. The instinct being described of feeling unsafe is not something that needs justification, as it has a relevance in the real world and in the ways in which many women unfortunately have to act in order to protect themselves. The response seemed particularly inappropriate when juxtaposed with the second dilemma, which detailed the fear a female therapist felt when a male client became aggressive in her home at the first appointment. Early in my own career, I remember hearing from a supervisor that therapy doesn’t work if the therapist is afraid, and that we should never feel forced to offer a service if our feelings are telling us not to.
THERAPY TODAY
19
Therapists should not, in my opinion, feel guilty about the impulse to protect themselves and feel safe when working, even if this means refusing the service to someone who may have turned out to be perfectly safe. Rebecca Rose, therapist in private practice I read with interest the ‘Dilemma’ (‘Therapist safety’, Therapy Today, July/August 2021), which described a counsellor receiving a malicious call. I was the victim of a disturbing call – the caller had found me on a listing service and left an abusive voicemail late at night. I logged a police report and an officer came to my home to discuss what had happened. Despite the caller withholding their telephone number, the police were able to trace the call. The person responsible was summoned to the local police station and cautioned. I would like to reassure therapists that, even when numbers are withheld, it does not mean that calls cannot be traced and dealt with appropriately. On hearing the person had been held to account, I was able to let go of what I had been carrying since receiving the call. Name and address supplied
Fatphobia? I don’t have any unconscious bias about obesity, as suggested by Mel Ciavucco (‘Counsellors aren’t immune to fatphobia’, Therapy Today, June 2021); my position is completely conscious, and founded on evidence-based information about the serious health risks to overweight people and the consequent pressure and costs on the NHS. Like smoking in the past, these costs – human and financial – are unsustainable, and we need to address the obesity crisis. In the recently published National Food Strategy, Henry Dimbleby said people who know they have a problem with food are desperate for help with it. We in the counselling profession need to help, and we must be allowed to provide the best possible support to clients who want to tackle these issues. Diana Stockford MBACP
SEPTEMBER 2021
91BAPSEP21137.pgs 09.08.2021 18:04
Reactions, 2
To the Editor
VERSION
The month
Mental health and the human experience in the arts, media and online REPRO OP
Art
ART
Wellcome Photography Prize 2021
CLIENT
YAEL REISFELD/TED-ED
PRODUCTION
Congratulations to London-based filmmaker and journalist Jameisha Prescod, winner of the Managing Mental Health and single image categories of this year’s Wellcome Photography Prize. Titled Untangling, her self-portrait taken during lockdown shows how being trapped in one room, ‘where I work a full-time job, eat, sleep, catch up with friends and, most importantly cry’, reinforced her sense of isolation and depression. For escape, she turned to knitting. Yoppy Pieter, a visual storyteller and educator based in Jakarta, Indonesia, won the overall series image prize and the Fighting Infections series image category for Trans Woman: between colour and voice. www.wellcome.org/photoprize
This essay, told with delightful joie de vivre through a short TED-Ed animation and available from the Aeon digital magazine, discusses a topic dear to most talking therapists – how we use language and what we may be saying when we are silent or, in this case, use linguistic tricks and devices to help us express ourselves. Most people’s spoken communication is littered with ums, ers, likes, y’knows, sort ofs and other seemingly needless interruptions. But, this essay tells us, these ‘filled pauses’ provide the listener with important contextual clues, communicate emphasis, help string related thoughts together, and much more. bit.ly/374k8tV
Books
SUBS
Ums, likes and y’knows…
JAMEISHA PRESCOD/WELLCOME PHOTOGRAPHY PRIZE
Essay
Wise words
• Listen: how to find the words for tender conversations is Kathryn Mannix’s follow-up to her bestselling With the End in Mind, inspired by her work as a palliative care doctor and witnessing important words left unsaid. (William Collins, out 16 September.)
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
20
• In The Man Who Mistook His Job for His Life, stand-up comedian turned psychotherapist Naomi Shragai explores the psychology of the workplace, from paranoia and a fear of conflict to perfectionism and workaholism. (WH Allen, out now.)
SEPTEMBER 2021
• This memoir by bestselling author and Christian academic Kate Bowler explores the process of accepting limitations in a society that insists ‘anything is possible’. In the subtitle’s words, there are ‘truths we need to hear’. (Rider Books, out 30 September.)
The Month, 1 Know of an event that would interest Therapy Today readers? Email therapytoday@thinkpublishing.co.uk
Don’t miss
Film
Catch-up
HBO
IN TREATMENT
NOWHERE SPECIAL James Norton (Happy Valley, Grantchester, The Nevers) plays Belfast window cleaner John, a single dad with months to live. He must interview potential adoptive couples in search of a new family for his three-year-old son Michael, played to perfection by Daniel Lamont. We know the ending already; it’s the small, otherwise inconsequential details of their everyday life, the simple daily rituals captured so poignantly in the title, that give this potentially mawkish film its veracity and depth. If you missed it on the big screen this summer, you can now rent it from Curzon Home cinema. www.curzonartificialeye.com/ nowhere-special
In the fourth series of the highly acclaimed In Treatment, Uzo Aduba takes over the therapist’s chair from Gabriel Byrne. Perhaps best known as Suzanne ‘Crazy Eyes’ Warren in Orange is the New Black, Aduba excels as Stanford-educated Dr Brooke Taylor. Her boundaries may be questionable at times – in the first episode, we see her pick up a late-night call from a client – but she also deftly holds three complex clients with honesty and humour. What we never find out, however, is how she funds her stunning home and designer wardrobe on a therapist’s salary. All episodes are available now on Sky Atlantic. Podcast picks
Therapy talk • In a recent episode of Conversations with Annalisa Barbieri, psychotherapist John-Paul Davies discusses when to stay and when to go, in ‘Is your relationship worth saving?’. www. annalisabarbieri.com
THERAPY TODAY
21
• The impact of the modern world on masculinity is explored in The Fragile Phallus, – just one of the many gems to be found in the Freud Museum’s collection of podcasts. www.freud.org.uk/ category/podcast
• In his long-running podcast series The Trauma Therapist, Guy Macpherson talks to Peter Levine, Bessel van der Kolk, Pat Ogden Gabor Maté, Janina Fisher and others. www. thetraumatherapist project.com/podcast
SEPTEMBER 2021
91BAPSEP21138.pgs 11.08.2021 16:42
VERSION REPRO OP
What works and why
SUBS
Catherine Jackson explores the wider messages to be gleaned from the PRaCTICED and ETHOS trials into the effectiveness of humanistic counselling
ART PRODUCTION
R
CLIENT
esearch into humanistic counselling has been given a major boost by the findings of two randomised controlled trials (RCTs) published earlier this year. The PRaCTICED trial,1 which was funded by BACP and conducted at the University of Sheffield, established that person-centred experiential therapy (PCET) does achieve comparable results with CBT when delivered in an IAPT setting – as analysis of practice-based data had already indicated. The ETHOS RCT,2 which was supported by funding from the Economic Social Research Council (ESRC) and led by a team at the University of Roehampton, found clear benefits for children receiving personcentred school-based counselling in terms of achieving their goals. Yet Mick Cooper, Professor of Counselling Psychology at the University of Roehampton and lead researcher on the ETHOS trial, admits to some disappointment. The benefits of counselling did not reach the levels of effect that he had hoped for and expected, given the findings in a previous pilot. Moreover, the extra spend (some £400 per child) made schoolbased counselling more expensive than usual pastoral support, with no evidence of short-term compensatory savings elsewhere in the health system in terms of GP consultations and other medical costs. Similarly, the ‘equivalence’ that the PRaCTICED trial established between
CBT and PCET faded away after the initial six-month assessment. By one year, people who had received CBT were doing better than those who had PCET and more of those in the PCET group were looking to return to therapy, while those in the CBT group were more likely to be using the techniques they had learned in therapy to help them through recurring difficulties. So, what do these results mean for the counselling profession? Professor Michael Barkham, who led the PRaCTICED trial team at the University of Sheffield, says the levelling off in benefit from the PCET interventions by one-year follow-up suggests that practitioners need to examine how they can adapt their interventions to better equip people to cope in the long term. For Cooper, these findings highlight a need for the person-centred counselling profession – and that means most counsellors raised on Carl Rogers’ theories of personality change and the six ‘necessary and sufficient conditions’ – to re-examine their model of practice. ‘I think there needs to be a rethink around what school counselling looks like. For some clients, it may be of greater value if it delivers more direction, more structure and more skills around developing their [young people’s] coping abilities.’ Drilling down into the data There is no doubt that ETHOS showed that counselling was effective – after six
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
22
SEPTEMBER 2021
months, the participating young people were significantly less distressed and a lot closer to their personal goals for what they wanted from counselling – to increase their self-esteem, reduce their anxiety and be better able to concentrate on their schoolwork. But there are also some very interesting and potentially challenging preliminary findings emerging in the qualitative interviews conducted with 50 of the participant young people, says Cooper. ‘Most of the young people were happy with the counselling – only a small minority didn’t like it, and there were a few who thought it was OK but didn’t find it that helpful. Clearly counselling isn’t going to be suitable for everyone. But there were two negatives in particular that stood out for me. One was a lack of input, structure and advice from the counsellor – a significant minority of the young people were saying they wished there had been more guidance, more techniques, more activity. And the other thing, equally common, was that they found the silences awkward. ‘If we really are listening to the voices of young people, a number of them are saying “I really like the counselling and that opportunity to talk about what’s going on for me, but I wish the counsellors would be a bit more active and a bit less silent”. They didn’t know how to use the space. They would have liked more direction.’ For Barkham, development of the experiential components – the more process-guiding, emotion-focused aspects of the therapy – also seems to hold most promise for enhancing the impact of PCET and making its benefits longer lasting. ‘Clients leave feeling better having told their story, but when the depression comes back, they don’t have the means to process and move forward again on their own – all they can think of is going back to therapy again. The findings are really demanding of practitioners to take that extra step in process-guiding, which is a step up and beyond the traditional person-centred model. The model has to compensate for the absence of some components, and I think the next step is for clinicians
PATRICK GEORGE/IKON IMAGES
to come together around that in the various training programmes.’ Is there a significant message here for the counselling profession? There is, says Cooper, an understandable wariness among person-centred counsellors about questioning Rogers’ six conditions and the fundamental client-led ethos of the person-centred approach. But, he argues, the research tells us this may not be what some clients want or find useful, and ethical practice demands that we listen to what clients say they want. ‘It is often assumed as a fixed position that it is the relationship that heals, but that’s not what the evidence always shows. It’s great if a therapist wants to be non-directive and work from a wholly relational stance, and there is evidence that it can really help some clients, but those practitioners need to be clear that it may not suit all clients, just as CBT doesn’t suit all clients. ‘It can be painful when you have trained in an approach and someone comes along and says “actually, the evidence challenges that”,’ Cooper agrees. ‘It may not feel great. But I don’t think the evidence says “abandon person-centred practices”. It is saying
‘It’s great if a therapist wants to work from a wholly relational stance, but they need to be clear that it may not suit all clients’ some clients maybe would benefit from more of something else. Of course, we can only offer what we are trained in, but having the skills and willingness to refer on may be an important element of a therapist’s work.’ So what works in counselling? The evidence on ‘what works’ in counselling, derived from a vast amount of research over the past several decades, can be summarised very swiftly. First, no one model has been proven to be significantly more effective than any of the others. This then begs the question, what is it about all the talking therapies that makes them helpful to people in resolving their distress
THERAPY TODAY
23
and regaining their resilience to life’s vicissitudes and an ability to cope? This is where the PRaCTICED and ETHOS trials have much to contribute. The supreme compendium of data on the effectiveness of relational factors in the talking therapies is Psychotherapy Relationships That Work,3 which is based on the findings of the Third Interdivisional APA (American Psychological Association) Task Force on Evidence-based Relationships and Responsiveness. Now in its third edition, it is in two volumes: Evidence-based Therapist Contributions, edited by John Norcross and Michael Lambert, and Evidence-based Therapist Responsiveness, edited by John Norcross and Bruce Wampold. The book brings together findings from 18 vast meta-analyses of data on what makes talking therapies effective. Norcross and Lambert offer several ‘take-home points’ from this massive body of research: ‘One: patients contribute the lion’s share of psychotherapy success (and failure)… Two: the therapeutic relationship generally accounts for at least as much psychotherapy success as the treatment method. Three: particular treatment methods do matter in some cases, especially more complex or severe cases. Four: adapting or customising therapy to the patient enhances the effectiveness of psychotherapy probably by innervating multiple pathways – the patient, the relationship, the method, and expectancy. Five: psychotherapists need to consider multiple factors and their optimal combinations, not only one or two of their favourites.’ And, they add: ‘… the patient’s perspective of the relationship proves more important to their treatment outcome than the therapist’s. The patient’s experience of the alliance, cohesion, empathy, and support relate and contribute more to their success than the practitioner’s experience.’ In other words, the client knows best when it comes to how they feel about the therapy relationship. But they also take pains to stress that treatment method is important: ‘It remains a matter of judgment and
SEPTEMBER 2021
91BAPSEP21139.pgs 09.08.2021 18:27
The Big Issue, 1
TheIn bigfocus issue
VERSION REPRO OP SUBS ART PRODUCTION CLIENT
methodology on how much each contributes, but there is virtual unanimity that both the relationship and the method (in so far as we can separate them) “work”. Looking at either treatment interventions or therapy relationships alone is incomplete. We encourage practitioners and researchers to look at multiple determinants of outcome, [and] particularly client contributions.’ Norcross and Lambert have also helpfully summarised what it is about the therapy relationship that is ‘demonstrably effective’: the therapistclient alliance, collaboration, goal consensus, therapist empathy, positive regard and affirmation, and the recording of client progress data.4 BACP recently published a (much shorter) good practice guide on What works in counselling and psychotherapy relationships,5 compiled by Ani de la Prida. This concludes that ‘a clear understanding of what a client wants from therapy, and explicit agreement on how to work together is essential’. It goes on: ‘Regularly asking for feedback, paying attention to the development and maintenance of the therapeutic relationship and working non-defensively to repair ruptures promote improved outcomes. Self-awareness and cultivating an active curiosity and appreciation of difference are essential to ensure ethical, inclusive, non-discriminatory, culturally sensitive practice.’ To sum up: ‘... a pluralistic perspective of good practice that is inclusive of all modalities is essential. The therapeutic relationship is key to effective therapy, and a focus on ingredients such as collaboration, empathy, and responding to client preferences is vital to ensuring ethical and effective therapeutic practice. The recognition that different clients need different things promotes a more pluralistic provision of therapy services.’ Mike Moss, an experienced personcentred counsellor and supervisor currently working in schools, sees nothing in all of this to challenge his approach to working with clients: ‘Whether they’re eight years old or 80, for me it’s the quality of the relationship that heals.’ Non-directivity doesn’t
mean never actively intervening or taking a lead, he argues; when Carl Rogers developed his theories, it was in contrast to the highly directive approach common in counselling and psychological practice where the practitioner was the expert who knew best what the patient needed in order to feel better. ‘I applaud CBT if it can give people a set of tools that they can use for the rest of their life, but that’s not what I do. I am trying to create a place where their own, innate actualising tendency can flourish; to give the client a greater sense of their own potentiality. If I discover something that is really useful, I will offer it, especially to young people – online tools, for example, which a lot find really useful – but it’s not directing, it’s offering.’ And if there’s an uncomfortable silence? ‘I’ll explore that with them. I’m interested in why. But I carry some cards with me, and I’ll sometimes bring them out and we’ll just play a game if a young person is feeling particularly anxious or uncomfortable. It’s all part of building the relationship.’ Goals and outcomes What many in the counselling profession are now saying is that Rogers’ six conditions certainly are necessary for most clients, but the six are not in and of themselves completely sufficient for everyone. More may be needed, primarily because clients are telling us so, often demonstrably with their feet. ‘What the evidence also shows is that Rogers’ core conditions are just some of many different relationship factors that are associated with positive outcomes,’ Cooper says.
‘I am trying to create a place where the client’s innate actualising tendency can flourish; to give them a sense of their own potentiality’ THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
24
SEPTEMBER 2021
‘For instance, alignment on the goals of therapy also seems to be important, and the therapist’s capacity to deal with ruptures in the alliance, and the use of systematic client feedback. Added to that, there’s some very good evidence, both quantitative and qualitative, that clients can really value and benefit from nonrelational interventions, like normalisation through the therapist’s expert knowledge, or behavioural activation. Maybe the relational elements of these therapeutic encounters are sufficient to bring about some degree of change, but to just focus on them would be to ignore what some clients themselves are saying matters most.’ Broadly, research findings point to a need for greater attention to collaborative goal-setting, progress monitoring and feedback, use of more active and creative ways to engage clients, and more attention to client preferences – ways of working that the client themself finds helpful. Listening to and learning from the client is a no-brainer for Barry McInnes, a counsellor in private practice and founder of the website Therapy Meets Numbers, which aims to bridge therapy research, evaluation and practice.6 ‘For me, the take-away from these two trials for person-centred therapists is to try to expand your repertoire and listen to what the client is asking for – do they have a preferred way of working and is what you are offering hitting the spot? – before they drop out because they aren’t getting what they want. For me, this is a wake-up call for the profession,’ he says. He argues that collecting and feeding back outcome data to the client should be integral to the therapeutic process: ‘First, I think that working with the client to capture the essence of what they are seeking can, of itself, be a therapeutic process. It also provides a clear shared understanding of the aims of the work. Second, it helps both me and the client to hold those goals clearly in mind. Third, it helps us both to know how well we are progressing toward the goals. We know the contribution of the therapeutic alliance to therapy outcomes. We also know that one of the cornerstones of the alliance is agreement on therapeutic
‘We also need to give clients space to think – not reach for this or that tool and think this will fix them. That’s not our job’ goals. Why then would we not seek to make their clarification a more systematic process?’ Taking outcome measures can help validate a client’s sense of distress – that they really do need help, which for some is important if they are to engage with therapy. Continuing to do so then provides a measure of progress, or an alert that progress has stopped. But McInnes’ own main reason for doing it originally was curiosity, he says. ‘I wanted to know how I compared with the overall effect rate. What’s my effect size? I’d be disappointed if therapists had no curiosity to know what difference they are making.’ Putting learning into practice University practitioner Afra Turner has followed a path from psychodynamic to CBT in her professional development and orientation over the past 27 years. Now a senior therapist and supervisor in the counselling and mental health service at King’s College London, she has worked in seven different university counselling services. ‘The decision to do post-qualification training in CBT came about in response to the student voice and my own sense of what I’d been trained for. A lot of the literature was on long-term, in-depth work, but in the university counselling context, often the student only wanted or stayed for four to six sessions. Students wanted a place to be supported emotionally but they also wanted support to navigate the practical aspects of their academic work, and CBT really stood out for me as a possible way to combine the two. And that is exactly what I found. A personal crisis may bring the student to the service, but the reality is they do have these deadlines and
commitments and will falter if they don’t have that support.’ King’s College London is a partner in a large-scale data collection initiative across the higher education sector called SCORE (Student Counselling Outcomes Research and Evaluation), which is supported by both BACP and UKCP and is amassing and publishing outcomes data from several student counselling services. Turner’s professional experience is that outcome measures are a helpful addition to her work and to the higher and further education sector. For her, collecting and pooling outcome data are essential for individual professional development and the development and status of the profession. ‘Large datasets ensure counselling services are fit for purpose. The data can help services strategically align themselves better to student need and practitioners shape their interventions to make them more useful and viable. I think studies like PRaCTICED and ETHOS are a huge opportunity for practitioners to look outside their own clinical practice and maintain our professional development in the way key stakeholders expect us to. These studies offer evidence of our value as a specialist service and that what we are doing is valuable from a more externalised measure.’ Carolyn Mumby, who currently chairs BACP Coaching, followed a similar professional trajectory, starting out as a person-centred counsellor working with young people and progressing to train in coaching and leadership. She relates strongly to the ETHOS finding that young people aren’t always comfortable with the person-centred approach. ‘What I found is that they didn’t respond to only being told “this is your space” – they were often coming with a particular problem that they wanted to solve. Some young people do need more of a holding space where they can have that sense of relationship, but what I found when I was running a service for young people was that practitioners were beginning to engage them in a more proactive way – working with them on how to make decisions and resolve problems, giving them information and
THERAPY TODAY
25
techniques that they could use to help them move forward. ‘I think young people are often not well supported in terms of their autonomous thinking. School is often really prescriptive and that doesn’t help young people to think for themselves. I approach working with young people with the attitude that they are the expert on themselves and I have some potentially helpful ideas and information that I might share with them with their permission. It is a subtle difference; I am offering information, not giving advice.’ She says coaching is frequently misunderstood as highly directive and technique based. ‘Yes, coaches often have a toolbag of frameworks to use, but we also need to have the discipline to be focused on the person in the room and give them space to think – not reach for this or that tool and think this will fix them. That’s not our job. The tools are a way of helping them to explore things further for themselves. And you are always listening for their strengths and for the resources within them as well as the pain and suffering.’ Unknowingness Keeley Taverner, who runs a flourishing counselling service in west London called Key for Change, says people generally come wanting CBT because that is what they’ve heard about in the media and they want that quick fix. A lot of her clients are aspirant young black professionals who are very focused on resolving whatever is blocking them from achieving their goals in life. But she likes to keep the space open. ‘We are very goal-oriented socially and culturally these days. I am always mindful of how the person perceives therapy and to meet them at that level. But quite often I’ll find they don’t do their homework and then they start feeling uncomfortable about coming to therapy, so I say, “That’s fine, let’s just have a talk”.’ Taverner originally trained in personcentred therapy but had already worked for some time in prisons, running CBTbased programmes for prisoners. ‘That equipped me to see the limitations of that approach. CBT was fine as a starter,
SEPTEMBER 2021
91BAPSEP21140.pgs 09.08.2021 18:27
The Big Issue, 2
The big issue
The Big Issue, 3
News The feature big issue VERSION REPRO OP SUBS ART PRODUCTION CLIENT
but then the prisoners would start opening up and wanting to talk about their lives, where they were coming from, and CBT didn’t recognise that bio-psychosocial context. My training enabled me to think much more broadly and I knew that often people want more.’ However, she is not an advocate of passively sitting and waiting for the client to take the lead. ‘For the lay person, therapy can be an uncomfortable experience, particularly for people who are working class, because of the mystique around it. So it’s good to establish with them what would be a good outcome from therapy for them. But what we end up working on very often isn’t the issue that brings them through the door. Often it’s very much more flavourful – attachment issues, how they were loved or unloved, self-fulfilling prophecies, humiliation – how all of these feed into their personal lives. I articulate to clients that in unknowingness I have seen magnificence unfold that neither I nor the client could have predicted. I see what naturally emerges, which takes me into a space of spontaneity, listening as their lives are unfolded to me and reacting to what they bring.’ Evidence Although in some ways the results of both ETHOS and PRaCTICED could be seen as disappointing for the personcentred community, both are rigorous and robust randomised controlled trials, and they provide much-needed evidence of the effectiveness of counselling. PRaCTICED may provide the evidence needed to encourage NICE to give PCET its backing and reinforce its provision in IAPT and other NHS-funded settings. ETHOS shows school-based counselling is a valid and effective intervention with children and young people that helps them achieve their personal and academic goals. Says Dr Clare Symons, BACP Head of Research: ‘Broadly for both trials, the findings remain very helpful and supportive because both underline the effectiveness of counselling and equip us with evidence that we are criticised for not having much of, by comparison
‘We overlook something important if we don’t use these findings to question how we work and what we do that is beneficial’ with CBT. While we argue that RCTs are not the single most effective way of evidencing effectiveness, we are hampered if we can’t say we have RCTs that show this too. Our argument is that people should have a choice of effective, evidence-based therapies and are not confined to the one therapy for which there is a greater amount of RCT evidence, and we can do that now.’ However, she points out, ‘Ideally we would have a whole tranche of such studies to counterbalance the evidence amassed for CBT.’ And putting so much focus on comparative effectiveness means we tend to lose sight of the other learning to be gained from the trials, much of it hidden in the qualitative findings, which are still being analysed. ‘Like all good research, these trials throw up lots of different questions. ‘What NICE has created is a culture of dogmatism – “my approach is better than yours” – when the reality is that any theoretical approach to talking therapies involves numerous factors – client, practitioner, model and extra-therapeutic influences. We overlook something very important if we don’t use these findings to question how we work and what we do that is beneficial and where we might be letting our clients down. The PRaCTICED trial invites us to drill down to explore what are the active change agents, which aspects of person-centred counselling promote initial change and why this progress isn’t sustained, and in the ETHOS trial, what is it about the nondirective approach that young people don’t always find helpful,’ she says. So, what can we conclude? Whether practitioners come from coaching, CBT, person-centred or psychodynamic
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
26
foundations, there is a clear steer from the research towards a pluralistic approach. The research increasingly tells us that listening to the client and adapting how we work to the preferences of the client is what helps keep them engaged and the work relevant to their needs. Often clients prefer a more directional approach and like having a measure of their wellness or distress. But we need to stay open to the broader psychosocial, family and early environment influences and experiences and leave some space for the unknown and unpredicted. If not, we risk closing down potentially fruitful avenues for exploration and growth.
REFERENCES 1. Barkham M, Saxon D, Hardy GE et al. Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial. The Lancet Psychiatry 2021; 8: 487–499. https://doi.org/10.1016/ S2215-0366(21)00083-3 2. Cooper M, Stafford MR, Saxon D et al. Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial. The Lancet Child & Adolescent Health 2021; 5: 178–189. 3. Norcross JC, Lambert MJ (eds). Psychotherapy relationships that work: vols 1 & 2. Oxford University Press; 2019. 4. Norcross JC, Lambert MJ. Psychotherapy relationships that work III. Psychotherapy: 2018; 55(4): 303–315. 5. BACP. What works in counselling and psychotherapy relationships. GPaCP 004. Lutterworth: BACP, 2020. 6. www.therapymeetsnumbers.com
About the interviewer Catherine Jackson is a freelance journalist specialising in counselling and mental health.
SEPTEMBER 2021
91BAPSEP21141.pgs 09.08.2021 18:27
VERSION REPRO OP
‘It turned out I didn’t really know how I felt about anything’
SUBS ART
L
PRODUCTION SHUTTERSTOCK
CLIENT
isa’s room is relatively small, with shelves of books adorning the back wall and a chair in front of them. Next to the chair are a box of tissues and a small, open bin. Opposite me, she sits down. I look down for a second at the bin by the tissues, and notice a few discarded used ones. Someone has been here before, crying. That’s not me, I think. This will be pretty brief. I explain my situation, that I am struggling to have close relationships without feeling the need to run away, and that I’ve just turned 30 and I don’t want to end up in record shops or at the cricket, alone, at 70, not remembering what happened with the rest of my life. I am in a pretty big band, you see, I try to drop in humbly. ‘What is the worst thing you can imagine in your life?’ she asks. I don’t even pause for thought. My band breaking up is the worst thing I can ever imagine happening. It isn’t until the end of the first session that she asks about my past. ‘My mum died when I was 17,’ I say. ‘But that was a long time ago. I don’t really want to go into that.’ In the following months, I return every week to Lisa’s. There are all kinds of theories we work through. The memory of my mum smiling through the suffering, not enabling me to vent any kind of suffering of my own, for what could be worse than her illness? Or, maybe worse still, it stopping me from allowing anyone else close to me to voice any suffering at all. The need for me to be ‘special’ in the eyes of absolutely everyone, alive in all their minds, no option or possibility ever closed – after all, the one person that I was truly special to was gone. That I had replaced intimate relationships, in which there was a chance of loss, with hundreds of tiny, controlled interactions. That we were brothers who never fought or squabbled as there was always something bigger happening, leaving me with a repressed child still inside somewhere. That my identity might have been completely dependent on being a ‘good boy’, attentive and passive, never disturbing any peace or adding any burden to anyone. That I might be holding onto adolescence because leaving it would mean leaving
her. That I might possibly have a more manipulative side, so that I could knowingly use people for my own gain. That it turned out I didn’t really know how I felt about anything. I knew how other people felt about things, and I knew how to agree with them. And, finally, that the feeling surging through my throat, threatening to pour out, was unprocessed grief. Every week I leave Lisa’s almost giggling, as if some knot has been undone. It is a mammoth relief to have a place to at least explore all of these things without the fear of something disappearing, away from judgment; to play with them and then use or dismiss each theory. It occurs to me eventually that, bizarre as it might sound and much as I know cerebrally that it is impossible, I still expect that my mum might just come back soon and that I’ll be able to show her all the stuff I have done. Close to seven years since my first visit to Lisa’s, imagining it then as a sort of GP meeting for a quick cure, I am still in therapy every week. I have learned, in time, to hold with me the conversations we have – the small breakthroughs and workshopping of theories – as I take myself back into the world. We have developed a language between us where, among whatever is happening in my day-to-day life, we occasionally use books, films, music and sport to provoke restless feelings or dormant pains to come to the surface, where they are kneaded out and, although never ‘solved’ (when is anything?), can eventually be observed and demythologised until they just become a conscious and accepted part of who I am. I think I am still in therapy for that reason – nothing is ever solved, but there is so much to explore and I have learned, over time, that people are complicated and require the space to understand themselves to be so. There is little doubt that, without it, I would have surfed a few seismic life changes far less successfully and would not have developed anywhere near enough perspective or expertise on my own brain to have written my book – which, I only realised in conclusion, has the work of the therapy on almost every page. I am deeply grateful for it.
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
27
About the author Felix White is a musician and writer. He was a guitarist and songwriter with the indie rock band The Maccabees, and is the co-founder of Yala! Records, which supports upcoming bands. A passionate cricket fan, he also co-presents the BBC cricket podcast and 5 Live show Tailenders. His first book, It’s Always Summer Somewhere: a matter of life and cricket, is published by Cassell (Octopus Publishing Group).
SEPTEMBER 2021
91BAPSEP21142.pgs 09.08.2021 18:00
It changed my life, 1
It changed my life
VERSION
REPRO OP
SUBS
ART
PRODUCTION
CLIENT
BLACK YELLOW MAGENTA CYAN
SOMEONE AT THE END OF THE LINE Rob Buttery describes how telephone counselling provided therapy for women in prison during the pandemic
MILES WALKER
W
hen a placement opportunity at the women’s prison, HMP Styal, came up on the Manchester College student list, I was immediately drawn to it. My mother, a person-centred counselling tutor and counsellor in private practice, had worked at HMP Styal in 1977. Having lost her to cancer during my training in 2017, I wondered if this was a sign for me to follow as I searched for meaning after the loss. So, I applied and was offered a placement at Room to Talk by Eileen Whittaker, who, alongside Michelle Cardona, started HMP Styal’s voluntary counselling service approximately six years earlier.1 Room to Talk was supported by a team of a dozen or so volunteer therapists, most of whom, like me, were trainees. Then I googled ‘women in prison’, and a wave of anxiety struck and stayed with me for several weeks. I learned that, of the 5% of UK prisoners who are women,2 70% are survivors of domestic abuse. More than half (53%) have survived emotional, physical or sexual abuse during childhood. Women in custody in the UK are five times more likely to have mental ill health than those in the general population and nearly half (48%) have committed an offence to support the drug use of someone else.3 Knowing all this, I wondered how could I, a man, possibly contribute to their life’s journey? There followed a three-year journey through the gate into the hidden world of women at HMP Styal, during which I grappled with my own preconceptions and impostor syndrome to eventually become co-ordinator of the service
and to pilot a client-led COVID-19 safe telephone counselling service that offers women access to a phone and counselling in their own cells.
A unique setting HMP Styal in Cheshire has been a prison since 1962 when the women of HMP Strangeways, now HMP Manchester, were transferred there. Prior to this, the site was known as Styal Cottage Homes, opened in 1898 as an orphanage for destitute children from the Manchester area. Around 17 Victorian detached houses still stand on the site today, housing up to 25 women in each. A wing was opened in 1999 to accommodate unsentenced female prisoners following the closure of Risley’s remand centre. This increased the capacity of the prison significantly to accommodate around 480 female adult prisoners and youth offenders from all over the north-west of England. Pre-COVID, counselling sessions would take place in a dedicated counselling department for the women. However, as a male working one to one, I needed to be visible to the wing officers and prison
‘On my first day I was told that, if you can hold clients in prison, you can hold clients anywhere’ THERAPY TODAY
29
staff, so my client counselling sessions were carried out on the prison’s wing in a converted prison cell with a small window. This allowed me and my clients to follow the security rules while achieving enough privacy for hour-long sessions. Presenting issues often include past trauma, such as childhood sexual abuse, domestic violence, self-harm, living with personality disorders, drug and alcohol addiction, suicide ideation, guilt, shame, inconsistent relationships, anxiety, depression, complicated grief and loss of family ties. On my first day I was told that, if you can hold clients in prison, you can hold clients anywhere. Counselling women in prison often includes working with clients who take prescribed medication for a range of diagnosed mental disorders. According to the Prison Reform Trust, 25% of women in prison report symptoms indicative of psychosis,2 compared with around 4% among women in general.
Power dynamic In my early days, I asked a prisoner what advice she would give to a man starting work as a counsellor in a women’s prison. She reminded me of the importance of being myself and not trying to play a role. In my experience so far, women in prison can detect inauthenticity with record speed, so genuineness, congruence, unconditional positive regard and being empathic were no longer phrases in a book – they were a platform to underpin my work. Armed with Carl Rogers’ core conditions as a way of being, the legacy of my mum’s prison work, and wise words
SEPTEMBER 2021
91BAPSEP21143.pgs 09.08.2021 17:54
Counselling Changes Lives, 1
Counselling changes lives
VERSION REPRO OP SUBS ART PRODUCTION CLIENT
from some of the women in prison themselves, I began my journey into this new, hidden world. I began with an acute awareness of the power imbalance in a prison setting, where the counsellor can be automatically perceived as the ‘expert’ who may possess the potential to ‘fix’ people. Counsellors have keys to open doors, while the women are locked behind those doors – just the sound of jangling keys means so much more in prison than on the outside. Carrying a prison radio further adds to the projection of power, which could threaten the development of the therapeutic relationship, allowing the counsellor the ‘upper hand’ in being able to radio for help. I tried to redress this power imbalance with the exchange of knowledge with clients. When starting prison counselling work, you simply cannot know all the abbreviations for departments, services and personnel across the prison estate, but clients know what the abbreviations stand for. So when you ask a client what they mean by OMU, the client will be more than happy to tell you, with a smile on their face, that it’s the ‘offender management unit’. Knowledge like this, shared by a woman in prison, provides a small advantage in the unconscious power dance with their key-carrying counsellor. A client once reminded me that the prison is her home and pointed out that it would be pretty hard for me to bring a kettle onto the wing. When she suggested she made the brews, using her portable kettle, I smiled inwardly; one of those precious moments had arisen, very naturally, in our quest to balance as best we could the power dynamic in personcentred prison counselling.
‘Naming the service Time for Me was a reminder that it was now time to focus on themselves and who they are’
What’s in the name? Two years into my placement, the Room to Talk service closed when the founders and service directors moved on. The few volunteer counsellors who remained were approached by the prison to continue our counselling work. The prison needed someone to step up and lead the service. Even though I was still a trainee at the time, I felt strongly that the service should survive, and was confident that, as long as we worked closely with the prison staff, my course tutors and the prisoners themselves, we could create a service that was ethical and could continue to make a difference. So, while I was coming to the end of my training, I found myself co-ordinating a counselling service. On paper, it looks like a big leap for a student counsellor, but in many ways, a prison is one of the most holding environments a trainee can work in. We were surrounded by a multidisciplinary team who knew the clients we were working with. If you have concerns about a client’s welfare in prison, there is an established protocol to follow, which prioritises the prisoner’s wellbeing. Training and oversight of our voluntary counsellors were taken on by the Head of Reducing Reoffending, to whom I am indebted for her support and resources during the past 18 months. But before we could relaunch, we needed a new name – a challenge embraced with enthusiasm by the volunteer counsellors until we realised it really wasn’t up to us. A client of the service pointed out that we should be asking them, the women of Styal, to name their own counselling service. Over Christmas week in 2019, dozens of suggestions came in, in response to flyers and posters inviting ideas to rename the new counselling service (with a ‘prize’ of a Christmas selection box offered as an incentive). Many names were put forward, and how innovative and creative many of them were is testimony to what is often referred to as the hidden potential of women in prison. After careful consideration by the management of the Reducing Reoffending department, we had a winner, and Time for Me counselling was born.
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
30
SEPTEMBER 2021
Often women in prison have spent years being many things to many others; naming the service Time for Me was a reminder that it was now time to focus on themselves and who they are. Allowing the clients to name their service also seemed like another way to shift the power imbalance back in favour of the clients and create a sense of ownership of the new service.
COVID challenges Having got up and running, we were hit by the COVID-19 pandemic in early 2020, meaning we needed to reconsider if, when and how we were to engage in in-person counselling with clients. HMP Styal was quick to follow Government guidance with a period of a restricted prison regime that mirrored the community lockdowns. In-person counselling was deemed high risk and became one of many services to be temporarily suspended. However, with secure telephones in each cell or dorm in the houses and the wing, there was an opportunity to continue to offer the women counselling over the phone. The Reducing Reoffending department was already planning to use the secure office-to-cell phone lines to engage women in the prison in selected priority interventions. When we were invited to consider using them for telephone counselling, it sounded like a solution to the suspension of our client work. The counsellors were keen to resume the work, but we first needed to hear from the women of HMP Styal who would ultimately be receiving the telephone counselling. Several new and existing clients at HMP Styal consented to take part in a trial period of telephone counselling over several weeks, followed by an anonymous questionnaire. By this time I had completed my training, and I recall thinking how rewarding it was, having carried out research as part of my training, that my first act as a qualified counsellor was the design and implementation of an appropriate research questionnaire in practice. The results of the telephone counselling trial were positive. We
covered specific themes such as sound quality, privacy and connectivity, but also included questions that captured in their own words the phenomenological experience of the women. Although many of the volunteers had anxieties and doubts around not being able to read the client’s body language and questioned whether the same level of trust and rapport could be created, the feedback suggested the clients saw benefits in the new way of working. One participant reflected that it was much easier to talk about feelings over the telephone without a counsellor looking at them, perhaps confirming the ‘disinhibition effect’ of remote counselling work,4 and the ‘invisibility’ or ‘you can’t see me’ phenomenon.5 One of the volunteer counsellors summed it up as ‘different’ but also said, ‘It’s been great to see how quickly psychological connections can be established over the telephone. This gives us the essential base for effective therapeutic work.’ However, the pilot did highlight the importance of privacy and taking active steps to limit interruptions during remote telephone counselling, especially when some women were sharing a room with a pad mate. Part of the revised contracting for counselling involves working with the client to find a session time slot that is most likely to offer them privacy. For counsellors, a ‘please do not disturb’ sign placed on the door of the telephone counselling room helps avoid unwanted interruptions, as does ensuring electronic devices such as printers that might interrupt a session are turned off. Security and safeguarding are particularly important in a custodial setting, which meant that calling into the prison from outside to do client telephone work was not an option. As well as the legal concerns, it was important for counsellors to be on-site, so as to be able to act quickly if a client presented with an issue around risk or harm. Being in close proximity to trained prison staff who can immediately assist with safeguarding and risk management is a key component to safe telephone counselling work at HMP Styal.
Improving access We started with just one phone line in August 2020 and offered on average eight to 10 counselling sessions per week, provided by two counsellors. Following the successful telephone pilot, in October 2020 a second phone line was installed to help meet demand. Despite the Greater Manchester area going into Tier 3 COVID restrictions at the end of 2020, following the second national lockdown, we were risk-assessed to continue the telephone counselling service, despite other services in the prison being suspended. Earlier this year, we expanded to using three counselling rooms and three phone lines. This means, as we enter the autumn of 2021, we will offer counselling sessions to approximately 30 women a week, supported by a new cohort of student trainee counsellors. Managing the growing waiting list is one of the biggest challenges. From a person-centred perspective, setting a limit on the number of sessions a client receives doesn’t feel right, but neither does leaving clients on the waiting list too long. Currently clients contract for 10 sessions, with an opportunity to extend the number of sessions if the work and client goals require it. Recently, a new partnership between Time for Me and the Greater Manchester Women’s Support Alliance (GMWSA) has received funding for an innovative pilot project. Women will have access to counselling in prison and then continue to work with the same counsellor in the community after release, supported by the GMWSA. It is hoped that the project will generate a valuable evidence base to inform future applications for funding. With the lifting of Government restrictions, we hope to offer women in prison the choice of either telephone or in-person counselling when it is safe to do so. There will still be a need to manage the spread of COVID and its variants, but Time for Me telephone counselling has firmly established a blueprint for COVIDsafe practice to continue. My work at HMP Styal has offered an opportunity to work in a hidden place that my mum once discovered, and to experience the true meaning of person-
THERAPY TODAY
31
centred theory and what it means in practice to work at relational depth. The women at Styal have taught me what it means to be truly human and endure the most unimaginable of human anguishes. I feel honoured that they were able to trust me, a man, with their stories, their traumas, and their hopes for a more balanced emotional future. ■
About the author Rob Buttery MBACP worked in radio advertising sales for 20 years before training as a person-centred counsellor, following in his late mother’s footsteps. He works part time as the Time for Me Counselling Service Co-ordinator at HMP Styal in Cheshire and part time as a bereavement therapist with Salford Bereavement Therapy Service (part of Six Degrees Social Enterprise CIC). He also offers in-person, telephone and online counselling in private practice in South Manchester.
REFERENCES
1. Jackson C. Through the gate. Therapy Today 2017; 28(1). 2. Prison: the facts. Bromley Briefings Factfile Summer 2021. Prison Reform Trust; 2021. www. prisonreformtrust.org.uk 3. Prison: the facts. Bromley Briefings Factfile Winter 2021. Prison Reform Trust; 2021. www. prisonreformtrust.org.uk 4. Suler J. The online disinhibition effect. Cyber Psychology and Behaviour 2004: 7(3): 321-326 5. Moller N, Vossler A. How to do counselling online: a coronavirus primer. Open University/BACP; 2020. www.bacp.co.uk/news/news-frombacp/2020/17-april-new-course-foronline-counselling
SEPTEMBER 2021
91BAPSEP21144.pgs 09.08.2021 17:54
Counselling Changes Lives, 2
Counselling changes lives
VERSION REPRO OP
The power of reverie Marjorie Wittle explores how Wilfred Bion can help us understand the impact of the COVID crisis
SUBS
J
ART
ust before last Christmas, I took an issue to my supervisor. It concerned my own supervisee, who was considering resuming in-person work with clients who had suspended their sessions at the start of the COVID-19 pandemic, because they did not want to change to remote working. I was wondering about the correct procedure for reconnecting with clients who have not been seen for nine months. My supervisor did not know of any procedure, but instead wondered with me about the different clients and their situations. I felt a little frustrated at the time, but afterwards realised that he had modelled an approach that reminded me of the theories of Wilfred Bion. Instead of ‘knowing’ what to do, we had ‘wondered’ together. There had been a mutual acceptance that, if we were both able to let our minds roam freely, we might come up with something more than we consciously knew. This led to a very positive discussion in the supervision group in which the supervisee’s colleagues were able to verbalise some of the possible issues they could envisage. My supervisee, who had the necessary knowledge of the clients, was helped to think more broadly about her own situation.
PRODUCTION CLIENT GARY WATERS/IKON IMAGES
National crisis In this article, I explore how Bion’s theories can help us to understand our inner ways of functioning in a time of national crisis, where changes and fresh demands arise with such short notice. Bion lived from 1897–1979, spanning an era containing two world wars. His theories were developed during periods of national crisis and it is worth considering what he may have to tell us about our current experience. I had found myself in a situation that Bion might have understood as looking for knowledge as a way to cope with the catastrophic effects of the pandemic. In his book on Bion, Egenfeldt-Nielsen1 says that Bion saw a certain kind of knowledge as
‘opposing growth’. Our everyday use of mental capacities, such as extra learning, setting goals, agreeing outcomes and developing new procedures, is useful but does not in itself constitute psychic growth. Thinking can become a means of escape or control. Psychological growth occurs when the ‘catastrophic condition’ of not knowing can be faced.1 Facing inner catastrophe can always offer the way to psychological growth for our clients. Maybe the enforced experience of external catastrophe now gives us an opportunity to reorganise our inner worlds, with their unchallenged assumptions. Bion believed that this requires a particular type of thinking, which he describes as ‘without memory or desire’1 – two conscious mental processes. My supervisor did not draw on his memory of procedures to come up with a new one, and nor did he follow a desire to be the one who could sort the problem out.
feelings and even intuitive hunches, allowing space for the influence of unconscious processes to be felt. Nowadays neuroscience describes this as switching between right-brain and left-brain thinking – drawing on both the intellectual parts of ourselves and also our creative and instinctive sides in order to process catastrophic experience. Such thinking is the dynamic part of Bion’s theory of containment. This familiar concept is generally considered to be about managing anxiety. When we look at Bion’s writings in A Theory of Thinking,2 we find no mention of anxiety. Instead he writes that the fundamental problem faced by the couple is not infantile anxiety but frustration. The Cambridge Dictionary definition of frustration is ‘the feeling of being annoyed or less confident because you cannot achieve what you want’. Although frustration encompasses anxiety, it also includes a sense of desire for self-agency.
Mighty space
Frustration
Useful as procedures, goal setting and outcome recording are, we misuse them if we rely on them to help us avoid facing the bewildering and potentially disturbing. Used properly, conscious knowledge becomes ‘a kind of diving board [into]… the mighty space in which actual growth may take place’.1 ‘Mighty space’ is a way of thinking about our unknown inner world. My supervisor was able to tolerate the position I had put him in and to go ‘off the diving board’. This was an invitation to explore together whatever came to mind, whether from our conscious minds or from
A baby experiences frustration as insuperable, and Bion suggests that, if it is not moderated, it will impede the development of the capacity to think sequentially. Instead, the mind will be bombarded with disorganised thoughts. Frustration becomes a barrier to thinking. Frustrations abound in the world of COVID. As counsellors we are frustrated that we can no longer work in our well-ordered rooms, greeting our clients in person and creating a dedicated, confidential space. Working with videoconferencing, we may be puzzling over our client’s body language from a two-
‘Frustrations abound in the world of COVID... we are frustrated that we can no longer work in our well-ordered rooms... creating a dedicated, confidential space’ THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
32
SEPTEMBER 2021
the feelings occurs and meaningful thinking emerges: ‘Reverie dilutes frustration.’1 Meaning can only be reached as the mother takes time to ‘dream’ the effect the child has on her. This is akin to Freud’s idea of ‘free-floating attention’.1 The consequent understanding is not her creation alone, but something to which the baby has contributed in its own limited way. Over a period of time, as this experience is repeated, the infant will internalise the process and develop his/her own capacity to process inner frustrations and, later, those in the external world. This becomes part of the process of separating from the mother and developing the ability to think for him/herself.
Reverie
dimensional image, while simultaneously seeking to ignore the awkward picture of ourselves. On the phone, we wonder whether the client is really in a suitable place. We have been interrupted by clients’ dogs and children. Devices run out of charge. The work seeps out beyond our carefully guarded boundaries because forms, contracts and invoices need to be emailed. Outside work, we have lived with regulations preventing us from seeing friends and family or engaging in our usual leisure activities. We have had periods of being restricted to our homes, managing our frustrations and those of the people we live with. We may have lost income or encountered bereavement or ill health. Like the little child Bion envisages, we have felt small and helpless, at the mercy of those making the rules. Bion suggests that frustration impoverishes thinking. To remain mentally available to our clients, we need to find ways of containing it. The alternative to containment, he says, is avoidance or projection onto others: ‘Incapacity for tolerating frustration tips the scale in the direction of evasion of frustration.’2
Containing thinking Everywhere we see the effect of uncontained thinking: the relishing of conspiracy theories; the righteous indignation vented on the Government, scientists, misbehaving citizens
and others. We may find ourselves struggling to remember our schedules or becoming rigid in our thinking about regulations. Could it be that remote working seems harder because we are battling our frustrations and struggling to think clearly but not making a connection between the two? Bion’s theory of the container is about child development with caregivers and babies, but also about how two human beings and in particular the counsellor and client, through relationship, can facilitate meaningful thinking for each other. The development of thinking is a two-person process. It is the quality of communication that brings about containment of frustration, restoring natural development of thinking for the baby. Bion named such communication ‘reverie’ – a word drawn from the French word ‘rêve’, meaning dream. A mother faced with a frustrated baby does not draw primarily on her intellectual resources or the active and energetic part of herself. Instead, she needs to be able to relax and reflect on her instinctive understanding of the child’s primitive, nonverbal communication. Bion writes that the vital quality is not logical, adult thinking, but the mother’s ability to tolerate frustration – both the baby’s and her own. She needs the inner strength to draw on early parts of herself that connect with the baby’s experience. When she can tolerate the screaming and rage, then something akin to mental digestion of
THERAPY TODAY
33
The concept of reverie holds in one word many ideas that are familiar in our modern world. CBT and neuroscience seek ways of thinking that enable self-regulation. To think ‘without memory or desire’ connects with mindfulness theories emphasising the importance of staying in the here and now. It is linked with dreaming, because it is a way of being with a client or with ourselves. It is playing with ideas, trying on roles and dreaming about possibilities. It includes empathy-dreaming about how it would be to be in the skin of another. A mother who is engaged in reverie with her baby is thinking from his/her point of view, drawing on a deeply instinctive part of herself, as well as her own adult perspective. How does the world look from a pram? It is not just about dreaminess but about openness to the frustration being projected on to her. Reverie involves ‘bearing psychological strain’3 when we encounter incomprehensible or hostile behaviour from our clients. This also needs to be ‘dreamed’. Thomas Ogden states that the ‘mother does the unconscious psychological work of dreaming the infant’s unbearable experience’.4 In our work, this involves an openness to the impact on us of unbearable distress, emerging from the client’s inner world and projected into our reflective space. My supervisor modelled to me a way of being with my own frustration caused by not knowing how to deal with an unfamiliar situation thrown up by the pandemic. This apparently left me without an answer, and I had to tolerate my frustration about this. This was followed by a realisation about what I needed to do. A realisation can be understood as a thought that arises
SEPTEMBER 2021
91BAPSEP21145.pgs 09.08.2021 18:29
Clinical Concepts, 1
Clinical concepts
Clinical Concepts, 2
Clinical concepts VERSION REPRO OP SUBS ART PRODUCTION CLIENT
unbidden, from the dynamic processing of reverie. It became my own and I then took my version of the approach to the supervision group. There I opened up a time of reflection, in which frustrations could be faced – the possibility that clients would choose not to return or would come back with reactions to the enforced separation such as anger or withdrawal. In this mode of communication, the supervisee was enabled to develop her own way of thinking. Symington5 describes Bertrand Russell’s approach to writing a book on an unfamiliar topic: ‘He would read up about the subject and then he would put it out of his mind and tackle some other subject… When that was over he would come back to the first one. By then he found that he had digested it and made it his own in such a way that he was able to write about it.’ There are reaches of the mind, and even of our whole being, of which we are not conscious but which are needed for processing experience, particularly catastrophic and unbearable experience. If we, like Russell, can set aside our frustrations about the pandemic to allow the process of reverie the space and time it needs, we may find that we have more resources than we know. In a TV interview, the author and food writer Nigella Lawson was asked about her experience of isolation during lockdown. She said that she feels ‘contained’ in the kitchen. Of course, Bion’s concept of the container includes an aspect of space as well as one of relationship. A mother caught in endless reverie with her child would not be useful in any way. Containers have edges. Nigella finds that overwhelming feelings and frustrations about isolation become bearable within the confines of her kitchen, with its firm walls, predictable procedures but enormous scope for creativity. The container with firm boundaries sets the stage for reverie. Here it becomes safe to explore and ‘dream’ catastrophe, knowing that there will be a limit to the experience.
The time of COVID, when frustrations increase, is not the time to slacken boundaries in our work. More than ever, we need clarity of thought about the space we are offering our clients – whether it is a physical room with safety measures or a virtual space. The limits need to be very clear – the beginning and the ending, the vital importance of confidentiality and the need to pay for the time. We have to decide whether we are prepared to conduct sessions with clients in dressing gowns, and whether to wave goodbye at the end. Some of this is still evolving and we need to be able to ‘dream’ ourselves as counsellors in this new world. Establishing firm and clear boundaries is needed more than ever. But what of ourselves? We are experiencing many of the same frustrations as our clients. How do we create containment for ourselves that will help maintain our mental availability for our clients? As adults, we have an internal two-person process and can experience reverie on our own. Our inner mother and baby interact with each other and can either give rise to inestimable conflict or offer a way of tolerating frustration. ‘Dreaming’ our distress and frustration about COVID-19 eases our minds and releases meaningful thinking. Like Bertrand Russell we may find that temporarily turning our conscious minds away from our frustrations will allow space for a deeper processing and digesting to occur. Zoom meetings with family and friends and watching favourite media shows were some of the ways we found that served this purpose. Many people have also found that walking in nature and letting their minds free-wheel to be a good way of finding a two-person process in connection with something beyond ourselves. Like Nigella, some find containment in the kitchen and others in the garden. Spiritual practices have been set up over the centuries to facilitate this type of reflective thinking. Now we are transitioning out of isolation, we may lend our capacity for reverie to each other for a while, taking it in turns to play the child
or the mother. Supervisors are the obvious source of this support in our work. Writing up session notes is another way in which we can draw on our inner processing capacities. Reading them back later, we may be surprised by the unexpected insights we discover. Bion’s concept of the container is not of a static safe place, but a boundaried space for the dynamic process of reverie. Here our work is to tolerate and ‘dream’ frustration again and again, while relinquishing our own agendas of memory or desire. As with the mother and the baby, the best outcome of reverie is to witness the development of the client’s own capacity to think and start to need us less. Strong containers with clear boundaries are undoubtedly needed in this bewildering time. However, such containers set the stage for reverie. Reverie takes time and effort. It involves tolerating and wondering about all kinds of frustrations within the counselling relationship and within ourselves. It takes humility not to have to be the one who knows. It means not being pushed by the pandemic into a narrower, solution-seeking way of thinking. Bion’s legacy is that finding a balance between ‘left-brain’ thinking and the more ‘right-brain’ reverie is one of the challenges of our profession. REFERENCES 1. Egenfeldt-Nielsen F. Attention and creation. London: Karnac; 2010. 2. Bion WR. A theory of thinking. In: Second thoughts. London: Karnac; 2003 (pp110–119). 3. Ogden T. The primitive edge of experience. London: Karnac; 1992. 4. Ogden T. On holding and containing, being and dreaming. International Journal of Psychoanalysis 2005: 85(6); 1349-64. 5. Symington N. The analytic experience. London: Free Association Books; 1986.
About the author
‘Now we are transitioning out of isolation, we may lend our capacity for reverie to each other for a while, taking it in turns to play the child or the mother’ THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
34
Marjorie Wittle MBACP (Accred) is a psychodynamic counsellor and supervisor. She has a private practice in Milton Keynes and works as a training supervisor for the Counselling Foundation.
SEPTEMBER 2021
91BAPSEP21146.pgs 09.08.2021 18:29
VERSION REPRO OP SUBS
Understanding why clients drop out
ART PRODUCTION
How should we respond when clients drop out of therapy? asks Frances Bernstein
SHUTTERSTOCK
CLIENT
A
fter two months of therapy, James,* 20, did not attend his appointment and sent no message. I wrote to him, inviting him to return to discuss whether he wanted to continue with his therapy. James attended his next session and told me he did want to continue but had been too tired to come. He did not attend on further occasions, but each time returned after I had written to him. After a year of therapy with these interruptions, James said, ‘When you write to me, it really helps to know you are thinking of me.’ He went on to say that the real reason he had missed appointments was because he had been terrified of talking about his father, who had killed himself. Before he could put this into words, James had managed the fear and his overwhelming sense of guilt by avoidance, using cannabis and staying away from therapy. As therapists, we will all have worked with clients who stop coming to therapy suddenly and without explanation – who ‘do not attend’ (DNA), to use medical terminology. In more
than 25 years of working in the NHS, voluntary sector and private sector as a therapist and supervisor, I have come across little or no consistency in the management of clients who DNA, even though the consequences for these clients may be dire; clients dropping out may feel they are failures, and their problems may become worse and more chronic.1 I have also seen how difficult client DNAs can be for the therapist. In one study looking at stressful behaviours of clients, therapists rated premature termination as being very stressful: not as much as suicidal ideation and aggression and hostility, but ahead of impulsive behaviour, intense dependency and paranoid delusions.2
‘Although we must respect their choice, it is my experience that the client who does not attend is communicating something important to us’ THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
35
Some therapists and organisations seem to have a casual attitude to the problem of clients who drop out from therapy. Bernard Schwartz describes the ‘infallibility error’ of the therapist who puts all the onus on the client who drops out, while not looking at their own role.3 Arnold Lazarus describes the high rate of client drop-out as ‘the slippery underbelly to the successful practice of psychotherapy’, saying that clients who DNA have poor outcomes, overuse mental health services and demoralise the therapist.3 Gemma* was 42 and had been attending weekly therapy for more than a year. She had to travel 20 miles to see me, yet was always apologetic if she was even a few minutes late. One day, she did not attend and sent no message. I wrote to her, inviting her to come back and talk about her decision to leave, but she did not take me up on my offer. She chose to leave me in the dark. We had started to talk about ending and my guess is that she became frightened. Perhaps she stopped coming in order to deny the painful acknowledgement of her dependency needs and the unbearable feelings attached to the loss of the ‘good breast’? Could I have anticipated Gemma’s reaction to our talking about ending? I am not sure, but I do believe I could have been more sensitively attuned to Gemma’s dependency and to her fears. Although we must respect the choice of our clients to end their therapy when they want to, and it would be unethical to pursue clients in an unthinking or persecutory way, it is my experience that the client who does not attend is communicating something important to us about themselves, the therapeutic relationship, or our blind spots or failures. I suggest we should take the issue of client DNA seriously and aim to minimise DNAs through careful assessment shared with the client. We should consider case management of complex clients, and reach out to clients who DNA, inviting return and the chance to complete their therapy or to say goodbye. As many as 20% of clients drop out from therapy. In a meta-analysis of 669 studies of therapy (83,834 adult clients),4 clients in their 20s and those seeking therapy for personality disorders and eating disorders were most likely to drop out. Novice therapists were most likely to lose clients prematurely, with some reporting drop-out rates as high as 75%.
SEPTEMBER 2021
91BAPSEP21147.pgs 09.08.2021 18:31
Best Practice, 1
Best practice
VERSION REPRO OP SUBS ART PRODUCTION
This is in contrast to non-attendance rates of 5% in primary care and 10% in hospital.5 Therapy is clearly different from treatment provided in primary care and hospitals, yet the large numbers of clients dropping out from therapy does, I believe, need greater emphasis in supervision and in the training of therapists. Many factors lead to premature client termination. Dissatisfaction with the therapist is a main reason cited by clients. O’Keeffe and colleagues divided young people who DNA into three groups – dissatisfied clients not helped by their therapy, clients who got what they needed, and troubled clients who had external difficulties and so could not continue with their therapy.6 They believed the first group was the most disadvantaged by the DNA and that the third group would benefit from a caseworker supporting attendance at therapy. Assessment shared with the client and client feedback during therapy are considered to increase client engagement in therapy and to reduce client DNAs. A strong therapeutic alliance, client choice and case management for clients with complex social needs are all important in reducing client drop-out rates.2
How we respond CLIENT
Browne and Dolan found that counsellor response to client DNAs was not linked to client need. Psychodynamic counsellors were more likely to contact clients who dropped out than were humanistic counsellors. Female counsellors were more likely than male counsellors to contact DNA clients. These variations were not linked to the counsellor’s attachment style.7 My experience as a supervisor and my training in both the person-centred and psychoanalytic models of therapy lead me to believe there are theoretical issues in the different management of DNAs. The personcentred therapist is likely to view DNA as an expression of the client’s actualising tendency. It is thought the client will contact the therapist in the future if they wish to do so. The therapist contacting the client to see whether the client might wish to return to therapy may be viewed as undermining the client’s autonomy and so to be avoided. The psychodynamic therapist views DNA as an enactment; a communication, perhaps unconscious, that is difficult to put into words. The attachment view is that a client with an
ambivalent or dependent attachment style may see the therapist as frightening or as an inconsistent attachment object and may then DNA. A client with a disorganised attachment style is likely to need a gradual entry into therapy, and DNA should be expected. These clients will need to be reached out to if there is to be any chance of successful engagement with the therapist.8 As I see it, the important point is that the client who does not attend raises questions for the therapist. Is the client leaving the therapist before the therapist leaves them? Is the client unable to express anger or fear verbally, so expresses it through non-attendance? Has
‘Is the client leaving the therapist before the therapist leaves them? Is the client unable to express anger or fear verbally, so expresses it through non-attendance?’ THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
36
SEPTEMBER 2021
the client experienced endings that were sudden and brutal, and are they repeating an unhelpful but familiar pattern of behaviour?
Organisational culture The approach to the understanding and management of clients who do not attend is also linked to the culture within an organisation. Some organisations believe that the way to allocate scarce resources fairly is to offer all service users the same. For example, a client with complex early trauma who struggles with relationships may receive the same number of therapy sessions as a client who has had a stable childhood but suffered a painful bereavement as an adult. The client with more complex needs may feel neglected or rejected by the experience of short-term and limited sessions. They will then be more likely to reject the therapy and to DNA. Organisations that adopt a one-size-fits-all DNA policy, such as ‘two DNAs and out’, may conceal an organisational fear of disturbance, of which non-attendance may be a sign. The needs of more complex clients and clients
with attachment difficulties will be overlooked in such an organisation. Non-attendance can feel like an affront to the narcissism of the therapist or the organisation, causing intense and unrecognised emotion. This can lead to the defence of splitting and projection, with the organisation or therapist seeing the client as ungrateful. The organisation or the therapist may then act out their own unrecognised feelings, such as retaliation by not contacting the client who fails to attend.
SHUTTERSTOCK
My experience of DNAs Ali* was 17. He had been brought to meet me by his foster mother, who supported him attending his appointments. Even so, Ali didn’t turn up for his appointment after my first planned break, three months after the start of the therapy. I wrote to him saying I could not know why he had not attended, and that I would keep the next two sessions for him in case he decided to return. Ali did come back but continued a tit-for-tat pattern of not coming if I had been away, missing one week if I had been away for one week and two if I had been away for two weeks. It was not until 18 months of therapy, and after I suggested to Ali that his not coming was retaliation for being left, that Ali became able to talk to me about his feelings of anger and powerlessness that my breaks aroused in him. As he became more able to verbalise, so Ali’s need to act out became less. My experience is that young people who have experienced inconsistent care when growing up and those with difficult early life experiences are more likely to DNA. I have found that a strong therapeutic alliance with the sense of a shared journey supports clients to complete their therapy. Assessment, shared with the client, with a focus on anticipating difficult areas of therapy where drop-out might occur, is important in avoiding DNA. Peter* was 40. He came into therapy wanting to understand why he found relationships difficult. When he grew close to a partner, he became increasingly anxious and frightened. He would then finish the relationship. At assessment, we spoke about how this pattern would be repeated in the therapy, and that, as he became more able to trust me and speak openly to me, he would also develop negative feelings towards me and the therapy, and would want to walk away. Peter was then
able to speak about and understand better his feelings in relationships, which included fear of his anger. Peter completed one year of therapy with a planned ending.
Reaching out I have learned that, if I provide a flexible and individual approach to clients who DNA and reach out by writing a personal letter, the client may choose to return, perhaps to resume their therapy or perhaps to say goodbye with an ending session. Clients have often told me how helpful it was that I reached out to them.9 Jenny* was 25. She had been attending therapy for three years and was no longer depressed. She was in a relationship and was starting a new job. Together we had set an ending date for her therapy, which we were working towards. Six sessions before the end date, Jenny did not attend and sent no message. I wrote to Jenny saying that, although I could not know why she had stopped attending for therapy, we had arranged to meet up for a further six sessions. I added that, since Jenny had not told me any different, these were still her sessions, whether or not she chose to attend them. Reaching out to Jenny enabled her to attend the last three sessions of her therapy and we were able to say goodbye to each other. She said, ‘Saying goodbye to you had felt too scary but when you wrote to me I thought I could do it.’ Jenny’s previous separations had been sudden and unplanned, so I believe it was helpful for her to attend a planned ending of her therapy. We need to carefully assess clients at the outset of therapy, with a focus on difficulties that might lead to premature drop-out. If the client has a caseworker or social worker, they may benefit from their support in attending therapy. In my experience, reaching out to clients who DNA with a personal letter, email or text is appreciated and enables some to continue in therapy and others to have a more satisfactory ending or to return at a future time. Our decision making concerning clients who DNA should be bound by clinical need and the wellbeing of our clients and should not be random or governed by assumptions, personal feelings, organisational culture or expediency. *Clients’ names and details have been changed to protect confidentiality.
THERAPY TODAY
37
REFERENCES 1. Ogrodniczuk JS et al. Strategies for reducing patient-initiated premature termination of psychotherapy. Harvard Review of Psychiatry 2005: 13(2): 57–70. 2. Farber BA. Psychotherapists’ perceptions of stressful patient behavior. Professional Psychology: Research and Practice 1983:14(5): 697–705. 3. Schwartz B. Three main reasons clinicians fail their clients. Newharbinger online blog. 27 October; 2017. 4. Swift JK, Greenberg RP. Premature discontinuation in adult psychotherapy: a meta-analysis. Journal of Consulting & Clinical Psychology 2012; 80(4): 547-559. 5. Oliver D. Missed GP appointments are no scandal. British Medical Journal 2019; 364: 1545. 6. O’Keeffe S, Martin P, Target M, Midgley N. ‘I just stopped going’: a mixed methods investigation into types of therapy dropout in adolescents with depression. Frontiers in Psychology 2019; 5(10): 75. 7. Browne A, Dolan B. Counsellors’ responses to clients’ non-attendance at counselling sessions. Counselling Psychology Quarterly 1991; 4(2-3): 109-118. 8. Holmes J. The search for the secure base: attachment theory and psychotherapy. London: Brunner Routledge; 2001. 9. Bernstein F. I don’t know who I am. Therapy Today 2017; 28(6): 20-24.
About the author Frances Bernstein trained as a counsellor, supervisor and psychoanalytic psychotherapist. She retired in 2021 after working in the voluntary sector, NHS and in private practice.
SEPTEMBER 2021
91BAPSEP21148.pgs 09.08.2021 18:31
Best Practice, 2
Best practice
VERSION REPRO OP
Hybrid working How can we make a blended approach work for us and our clients? asks Sally Brown
SUBS ART
M
PRODUCTION CLIENT
ost of us embraced remote working last year as an emergency measure, but now many practitioners – and clients – are saying they can see the benefits in continuing this way of working after we’ve got back to ‘normal’ (should that mythical day ever transpire). It seems that hybrid or blended working is here to stay for many professions, including ours. But what does a hybrid way of working mean in practice, and what do we need to consider when blending approaches, to ensure we work ethically and effectively? In its simplest form, hybrid working means conducting some of our work with clients remotely and some in person. But there’s more to it than simply adding back in-person work when it’s safe to do so, and we’re wise to pause and consider the implications of rushing to embrace a hybrid way of working – after all, it’s another transition to manage after a year of disruption, adjustment and compromise.
Client autonomy
At its simplest, a hybrid approach offers clients the choice of working via a range of delivery methods, which may include in-person, videoconferencing, telephone and perhaps asynchronous approaches such as email or texting. But it becomes more complex when we consider how that will work – who decides the method of delivery, for instance? Is it purely down to client choice? Client autonomy is important, but should we also be assessing whether it would be better for the client if the work is delivered in a particular way? And what about clients who want to return to the therapy room, but not for every session, having got used to the convenience of therapy sessions minus the travelling? For Kate Dunn, counsellor in private practice and co-author of the BACP member resource, COVID-19 Response: counselling under localised and rapidly changing lockdown restrictions, it raises questions of containment. ‘One of the things we do as therapists is to
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
38
SEPTEMBER 2021
think about setting the frame to create a containing space. When we’re in the same room, we control the conditions in the room. When we’re working virtually, we don’t have that control over the client’s space, even though we may collaborate with them to help them make sure it’s suitable. But it’s their decision and choice where they take their remote sessions. So, in terms of the container, the boundaries and the holding of the client, there are lots of questions to ask about what we’re letting go of when we’re moving between in-person and remote working.’ Personally, I wonder about the adjustment to the difference in how much we – and the clients – are ‘seen’ between the different modes of working. Like many, I invested in a specialist camera and light to ensure a clear on-screen image for videoconferencing, but it’s still a very controlled image (head and shoulders only). Below the desk, my feet are in slippers and there’s often a soft blanket on my lap in winter. Not only does a return
inconsistent environments, may be unsuitable for hybrid working,’ she says. ‘It may also be important to consider the client’s attachment style and behaviour when assessing the impact of hybrid working; for those with insecure attachment patterns, the changing setting may prove challenging and impact on the development of the therapeutic relationship.’ How you feel about hybrid working may be harder to unpick if it’s mixed up with beliefs about what’s expected of you as a practitioner. Do you feel pressure to return to the room before you’re ready because clients are asking for this? A discussion in supervision could start with examining your motivation for offering a hybrid approach, and anything that might get in the way of you fully committing to it or feeling comfortable.
Scheduling
The rearranging of a room to make it work via videoconferencing may be minor but it’s a consideration when you’re contemplating
‘I’ve had to think about where the computer is and where the chairs are, and whether it can be appropriate for both to be in the same room’
potential appointment arrangements for hybrid working. ‘There is one factor that I’ve become aware of since restrictions have lifted and that was that, when I worked solely online, I arranged the positioning of my desk and my computer accordingly – the room became dedicated to online,’ says Dunn. ‘Now I’m back to doing a mix of online and in-person, I’ve had to think about where the computer is and where the chairs are, and whether it can be appropriate for both to be in the same room. So it may be we need to think about how we arrange our appointments if it means rearranging the room.’ If you’re hiring a room by the hour or working for an agency, you may have less control over how you group your sessions. But if you’re in a position to do so – and it doesn’t mean a major room rearrangement – breaking up remote and in-person sessions throughout the day may help reduce Zoom fatigue.
Staying flexible
For many clients, the convenience of working remotely makes regular therapy more possible. A client* reminded me recently of how she used to arrive at our sessions out of breath and agitated, having negotiated the rush hour and found a place to park. On Zoom, she starts our sessions from a much calmer place. But others have talked about missing having a physical space where they can bring all the messy, difficult stuff and then leave it
SHUTTERSTOCK
to in-person work mean letting go of these comforts, it also means adjusting to the intensity of person-to-person proximity and being back under clients’ scrutiny – and they under ours, having had our physical presence kept at arm’s length for more than a year. This adjustment is one reason why it’s wise to schedule an assessment session to consider the potential impact of this transition, even if the client is established, and then check in at regular intervals about how you are both adjusting to hybrid working. ‘We need to consider the client’s resilience and ability to adapt to change, perhaps by exploring with them their experience of change and unpredictability in life and how they reacted,’ says Dunn. ‘How able is each individual client to engage constructively with change within any form of therapy? If you have previously met exclusively online but then decide to meet in person, it may be important to ensure that the first in-person session includes an assessment of the client’s response to moving between modes of delivery.’ When taking on new clients and considering a hybrid approach, Dunn suggests using a twoassessment model, completing one session in person and one online before agreeing to work together. ‘Clients who experience high levels of distress associated with unpredictable and inconsistent environments, or who are unable to identify any means to calm themselves when faced with unpredictable and
THERAPY TODAY
39
SEPTEMBER 2021
91BAPSEP21149.pgs 11.08.2021 16:17
In Practice, 1
In practice
In Practice, 2
In practice VERSION REPRO OP
behind – one described feeling that, with Zoom sessions, they now ‘contaminate’ a space in their home with it instead. And even if we stress the importance of creating a transition ritual to replace the physical travelling to and from the session, sometimes clients have to come straight from a work call into a session, or go straight into one afterwards, which isn’t ideal. If you’ve transitioned well to working remotely over the past 18 months, there are lots of arguments for keeping a purely online practice, not least because it widens our potential client base beyond our local area – how many ‘out-of-town’ clients have you taken on since lockdown? It may also mean reduced outgoing costs on room rental, and it eliminates the need for a risk assessment, or having to sanitise the space between clients. But your modality of working may also influence the importance you place on inperson work. If your work is psychodynamic or attachment-informed, you will be particularly aware of the potential implications of clients who resist being back under our full gaze. ‘Working remotely rather than in person may be a defensive position for a client to take,’ says Dunn. ‘But there are also people who would never have come to therapy if it hadn’t been via remote working. There are some clients we simply would never have reached because they would not entertain the idea of sitting in a room opposite their therapist.’ A hybrid approach could act as a compromise for those clients who wish to remain working remotely, but for whom you feel a need to work in person. You may feel it’s safer, for instance, to ask at-risk clients to attend at least some sessions in person as it’s arguably easier for the impact of self-harm or an eating disorder to be hidden when working remotely.
SUBS ART PRODUCTION CLIENT SHUTTERSTOCK
Contracting
Any transition in working with a client, such as changing the focus of the work or the frequency of sessions, is a form of recontracting, and often it’s something we address verbally during a session. But if you do opt for an approach that involves switching between in-person and remote working with a client, it’s best to recontract more formally, perhaps with a written document. But that doesn’t have to mean ‘reams and reams of paperwork’, says Dunn. ‘You can pare down to the essential critical, informed-consent kind of contracting.
FURTHER INFORMATION COVID-19 Response: counselling under localised and rapidly changing lockdown restrictions. www.bacp.co.uk/ media/11151/bacp-covid-19blended-approach-memberresource.pdf Working online. Good Practice in Action Fact Sheet (GPiA 047). www.bacp.co.uk/events-andresources/ethics-and-standards/ good-practice-in-action/ gpia047-working-online-fs
‘A hybrid approach could act as a compromise for those clients who wish to remain working remotely, but for whom you feel a need to work in person’ I try to take a drip-feeding approach rather than overwhelming clients with a great long contract, partly because I don’t want them to think that online work is hugely different from work in the room. So instead, I have a number of information sheets that I share at a time that feels right during the different stages of referral, assessment and contracting.’ But there are elements that need consideration. For example, if the agreement is for weekly sessions via videoconferencing, with every fourth session held in person, what kind of flexibility are you going to offer? Does that fourth session have to be taken in person or are you going to be flexible if the client messages at the last minute and says, ‘The traffic is bad, can we do it by Zoom instead?’ It’s worth working out what your policy might be – for example, does a session that’s arranged in person have to be attended in person and if changed to online it counts as a cancellation and you charge accordingly? How will that go down with a client who wants to know why you can’t just do it by Zoom as usual? One counsellor I spoke to
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
40
Practice Beyond the Pandemic: considering a blended approach to delivering therapy. Online resource. www.bacp.co.uk/ events-and-resources/bacpevents/or1406-practicebeyond-the-pandemic
said she allows flexibility with this because she does both Zoom and in-person sessions from home, and there is no major rearranging needed to switch between sessions. And the result of her flexibility is fewer DNAs. ‘My clients are busy professionals who may be held up at work. Offering Zoom sessions has meant a significant reduction in client DNAs over the past year because they can take our sessions from a meeting room in the office,’ she says. ‘I’d rather they attended their session in whatever format than cancelled.’ As we adjust to life without restrictions, there is still much to navigate, but with that comes opportunities to expand our offerings to better meet client need and grow our skill set. As Dunn says, ‘We’re all changed by the events of the past year, and there’s no question of going back to where we used to be.’ *Client permission given About the author Sally Brown is a therapist in private practice and the editor of Therapy Today.
SEPTEMBER 2021
91BAPSEP21150.pgs 12.08.2021 10:36
VERSION REPRO OP
Articulating what we offer
SUBS
How do employers and commissioners think SCoPEd will help counsellors and psychotherapists become more employable? Catherine Jackson reports
ART
ne of the key aims of SCoPEd is to improve the employment opportunities for counsellors and psychotherapists by bringing consistency to how the profession articulates its standards of qualifications and expertise across all its representative bodies. Currently, each professional association has its own qualification standards and ways of differentiating newly qualified from more experienced practitioners/members and its own terminology. Then there’s the titles: counsellor, psychotherapist, psychoanalyst… Who can call themselves which and on what basis? With no statutory protection for any of these titles (unlike in most other health and medical professions, including psychologists), the answer is anyone. Employers who don’t come from within the field, and the general public too, don’t always accurately understand the difference. There’s a problem in particular for the NHS, the largest employer of mental health practitioners in the UK. If counsellors want to work more in the NHS, they need to be able to articulate what they do so that the NHS knows what it is (to put it crudely) getting for its money – the skills and competences the practitioner brings – and can deploy them to the best benefit for its patients. More broadly, if counsellors and psychotherapists are to secure
O
PRODUCTION SHUTTERSTOCK
CLIENT
employment in the NHS, and if the NHS is to benefit from this vast pool of self-funded, highly trained practitioners, both parties need to look outside their silos. Again, counsellors and psychotherapists need to be able to articulate what they can offer in terms of transferable skills and competences to guide NHS employers who are seeking to recruit to their mental health workforce. Organisations employing counsellors commonly describe the situation as a ‘wild west’ – lawless, unregulated and potentially dangerous. As employers of counsellors, they are accountable for the standards of those providing their services – to the clients and to the organisations commissioning services from them. Kris Ambler, BACP Workforce Lead, says: ‘The SCoPEd framework is intended to give greater clarity about the range of skills that individual counsellors and psychotherapists can bring to clients and counselling provider organisations. One of the difficulties we face as a profession is finding a common approach and meaningful language to promote our members to employers and commissioners. Terms such as “registered” and “accredited” mean different things within the different professional bodies, which can be confusing and means our members may miss out on employment opportunities.’
‘My hope is that SCoPEd will give us a clear structure so that we know the skills and competences we can expect a particular level of qualification, training and experience to bring’ Toby Sweet, Chief Executive, Sunderland Counselling Service
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
42
SEPTEMBER 2021
He says the Government’s current focus on mental health, particularly in workplace settings, is opening up new opportunities for counsellors, but the gaps are often being filled by other professions, and sometimes newly invented ones, simply because policy makers, planners and commissioners don’t understand what the counselling and psychotherapy profession can offer. ‘Some of the people employed in these roles may lack the specialist skills and knowledge that qualified counsellors and psychotherapists can offer. What SCoPEd can do is provide a clear framework that people who work outside the profession can understand. These people want to know two
‘SCoPEd is part of that whole movement towards breaking down the barriers between professional groups and accepting that health is everybody’s business and everyone has a part to play’ Professor Dame Sue Bailey, BACP Vice President things: whether what this practitioner does will help the people they are commissioning the service for, and that they are competent, safe and skilled. That is what matters to them, and SCoPEd will deliver this information across the board and for all levels of qualification.’ BACP Vice President Professor Dame Sue Bailey has a long career in health and medical workforce education policy, in addition to her professional practice as a child and adolescent psychiatrist. She regards SCoPEd as fundamental to ensuring the counselling and psychotherapy profession is in a position to maximise the opportunities created by increasing role flexibility within the NHS and the likely expansion of social care. She says the COVID pandemic has had one benefit in that it has demonstrated the speed with which regulators have been able to approve new ways of working and release people to apply relevant skills outside of the traditional job-role silos. ‘We
need to be in a position to take a broader view of mental health that takes a dynamic approach to understanding human wellbeing. For the individual, what they care about is how the treatment will help improve their functioning in their particular circumstances,’ she says. A framework like SCoPEd provides exactly that information to planners and commissioners, clearly and simply, she says. ‘All the people who provide therapy at any level – psychotherapists, counsellors, psychologists and psychiatrists – should know where they fit in, what they offer and their limits, and who to refer on to if needed. The NHS needs those very clear pathways and part of that is having a framework that shows exactly what it is that you will get from this counsellor that can help improve the life of this patient. SCoPEd is part of that whole movement towards breaking down the barriers between professional groups and accepting that health is everybody’s business and everyone has a part to play.’ As BACP’s Policy and Engagement Lead for Mental Health, Matt Smith-Lilley works at the interface with NHS policy makers and employers. He too sees opportunities opening up across the mental health workforce, not just in new roles but also in aspects of work traditionally delivered by other professions. ‘There’s confusion among commissioners and policy makers about counsellors and psychotherapists – their skills, experience and their competences. They are often underestimated in terms of their capabilities and the lack of clarity leads to a lack of trust in them as a professional group. There’s uncertainty about what recruiting them brings to the workforce. Do they have the required skills? The initial training routes are so varied and the range of post-qualification experience and skills and training makes it hard for us and for our members to give a clear description of what the employer will get when they recruit them. It has led some commissioners to create new roles in order to
THERAPY TODAY
43
fill a gap, instead of looking at what is already available to them. ‘Counsellors need to be able to evidence that they are this extremely motivated, qualified, skilled workforce of individuals who have invested considerable amounts of their own time and money in training for this role and career. The NHS has big ambitions to expand services and we are hearing that a lack of workforce is the biggest barrier to faster expansion. We are saying to them: “We have more than 40,000 registered, accredited or senior accredited members [from a total membership of 58,000] who can help with this – you have got to open the opportunities to them.” NHS employers are saying, “Help us understand how we can do this.” And that is what SCoPEd is doing. It is a reliable measure of what our members can bring to the workforce.’
Jobs on the ground
We talked to a number of people heading up organisations that directly employ counsellors and psychotherapists to find out how they feel SCoPEd can address the challenges they face with recruitment and deployment and help them make best use of this important resource. Toby Sweet is Chief Executive of Sunderland Counselling Service, which has contracts with a wide range of commissioners for a very wide array of practitioners working at different levels of skill, in varied roles and across a wide geographical area. Some of the counselling is grant-funded, some in NHS and IAPT services, and some is highly specialised – hospice work and support for people living with cancer, for example. The complexity of recruiting to and managing such a workforce and ensuring available skills match commissioners’ and clients’ needs is immense. ‘My hope is that SCoPEd will give us a clear structure and map so that we know that, whether we call ourselves counsellors or psychotherapists, these are all the skills and competences we can expect somebody with a particular level of qualification, training and experience to bring,’ he says. He believes SCoPEd will both establish the professional status of counselling and provide clearer career pathways for counsellors. ‘I think it will also really help make the case for our professionalism – we aren’t just delivering tea and sympathy. Like a lot of people, I went into the profession for idealistic reasons – not financial or career. I thought it would be a way
SEPTEMBER 2021
91BAPSEP21151.pgs 09.08.2021 18:35
SCoPEd, 1
Workplace
VERSION REPRO OP SUBS ART PRODUCTION CLIENT
of making a contribution to society. I was a lot younger, I didn’t have kids or a mortgage. As time went on, I did start to think about a career and that is when I began to see the lack of structure and clarity. These days there are more young people coming into the profession expecting a career and to earn a decent salary. There’s room for both. But it can be a career and it can and should offer progression and it should be recognised as such. We shouldn’t be expected to work for peanuts or for free.’ Gloucestershire Counselling Service (GCS) is both a provider of counselling, supervision and consultancy and runs its own training courses, from introductory counselling skills courses through to its three-year diploma in psychodynamic counselling. It offers low-cost, open-ended psychodynamic counselling to children, young people, adults, families and couples from its offices across the county – some 12,000 sessions last year and many more this year, because of COVID – as well as employee wellbeing, school- and GP-based counselling services under contract and some specialist services for the local authority and NHS clinical commissioners. In the absence of any alternative benchmarks for high quality and standards, Chief Executive Emma Griffiths says GCS expects all its counsellors to be BACP accredited, or equivalent, and will support its affiliates through accreditation if they aren’t when they are appointed. GCS has historically been almost self-sufficient in filling vacancies from its own graduates, but the COVID-related upsurge in demand has meant it has had to look further afield to find enough practitioners to meet need, which has heightened her concerns about recruitment and standards. ‘Everything we do is focused around quality. In our view, individual accreditation is as important as our organisation’s accreditation. We see it as part of professionalising the workforce, alongside our CPD support and our ethos as a learning culture,’ she says. ‘We have a good insight into the quality of people applying
to work with us from our courses, but when we are recruiting externally, it’s very confusing. Even when you are in the profession, you don’t always know what exactly you are buying in when you are choosing from applicants – there is such a variety of types, lengths and quality of courses. And our commissioners mostly don’t understand that being a registered member of BACP is not equivalent to being accredited and that accreditation means something totally different in other organisations. In the absence of clarity, we have had to do a lot of education on this ourselves.’ Organisations that work under contract are under constant pressure to reduce costs, which can mean compromising on quality. Griffiths hopes that, by bringing clarity about the skills and training of practitioners, SCoPEd will help her win her argument with commissioners that standards of training and skills are not something that can be compromised. ‘The biggest threat to our service is a large national organisation swooping in that can see high volumes of people for less money by paying its counsellors less and using time-limited models. I am constantly concerned about funding being given to services that don’t have accreditation as a service or as a requirement of their practitioners, especially given the level of complexity of work that is coming to the voluntary sector from statutory services. We struggle to find enough clients who are suitable for our trainees these days. Do commissioners understand what a counselling training means – who you are at the end of a one-year course and a four-year course, and the different standards of CPD courses? I’ve been banging a drum locally about service accreditation for
‘The content of trainings is so variable. It is hard to quality-assure the applicant’s levels of training and skills. SCoPEd will, I hope, streamline the process for employers and commissioners’ Claudia Slabon, Chief Executive, Service Six
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
44
SEPTEMBER 2021
years and, as a result, the county council has just introduced it as a service specification in the latest round of contracts, which means we are now better able to compete on quality, not price.’ In the absence of any national agreed quality benchmark or statutory regulation, she feels it has been left to counselling providers to champion standards and quality. SCoPEd will, she hopes, help them in their battle. Claudia Slabon, Chief Executive at Service Six, which provides counselling services across Northamptonshire, has similarly had to introduce a specific measure of qualification and skills to ensure her counsellors are adequately qualified for the work. Much of their work is with children and young people (which SCoPEd doesn’t cover), and they require all these applicants to have undertaken a qualification in working with this age group. Recruiting counsellors for its adult and generic services presents more of a problem. ‘It’s OK for us because we are in the profession and often we know what is a quality training course and what isn’t. What’s written on a CV or application form may not accurately describe the applicant’s levels of training and skills, because the content of trainings is so variable,’ she says. ‘It is hard to quality-assure that. We have introduced a skills assessment component to our interview process – a role play, which we record, so we can see how they handle contracting, how they deal with disclosures and so forth. SCoPEd will, I hope, streamline the process for employers and commissioners who don’t have much understanding or knowledge about the counselling profession. My concern is that not all counselling providers will do that level of checking that the information is correct. Completing a counselling course doesn’t always qualify the person to work as a counsellor.’ She also hopes SCoPEd will make the tendering process less demanding. ‘You go into a tendering process and you don’t know who is going to come in and undercut you. We say we won’t compromise on the cost because then we would be compromising on quality, which
‘Currently, the pool of BACP accredited therapists who are applying to work with us is becoming limited. SCoPEd would open it up to a broader spectrum of qualified practitioners’ Kayleigh Frost, Head of Clinical Support, Health Assured would put our clients at risk. We have to keep saying, if you give us less money, this is all you will get. Negotiation with the commissioners is really difficult and can be a long process.’ SCoPEd will provide organisations like hers with, she hopes, more muscle to argue for standard unit costs that adequately reflect that some clients need much greater expertise and experience than others, and to explain why.
SHUTTERSTOCK
Workplace roles Another source of employment for counsellors is with employee assistance programmes (EAPs). The Government is increasingly expecting employers to do more to safeguard their employees’ mental health, and counsellors already have a strong foothold here. Nathan Shearman is Head of Therapy with Red Umbrella, which (alongside Mental Health First Aid training) offers employers what it calls its Care Coins EAP, through a bank of affiliate counsellors. Shearman says EAP providers desperately need a framework like SCoPEd to ensure they are matching clients with an appropriately skilled counsellor and are able to justify these decisions to the client’s employer if they question the costs. ‘We need a way to differentiate who has the expertise we are looking for. There are clients who just need someone to talk to and others who need more in-depth psychotherapeutic work and we need to ensure we allocate clients to the most appropriately qualified practitioner to help them. As an employer, we also want our counsellors to be sufficiently trained to be able to manage the presenting problem, so the work doesn’t impact negatively on them through vicarious trauma,’ he points out. ‘At Care Coins, our therapists aren’t just names on a spreadsheet, these are people we want to get to know and we don’t want to expose them to a situation beyond their level of competence. SCoPEd will also assist us with recruitment. We can look across our workforce and ensure we have the necessary balance of skills to meet client demand,’ Shearman says.
And it isn’t just the customer who might quibble about the level of therapist skill needed. ‘You might have an organisation whose employee has severe OCD, for example; we could justify the cost of a highly experienced, specialist CBT practitioner by referring to the SCoPEd framework,’ Shearman points out. ‘But we have had clients who insist they want to see a psychologist. They don’t understand what a psychotherapist is. SCoPEd would give us a means to explain the qualifications of the therapist we are suggesting, what they bring to the work, and why that level of expertise is needed. By the same token, it would also ensure we can make good use of other practitioners who can bring something of equal value to the client relationship.’ Some BACP members have raised fears that SCoPEd will reduce employment opportunities for practitioners who either don’t want or don’t feel able to complete accreditation. Kayleigh Frost, Head of Clinical Support with the EAP provider organisation Health Assured, welcomes SCoPEd precisely because she says it will allow her to offer more opportunities to many more counsellors to work with them. Currently, she says, the employer organisations contracting their EAP service stipulate that they want their employees to have counselling with BACP accredited practitioners, even though she knows it is not the only way of assessing that the counsellors have the relevant and appropriate skills to do the work. ‘The simplified framework will produce a more useful and accurate measure for us to use that applies across all the professional membership bodies. We have an excellent clinical governance system in place, but I know there are counsellors who aren’t members of BACP or haven’t gone for accreditation and who would provide an incredible intervention for clients and may have more experience than an accredited counsellor does,’ says Frost. It would also help them with their recruitment. ‘Currently, the pool of BACP accredited therapists who are applying to work
THERAPY TODAY
45
with us is becoming limited. SCoPEd would open it up to a broader spectrum of qualified practitioners. I think there is a belief that some of the professional bodies are superior to others. By aligning their standards, SCoPEd would make it much easier for us to assess candidates applying to work with us.’ Several of the counselling providers we spoke to hoped that SCoPEd might also help with standardising levels of pay and grading across the profession, cutting out the considerable disparities that exist in IAPT and in EAPs. Says Ambler: ‘SCoPEd is not intended to address this. We know that employers pay different rates, often depending on levels of training and experience. Our position is that all members should be paid fairly, commensurate with their considerable training, skills and experience. Salaries and pay scales are determined by market forces and it is outside our charitable remit to actively challenge employers on these issues. But we do think a shared framework would make it easier for us to argue for paid roles for all our members, whatever their levels of training and experience.’ If SCoPEd is to achieve one of its main purposes – to expand employment prospects for qualified therapy professionals – it needs to establish equity in terms of public access to appropriately trained, qualified and experienced practitioners, whatever model they practise or service they work for. There will of course be practitioners who do not see mainstream employment as their career path, but if the profession wants to make the most of opportunities within the growing mental health industry, it’s essential that its skills and experience are properly understood and used. As Ambler says: ‘SCoPEd is already having an impact on external stakeholders who see the co-operation and collaboration between professional bodies as positive in that they have a route to engaging with the profession as a whole, rather than with each individual professional representative body.’ ■ To find out more about SCoPEd, see www.bacp.co.uk/scoped
About the author Catherine Jackson is a freelance journalist specialising in counselling and mental health.
SEPTEMBER 2021
91BAPSEP21152.pgs 09.08.2021 18:35
SCoPEd, 2
Workplace
VERSION
Please join our ‘Talking point’ panel! Email therapytoday@ thinkpublishing.co.uk
REPRO OP
Lockdown for students
SUBS
How did the pandemic affect trainee therapists?
ART
‘It became a literal exploration of learning to bear not knowing’
PRODUCTION CLIENT
In the days after the first lockdown was announced in February 2020, there was a feeling of panic among the trainees on my counselling diploma course. We all struggled with Zoom, although the willingness with which some of the staff embraced it, including those nearing retirement – ‘digital aliens’ until then – was heartening. Sometimes there was a comedy shuffle of Zoom malfunction that felt like a clumsy metaphor, sent to warn us of the futility of control fantasies. I quickly realised I couldn’t attend the online Monday morning seminars, with children to home-school. Luckily, my training organisation was flexible, allowing some of us to move into the late afternoon cohort to accommodate childcare, and providing online equivalents for all sessions. I couldn’t make the majority of last summer’s experiential group sessions, though. When I came online for the final session, I felt tearful, and sorry for what I had missed. The uncertainty around the changing restrictions, long-term impact on client work and the imperative to wait and see became a literal exploration of learning to bear not knowing. It is odd to consider that the final 18 months of my four-year training have been online. It has been harder for those who started the course a year later, some of whom experienced a huge delay in starting work with in-person clients. On the upside, the situation has forced a new resilience and a flexing of rigid ideas about what is and isn’t possible, and what is and isn’t therapeutic. This feels hopeful, even if we’re still working it out as we go along.
‘It will make me a better counsellor’ I was six months into my postgraduate diploma when the pandemic hit. One week we were discussing toilet roll shortages and the next we were told teaching had stopped completely. I felt like everything had been taken away from me. Fitting in online lectures was a daunting prospect while also home-schooling three children and working from home, although no longer having to commute saved time. My placement at a hospice was suspended and that was a real low point for me. But I did some CPD to help me feel more confident about working remotely and, after six weeks, I was able to start telephone bereavement counselling. Initially I thought telephone counselling would feel detached and remote, but the opposite was true. Being on the same rollercoaster as my clients was challenging, but at times led to moments of real relational depth. As for online lectures, I felt more confident participating than I had done in person. I feel sad that I did not see my peers in person for over a year, but I have still made friendships for life, and learned skills I never thought I would possess. My view of counselling and my approach have been shaped by this experience and I think it will make me a better counsellor. Suzanne Shenderey, newly qualified counsellor
‘I have gone through a transformation’ This year I have gone through a transformation, not just in the sense of learning the theory or skills, but I have started reaching out to the world while simultaneously closing in during a lonesome process of self-discovery. I have, like many other students, gone through this crucial first year of training on a postgraduate diploma learning to relationally connect with clients, in supervision and to our ‘practitioner selves’ while being shut in my own house with just a sleepy cat for company. Often my deep dives into reflective layers of my own mind did not make any logical sense to me, let alone my fiancé who, to his credit, would listen, albeit with a lost look in his eyes. I like to think my peers would have listened if we had had the chance to connect in ‘real life’. I do not know if I have done more reaching out or closing in this year. Perhaps even without the pandemic, I was meant to learn how to connect both outwards and inwards. Perhaps the ‘training in a pandemic’ element will be useful in dealing with the fallout and effect of it for years to come. We are just starting out. I am proud of what this generation of trainees has managed so far and have every confidence we will come to appreciate the hardships of this year. Tena Rapčan, trainee integrative therapist
Zoe McDonald, trainee psychodynamic practitioner
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
46
SEPTEMBER 2021
Talking Point, 1
Talking point
SHUTTERSTOCK
‘I missed the nuance and intensity of physical presence’ Thanks to the coronavirus restrictions, I got experience of working with clients via webcam, over the phone and even, for one session, by text. But the 60 client hours I spent working remotely confirmed my individual preference for in-person contact, which my placement agency allowed me to resume last year, while following infection control protocols. I accrued an additional 85 client hours this way. I feel blessed to have had this option as, without this in-person experience, I would have felt unprepared on qualifying. Difficulties for me arose with the increased reliance on remote working for college hours. I was diagnosed with Asperger’s last year, and technology can be a trigger for me, coupled with a poor internet signal at home. I also missed the nuance and intensity of physical presence. As a result, I do feel that I may have lost out on opportunities for personal and professional development. At times I struggled with the inconsistency and contradictory and arbitrary nature of certain Government restrictions and additional college policies, which distracted me from the course material. My mind is wired for congruence, so I find it counterintuitive and a kind of betrayal to simply play along when I have strong convictions to the contrary. I continually wrestle with this and sometimes feel overwhelmed by the impact of the so-called new normal on unique feeling and thinking human beings. Mark Misselbrook, newly qualified counsellor
THERAPY TODAY
47
My college was quick off the mark in moving classes online and the more I became conversant with the technology, the more I found a whole new world of learning opening up to me. Once I’d completed the BACP/Open University CPD on working remotely, I figured I’d just keep going. I discovered I could access CPD by some of the leading names in the profession – Mick Cooper, Sheila Haugh, Arthur Bohart and Ernesto Spinelli, to name a few. CPD isn’t required for trainees but there is so much available that complements and expands on the core learning. Highlights for me included completing a four-week core competency training in Collaborative Assessment and Management of Suicidality (CAMS), and a 10-week course on race, culture and anti-discriminatory practice. It also provided me with the opportunity to help found ANDT (the Association of Neurodivergent Therapists) and become actively involved with other therapyrelated projects. It raises the question for me of whether we still need on-site learning anymore – we now have the ability to train high-quality therapists without the need for a physical classroom. All theory and personal development can be delivered online, and being trained remotely allows students to practise their counselling skills online. For me, training during the pandemic has been wonderful and I’m hopeful this will ensure better experiences for potential future clients. Zoë Stephens, trainee person-centred therapist
THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN
‘Do we still need on-site learning?’
SEPTEMBER 2021
91BAPSEP21153.pgs 09.08.2021 17:50
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
The Race Conversation: an essential guide to creating life-changing dialogue Eugene Ellis (Confer Books, £16.99)
Keeping Your Head in the Game: untold stories of the highs and lows of a life in sport Gary Bloom (Penguin Life, £14.99)
Sedated: how modern capitalism created our mental health crisis James Davies (Atlantic Books, £18.99)
This book explores racism and the race construct through the lens of trauma. Developmental and intergenerational trauma provide the conceptual frameworks to understand the challenges of having conversations about race and culture that ignite feelings of pain, blame, shame, guilt, denial, confusion and fear. The author highlights how race trauma impacts the bodies of people of colour and white people alike. The possibility of changing communication through body-mind awareness and interaction is presented through a five-part race construct awareness model. Race history is documented, using sources from current and historic writers, scholars, historians, practitioners, leaders and thinkers from diverse racial and cultural identities. Ellis invites us to tune into our cognitive and physiological triggers in conversations about race, so that we can listen and understand our own and others’ experience and move away from cycles of defensive and fearful discourses towards a more informed, open and ethical dialogue. The first two chapters might seem to jump about a bit but this is to lay the foundations for the discussion that follows and may be useful for readers who are not psychology/therapy trained. The conversational style provides an accessible route into the complexity of race construct discourse. Examples of race conversations in the final chapter invite reflection and bring to life the race construct model. This book is a call to action and an enriching resource for trainers, therapists, educators and anyone who wants to develop the compassionate awareness that offers hope for meaningful change.
This is a fascinating book for the sports fan with an interest in the human mind and behaviour. It is very much directed at the general reader and consequently is light on psychological theory, although the author’s integrative, relational-developmental theoretical base clearly underpins his interactions with clients. The book is an antidote to the way sports celebrities are put on a pedestal, to be idolised or vilified – here we are reminded that they are just human beings like the rest of us, but with their life and work played out in the glare of public opinion, where the stakes are sky high when it comes to success and failure. The book comprises a set of 10 case studies featuring people from a range of sports with an array of presenting issues. The case studies are organised, a little confusingly, under chapter headings such as ‘Shame’, ‘Anger’, ‘Fear’ and ‘Love’, with each chapter featuring some of the 10 sportsplayers, but not all. The chapter headings seem a little contrived and the splitting up of the sportspeople’s stories can make them hard to follow. Having said that, the clients’ stories and the author’s work with them provide an enjoyable peek behind the scenes, and any counsellor or therapist will recognise some familiar processes playing out. We can always learn from other therapists and this book was no exception. I enjoyed seeing how another therapist interpreted and responded to his clients’ stories and how he acknowledged both his successes and his (relative) failures. Sports psychotherapy is a relatively new field, but this specialism is surely much needed. The author certainly makes a strong case for it.
Written by James Davies, author of Cracked (Icon Books, 2013), a critique of the flawed psychiatric system, this book unpicks the toxic relationship between neoliberalism and what he presents as the deliberate encouragement of consumerist individualism that allows Western world leaders to shrug off responsibility for the psychological harms of their economic and social policies. Davies draws a direct comparison between today’s pathologising, diagnosing and medicating of human misery with Marx’s view of religion in 19th-century industrialising Britain as the ‘opium of the people’. In Marx’s day, the poor and working classes were promised their reward in heaven to persuade them to continue to submit to exploitation. Today, one could argue that the ‘opium’ has become antidepressants and the six sessions of CBT offered on the NHS to the workless, insecurely employed, inadequately housed and socially excluded. They are told their problems lie ‘in the space between their ears’, not with the policies of their Government or the employment practices of their workplace. If they can’t afford bread, let them eat pills! I was particularly struck by Davies’ linking of Keynesian economics with the humanistic psychological theories of human thriving that prevailed pre-1980s: the ‘being’ mode of living, not the ‘having’ mode now prevalent and encouraged by neoliberalism. He cites the research of psychologist Tim Kasser, showing how materialism is an attempt to assert status and block painful feelings of loss and failure – compulsive consumerism and a form of addiction. Not all will agree with Davies’ politics, but he makes a compelling case in this mind-opening, invigorating book.
Nick Campion is an integrative psychotherapist in Derby
Catherine Jackson is a counselling and mental health editor and writer
Michelle Higgins is a counsellor in private practice and an associate lecturer with The Open University
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
48
SEPTEMBER 2021
The Bookshelf, 1
Reviews A Tiny Spark of Hope: healing childhood trauma in adulthood Kim S Golding and Alexia Jones (Jessica Kingsley Publishers, £19.99)
Enjoying Research in Counselling and Psychotherapy: qualitative, quantitative and mixed methods research Sofie Bager-Charleson and Alistair McBeath (eds) (Palgrave Macmillan, £29.99)
I was initially drawn by the title’s suggestion of the possibility of hope after what are often described as adverse childhood experiences (ACEs). The foreword by Dan Hughes outlines how dyadic developmental psychotherapy (DDP) was adapted to guide the therapeutic relationship of Alexia (an adult client) and Kim (her therapist). Their decision to write this moving account as co-authors was, in itself, an analogy for the transforming therapeutic process that they experienced together. Alexia’s and Kim’s voices are heard in alternating chapters, drawing on their reflections during the three-year process of exploring Alexia’s early abuse and neglect and her life in foster care. In these beautifully crafted stories by Kim, adopting the safety of metaphor to reflect back to Alexia how she presented to the world her different masks, the use of the Russian doll emerges as a simple but totally affecting image and device. There is also a third voice in this account of therapeutic transformation – Alexia’s partner Andrew. This adult relationship gives us the answer to the ‘why now for therapy?’ question. Their loving and secure adult relationship meant Alexia could safely access therapy to explore her past. Alexia’s courage enabled her to see in Kim ‘a tiny spark of hope’ – the hope to trust that she would be willing to help her recover her authentic self and live life fully. This book will be of value to any practitioner working with adults who have experienced childhood trauma, and to any adult considering exploring their childhood trauma in therapy. It offers a reference point and guide for the therapist and client’s journey together.
‘Therapists are natural investigators, exploring, tracing and considering underlying meanings – it is what we do,’ write editors Bager-Charleson and McBeath in the introduction to this book, as they invite practitioners to consider undertaking research. This is a familiar call to action. As therapists, we might be very skilled at doing the work, but we don’t always confidently measure outcomes or translate our experience into research to further the field. This edited collection of chapters by different authors is aimed at current research students and those contemplating embarking on research. Some chapters assume no prior knowledge and are a good introduction to the world of academia and research. For instance, the difference between qualitative and quantitative is outlined, and there is a section about statistics that I found illuminating, as someone with a background steeped more in the humanities than the sciences. Some parts are more technical, going deep into the philosophy of different methods, and these chapters may be more relevant to those who already have some theoretical or academic grounding. Interspersed among passages about research are snippets of the contributors’ work and insights into their areas of interest, which I found inspirational. Barton’s chapter on ‘interpretative phenomenological analysis’ and Etherington’s on ‘becoming a narrative inquirer’ are among those that incorporate compelling personal storytelling alongside a glimpse into these authors’ motivations and processes. Reading this has renewed my conviction that all therapists have something valuable to offer in terms of research. I can imagine this book becoming a practical companion in helping me shape my ideas about researching my own areas of interest into something more rigorous.
Julie Blackman-Nandi is a transitional space therapist
Emmanuelle Smith is a psychodynamic psychotherapist in training
THERAPY TODAY
49
The book that shaped my practice
Living with the Dominator Pat Craven (Freedom Publishing, 2008) For anyone not familiar with the Freedom Programme, it is a course for those affected by domestic abuse. The course and this book are designed to examine the roles, beliefs and actions of male abusers and the reactions of female victims. They do this by looking at the character personification of a behaviour/ attitude, such as the ‘good father’, the ‘jailer’ etc. This allows the reader to understand the intricacies of abusive behaviour without jargon. The book constantly educates the reader, empowering them to see what domestic abuse is but without judgment. As a professional, I found the book informative. It equipped me with the knowledge I need to understand the complexities of abuse. I have found myself dipping into it for key phrases and explanations to further my understanding. Counsellors often don’t have specialist training in all areas and this book is a great first step into understanding domestic abuse. Samantha Airey MBACP (Accred)
SEPTEMBER 2021
91BAPSEP21154.pgs 11.08.2021 16:19
Dilemmas VERSION REPRO OP
OUR ETHICS TEAM CONSIDERS THIS MONTH’S DILEMMA:
SUBS
CAN WE ASK CLIENTS ABOUT THEIR VACCINATION STATUS?
ART
Our Ethics team and readers respond to a member’s dilemma about staying safe when returning to in-person work
PRODUCTION
I have been practising online since the start of the pandemic but I am now back to seeing clients in my counselling room at home. I have been offering new and pre-existing clients the choice of meeting in person or working online. When I receive a new enquiry, I explain that I have had both COVID vaccinations, and I ask them if they have too. I consider it a reasonable question to ask, as I want to protect both myself and my family. I have been contacted by a potential client seeking therapy, and when I asked about vaccinations they said they didn’t believe in them on principle. They became quite angry and accused me of violating human rights. I’m left wondering if I am allowed to ask the question again and if I can refuse to see clients who have not been vaccinated?
CLIENT SHUTTERSTOCK
Stephen Hitchcock, BACP’s Ethics Consultant, replies: This is a thorny issue
and is bound to cause controversy within the profession. There will be strong feelings on both sides. To complicate things further, the situation is changing rapidly, with the possibility of compulsory vaccination for some occupations such as care workers. Who knows – by the time this is in print, vaccination could become mandatory for all health workers, and if so, that may include mental health practitioners. However, we can only respond on the basis of the information available at the time of writing. This is one of those situations where long-established ethical principles appear to be in conflict. For example, how do you reconcile ‘Autonomy: respect for the client’s right to be self-governing’ with ‘Justice: the fair and impartial treatment of all clients and the provision of adequate services’ and the personal moral quality of ‘Fairness: impartial and principled in decisions and actions concerning others in ways that promote
equality of opportunity and maximise the capability of the people concerned’ (BACP Ethical Framework)? As acknowledged in the Ethical Framework (EF) section on Ethics, point 7: ‘… practitioners may encounter circumstances in which it is impossible to reconcile all the applicable principles and will need to choose which ones to prioritise. A decision or course of action does not necessarily become unethical merely because it is controversial or because other practitioners would have reached different conclusions in similar circumstances. A practitioner’s obligation is to consider all the relevant circumstances with as much care as possible and to be appropriately accountable for decisions made.’ Let’s start with the principle of ‘Self-respect: fostering the practitioner’s self-knowledge, integrity and care for self’. As stated in the EF, Good Practice point 91: ‘We will take responsibility for our own wellbeing as essential to sustaining good practice with our clients by:
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
50
SEPTEMBER 2021
a. taking precautions to protect our own physical safety b. monitoring and maintaining our own psychological and physical health…’ You might reasonably expect clients to have been vaccinated out of consideration for your own health and that of other clients entering your premises, as well as others who might be sharing your home, especially those in a higher risk category. You could argue that, were you not to check on a client’s vaccination status, you would be acting irresponsibly and would not be modelling self-care. However, vaccinations are not the only precaution you can take, and you need to consider your overall risk mitigation strategy. After all, vaccination isn’t a guarantee against contracting or spreading the virus. Despite restrictions lifting, it seems advisable to retain social distancing, sanitisation, room ventilation and testing requirements, and asking clients not to attend if they (or you) have symptoms or test positive. The question of vaccinations could form part of a risk assessment, but it is by no means the only element to take into account when mitigating risk and should not be solely relied on. Much will depend on what you state when advertising your services. If you are offering only online therapy, you would not be expected to see clients in person, but if you are offering in-person therapy, or a blended approach of in-person and online sessions, refusing to accept a client because of their vaccination status could be seen as behaving in a discriminatory way. For example, being vaccinated may be contrary to the client’s belief system or raise concerns regarding a current or future pregnancy. Religion or belief, as well as pregnancy, are among the characteristics listed as ‘protected’ under the Equality Act 2010. This defends the public’s right not to be discriminated against on those bases, and we need to be mindful that some people are unable to have the vaccine on medical grounds. You could also be accused of compromising your adherence to the EF. As declared under the heading of ‘Ethics: Values’: ‘Our fundamental values include a commitment to: ● respecting human rights and dignity … ● appreciating the variety of human experience and culture … ● striving for the fair and adequate provision of services.’
Dilemmas, 1
Then there is our commitment under Good Practice point 22 to: ‘… respect our clients as people by providing services that: a. endeavour to demonstrate equality, value diversity and ensure inclusion for all clients b. avoid unfairly discriminating against clients or colleagues … f. make adjustments to overcome barriers to accessibility, so far as is reasonably possible, for clients of any ability wishing to engage with a service.’ The whole issue becomes further complicated when you consider that new variants of the virus may emerge, perhaps requiring a booster vaccine. Would you insist on clients having that as well? And what about existing clients who wish to resume in-person sessions? Or clients who cannot access online therapy?
Until or unless it becomes a formal Government requirement to be vaccinated, you may be making yourself vulnerable to a discrimination claim. If in doubt, you could always check with your professional insurer who may offer a legal advisory service, or other legal advisor.
Until or unless it becomes a formal Government requirement to be vaccinated, you may be making yourself vulnerable to a discrimination claim. If in doubt, check with your insurer’s legal advisory service THERAPY TODAY
51
So, as you can see, there is no simple answer to your question. What is recommended is that you assess who to accept as a client on a caseby-case basis, rather than it being a one-for-all blanket policy; that you have a rationale for your decision, arrived at in consultation with your supervisor; and that you have carried out a thorough risk assessment, of which your question about vaccination could be a part. 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.
SEPTEMBER 2021
91BAPSEP21155.pgs 09.08.2021 18:12
Dilemmas VERSION
MEMBER RESPONSES REPRO OP
‘We are not an emergency service’
SUBS
I would not feel comfortable asking clients whether they have been vaccinated, because it has become politicised. If I were to ask, clients may well feel that it is none of my business. Instead, I have decided to continue to work solely online, not just for the rest of the pandemic but for the future beyond that. Working online means that this does not need to be an issue, so I like to think that this allows for access to sessions even if a client has not been vaccinated. I also believe consistency is very important in therapy and perhaps especially so when there are so many uncertainties. I am uncomfortable with the idea of opening up my practice only to close it again suddenly if the law changes. I also wish to protect myself and my family from the virus as much as possible, but I do not want to work with screens or masks – to do this would feel like a bigger barrier than working online. After ‘freedom day’ in July, I sent an email to all my clients explaining my rationale for remaining online. Every single one of them said they did not feel ready to return to in-person working until they were sure of what might happen during the third wave. I have also made clear on my professional profile that I am only working online. Despite this, I did have two enquiries about in-person work, and I felt justified in not taking them on, as I had been transparent in my advertising. As a profession, we can easily fall into feeling that we should be available to everybody, but we need to work within our own limitations – we are not an emergency service. Beatrice Perez-Barreiro MBACP (Accred), counsellor in private practice
ART PRODUCTION CLIENT SHUTTERSTOCK
‘Asking would interfere with the client’s right to choose’ As counsellors and psychotherapists, I believe we have an ethical responsibility to explore in our personal therapy, or with a supervisor or a colleague, how we relate internally to COVID-19 and the pandemic. What is our internal reaction to the virus and how much are we potentially responding from a base of fear of contracting COVID-19? By clarifying this issue within ourselves, we will be in a much stronger and
I don’t feel I have the right to ask a new client about their vaccination status as that would, in my view, be a form of discrimination and would interfere with the client’s right to choose what they wish to disclose to me clearer position to work out how to respond practically and therapeutically to related issues in our work with clients. As a person with no secondary health conditions and now with a better understanding of COVID-19 due to more information being available, I have felt more confident that, should I contract the virus, I would be unlikely to become seriously ill or even die. Of course, I am always vigilant and try to act responsibly, which is why I opted to be fully vaccinated. I don’t feel I have the right to ask a new client about their vaccination status as that would, in my view, be a form of discrimination and would interfere with the client’s right to choose what they wish to disclose to me. Likewise, I don’t feel that a client has the right to ask me about my vaccination status. Just recently, as part of the couples work I do for an agency, this happened to me. I responded that I was double-vaccinated, but I felt quite uncomfortable and intruded upon. I discussed this with my line manager and I am not sure what my options were to respond differently. We both agreed that a lot more thinking will need to be done in this area. I returned to in-person work when the first lockdown was lifted in May 2020, and I gave each client the choice to continue working remotely, if they wished. I am fortunate as my consulting room has a separate entrance and separate facilities to my home, and so it has been relatively easy to maintain in-person work safely. I have also operated a hybrid approach, working with clients remotely when this became necessary. I expect to continue with this approach, always reviewing the therapeutic impact of not being together in person. I have been very surprised that almost all new clients who have approached me in the past year have asked specifically to be seen in person. Ingrid Schultz MBACP (Accred), psychodynamic therapist and supervisor
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
52
SEPTEMBER 2021
‘Double-vaccinated people are still catching the virus’ Since the start of the vaccination programme towards the end of 2020, I have not enquired about clients’ vaccine status. I see this as a right of privacy that I respect. Taking this stance is made easier because I am fully vaccinated and feel relatively secure, regardless of my clients’ vaccine status. I choose to forego my own privacy and I tell clients my vaccine status in person, on social media and on directory profiles, so they are aware and somewhat reassured. The science tells us that vaccines significantly reduce the chance of catching and spreading the virus, as well as reduce the risk of long COVID. But double-vaccinated people are still catching the virus. Even after the lifting of restrictions in England on 19 July, I continued to operate my COVID-19 policy as best practice to provide a secure space. This includes hand hygiene, no-touch temperature gun, sanitisation of touchpoints between clients, two-metre distancing, natural ventilation, contactless payments and regular lateral flow self-tests. As the highly transmittable Delta variant circulates and cases remain high, I consider I have a duty of care towards myself and my clients to continue all reasonable measures. A neighbouring town has a significantly lower vaccine uptake in comparison to the area where I am based. Also, this area has had high infection rates throughout the pandemic. A question for me is, how do I work with people from areas where the vaccine uptake is lower and infection rate high? Would offering Zoom therapy to certain communities be considered discriminatory, or is this best practice and a form of mitigation, helping me provide a COVID-secure space for me and my clients? There are no easy answers. Indira Chima MBACP, individual and couples counsellor in private practice
We need to be aware of our own reactions to these viewpoints that clients disclose. It’s an opportunity to revisit the philosophies of our practice – how much can we tolerate the other and suspend ‘knowing better’?
Dilemmas, 2
‘We need to be aware of our own reactions’ In the innocent days before COVID, I remember noticing different levels of comfort among my colleagues about illnesses such as the common cold, and how they would deal with clients sniffing and even sometimes finding creative alternatives to tissues. Now the stakes are far higher for our health, and cultural and political values, along with physical fears, are intertwined in our response to the pandemic. There are many things to consider with this dilemma, but here are two I am curious about. I think we have to be seriously honest with ourselves about the extent to which we are bothered or frightened by a client’s vaccination status. We have to balance our desire to keep ourselves and our loved ones safe with what moral duties and potential legal obligations we have. We could, of course, only offer online sessions to unvaccinated people, though that may disadvantage those who haven’t been offered the vaccine, are concerned about effects such as implications for fertility and pregnancy, or have health anxiety around side effects, among others. If this practitioner decided they would not ask the question and would risk seeing the unvaccinated in person, I would ask just how OK they really are about that. If a client they were seeing admitted being vaccine hesitant, how would the therapist’s fears and disquiet play out in the relationship? Even if these fears were unspoken, the client mighty realise something was amiss. We need to work within our competence and that can sometimes mean knowing when we’re loosening our boundaries too much to be able to unconditionally offer genuine warmth.
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: Working in private practice within the counselling professions (GPiA 004) Ethical decision making in the context of the counselling professions (GPiA 044) Equality, diversity and inclusion within the counselling professions (GPiA 062, 063 and 108)
Reasonable adjustment in the counselling professions (GPiA 080) Self-care for the counselling professions (GPiA 088) Race, religion and belief within the counselling professions (GPiA 101) Safe working in the context of the counselling professions (GPiA 106)
BACP’s ethical decision-making model and supplementary questions can be found at: www.bacp.co.uk/media/6875/bacp-ethical-decision-making-model.pdf
Another thing we should be mindful of is how we think about people who have different beliefs to us. Reasons for vaccine hesitancy vary – someone might have a very specific health concern, or have a seed of doubt planted by an image shared on WhatsApp. They might have a considered distrust of governments; they could be a committed anti-vaccine activist or they could believe the vaccines may contain sinister microchips as part of a globalist conspiracy. Conversely, there will be vaccine-hesitant therapists who may be concerned that the vaccinated majority have not thought things through and will force them to get the jab. This being an emotive and politicised issue, we may find ourselves impatient, angry, dismissive or even scornful of those with different positions. Again, as a question of competence, we need to be aware of our own reactions to these viewpoints that clients disclose. It’s an opportunity to revisit the philosophies of our practice – how much can we tolerate the other and suspend ‘knowing better’? What impact do our fears have on that ability? David Blowers UKCP (Reg), counsellor in higher education
becoming increasingly difficult to find enough placement opportunities to go round, partly because some local counselling agencies have closed, while others are limiting the number of new trainees as they are keeping on those from previous years who still need to complete their hours. I am therefore having to search more widely and go ‘cap in hand’ to organisations that we would not normally consider to be suitable for trainees, such as a rape and sexual violence service, an eating disorders clinic and a schools counselling service. We do not have time within the training programme to put on modules in all these specialisms, but we are under pressure from the college and from students to help them find a placement. I feel uncomfortable sending students into situations where they might feel overwhelmed and ill-prepared.
HOW WOULD YOU RESPOND?
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.
Placement crisis I am a tutor on a diploma level counselling course and have responsibility for approving students’ placements. It is
THERAPY TODAY
53
We welcome your responses to this upcoming dilemma. Please email no more than 500 words by 20 September 2021 to therapytoday@thinkpublishing.co.uk
SEPTEMBER 2021
91BAPSEP21156.pgs 09.08.2021 18:12
Analyse Me, 1
The questionnaire VERSION SUBS
Lisa Bent speaks for herself
ART
What motivated you to become a therapist? In my late 20s, I had
PRODUCTION
a part-time job at a holistic centre in London’s Bond Street. A practitioner noticed how I was with clients and suggested I do a 12-week course in counselling, which I did and loved. I continued to degree level and left with first-class honours. It was the best advice I have ever taken. Do you have a specialist field of practice? I help single, 30-plus
CLIENT
women uncover the stories that are potentially running their love life. My work was the inspiration for my book, Symona’s Still Single, a romance novel for self-help lovers, which I wrote to highlight the thoughts and feelings of black women who are trying to exist and find love in Britain while their biological clock ticks on. It’s a perspective I had never read, so I wrote it. Through Symona’s journey, I show the power of introspection, self-awareness, self-acceptance and self-power and how it impacts both love of self and love relationships.
What have you learned about yourself since becoming a therapist and coach? I have
learnt that what I have to offer is valuable and has a place in both the therapeutic space and beyond. My diverse skill set is an asset and it’s OK for me to show up as my whole self in all areas. Being grounded and boundaried is an act of self-care and self-love.
ARNAB GHOSAL
REPRO OP
me Analyse
What do you find challenging about being a therapeutic practitioner? I have found that
some results-driven clients do not see the value of looking at the past to help give further insight into their patterns or barriers. The focus is on the future, but the past has rich information that can be accessed to help make better present and future decisions. And rewarding? Seeing people’s ‘Aha’ moment when they connect the dots to uncover what holds them back, and seeing an increase in self-trust, confidence and self-power. How do clients find you?
Mainly via social media, where I try to remain active, and through recommendations, articles I have written, interviews and podcasts that I have appeared on. Where would you like to be in five years’ time? I would like to
go further with my specialism by forming an agency or group practice and extending into other media, such as events. I think I have at least another two books to birth out. Both novels...? Let’s see.
What book, blog or podcast do you recommend most often?
In the Meantime: finding yourself and the love you want by Iyanla Vanzant. I stumbled on this book when I was 21 and it changed my
THERAPY TODAY
BLACK YELLOW MAGENTA CYAN
74
life. It was the first book I read that highlighted the power of self-enquiry and working on yourself in story form. What is your favourite piece of music and why? I love the
vibe of neo-soul, which I call music with meaning – Jill Scott, India Arie and Musiq Soulchild. When working, I love listening to mellow music without lyrics as it enables me to think. I start the day with afrobeats and the sounds of House Gospel Choir.
What do you do for self-care/ to relax? I have a strict morning
routine that consists of writing my morning pages and gratitude journal, followed by a 10-minute meditation. I also do 5k around my local park three times a week and I’m learning to skate, which is relaxing and fun.
What gives your life meaning?
I believe I’m here for a reason. The signs to my purpose lie in the things that light me up. I’m therefore intentional about where I put my energy, what I say yes to and what I do. What would people be surprised to find out about you? I’m a
former radio presenter. I used to write, produce and host SelfCentral, a three-hour personal development show, every Sunday on Colourful Radio.
About Lisa Now: As the Coaching Counsellor, I work with clients who want to let go of old stories that no longer serve them. ‘What’s your Love Story?’ is my group programme that helps people uncover limiting narratives and rewrite healthier ones. Using my HR professional hat, I also work with individuals to find their voice, confidence and passion in their work life. My first novel, Symona’s Still Single, is published by Jacaranda Books. Once was: I used to be a freelance dance teacher and TV presenter, which I loved (I have a degree in performing arts). I left to start counselling training because I just wasn’t catching a break in TV land and I was becoming tired and jaded by rejection. First paid job: When I was nine years old, I appeared in Aladdin’s Magic Lamp at Lewisham Broadway Theatre, with Cheryl Baker and Rod Hull and Emu.
Who would you like to answer the questionnaire? Email your suggestions to therapytoday@ thinkpublishing.co.uk
SEPTEMBER 2021
91BAPSEP21157.pgs 09.08.2021 17:35