Therapy Today September 2024 by Think Publishing

Celebrate

DynamicInterpersonal Therapy

Join us to connect with practitionersacross the DIT communityand hear from world-leadingexperts.

The day includes: panel discussions and talks from leading DIT experts including Professor Peter Fonagy, Professor Alessandra Lemma and Professor Mary Hepworth discussions of the latest research and clinical applications including supporting trauma and complex presentations a drinks reception and book launch for the second edition of 'Brief Dynamic Interpersonal Therapy: A Clinician's Guide'

(9 9am to 5pm hlB14 December 2024

g Anna Freud, 4-8 Rodney Street, London Nl 9JH

Online and in person

Anna Freud buildingthe mental wellbeingof the next generation

‘Knowingwhoweareandwhy weareimpactsboththeclient

Dr

we turn down EAP clients with serious presenting problems?

quiet place Why silence in therapy is more than the absence of sound

50 7 strategies for a successful private practice Simple ways to improve your chances of success

Making the internal visible Why self-exploration is not just for trainees

THERAPYTODAY

Welcome to the new-look Therapy Today!

As well as a design update that includes font and colour changes to improve readability, we have also introduced new signposted sections so you can easily find what you’re looking for – whether it’s articles on CPD or career development (turn to the ‘In progress’ section), discussions of ethics and good practice (see ‘In practice’) or client presenting issues and case studies (see ‘In the room’). I’m particularly excited about our new upfront ‘In the know’ section, which brings together key member news, updates and events, along with columns by the CEO, Board and President, and our ‘Research digest’, in a lively, easy-to-read bulletin.

We have also put some thought into how we present the content of each article, looking at easier navigation to make it clearer what you’ll learn from investing the time in reading. I’d like to thank our talented Art Director, George Walker, for his input and enthusiasm for creating this fresh, modern design, along with Emma Godfrey, Marion Thompson and the rest of the team at Think.

We’ve also got a new-look digital version thanks to the BACP web team – you can now read every issue

Contributing to TherapyTodayTherapyTodayincludes submissions from members and other practitioners, and we very much welcome your contributions. For TherapyToday-specific guidelines on the types of articles we are looking for, please email d therapytoday@thinkpublishing.co.uk

Please note, we do not publish poetry, blogs or dissertations.

BACP Senior Leadership Team

Chief Executive Officer Dr Phil James

Director of Professional Standards, Policy and Research Dr Lisa Morrison Coulthard

Chief Financial Officer Philippa Foster Transformation and Digital Director Ben Kay HR Director Jamie Redmond

Editor Sally Brown

Art Director George Walker

Managing Editor Marion Thompson

Contributors Ellie Broughton, Jeanine Connor, Katy Georgiou, Nicola Knott, George Salaminios, Karen Stainsby

Production Director Justin Masters

Client Engagement Director Emma Godfrey

Executive Director John Innes

Commercial Partnerships Executive Cara Termine

M 020 3771 7214

d cara.termine@thinkpublishing.co.uk

Sustainability TherapyTodayis printed on FSC® certified paper supporting sustainable forestry 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.

‘Wehaveintroducednewsignpostedsectionsso youcaneasilyfindwhatyou’relookingfor’

online as a ‘flipbook’, and still search for past articles in our archive in the same way. If you haven’t checked that out already, do take a look at bacp.co.uk/bacpjournals/therapy-today

As ever, most of the content of Therapy Today comes from you, the members, and reflects the breadth and depth of your experiences in our wide-ranging profession. It’s hard to pick out highlights, but don’t miss Olivia Sagan’s beautiful exploration of silence in the therapy room, David Morrison’s tips for a successful private practice, and Lucy McDonald’s compelling report, ‘The inflammation factor’. We very much welcome your feedback – do email therapytoday@thinkpublishing.co.uk

Sally Brown Editor

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Please email d bacp@bacp.co.uk to: ● Opt out of receiving paper copies of TherapyToday● Inform us of a change of address ● Report a missing issue

BACP Board of Trustees

Chair Natalie Bailey

Deputy Chair Sekinat Adima Governors Josephine Bey, David Chenery, Punam Farmah, Emma Farrell, Ewan Irvine, Ian Jones, Marc Leppard, Charlotte Venkatraman

THINK

TherapyTodayis published on behalf of the British Association for Counselling and Psychotherapy by Think, 65 Riding House Street, London W1W 7EH v thinkpublishing.co.uk

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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.

M 01455 883300 d bacp@bacp.co.uk

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

Case studies All case studies in this journal, unless otherwise stated, are permissioned, disguised, adapted or composites, to protect confidentiality.

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

Noticeboard

Our monthly digest of news, updates and events

Burst your self-doubt

As part of our strategy to raise public awareness of our profession and how we can help, we launched a new campaign earlier this year about self-doubt and low self-esteem in women. It featured an interactive art installation outside Battersea Power Station in London where women could write their feelings of self-doubt onto paint-filled balloons and fire them at a large canvas. When the canvas was covered in paint, it revealed the message ‘Burst your self-doubt’. The aim of the campaign is to encourage women with self-doubt and self-esteem issues to seek the qualified therapeutic support they need. We also carried out a survey of 1,000 women that found that close to half (49%) say they struggle with or are affected by self-esteem issues. More than half (54%) of the women surveyed agreed their selfesteem impacts their day-to-day choices, such as what events to go to and whether to speak up at work. And nearly half (48%) said their self-esteem has been a barrier to seeking new opportunities.

73% of clients find therapy helpful*

New award nominations

BACP received three nominations at the Association Excellence Awards – Best Lobbying Campaign, Best Development of an Existing Association Event and Best Awareness Campaign or Advancement of a Cause. The winners of the awards will be announced in ceremonies taking place in November. This follows our earlier nominations for three MemCom Membership Excellence Awards – Best Lobbying Campaign, Best Public Awareness Campaign and Best Email Newsletter. These awards will be announced this month.

Noticeboard

FROM THE CEO

Phil James, Chief Executive Officer

In this edition, our ‘Big issue’ report, ‘A fair slice’, looks at the task facing the new Government to improve the mental health of the nation. All national elections have potential implications for the counselling and psychotherapy professions, the future delivery of psychological therapies, and the direction and focus on mental health policy and funding over a five-year period. This particular election has brought significant change, not just through the election of a Labour Government for the first time in 14 years but with a huge turnover of new MPs elected to Parliament for the first time. This brings renewed and increased opportunities for BACP to engage with parliamentarians on behalf of members and the profession.

Many of the mental health commitments from the Labour Party in its election manifesto and brought forward in the King’s Speech reflect issues we’ve campaigned for over many years. Pledges include a mental health professional in every school, a roll-out of Young Futures hubs, an increase in the NHS mental health workforce and an inclusive ban on conversion therapy.

How these commitments are implemented will ultimately be the key to their success or failure in improving people’s mental health and wellbeing. Our focus is to ensure that these commitments maximise the value of counselling, psychotherapy and psychotherapeutic coaching. Since the election, with the support of our Policy Team, I have reached out to new Ministers offering our expertise and support to help deliver their policy programme, as well as contacting opposition parties with offers to assist them to hold the new administration to account.

Throughout September and October we’ll be attending all the main party conferences, seeking to secure early opportunities to meet with stakeholders, including hosting an event at the Labour Party Conference on children and young people’s mental health. We’ll also be engaging with partners in support of our agenda and with our members too. Together we all have a valuable and influential role in helping to push counselling and psychotherapy up the political agenda.

Third sector grants relaunched

Following evaluation of our third sector pilot grant scheme, which funded two BACP organisational members to deliver projects in support of our work to improve equality, diversity and inclusion in the counselling professions in 2023, we’re making further grants available. Applications opened in July and close on 6 September 2024. This round will reflect and build on the findings from the pilot scheme:

• Co-production with trusted community organisations was effective in removing barriers to therapy

• Clients valued working with therapists with similar identities.

One grant of up to £50,000 is available to deliver a project in collaboration with a community-led partner organisation or group, improving access to counselling for people from marginalised and racialised community backgrounds. Two grants of £20,000 are available for innovation in support of meeting demand for existing specialist counselling to clients from racialised community backgrounds. Three grants of £10,000 are available to deliver an activity to support improved access to counselling for people from racialised community backgrounds.

We’ll be awarding the grants in September and will keep you updated on their progress. For more, see bacp.co.uk/about-us/edi/ bacp-third-sector-grants

MIKE SEWELL

Adoption support crisis

The number of adoptive families in England at crisis point or facing severe challenges has increased from 30% to 38% in just one year, according to the annual Adoption Barometer Report from charity Adoption UK (adoptionuk.org. uk). More adoptive families are in crisis than ever before and adult adoptees face a void of support – the survey found that more than eight in 10 adult adoptees (82%) do not have confidence that appropriate therapeutic services are available to them. The survey also found that the number of adoptive families who are optimistic about their future fell by 9% since last year to an all-time low of 69%. The recently released survey of 1,000 people carried out in 2023 found that in England only 1% of adoptive parents and 3% of adult adoptees completely agree that statutory services have a good understanding of the needs of people who have been in care. This aligns with our recent report on the crisis in post-adoption support by specialist practitioner Alison Roy – see bacp.co.uk/bacp-journals/therapy-today/2024/ april-2024/opinion

● Find out more at our CPD event ‘Working with adult adoptees’ (bacp.co.uk/events).

1 in 10 therapy sessions are now online*

Spreading

Promoting our members and our profession through the media

The Independent featured Cate Campbell about the ethics of checking your partner’s phone, and Georgina Sturmer on ghosting. ● Susan Critchley spoke to The Sun on the limits of self-therapy ● HELLO! magazine featured Lindsay George on divorced parents, and Eimear O’Mahony about why people are indecisive. ● Stefan Walters spoke to the Evening Standard about famous women altering the pitch of their voice. ● Philip Karahassan featured in a Woman & Home article about stress-free summer holidays. ● A Women’s Health article about friends sharing the same therapist featured comment from Ashley Duncan ● The Daily Telegraph spoke to Kate Daly about waiting to be grandparents, Kamalyn Kaur and Georgina Sturmer on the difficulties of downsizing, and Denise Freeman on multitasking. ● Janey Morrissey, Deborah Hill Jayne Booth and Laura Jones gave advice in Pick Me Up! magazine. ● GoodtoKnow featured Laura Jones and Jenny Warwick on anxiety, Susie Masterson on toxic traits, Katie Rose on healthy relationships, Nicola Saunders on working mums, Charlotte Monk on grandparents, Dee Johnson on ghosting, Nicola Vanlint and Heidi Soholt on youngest children, Kemi Omijeh on generational perspectives on children’s behaviour and Charlotte Fox Weber on spotting infidelity.

Fostering effective supervision in an

EIMEAR O’MAHONY

KEMI OMIJEH PHILIP KARAHASSAN KAMALYN KAUR

67% feel too uncomfortable to ask for mental health leave***

YOUR QUESTIONS ANSWERED

Accreditation support

How are you making the accreditation process more accessible? A key part of my role is to work with members who identify with a learning difference, long-term health condition or disability to support them through the accreditation process. I spend a lot of time making sure the webpages and application forms are as accessible as possible. It’s an evolving process as there are always ways to make things more accessible.

Liz Gascoigne, BACP’s Support and Inclusion Officer

Is support personalised? Very much so. A lot of my time is spent one-to-one with members. Each member I support has a unique set of circumstances so I spend time talking through the process and answering their questions by phone, email or videoconferencing. I always try to meet individual member needs rather than offering set solutions. If a member can’t access the application form, for example, I’ll reformat it based on their needs, or we can offer an audio application if that’s appropriate. There’s always something that can be done, so I’ll work with members to find a solution that works for them.

Will any additional support be available in the future? Yes, absolutely. Along with the support I currently provide we’re looking at what else we can offer. Earlier this year we undertook an access to accreditation survey, which highlighted some areas for improvement, so we’re working on these and hope to be able to share more information soon.

How do members get in touch with you? The easiest way is to send an email to accreditation@bacp.co.uk or call BACP’s Customer Services Team on 01455 883300

Plan your CPD

If you’re looking for thought-provoking and topical CPD, take a look at our Professional Development Days (PDDs) designed to help you develop practitioner skills in specific areas. The days are interactive and delivered by an expert in their field. Delegate numbers are limited so you gain maximum interaction with the presenter and your peers throughout the day. We have a full programme of PDDs taking place over the next year, both in person at a venue and online. PDD themes include ‘How to succeed in private practice’, ‘Suicide and self-harm – working ethically and safely with clients at risk’, ‘Integrating coaching into your counselling practice’, ‘Integrating artwork into your counselling practice’, ‘How to help clients with their anger – therapist’s toolkit’, ‘Working with erotic transference and countertransference’, ‘Difference, diversity and anti-oppressive practice’ and ‘Working with groups’. To find out more and how to book, see bacp.co.uk/events

PROFESSIONAL CONDUCT

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

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

and

Free CPD and networking event for members

The relationship between posttraumatic growth and spirituality

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Tues. 23 April 9:30 am -10:30 am

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60 min Intake Session Tues. 23 April 11:30 am -12:30 pm

EVERYTHING YOUR PRACTICE NEEDS:

.,/ Scheduling & payments

.,/ Client waitlist & reminders

.,/ Online forms & bookings

.,/ Progress notes, letters & reports

.,/ Practice operations manual

.,/ In-platform telehealth

Private Practice Conference

Dealing with the unexpected can be one of the most challenging aspects of being in practice, so don’t miss this year’s Private Practice Conference: ‘Help! What do I need to do now? Tricky situations and ethical dilemmas in private practice (and how to handle them)’. There’s still time to book on to this hybrid event, which takes place on Saturday 14 September. Highlights include two must-see keynote presentations – Professor Andrew Reeves on the importance of dialogue when working with clients at risk of suicide, and Anne Power on the art of reinvention as a practitioner. On the day, you can also attend two workshops from a choice of six, and access the others afterwards on demand. Workshop topics include cultural ignorance and how lack of exposure to diversity may impact client work; client complaints and how to manage the effect on our professional and personal lives; dealing with the threat of stalking or harassment; and working through a request for your patient notes. There will also be a panel discussion on what happens when there seems to be no obvious answer to an ethical dilemma. The event will take place online and in person in London at etc.venues St Paul’s. For further information and to book, see bacp.co.uk/events/pp2024-privatepractice-conference-2024

FROM THE PRESIDENT

Professor Lynne Gabriel OBE

‘No health without mental health’ is a long-standing mantra yet only approximately 9% of health spend is on mental health,1 despite campaigning by professional bodies, third sector organisations and policy makers. A new Government heralds opportunities for change, and the reminder from Prime Minister Keir Starmer that politics is about public service resonates strongly with the counselling professions. We too are about citizen engagement and public health through valued mental health interventions and practices. This is just one of many reasons for state regulation, which I believe would bring pragmatic and tactical opportunities for inclusion of the counselling professions in UK work planning.

Recently I had the opportunity to be a key player in a successful £2.4 million NHS England bid to develop a pilot 24/7 community mental health centre. The project places citizen collaboration, co-design and person-centred compassionate care at the heart of provision. Psychological therapies feature as part of a multidisciplinary, comprehensive, co-ordinated and integrated mental wellbeing system. Creating a UK mental health system that extends the presence and impact of the counselling professions is crucial, and BACP’s role in this is fundamental. It’s now more than a year since I was honoured to be invited to take up the voluntary role of BACP President. Since then I’ve advocated for key aspects of the Association’s work, including advancing research and employment opportunities for counsellors and psychotherapists. A community volunteer since my early teens, on occasion I’ve met strange reactions to my gifting of time and work, including the misperception that rather than an act of empathy and compassion, volunteering is a means of gaining ground and power, and treated suspiciously.

As a counselling profession we must acknowledge and address our positionalities and pathologies. No person or profession is invincible, hence the need for sustainable, collaborative and positive change. We are a formidable workforce when we don’t get caught up in our own dramas.

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WORKING FOR YOU

Updates from BACP’s Policy Team

Mental Health Act reform

We have long campaigned for parity of esteem between mental and physical health so we are optimistic about plans announced by the Government in the King’s Speech in July that include an ambitious set of progressive bills and a pledge to give mental health the ‘same attention and focus as physical health’. The Government has also committed to a much-needed modernisation of the Mental Health Act. The reform would include giving service users more say in what treatments they receive and ensure that all patients, including those detained under the Act, are treated with dignity and respect throughout their treatment.

School counselling’s economic benefit

The long-term benefit to the taxpayer of access to counselling in all schools is eight times the cost of the investment, a first-of-its-kind report has revealed. The figure rises to a tenfold return on investment for counselling for primary school-age children. The research was carried out by policy and economics consultancy Public First on behalf of BACP and Citizens UK. It concluded that earlier intervention has a greater impact on children’s lives, leading to more positive long-term consequences for the country’s finances.

Sickness support

We support the Government’s recognition that a more nuanced approach in ending long-term sickness is required. Liz Kendall, Secretary of State for Work and Pensions, has acknowledged that addressing long-term sickness is key to boosting economic growth but that the priority is ensuring people have access to better health and employment services. BACP Workforce Lead Kris Ambler said, ‘Better integrating health and employment support services would be a welcome move. With better targeted support for the economically inactive, including psychological therapies and work coaching, we will better help those consigned to a life devoid of both work and hope.’

• To find out more about how we’re working on your behalf, see bacp.co.uk/news/news-from-bacp

FROM THE BOARD

Charlotte Venkatraman, Trustee, BACP Board of Governors

The BACP Annual Research Conference earlier this year was a phenomenal testament to the hard work of the Research team. I am glad that I am able to support such powerful work in my role as interim Research Committee Chair.

I was particularly encouraged by the willingness of researchers to have difficult conversations on bias and inclusivity in the field.

My own research journey began during my medical training at the University of Leicester. During my tenure there I also completed a BSc and MMedSci in research. The first involved a qualitative project on service users’ views about addiction services, and the second a hybrid project on psychotic-like symptoms in a GP practice population.

I specialised in forensic psychiatry and began work in prisons. I became aware how important it is to keep women out of prison as they are often a linchpin in their community, which collapses on their incarceration. I attended lectures on creative sentencing in order to avoid children or elderly relatives being taken into care.

I left psychiatry after my brother ended his life due to symptoms of schizophrenia, and became a Trustee for the central organisation of Mind. I learned about governance of a large charity, strategy development and delivery, and took on a role of diversity champion, which allowed me to view decision making through a lens of inclusion.

I also leaned into my spirituality and the tarot and modern witchcraft I learned from my grandmother. I trained in counselling with a Buddhist underpinning and then studied Western esotericism and shamanic practices. These interests helped me to balance my natural scientific curiosity with a gentle, accepting and understanding attitude. I now run a private practice specialising in integrating spirituality into daily life and its effects on psychological health.

I bring this personal, professional and spiritual background with me to the Board, which I joined in November 2023, and to the Research Committee. Despite being a natural introvert I am enjoying helping to shape our service for members and the wider public, and being supported to do so.

VECTORBUM/SHUTTERSTOCK

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RESEARCH DIGEST

Research updates on suicide prevention

1 Negotiating tension

THE STUDY: A qualitative investigation explored how counsellors describe and comprehend their experiences of working with young people who are at risk of suicide. Counsellors across two clinical sites participated in focus groups.

THE FINDINGS: A reflexive thematic analysis revealed two broad themes. First, counsellors explored their competence, compliance and accountability to institutional requirements of working with young people at risk of suicide as well as concerns with the standard approach. The second theme of ‘artful shifts and conversational openings’ captured counsellors’ various conceptualisations of suicide and counselling.

THE TAKEAWAY: Working with youth at risk of suicide can be seen as a series of ongoing tensions that must be negotiated through critique and compliance of the standardised risk management approach.

READ MORE: White J et al. bit.ly/3yawbXG

2 Mentalization and mindfulness

THE STUDY: Building on the established efficacy of mindfulness therapy in alleviating anxiety and depression symptoms, the research aimed to determine whether combining mindfulness therapy with mentalization-based family therapy (MBFT) would lead to better outcomes for adolescents experiencing suicidal ideation and depression. One group of 40 adolescents received both MBFT and mindfulness therapy, while the other group of 40 received only MBFT.

THE FINDINGS: MBFT alone positively influenced psychological health and reduced suicidal ideation. However, the combination of MBFT with mindfulness therapy produced more significant improvements.

THE TAKEAWAY: Integrating mindfulness therapy with MBFT may offer a more effective therapeutic approach for adolescents with suicidal ideation and depression.

3 Pluralism for actively suicidal clients

THE STUDY: The experiences of pluralistic counsellors and psychotherapists working with active suicide risk were explored through semi-structured interviews.

THE FINDINGS: Four themes were identified. Theme one covered equal relationships, client collaboration, and the pluralistic counselling and psychotherapy (PCP) framework’s flexibility. Theme two captured PCP as supporting clients to become their own therapist, while ensuring therapists feel confident when working with this client group. Theme three explored how PCP supports the idea of therapists being responsible for delivering therapy the best they can, while maintaining clients’ responsibility on deciding whether they continue living. Theme four identified PCP as enabling therapists to bring their authentic self into sessions.

THE TAKEAWAY: PCP can be an effective client-led approach for working with actively suicidal clients.

What’s on Mental wellbeing in the arts and media

How to Be a Man

Riding the crest of a wave of new content on male mental health, Danny Dyer’s two-parter takes a tour of Britain to meet a gay men’s chorus, men who’ve survived domestic abuse, psychologists and a sex therapist, and even tags along on a retreat around male archetypes. Of course, there are no Jungian eggheads in this double bill, which leaves Dyer all the more room to explore solutions to isolation, disempowerment and men’s lack of connection with themselves. A light-touch introduction to contemporary masculinity in the UK that doesn’t miss a beat. Available to catch up now from C4. bit.ly/3VUNMuI

LIGHTER LIVING

The Power of Closure: why we want it, how to get it, and when to walk away is a bold new overview from psychotherapist Dr Gary McClain of the fantasies we hold around endings. Although aimed at general readers, his firm case for challenging the need for control over our losses has much relevance in the therapy room. (Piatkus, out now)

THE OUTRUN

Compiled by Ellie Broughton

Email details of events to

Saoirse Ronan stars as Rona, 29, who returns to Orkney after a stint in rehab. Lonely after a decade in London, she decides to move to the tiny island of Papay for the winter to get to the depths of her sense of isolation. The film is based on an acclaimed memoir by

Amy Liptrot, improvised from prompts and directions and shot on location with locals – all of which prevent the film from falling into a glamourised recovery story. Meanwhile, glorious shots of Orkney and its wild seas add colour and power into a deep, dark tale of redemption. Nora Fingscheidt (System Crasher, The Unforgivable) directs. On general release from 27 September.

Stacking up the evidence in black and white, Stanford psychologist Dr Jamil Zaki makes a case against cynicism in the post-truth age in Hope for Cynics: the surprising science of human goodness, arguing that not only is negativity bias now a lucrative business, it’s making us sick. What follows is an ode to contemporary critical thinking. (Robinson, out 5 September)

Early Sobrieties, a debut novel from US writer Michael Deagler, follows newly sober 20-something Dennis as he leaves his parents’ home and returns to old friends with a new way of life. This warm and witty novel has a fresh take on the pressures facing Generation Z, and the inevitability of the quarter-life crisis. (Cornerstone, out now)

STUDIOCANAL

GAllYi.kCIAIN,P1D

Postcard for the Planet

Apprehension, fear, distress and shame – how do we ‘see’ our feelings about the climate crisis? The diversity of our emotional experiences is the subject of a new exhibition by The Art Therapy Agency. This online, open-submission collection calls for virtual postcards of photography, painting, illustration and mixed media collage. Its mission is based on core therapeutic principles of being seen and heard, and the ability of art to hold and heal difficult feelings. Launched last February, the project now adds new work every week –follow the Instagram account @postcardfortheplanet to see their latest pieces, or find out how to join in at postcardfortheplanet.co.uk

In their own words

Young members of the Irish Traveller community Latisha McCrudden and Emma Ward talk about their life and challenges in a new podcast Mincéirs; paving the way. In episode three, they discuss Traveller mental health with Thomas McCann, founder of the Traveller Counselling Service. spunout.ie/minceirs

In Developing Mental Wealth, a new audio series from trailblazing magazine Positive News, broadcaster and wellbeing expert Dr Radha Modgil and journalist Seyi Rhodes explore projects in Guatemala, Nigeria, Peru and Zimbabwe that offer alternatives to the Western approach to mental health. positive.news/podcast

Radio 4’s excellent series Is Psychiatry Working?, with writer Horatio Clare and psychiatrist Professor Femi Oyebode, is back for a third season with lived experienceled episodes on serious mental illness. Guest Emily’s episode on treatment-resistant depression is a great place for newcomers to start. bit.ly/3WrKjoR

DOCUMENTARY

The Flats

In a tower block in Belfast, Joe re-enacts memories from his childhood during the Troubles. Made in partnership with the charity PIPS Suicide Prevention Ireland, this independent documentary film by Alessandra Celesia is its director’s return to the city and its history. Joe and his neighbours’ re-staging of scenes from their life connects the present day lives of the community with the violent trauma that many of the participants experienced as children. The film is brutal and unflinching, but unlike so much media about modern-day Northern Ireland, it gets under the skin of its subject. Available to stream from MUBI. mubi.com/en/gb/films/the-flats-2024

Bookshelf

Edited by Jeanine Connor. To join our panel of book reviewers, please email therapytoday@thinkpublishing.co.uk

'You're not a~d

other things Genz my sayin therapy

mother'

‘You’re

Not

My F*cking Mother’ and other things Gen Z say in therapy

Jeanine Connor (PCCS Books)

Generation Z – broadly those currently between 12 and 27 – is struggling, according to psychodynamic psychotherapist and author Jeanine Connor. Those of us either parenting or working with young people will recognise this assessment, and the profound effect that the ‘permacrisis’ (including the pandemic, social media, climate change and the political landscape) is having on Gen Z’s mental health and wellbeing.

In this series of clinical stories, Connor delves deep into her work with this age group. The book opens with a ‘real-life’ infant observation, as she recounts her feelings and experiences observing a baby and his family, and how it informed her practice. And it closes with a beautiful chapter about gardening, and how it links with psychotherapy, titled ‘For tomorrow’ after a Blur song. The chapters in between are fictional stories. The exchanges between client and therapist are what I find most interesting. We are introduced to eight clients, including an adolescent whose GCSEs were cancelled because of COVID-19 and who is now about to sit A-levels; a young woman whose mother doesn’t understand her job as a social media influencer; and a 13-year-old who needs help navigating puberty without a mother.

Connor writes with compassion and sensitivity, interweaving theory and practice, and effortlessly bringing to life complex psychoanalytic concepts, which makes this book of interest to trainees, experienced therapists, parents and of course Gen Z themselves. Her wide-ranging references are weaved into the fabric of the text: Freud, Winnicott and Bion sit alongside Blur lyrics, Jarvis Cocker quotes and feminist theory. Impressively, no prior knowledge is assumed, whether of Gen Z culture, social media or psychotherapy, all of which is explained in a compelling, accessible way.

Emmanuelle Smith, psychodynamic psychotherapist

Eating Disorders Don’t Discriminate: stories of illness, hope and recovery from diverse voices

Chukwuemeka Nwuba and Bailey Spinn (eds) (Jessica Kingsley)

Are we aware of the myriad presentations of eating disorders or do we, like many, tend to see them predominantly as the problem faced by thin, white, cisgender girls? This book tells the stories of a range of people who do not fit the stereotype and, because of this, either did not realise they had a disorder or were unable to find help until they were firmly in its grip.

The book is split into sections detailing five of the eating disorders listed in DSM-5: binge eating disorder, bulimia nervosa, anorexia nervosa, avoidant/restrictive food intake disorder and other specified feeding and eating disorders. A final section briefly touches on links with muscle dysmorphia and autism. A theme that runs throughout is the relief people felt when they understood and could name their problem and realised they were not alone. For most, getting support was difficult, and there was a wish for a more diverse range of professionals and an understanding of the diets of different cultures.

A similar theme runs through the stories, of how coping strategies developed into full-blown eating disorders, which one person described as a ‘carousel in hell’. However, these stories are about people who stepped off the carousel, keeping hope as a predominant theme. My only criticism of the book is that it lacks detail about the different treatments that have been successful. However, it is a good book for anyone interested in learning more about eating disorders.

Rachael Sharrad MBACP, child and adolescent psychotherapist

Jeanine Connor

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

Truth: developmental, cultural, and clinical realms

Salman Akhtar, a notable academic and poet, has put together a wide range of contributions from 12 authors from the US and Israel, all practising in the psychoanalytic field. The book presents perspectives of truth derived from studies, research and clinical practice in childhood, adolescence, later life and cultural viewpoints. Reading the book, people might conclude that the truth can be seen as an account of a person’s experience, but the way in which the listener hears and interprets that account, and the things to which we give the most attention, are likely to influence both the way in which we might approach the client and our therapeutic interventions.

The contributing authors write with academic terminology and authority. Each provides sustaining food for thought. For example, Richard Waugaman, clearly a keen archivist and researcher in Shakespeare’s life and work, draws on his explorations to expound the psychology of pseudonymity in supporting Freud’s theory that Edward de Vere, the Earl of Oxford, wrote the works of Shakespeare, based on the discovery of de Vere’s annotated copy of Sternhold and Hopkins’ Whole Book of Psalms, which is repeatedly echoed in Shakespeare’s work.

This book’s academic stance would be of particular interest to researchers and readers working in the psychoanalytic field, and although for me the language used was not easy reading, it offered both information and challenges to my present understanding of the truth. Waugaman ends his chapter with a quote from Emily Dickinson’s poem ‘Tell all the truth but tell it slant’, which may be a good motto for practitioners: ‘The truth must dazzle gradually / Or every man be blind.’

Dr Barbara Mitchels FBACP (Snr Accred), psychotherapist

'Asimilarthemerunsthroughthestories,ofhowcoping

strategiesdevelopedintofull-blowneatingdisorders, whichonepersondescribedasa"carouselinhell"'

Rachael Sharrad MBACP

-THERESILIENT PRACTITIONER

The Resilient Practitioner

Thomas M Skovholt and Michelle Trotter-Mathison (Routledge)

This is the fourth edition of this exploration of burnout and compassion fatigue, a skilfully curated treasure trove of theory, practitioner insights, client vignettes and exercises for self-reflection. As well as being established academics and private practitioners, the authors are also talented writers, making for an engaging read.

This is far more than a book about selfcare – resiliency is explored within the context of practitioner development and effectiveness, a subject that Skovholt has researched throughout his career. I felt like chapter five, ‘Hazards of practice’ –a sobering summary of the reasons why there will always be clients that we fail to help – should be required reading before any would-be therapist embarks on

training. Every chapter ends with reflective exercises and there is much to reflect on, including a chapter on co-dependency in the caring professions. The chapter on the characteristics of highly resilient practitioners based on recent research, new to this edition, was also a highlight. Although much of the research and vignettes are therapy specific, the book is written for a range of caring professionals, including social workers, teachers and clergy. I appreciated being reminded that we are not the only professionals who – as the authors put it – use our ‘own self as a method of change’. Although it may have more obvious appeal to students and the newly qualified, there is also much here of value for experienced practitioners. It is a book I will dip into whenever I feel in need of a boost in professional confidence.

Sally Brown MBACP, integrative therapist

Grandmotherland: exploring the myths and realities

Judith Edwards (Karnac)

Edwards is a child and adolescent psychotherapist with, it says in her bio, an interest in the links between psychoanalysis, culture and the arts, and a desire to make psychoanalytic ideas accessible to a wider audience. This book is testament to those aims. Written in a conversational style, I felt as if I was riding through a mystical ‘grandmotherland’ with Edwards from the off. Her book is couched in 35 years of experience working with families from diverse cultures. She encourages us to look beneath family norms and wonder about the way that myth turns to history, turns to myth. The tropes of grandmother as ‘Heffalump’, crone, big bad wolf and crazy old woman in a rocking chair and ‘off her rocker’ are explored.

Edwards questions the dichotomy of great sorrow or great relief at not being a grandmother. She shares stories from an artist, an educator, a queer woman and a yoga teacher who have found fulfilling alternatives to ‘the pram in the hall’. Alienation and estrangement are explored, as is the case when parents split and parent-in-laws might get pushed out of their grandchildren’s lives. The book closes with Edwards’ story about her own grandmother, a relationship that probably ignited her desire to write this book in the first place. Edwards insists this isn’t a ‘how to be a good grandmother’ book, but it is, I would argue, a ‘how to think about grandmothers’ book – and it is wonderful. Jeanine Connor MBACP, psychodynamic psychotherapist

Salman Akhtar (ed) (Karnac)

A fair slice

Will mental health get the funding it needs from the new Government?

Ellie Broughton reports

With a new Government in place for the first time in 14 years many are hopeful for change. According to BACP’s latest Public Perceptions Survey, published earlier this year, 68% of people think that addressing mental health should be a priority for Government, with

only 14% feeling that the previous Government had done enough on the issue.1 But the task ahead for Keir Starmer’s cabinet is considerable, says Kris Ambler, BACP’s Workforce Lead: ‘Legacy impacts of the pandemic, alongside massive strain to household and business finances, have created a perfect storm of pressure and challenges which, taken together, have exceeded our capacity to cope. These impacts have not been felt equally and have served to widen existing mental health inequalities for women, young

people and minoritised groups.’ Some 74% of survey respondents reported that their mental health was worsened by the current cost of living crisis, up from 53% in 2022. Ambler adds that BACP’s work with partners has long revealed a need for ‘better targeted, more nuanced’ support – support that many are still waiting for.

But is hope in a better future misplaced? Can a million-pound fund here or there really fix the web of problems affecting mental health care in the UK? Averting the escalating mental health crisis needs more than lip service and grand pledges, says Steve Mulligan, BACP Four Nations Lead. ‘Successive Government strategies, including the Five Year Forward View and the NHS Long Term Plan, made mental health a priority. However, these plans have failed to successfully address the chronic shortage in workforce, meaning that any service expansion is hampered by a lack of recruitment of mental health professionals to deliver the services,’ he

says. ‘In their manifesto, Labour made a number of important policy commitments to extend accessible mental health services – including counselling and psychotherapy – across primary care, in schools and in community settings. But they are facing significant challenges in making meaningful change happen, and specifically in addressing growing demand for mental health services.’

Given the challenges facing the new Government, what key issues are a priority? We asked stakeholders and practitioners for their insights on where efforts and funding need to go:

1Investment in the workforce

Some 1.9 million people are currently on waiting lists for mental health support – just one index of the UK’s far-reaching mental health crisis.2 The latest Office for National Statistics figures on death by suicide found that the rate rose 6% from 2022 to 2023.3 The Centre for Mental Health has warned that the cost of mental ill health in the UK is now economically equivalent to ‘a pandemic every year’.4 Demand from young people in particular has more than doubled since 2017.5

Many stakeholders believe long-term lack of investment in services and workforce is the key driving force behind the lack of provision. ‘There is a significant and undeniable mental health crisis in the UK,’ says Gemma Byrne, Policy and Campaigns Manager at Mind. ‘People are telling us that they are feeling overwhelmed and hopeless.’

Byrne highlights the staffing crisis at all levels of mental health care: ‘Staff on the ground are doing their very best with extremely limited resources and unprecedented demand. However, there are significant workforce issues, with retention and staffing shortage issues impacting the safety of patients and staff.’

A Public Accounts Committee report last year found that staff vacancy rates in acute inpatient services run at 20% or more.6 Figures from the British Medical Association show that, as of March 2023, around one in seven full-time equivalent doctor roles in NHS mental health services in England were vacant.7 The NHS Confederation has described how this has

left mental health services in ‘persistent crisis mode’. ‘Therapeutic relationships are essential in making sure people fully engage with treatments and interventions,’ she adds.

Byrne also notes the under-reported problem of crumbling NHS premises: ‘People detained under the Mental Health Act against their will often have to stay in unclean, barbaric, subhuman conditions. The properties from which many mental health services are delivered have experienced years of underinvestment –these estates are some of the oldest in the NHS.’ Data for 2021/22 show that 15.5% of mental health and learning disability sites in England were built before the NHS was established.8 ‘It is not good enough that people in mental health crisis, many of whom are experiencing psychosis or suicidal thoughts, are subject to run-down and squalid environments,’ says Byrne.

Martin Bell, BACP’s Head of Policy and Public Affairs, also highlights workforce issues as a core problem facing the sector. A recent BACP policy report revealed that the workforce crisis has also hit the wellbeing of counsellors and psychotherapists who face overwhelming demand and increasing complexity and severity of client symptoms.

‘School counsellors are being expected to work overtime, often for free, to help address the mental health crisis among children and young people in chronically underfunded schools,’ he says.

‘Organisations delivering third sector counselling services are reporting increased numbers of referrals from statutory services without any accompanying funding, putting added pressure on services that were already struggling with rising costs, falling income and limitations of short-term contracts.’

Ambler reports a similar problem facing workplace therapists. ‘Counsellors working with EAP providers have seen an increase in the complexity and volume of caseloads.

The BIG issue IN THE KNOW

This has led to growing fears of compassion fatigue and secondary trauma, where therapists are increasingly working with clients with difficult or distressing problems. The increase in trauma-focused cases and those involving occupational suicide are examples of this.’ In the financial sector, for example, there have been recent high-profile cases of employees taking their own lives due to work and financial pressures. Ambler says: ‘Often therapists are at the front line after these deeply distressing events, supporting co-workers and managers, and this takes its toll. More organisations from across the sectors are seeking trauma-informed therapists to help meet these challenges, recognising that one-size-fits-all provision is no longer adequate.’

2 Support for marginalised groups

Claudia Turbet-Delof is a councillor and a person-centred therapist in Hackney, east London, with previous experience as a welfare benefits officer. Last November she led a successful call to enshrine mental health as a human right in Hackney. Today she remains deeply concerned about the impact of austerity and the cost of living on her borough and the rest of the UK. Clients she sees who are on long-term sickness leave struggle with isolation, lack of confidence and lack of opportunity to integrate back into work. ‘The numbers are speaking,’ she says. ‘Young people’s suicide rates are higher than before, especially women. We need to look at the data. We can’t just say that people are lazy. It’s not a culture – it’s a crisis.’

After a year of inflammatory headlines about the UK’s ‘sick note’ culture and the ‘pathologising of normal emotions’, we need to focus on the impact of people’s social context on their mental health, says clinical psychologist Dr Lucy Johnstone, who developed the Power Threat Meaning Framework and co-founded the campaign group A Disorder 4 Everyone with therapist

‘Organisationsdeliveringthirdsectorcounselling servicesarereportingincreasednumbersofreferrals withoutanyaccompanyingfunding’Martin Bell

STATE OF THE NATION

88% think it’s important that counselling is accessible to those who want it

52% say their mental health suffers due to worrying about debt

68%

think that

addressing mental health should be a Government priority

Jo Watson. ‘Why do we live in a society where nobody feels that they fit in? Why are people feeling so genuinely insecure and worthless and fragile about their sense of identity? Those much bigger social and political questions get obscured when the individual is labelled as the problem, not their social context.’

Bell says a focus on upstream preventative measures is key to address problems before they become a crisis and require more expensive solutions: ‘We would like to see more focus on early interventions like counselling and psychotherapy across a range of accessible settings, including the NHS, voluntary, community and social enterprise settings, and in workplaces and schools.’

Graham Johnston is a therapist and co-founder of the London Centre for Applied Psychology who worked in policy for around 15 years before retraining. One of the problems holding back meaningful change is that ‘different parts of Whitehall often don’t talk to each other’, he says. ‘For example, you won’t necessarily have

the Department of Health and Social Care talking to the Department for Work and Pensions, talking to the Treasury, talking to the Home Office and making sure that there’s a cross-government strategy for helping this cohort of people back to work. Focusing on “sick note culture” and the role of GPs, as the last Government did, may make headlines but the problem of long-term unemployment due to physical and mental illness has a number of reasons and factors playing into it.’

Addressing the social determinants of mental ill health such as poverty, racism and ableism by tackling systemic inequalities and expanding support for preventable mental health conditions should be a priority, says Bell. ‘Third sector services are often best placed to support marginalised communities underserved by mainstream services. Targeted funding for third sector counselling services could alleviate pressure on statutory services, especially for issues transcending the scope of NHS Talking Therapies. It could increase access to mental health support

‘Therehavebeencriticismsthatneurodivergence isnow“overdiagnosed”,butadiagnosisisthekey togettinghelp’Kat Brown

for marginalised groups requiring specialist, culturally sensitive and trauma-informed psychological support.’

3

More NHS resources for neurodiversity diagnosis and support

Since 2019 waits for autism assessments have gone up fivefold according to a report published by the Nuffield Trust last spring.9 Between 1998 and 2018 there was a 787% rise in autism diagnoses in the UK, and ADHD prescriptions are up 51% since 2019.9 A recent report from the BBC found that many areas of the UK have such a backlog for adult ADHD referrals it would take eight years to clear them.10 Long waits have led to desperate measures – last year, a BBC documentary questioned the validity of diagnoses by some private clinics.11

There have been criticisms that neurodivergence is now ‘overdiagnosed’, but a diagnosis is the key to getting help, says Kat Brown, author of It’s Not A Bloody Trend: understanding life as an ADHD adult (Robinson), who has previously written about her ADHD diagnosis for Therapy Today. ‘The diagnosis just helped to make sense of everything – anxiety, depression, insomnia, binge eating disorder, all of these issues that I’ve been trying to deal with separately,’ she says. ‘People who are healthy, the “worried well”, do not start

thinking, “Do you know what, I think I’m autistic or ADHD” or “Do you know what the secret of making me interesting would be? It would be to give me quite a stigmatised neurological condition”.’

Sarah Worley-James is a neurodivergent therapist who was diagnosed in her 50s. She says she didn’t recognise her ADHD traits until recently, despite working with neurodivergent clients and attending a training on ADHD last year. ‘It can give you that sense of validation, but at the same time you’re still going to get people who are sceptical, who don’t believe it.’

Worley-James now runs a support group for neurodivergent students, where they can share lived experiences and challenges. She looks forward to a time when neurodivergence is no longer treated as a disorder or disability. ‘I hope that we get to the point some day where we don’t have these separate categories,’ she says. ‘We categorise things into boxes, but of course, that’s not what people are.’

According to the Nuffield Trust, the pandemic and sustained underfunding are two factors that have led to growing backlogs in diagnosis and longer waiting times. Research by the charity Autistica estimates that 2.5 million neurodivergent adults in the UK have not been diagnosed.12 The social and economic costs of undiagnosed autism and/or ADHD, according to a review of research led by Dr Blandine French from Nottingham University, includes higher rates of depression, anxiety, self-harm and suicide.13 Studies have also found that lack of diagnosis impacts educational and work prospects, as well as relationship difficulties.

4More information about medication

Lack of available talking therapy and other support services has been linked to the rise in use of medication for emotional distress. In 2022/23 antidepressant prescribing was up 2% year-on-year, equivalent to 200,000 more patients.14 Four in five of the British National Formulary sections covered in the report have seen increases. Antidepressant prescriptions had already doubled between 2008 and 2018, according to the report.

In 2017 the Beyond Pills All-Party Parliamentary Group (APPG) for Prescribed

Campaign success

Several of our long-term campaign issues were included in the Labour pre-election manifesto:

● We asked for: Counselling across all England’s primary schools, secondary schools, further education colleges and sixth form settings.

Election promise: Specialist mental health professionals in every school, so every young person has access to early support to address problems before they escalate.

● We asked for: Fund the roll-out of early help community hubs for 11- to 25-year-olds across England.

Election promise: ‘Setting up Young Futures’ hubs will provide open-access mental health services for children and young people in every community.

● We asked for: Recruit more trained counsellors and psychotherapists into the NHS to meet workforce expansion targets and increase access to treatment.

Election promise: Bringing down waiting times and intervening earlier by recruiting an additional 8,500 new mental health professionals to treat children and adults.

● We asked for: Expand the range of evidence-based psychological interventions available in the NHS.

Election promise: Reforming the NHS to ensure we give mental health the same attention and focus as physical health. Modernising mental health legislation to give patients greater choice, autonomy, enhanced rights and support, and ensure everyone is treated with dignity and respect throughout treatment.

● We asked for: Bring forward a ban on conversion therapy within the next Parliament.

Election promise: Delivering a full trans-inclusive ban on conversion practices while protecting the freedom for people to explore their sexual orientation and gender identity.

We will continue to campaign on the following issues that weren’t adopted into Labour’s manifesto:

● Appoint a cabinet-level Minister for Mental Health to lead a new crossGovernment 10-year mental health and wellbeing plan

● Provide tax incentives to support more employer investment in workplace counselling and therapeutic coaching

● Ensure that third sector mental health providers are given sustainable contracts and appropriate funding for NHS referrals

● Remove VAT on counselling and psychotherapy services to improve accessibility.

For more details, see bacp.co.uk/about-us/about-bacp/ general-election-2024

Drug Dependence commissioned an international survey on drug withdrawal from 1,700 respondents. Results showed that two in three patients claimed not to have received information on the risks of antidepressants, and one in four had no advice on withdrawing from them.15

The APPG now recommends that the UK sets up a deprescribing helpline, not just for those currently withdrawing from psychiatric medication but for those who have been poorly prescribed in the past, who experienced or still live with its lifealtering effects. Dr Anne Guy, co-ordinator for the APPG and project lead for the 2019 Guidance for Psychological Therapists: enabling conversations with clients taking or withdrawing from prescribed psychiatric drugs, says people are still struggling to get help: ‘They need ideas about how to cope with withdrawal symptoms, and they need emotional support.’

5Parity of service across devolved nations

While England struggles with long waiting lists, crumbling NHS premises, staff shortages and burnout, the devolved nations face their own unique challenges. Following the return to power-sharing in Stormont last winter, Northern Ireland needs time, collaboration and funding to get its health service back on its feet. The latest figures show more than one in two children and young people seeking mental health care wait more than nine weeks to be assessed.16 Funding for counselling through the Extended Schools and Healthy Happy Minds programmes was scrapped last year, and funding from Barnardo’s also stopped in 2023.

‘While the return of Stormont is hugely important, Northern Ireland’s Health Minister recently warned that the latest budget from Westminster leaves an £85 million shortfall in funding, which will delay implementation of the mental

health strategy,’ says Steve Mulligan. ‘This will impact funding of critical nonstatutory third sector services and prevent reinvestment in important interventions like primary school counselling provision.’ He called for urgent action from the UK Government to address the shortfall.

In Wales, the Government’s consultation on its new 10-year Mental Health and Wellbeing Strategy could transform the situation on service provision. In its response to the consultation, BACP called for changes to legislation to enable members to undertake local mental health assessments, to address barriers to working in NHS settings, and for investment in primary school counselling and therapeutic interventions for children and young people from age four onwards.

Meanwhile in Scotland, problems with access to mental health services continue to impact patients and their families, says Mulligan. Last year the Scottish Health Survey found mental health was at an all-time low. Only one in two children and young people got treatment within six weeks, and last March those starting treatment appeared to be bottlenecked –numbers are down 10% on the previous quarter and 18% on the quarter before.16

BACP worked with Scottish Government and First Minister John Swinney, in his previous role as Cabinet Secretary for Education and Skills, to implement counselling across Scottish secondary schools. Now BACP is calling for longterm funding for university and further education student counselling from the Scottish Government, as well as better support for GP hubs to hire counsellors, better funding for NHS referrals to counselling, and more multi-year contracts for community counselling providers.

While the challenges facing the new Government are complex, what’s plain and simple in mental health care across the country is the case for change. ●

‘InScotland,ongoingproblemswithaccessto mentalhealthservicescontinuetoimpactpatients andtheirfamilies’Steve Mulligan

REFERENCES

1. BACP’s response to Labour’s Review of Mental Health led by Luciana Berger. [Online.] BACP; February 2024. bit.ly/3RnQnff 2. Hughes S. Taking away crucial support will ‘make things worse’. [Online.] Mind; 29 April 2024. bit.ly/45ha5Pr 3. Census 2021 Quarterly suicide death registrations in England. [Online.] Office for National Statistics; 4 April 2024. bit.ly/3x95bYb 4. Cardoso F, McHayle Z. The economic and social costs of mental ill health. [Online.] Centre for Mental Health; 27 March 2024. 5. Hill A. Young mental health referrals double in England after lockdowns. The Guardian 2021; 15 July. bit.ly/3RolOps 6. UK Parliament. Progress in improving NHS mental health services. Committee of Public Accounts; 21 July 2023. bit.ly/4bWfCgJ 7. Blackburn P, Ireland B. Further than ever. [Online.] BMA 20 April 2023. bma.org.uk/news-and-opinion/ further-than-ever 8. UK Parliament. Written evidence submitted by The Royal College of Psychiatrists. [Online.] April 2023. committees.parliament.uk/ writtenevidence/119824/pdf 9. Morris J. The rapidly growing waiting lists for autism and ADHD assessments. [Online.] Nuffield Trust; 4 April 2024. bit.ly/3yUjGQ2 10. Burns C, Loader V. Eight-year NHS backlog at NHS clinics revealed. BBC News. [Online]. 25 July 2024. bit.ly/4dq6voL 11. Carson R. Panorama: Private ADHD clinics exposed. BBC One, 15 May 2023. bbc.co.uk/programmes/m001m0f9 12. Autistica. What are the personal and economic costs of undiagnosed ADHD and/or autism? bit.ly/45mvUNl 13. French B, Daley D, Groom M, Cassidy S. Risks associated with undiagnosed ADHD and/or autism: a mixed-method systematic review. Journal of Attention Disorders 2023; 1-18. 14. NHS BSA. NHS releases mental health medicines statistics for 2022/2023 in England. [Online.] NHS Business Services Authority; 6 July 2023. bit.ly/4cjMz6N 15. James D et al. Antidepressant withdrawal: a survey of patients’ experience by the All-Party Parliamentary Group for Prescribed Drug Dependence. September 2018. prescribeddrug.info 16. Publication of CAMHS waiting time statistics for Northern Ireland (March 2024). [Online.] NI Department of Health; 23 May 2024. bit.ly/3VjBNX5 17. Rule S, Wilson V (eds). The Scottish Health Survey 2022. [Online.] Scottish Centre for Social Research; 5 December 2023. bit.ly/3RSJsuv

ABOUT THE AUTHOR

Ellie Broughton is a journalist specialising in mental health who has more than 12 years of experience writing for news titles. She has also worked as a copywriter for UK therapists, therapy services and platforms.

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Reframing masculinıty

Angelina Archer describes a three˜part framework for working with a male victim in a controlling relationship

Paul* was a 31-year-old white British male from London who sought therapy to develop healthier expressions of emotion and to address low self-esteem. Paul worked in the financial sector and often became involved in verbal conflicts with his colleagues, which left him wanting to cry, but no tears would emerge. He associated crying with weakness and said he has felt threatened by ‘strong, extroverted characteristics’ in men since childhood.

It soon emerged that Paul was in a long-distance relationship with a woman who would repeatedly tell him he lacked ambition and was ‘not enough of a man’ to make decisions, which left him with insecurities about

his masculinity. He said she often criticised him in front of her friends and family, leaving him feeling humiliated and invalidated. Although I recognised risk factors for intimate partner violence (IPV), physical abuse was not mentioned.

Paul was one of my first male clients at the beginning of my private practice. From a cultural perspective, I found Paul’s perspectives and questioning of his masculinity refreshing. I remained aware and reflective of the attitudes towards masculinity and domestic violence informed by my own Caribbean cultural background. In many Caribbean communities, the impact of femaleperpetrated IPV against men is typically under-reported, and domestic abuse intervention systems often work against male victims,1 with male victims of IPV frequently disregarded due to a heteronormative perception of men and their masculinities.

Paul said his father left his mother when he was four years old. He had a distant, competitive relationship with his brother, who was three years older. He described his mother as ‘overbearing’ and said that she frequently disagreed with Paul about politics and his mental health difficulties. She also compared the brothers’ achievements, and Paul felt pressured to settle down after his brother got married and had a child. He described a history of periodic self-harm from ages 10 to 15; he punched his legs and cut his arms with razor blades when feeling angry or frustrated. He found it difficult to make friends at school, which he put down to being quieter and reflective, whereas his peers were adventurous and sporty.

All of Paul’s significant romantic relationships were long distance. In his previous relationship Paul moved to Italy to live with his female partner after two years, but after one year together he was unfaithful to her as he felt he had failed in the relationship. Prior to this, Paul dated a woman from the US for two years. Paul had now been in an on-off long-distance relationship for two years with Emma,* a 28-year-old who lived in Canada. He visited her for around two to three months, three times a year.

Although Paul said he loved Emma and enjoyed their time together, he felt she was not interested in finding solutions and common ground. He felt pressure to adapt to the type of ‘wealthy, confident and powerful’ man she wanted to marry, and did not feel accepted as he was. Like

his mother, Emma argued with Paul about politics and socioeconomic class.

Three-part framework

I used a three-part psychodynamic object relations framework3 to help understand Paul’s presenting issues, which is a formulation that focuses on the client’s current life situation, infantile object relations (understanding presentday relationships in relation to their childhood attachments to their caregivers) and the relationship with the therapist. In psychodynamic terms, an ‘object’ is a significant person in a client’s life who forms part of their internal world. I chose this model because it considers the transference and countertransference of the therapeutic alliance – as I am a female therapist, I believed the formulation would help me to understand how Paul may redirect feelings towards me and vice versa, and how his relationships may have been internalised.

Current life situation

From the beginning of our work together Paul explained that he struggled to fit in with ‘macho’ male stereotypes and expectations as a child and in his job. He said he found it difficult to understand what masculinity meant to him, and feared others perceiving him as vulnerable. Emma frequently criticised him for his masculinity, and accused him of being weak and indecisive. Because he insisted on staying with Emma, he may have tried to reconcile his internalised feelings of self-blame, failure, guilt and shame associated with his relationships with females, particularly his mother and previous partners.

Infantile object relations

Paul did not have a consistent male presence in his life as a child other than

his older brother, who he said received favourable treatment from his mother. Through unresolved conflicts with his mother, he may have internalised a persecutory female image and the belief that his needs were unimportant compared to the needs of others. His childhood self-harm may have represented isolation and feelings of being emotionally disconnected, which could have affected how he expressed emotions and possibly influenced his choice of long-distance relationships. By being compliant with Emma’s abusive behaviour, he may have believed he was demonstrating a form of masculinity and resilience.

3

Relationship with the therapist

Paul was softly spoken when describing Emma’s abusive behaviour. He was often late for our Zoom sessions, apologising and attributing his lateness to technical issues, but I believe he may have been testing to see if I would be disappointed in him. He said he was creative and enjoyed drawing in his spare time – in the third session, he proudly declared that his Zoom profile picture was one of his own drawings. He may have shared this to see if he would receive validation, especially as he said his mother never gave him praise for his art.

Goals

During goal setting in our first session, Paul initially wanted to understand what masculinity meant to him personally and to feel less shame in expressing his emotions. As he opened up about Emma’s behaviour in the next two sessions, he said he wanted to be a good partner because he felt as though he was doing everything wrong. This alerted me to the possibility of Emma’s controlling behaviour. We agreed to work towards his

‘ThroughsupervisionIrealisedPaulwasreceivingthe femalevalidationhewaslookingfor.Thetransference suggestedhewastestingwhetherthetherapeutic relationshipwasasafeenoughspacetoexpresshimself’

original goals, which allowed me to gather more information about the dynamic between Paul and Emma before addressing my suspicions of coercive control with him. From the third session onwards he described some indications of coercive control by Emma when they lived apart and when they spent time together. He said she expected him to call or text at specific times, and she became angry and verbally abusive if he did not comply. Emma refused to move to the UK but she did not appear to understand his concerns about being financially independent in Canada. When he visited, Paul said Emma expected him to pay for expensive restaurants for their dates and to entertain her friends, otherwise she would verbally abuse him and accuse him of ‘not being enough of a man’.

As Paul spoke about his relationship with Emma, he appeared to dismiss her degrading comments. He felt they would reconcile their differences once he moved to Canada. When I asked how Emma’s comments made him feel, he appeared to smile and become quiet but eventually said he felt she was cruel but loving at times. My supervisor suggested that he learned that his needs were not important as a child, and this may have predisposed Paul to behave in an excessively compliant way towards Emma. This confirmed my initial formulation, and I decided to work with the transference and countertransference in the therapeutic relationship and what I might represent to him.

I tried to create a safe, open space for Paul to express his emotions. He spoke about his childhood and teenage years, and the feeling of never measuring up to others. He said he found solace through art, and his father was an artist. I reflected on how isolated and rejected he must have felt, and the conflict with the man he was expected to be. He realised that although he did not have a consistent relationship with his father, he was grateful to him for sparking his interest in art and for providing a form of masculinity he connected with. He decided he would organise a meeting with his father, and we discussed writing a letter about his feelings towards him, which he chose to share with him.

BEST PRACTICE

Working with Paul provided insight into the key areas therapists should explore in cases of coercive control with male clients:

Childhood

The client’s past history should be investigated as early as possible in the work, holding in mind their relationship as a child with their parents/caregivers and any siblings. Understanding the subtle impact of coercive control could begin with building a picture of how they were raised to perceive masculinity, particularly if their beliefs were based on harmful stereotypes or stigmatising language from their caregivers. This could affect their relationships with females and males, and how they navigate the world as a man.

Verbal and non-verbal communication

Signs of coercive control may be less obvious than in female victims, so it’s important to observe the client’s verbal and non-verbal communication and any noticeable changes in their use of language, tone and behaviour throughout the work, such as becoming subdued, along with any physical/external ways of expressing psychological distress such as self-harm, risk-taking or aggression, past or present. These may provide guidance about when it is safe to disclose concerns about coercive control to the client, and determine if the client is testing the therapeutic relationship.

Artwork

We then used some of his artwork to explore his emotions. One particular drawing was of himself on stage with a guitar playing to crowds in a dark venue, which we discussed could have been a way to express his unconscious conflicts in a socially acceptable way to feel validated and heard from something he created, and possibly expressed a need to feel masculine and powerful as his relationship with Emma and his mother

Relationship patterns

Exploring how they relate to colleagues, friends and other men in the present may be helpful in establishing how they feel about themselves in relation to others. The client’s past romantic relationships may provide information about what the current relationship may be providing for them in comparison to previous ones. It may be useful to explore the significance of their current romantic relationship, and whether it may be reparative in some way to the client, despite being harmful to them. This also applies to the therapeutic relationship. Paul chose me as his therapist, which suggested he could have been seeking a safe and caring, possibly reparative, relationship with a female, but he also chose to meet online, perhaps mirroring his pattern of ambivalence towards proximity in relationships.

Masculinity

Discussing the client’s understanding of masculinity could help the client understand what the abusive behaviours might mean to him, and help to confront his fears of ending the relationship. There may also be implications of the client staying in the relationship that could be explored, such as cultural expectations, pressure from family, fear of failure, and financial implications. Being mindful of language that labels and stigmatises masculinity, tailoring the therapy to the client’s communication style and focusing on helping the client shape their own expressions of masculinity are important to the therapeutic work.

Endings

Any sudden ending by the client should be explored in supervision, as it is likely that some aspect of the work has resonated with the client and they no longer wish to develop this further or, as I believe in Paul’s case, it may be a repeated dynamic of the client feeling vulnerable in a relationship with a female.

appeared to be disempowering to him. He found this insightful and he realised he was already expressing aspects of his emotions and said my interpretations made sense.

I perceived Paul as a pleasant, reflective and sensitive man who seemed to desire acceptance and approval throughout his life. I felt frustrated and angry at times after sessions, especially when he responded quietly, seemed compliant or appeared to affirm the abuse from Emma.

Through supervision I realised he was receiving the female validation he was looking for which he feared losing. The transference suggested Paul was testing whether the therapeutic relationship was a safe enough space to express himself, and talking about his artwork appeared to be a safe way of opening up.

Towards the end of our work together Paul said he and Emma were arguing more about him moving to Canada, and she started challenging him to leave her. In the

12th session I explained that by trying to mould him into an image of the ‘successful’ man her family would find acceptable, Emma’s behaviour may resemble coercive control. I said his emotions about moving to Canada were valid and should be heard by Emma.

He appeared to nod and accept my observations quietly, but it was difficult to gauge how much he had understood and absorbed. He then messaged to say he wanted to pause therapy in advance of a Christmas break and would get in touch about starting again. He did not email to resume further sessions and also did not respond when I contacted him to check his wellbeing.

Outcome

As the work ended abruptly I did not have a full sense of what Paul gained from the sessions, and why he chose not to continue. Establishing his own masculinity may have represented developing autonomy, acknowledgment of his needs and freedom from the expectations of his mother. But in doing so he risked becoming isolated from Emma and his family as well as being labelled a failure, all of which probably became too overwhelming.

Working online meant that I had to work with limited body language and facial expressions, and mostly rely on verbal and non-verbal observations, which may have impacted my ability to provide an approach to therapy fully tailored to his communication style.4

In relation to the goals, although we explored the role of art in his expression of emotions, I felt any further work may have been sabotaged by Emma’s controlling behaviour, as he seemed to avoid expressing himself more to avoid further conflict. However, he had begun to become more accepting of his own masculinity, assert himself with his male colleagues and flatmate, and reconcile his relationship with his father.

Paul’s clinical presentation seemed to confirm research by Costa and colleagues that identified childhood and adolescent issues as predisposing factors for IPV.5 However, the study was not specific about these issues, and did

‘Itisimportanttonotethatonesizedoesnotfitallmale victimsoffemale-perpetratedIPV.Anyriskofharmto theclientbyothersand/ortoothersshouldbeevaluated atallstages,especiallyasmenareathigherriskof suicidethanwomen’

not explore the role of self-harm, relationships with peers at school, the role of masculinity, or the individual’s relationships with their parents/caregivers and any siblings.

In retrospect I could have explored whether Paul may have been punishing himself for being unfaithful in his previous relationship by staying with Emma. I also wondered whether his discontinuation of therapy could have been a decision made by Emma, or if other family members had noticed changes in his behaviour. However, I had no immediate concerns about risk throughout our work. Like me, many female therapists may feel unprepared to work with a male victim of domestic violence, due to limited knowledge and exploration of gender differences in therapeutic training programmes,6 and internalised messages of traditional male and female roles in society.7 There is also a risk that the therapist’s cultural and ethnic assumptions about male victims of domestic violence are subconsciously communicated, potentially creating shame and discomfort for the client.8 However, by remaining aware of these pitfalls, I felt I was able to acknowledge the limitations of my training and gender experience, while providing a safe, empathic therapeutic environment respectful of Paul’s masculine identity.

However it is important to note that one size does not fit all male victims of female-perpetrated IPV. Any risk of harm to the client by others and/or to others should be evaluated at all stages, especially as men are at higher risk of suicide than women, and are more hesitant to report symptoms due to shame.9 Working with Paul highlighted the importance of supervision, self-care and

personal therapy to maintain wellbeing when our work becomes challenging. ●

* Names and identifiable details have been changed.

REFERENCES

1. Cummings CT. A sociological perspective of men’s underreporting of domestic violence and a lack of appropriate interventions in the Caribbean. In: Bissessar AM, Huggins C (eds). Domestic violence in the Anglophone Caribbean: consequences and practices. New York: Palgrave Macmillan; 2022 (pp 131-155). 2. Lacey KK, Jeremiah RD, West CM. Domestic violence through a Caribbean lens: historical context, theories, risks and consequences. Journal of Aggression, Maltreatment & Trauma 2021; 30(6): 761-780. 3. Hinshelwood RD. Psychodynamic formulation in assessment for psychotherapy. British Journal of Psychotherapy 1991; 8(2): 166-174. 4. Seager M, Barry J. Psychological interventions to help male adults. London: British Psychological Society; 2022. 5. Costa D et al. Intimate partner violence: a study in men and women from six European countries. International Journal of Public Health 2015; 60(4): 467-478. 6. Russ S et al. ‘I hate generalising, but…’. Coaches’ views on differences in treatment style for male and female clients. New Male Studies 2015; 4(3): 75-92. 7. Hogan KF et al. Counsellors’ experiences of working with male victims of female-perpetrated domestic abuse. Counselling and Psychotherapy Research 2012; 12(1): 44-52. 8. Westmarland N et al. ‘Living a life by permission’: the experiences of male victims of domestic abuse during Covid-19. London: Respect UK/Durham University; 2020. 9. Martin L, Panteloudakis I. Toolkit for work with male victims of domestic abuse. London: Respect UK; 2019.

ABOUT THE AUTHOR

Dr Angelina Archer MBACP is an integrative counselling psychologist and clinical supervisor in London. She works with a wide variety of presenting issues in young people and adults.

Clinical Wills Made Easy

The inflammation factor

Therapists need to be aware of when inflammatory disorders can masquerade as psychiatric conditions, says Lucy McDonald

In autumn 2018, 12-year-old Harry* was waiting to be admitted for a four-month stay in a psychiatric unit, when his psychotherapist called with news that changed his life. The therapist, Julie Lynn Evans, had worked with Harry for a year and was perplexed by his presentation – a combination of psychiatric and neurological symptoms. Chronic obsessive compulsive behaviour, violent tics, paranoid thoughts and distressing auditory and visual hallucinations had turned Harry into an anxious and depressed shadow of his former self. There was no explanation for the sudden change – no childhood trauma, no attachment difficulties, no trouble at school. He had gone from being an outgoing child who loved cycling to being frightened to leave his room. Social interactions triggered obsessive thoughts around being physically assaulted, which were followed by debilitating, time-consuming compulsions. He could not move without rubbing his arms and crossing his legs many times.

By the time Evans saw him, he had been seen by two doctors, two psychiatrists and two psychologists, and was on antipsychotics and antidepressants, but nothing worked and none of the experts could explain how this normal child had disappeared before his parents’ eyes. His health was deteriorating rapidly and his parents feared for his life.

Evans says: ‘I’ve been a psychotherapist for 36 years, and Harry was one of the most unwell children I’ve seen. No one had an explanation. It felt like his brain was on fire, and nothing made sense until I read about PANS and PANDAS.’

Paediatric acute-onset neuropsychiatric syndrome (PANS) is an illness triggered by a misdirected immune response. It captures a broad spectrum of neuropsychiatric disorders and is hypothesised to be caused by a variety of disease mechanisms and aetiologies. In short, instead of fighting an infection, the immune system attacks the brain – specifically the basal ganglia, which controls emotions and movement. PANDAS (paediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) is a subset of PANS associated specifically with strep. PANS can sometimes affect adults too.

The clinical criteria include a suddenness of onset, an unusual combination of psychiatric and neurological symptoms, and an association with immune events like infections. Symptoms must include either obsessive compulsive disorder (OCD) or restricted eating, and two or more of the following: tics, sensory problems, anxiety, depression, irritability, sleep disturbance, urinary frequency, enuresis, regression, sensory abnormalities, oppositional behaviours, deterioration in schoolwork and emotional lability. The first-line treatment is not psychiatric drugs but anti-inflammatories and/or antibiotics.

Diagnosis

Harry was a week away from admission, and after hearing about PANS his mother, Sylvie, frantically researched the illness. By chance that month, the charity PANS PANDAS UK (panspandasuk.org) had published minutes online of its inaugural AGM, including clinicians who had attended. Sylvie called every doctor on the list and paediatrician Dr Tim Ubhi was the first to respond. In an online consultation, after taking an extensive medical history, he agreed it sounded like PANS, and ordered blood tests. He really listened and the family felt as if someone understood them for the first time since Harry got ill. But the clock was ticking. The test results would take time, and if drugs were prescribed they would need time to work. Harry’s parents feared if they refused the NHS hospital place, and the tests came back negative or the proposed medication did not work, Harry would be in trouble. They sought advice from the CAMHS psychiatrist responsible for his admission, who shook her head and dismissed the illness as ‘highly unlikely’ in his case. Sylvie says: ‘We felt so hopeful but it was weird because on the one hand you had this

Presenting issues Ill

small group of committed doctors saying it was a thing, and these amazing success stories on US forums of children who’d recovered, and on the other we thought we were going mad. Clutching at straws! If something as simple as antibiotics could cure Harry, why had no one mentioned it?’

Two days before his planned admission, the blood tests came back. It was what they had hoped for. A potential reason for Harry’s descent into near madness – his blood showed abnormally elevated levels of strep and other infections, including the Epstein-Barr virus. Dr Ubhi confirmed Harry had PANS. Sylvie says: ‘He was given two weeks of the antibiotic azithromycin, but we knew it would take about three days to work. We didn’t have three days. His bags were packed for the psychiatric unit. We were torn. There’d been false hope before.’ His parents asked CAMHS about delaying admission, and a compromise was reached – Harry would be admitted but would take the antibiotics alongside his other medications.

Cured

Admitting Harry to a psychiatric unit was the hardest thing his parents had ever done. Although he quickly made friends, in nightly phone calls home he spoke about how nurses physically restrained distressed children and how at night children had nightmares and cried out for their parents. Sylvie visited on his third day, and despite the obvious trauma of the unit she could not believe the change. He greeted her with a smiling and relaxed face. She says: ‘It was like a switch had been flicked. He told me: “Mum I feel better. I want to come home.” It was like I had my boy back. The tics had reduced, the OCD decreased, the psychosis gone, his mood improved. I was in shock. Two years of illness, and two years off school, cured just like that.’

‘Arewepotentiallyoverlookinganimmunecomponent insomepsychiatricdisorders?Thisquestionis especiallypertinentwhentraditionalpsychiatric treatmentshavebeenexhaustedwithout substantialimprovement’

Dr Paul Bain

IN THE ROOM

Ten days in Harry was discharged. He had received no therapy in the unit or input from doctors. The only variables were not being at home, and the antibiotics. The unit said his recovery was due to the ‘therapeutic nature’ of the setting. The family thought otherwise and now campaign to raise awareness in the hope others won’t suffer similarly. They are acutely aware that Harry’s life could have taken a very different turn. Dr Ubhi says, ‘Children like Harry are often referred to mental health doctors with the assumption that’s the standard of care. However, with PANS, if we don’t investigate potential medical triggers we will miss the underlying inflammation and disease.’ With his team of multidisciplinary experts Dr Ubhi has seen 1,200 PANS and PANDAS patients since 2017 at the Children’s e-Hospital, his online and Harley Street clinic. His auditing process shows nine out of 10 of his patients had a ‘good’, ‘very good’ or ‘excellent’ response to treatments that typically modulate immune response (anti-inflammatory medications) or treat an underlying infection (antibiotics). In other words, the treatment works.

Therapists

Harry’s experience shows that therapists are key, along with parents, GPs and teachers, in potentially spotting the illness early. So it is baffling why so few have heard of it, especially when PANDAS was first identified in 1998 by Susan Swedo, Chief of Paediatrics and Developmental Neuroscience at the US National Institute of Mental Health, and her team. It has been written about in respected medical journals and studied by scientists from Harvard, Stanford and Oxford. But not all physicians or psychiatrists are knowledgeable of how inflammatory disorders can masquerade as psychiatric conditions, nor do some feel comfortable diagnosing or treating PANS/PANDAS. Diagnosis can be difficult because modern healthcare can be siloed, and a multidisciplinary approach hard to achieve, even though experts say collaboration is key.

PANS/PANDAS patients make up a fifth of child and adolescent psychiatrist Dr Paul Bain’s caseload at his London clinic. These immune-mediated cases are often referred

‘Inourclinicalpractice,we’reobserving anintriguingpattern–certainpsychiatric symptomsthatappearabruptlymighthave animmune-mediatedorigin’ DrPaulBain

to him because of his expertise and experience in this area. He advocates for co-ordination of care, and integrated psychological, psychopharmacological and medical interventions to improve treatment outcomes, and works in a multidisciplinary team with a neurologist and an immunologist. He says, ‘In our clinical practice, we’re observing an intriguing pattern – certain psychiatric symptoms that appear abruptly might have an immune-mediated origin. This observation aligns with practices noted in the US and Nordic Europe, though it continues to be met with scepticism in other regions.’

He appreciates the diagnosis’s controversy but also advocates for a greater understanding. He asks, ‘Are we potentially overlooking an immune component in some psychiatric disorders? This question is especially pertinent when traditional psychiatric treatments have been exhausted without substantial improvement but patients then exhibit rapid

improvements on immune-modulating or antibiotic treatments.’ There’s no one biomarker that proves the presence of an immune-mediated factor, and there is a current discussion around how to more precisely establish an immune factor.

Dr Bain and Dr Ubhi are part of a small, influential group of clinicians focusing on this question. They have formed the PANS PANDAS Clinical Guidelines

95% of parents whose children had the disease said their GP had not offered the diagnosis

Development Group, including paediatricians, immunologists, psychiatrists and neurologists, and have set themselves the task of developing UK clinical treatment guidelines. It feels a bit like turning a tanker. There is inevitably opposition to paradigm change, especially from those who have spent their scientific careers working within the earlier paradigm. With PANS and PANDAS there is resistance from medics who cannot accept that an infection could be the cause of an emotional and behavioural disorder.

COMMON SIGNS OF PANS/PANDAS

● Sudden onset of OCD or eating restrictions

● Anxiety and low mood

● Developmental regression –eg, return to bedwetting or deterioration in schoolwork

● Oppositional behaviours

● Sleep disturbance

● Development of tics

● Enlarged pupils

● Symptoms worsen/appear following infection.

Immune disturbance

But there is increasing research to show how different mental illnesses are linked to immune problems. Robert Yolken, a scientist at Johns Hopkins University, estimates that about one-third of schizophrenics show signs of immune disturbance, and autoimmune diseases are more common among schizophrenics and their immediate families than the general population, which could mean a shared genetic vulnerability. Immunological abnormalities have been observed in patients with bipolar disorder and depression, while scientists have noted that certain autoimmune diseases, such as lupus, can be associated with psychosis. It takes around 17 years for research to trickle into clinical practice, so an educational gap exists for many clinicians who may be unaware of advances in the field. In a 2020 survey by PANS PANDAS UK, 95% of parents whose children had the disease said their GP had not offered the diagnosis, and only half of paediatricians were aware of it. One in five said their paediatrician felt the diagnosis was controversial. Very few countries issue guidance on diagnosis or treatment,

leaving parents exhausted looking after a seriously ill child, and educating themselves and doctors about the disease. Vicky Burford from the charity says, ‘It can be an uphill battle. Yet we know that inflammatory brain disorders are treatable medical conditions when caught early. So spreading awareness and early intervention are key.’ US rheumatologist Jennifer Frankovich who works solely with PANS and PANDAS children at her California clinic reports that delayed medical care may cause the condition to progress to a chronic state over time, condemning those affected to more severe and disabling psychiatric disease. In the absence of NHS help, parents typically seek private treatment, and there are horror stories of families selling their home or using life savings to afford medical bills.

Progress

The guideline development group is not the only place where change is happening. The psychiatric unit where Harry was admitted now asks parents pre-admission about recent infections, or a PANS/PANDAS diagnosis. The illness has been debated in parliament. Labour MP Ruth Cadbury established an All-Party Parliamentary Group on PANS/PANDAS in 2020 after a constituent’s child got ill. In September last year, Maria Caulfield, a Government health minister, weighed in, raising awareness among MPs and on Good Morning Britain

The UK charity’s Facebook forum was started in 2018 and now has more than 6,500 members. These include Evie Meg, a 23-year-old who has 16 million followers on TikTok, where she shares updates on her diagnosis of autoimmune encephalitis, a form of PANS, which has rendered her often unable to walk and with frequent seizures. Her candour has raised the illness’s profile, for better and for worse, with reports of doctors remarking to some patients who presented with tics that they were ‘doing an Evie’. It took Evie Meg eight years to be diagnosed, after a viewer suggested to her it was PANS.

Misdiagnosed

Chances are that therapists reading this will have worked with someone who has PANS/ PANDAS without realising it. The illness is

Presenting issues

sometimes misdiagnosed as ADHD or autism. A US study of young people in a therapeutic day school found that eight in 10 of those screened met criteria for PANS/ PANDAS, and that the medical condition had been missed by previous clinicians.

The best standard of care is determining the immunological cause while treating the associated psychiatric symptoms with psychiatric drugs and a combination of CBT and family counselling, as recommended by evidence-based protocols for the specific psychiatric syndromes (for example, OCD, tics, anxiety). Trauma-focused therapy is sometimes required at a later stage due to the abrupt and distressing onset of symptoms. Dr Bain’s experience, shared by other physicians, has shown him this cohort can be sensitive to psychotropic medication, so need slow titration and careful monitoring. Pharmacogenetic testing can be useful to explore potential intolerances.

Evans had no experience of treating PANS/PANDAS, and her work with Harry before his diagnosis and subsequent antibiotic treatment focused on safety. She says: ‘He had many paranoid thoughts. So I worked very slowly and would gently question him on whether his feelings fitted the facts, only when he was well enough. Using Rogers’ unconditional positive regard, I always treated him and what he was feeling with the utmost respect.’

For many weeks, Evans was the only person Harry saw outside his family, so she provided a vital connection to the outside world.

‘We had nice times. We’d lie on the floor and laugh and play draughts. He was very clever so we talked about books and films. He was often alone so communication and conversation were so important.’ She worked around his NHS CBT for his OCD, helped his transition back into school, and supported him through GCSEs and A-levels.

Flares

US therapists have a longer history of working with the illness, and Dr Zoe Gillispie is one of the longest-standing clinical psychologists involved with PANS/PANDAS children. Her work is detailed, and she charts the illness’s course, ranking it as mild, moderate, severe or extreme. She correlates flares – when symptoms return

Presenting issues

‘Thebestchancewehaveof providingearlier,moreeffective treatmentistoworktogether, providingco-ordinatedcare’ BritaList

or worsen, typically after another exposure to infection – with emotional and behavioural dysregulation. She then tailors treatment, mindful of the illness’s waxing and waning nature. Dr Gillispie treats OCD with CBT with exposure and prevention therapy but warns that the most important part of treating PANS/PANDAS is to get medical treatment on board first. She says: ‘CBT can only be administered when the child is well enough and having medical treatment. It shouldn’t be given when a child is having a flare; then treatment would become untenable. This shouldn’t be seen as the child resisting treatment, the child is simply too ill. When flaring, children should be treated as if they have a brain injury. They need rest and to feel safe.’

PANS/PANDAS affects all aspects of the child and family’s life, with rapid and often unpredictable changes. One study compared the disease burden to that of Alzheimer’s. Another found that flares can create a family crisis severe enough to trigger post-traumatic stress disorder. Family support is vital, especially when the child is too unwell for therapy themselves. US therapist Julie Cox says, ‘In some cases, working with parents can be as effective as direct work. I help parents support their child and deal with the extreme stress and trauma of living with PANS/PANDAS. Siblings can be greatly affected too.’ She

advises thorough safety planning and risk assessment, particularly around flares.

While medical clinicians like Dr Bain and Dr Ubhi will only work within an MDT, Australian psychologist Brita List also recommends collaboration. She says, ‘With low awareness and lack of research on PANS and PANDAS, many of the very experienced health professionals on the child’s care team may still not know a lot about this complex presentation. The best chance we have of providing earlier, more effective treatment is to work together, providing co-ordinated care for this multisystemic syndrome.’ She is involved with the PANS PANDAS Therapists Collective on Facebook, a group that now has more than 1,000 members.

Tina Coope works for PANS PANDAS UK as Education Lead. She is currently co-chairing an Education, Social Care and Health Group aiming to disseminate information about the conditions, with a focus on education, as sufferers may develop sudden learning difficulties including a deterioration in handwriting. She says: ‘Symptoms can easily be misconstrued as a result of poor parenting, behavioural disorders or neurodevelopmental conditions due to a lack of awareness, and the overlapping symptomatology with other conditions or behaviours that teachers are more familiar with.’

There was a report in The Washington Post last year about April Burrell, a university student who became catatonic at 21 and was put in a psychiatric unit. She was diagnosed with schizophrenia in 2000. She was still there in 2018, when it was discovered she also had lupus, a treatable autoimmune condition that was attacking her brain. After months of targeted treatments and more than two decades trapped in her mind, April ‘woke up’. Researchers estimate that other long-term institutionalised patients could also be helped by immune-targeted treatments.

Had Evans not googled Harry’s symptoms, could the same have happened to him? Thankfully, his family will never know. His road to recovery has been long, as subsequent infections triggered flares, OCD and tics. He spent a week in hospital after an unexplained seizure.

Once the immune-mediated illness was under control, recovering from the mental impact of the illness was hard. For a long time he was disturbed by the memory of the hallucinations, the time in the psychiatric unit, the isolation of missing school and the sheer terror of having an illness doctors did not understand. Occasionally he still struggles with tics and flares, but the validation of a diagnosis and the continuing support of Evans, clinicians like Dr Ubhi and Dr Bain, and his friends and family mean he is now able to live a good life. He passed his A-levels with flying colours and starts university this year. His weekends are spent going out with friends or cycling, but he will never forget what he has endured. An earlier diagnosis would have meant earlier treatment, and fewer years lost to an illness no one understood. ●

* The client agreed to share his story, but both his and his mother’s names and identifiable details have been changed. © Article copyright – Lucy McDonald

ABOUT THE AUTHOR

Lucy McDonald is a counsellor at the Children’s e-Hospital, a journalist and the co-host with Jo Joyner of the PANSPANDAS Storiespodcast (available on most podcast platforms).

It changed my life

‘I spent my first sessions telling my therapist how well I was doing’

It’s ironic really that I ended up in a publicfacing industry as a TV presenter, as the way I learned to cope from a very young age was to stay quiet and make myself as invisible as possible. It’s how I survived domestic abuse growing up, and then sexual abuse as a teenager by my running coach.

Standing on stage, speaking into a microphone to an audience of millions and smiling down a camera lens felt more comfortable for me than telling someone one-on-one what I was feeling. Those who have survived trauma are the most resilient people you’ll ever meet, but that’s not always helpful. I’d become so resilient that I struggled to be vulnerable – not just to others but also to myself.

One of my coping mechanisms was to keep on moving, work harder and push harder. In 2016 I cycled 3,000 miles from London to Rio de Janeiro for charity, and 24 hours after finishing the last mile I was in hospital fighting for my life. Malaria and three other hard-to-pronounce diseases left me in a coma and on life support with multiple organ failure. After a long period in hospital and an even longer road to recovery, I was diagnosed with posttraumatic stress disorder. I was having flashbacks, nightmares, anxiety attacks and major lows, and felt like I’d completely lost who I was.

Five months later I sat face-to-face with my therapist, Rachel, a clinical psychologist, but despite wanting help I couldn’t open up. I spent the entire first session telling her how well I was doing and the following sessions doing the same. I wasn’t doing it on purpose, I just couldn’t seem to help it. Every time I wanted to cry and scream it was like a robot took over and buried my feelings. Rachel finally said to me, ‘If you are fine, then why are you here?’ It totally threw me

and, for the first time, I got upset and told Rachel I wasn’t OK.

I’d been diagnosed with depression at 17 years old and put on antidepressants with no mention of talking therapy or questions about why I was feeling the way I was. When I later decided to try counselling I couldn’t seem to emotionally connect to it. I told an edited version of my story as if it had happened to someone else. I left counselling telling myself I’d tried but it didn’t work. One of the things I wish I’d known back then is that therapy isn’t a quick fix. It can take time to understand what we are feeling and why, process the things we’ve experienced, see our patterns of behaviour and reframe our thoughts. For me it’s also been about letting the feelings out that I kept at bay for so long, allowing myself to openly feel the upset inside and learning compassion for myself.

I saw Rachel for two years and for a year after that I was part of a weekly therapy group that she ran. It focused on schema therapy and was structured like a progressive course that you had to attend every week. Sitting in that group was extremely uncomfortable but it’s exactly what I needed and the best thing I could have done. I was always on the run, but being on the run from your own feelings is near impossible. The group showed me for the first time that I wasn’t alone and I wasn’t a failure because of the way I felt. When I first walked into Rachel’s therapy room I could never have imagined I would go on the journey I did. At times I felt worse during therapy, I cried more than I’d ever cried in my life, and it brought up things I had hidden even from myself. It was exhausting but it was even more exhausting carrying on living the way I was, constantly at war in my own head. I can now treat myself with the love and kindness I always deserved.

ABOUT THE AUTHOR

Charlie Webster is an award-winning broadcaster, journalist, campaigner and athlete. Her book, Why It’s OK to Talk about Trauma: how to make sense of our past and grow through the pain, was recently published byWelbeck. Follow Charlie on Instagram: @CharlieWebster

SHOULD I TURN DOWN EAP CLIENTS WITH SERIOUS PRESENTING PROBLEMS?

QI work with several EAP providers and for each the work is allocated by an intake counsellor who assesses each client’s suitability for counselling then sends out brief details to a chosen counsellor. Often my first reaction when reading the presenting issue is that it is simply impossible to properly address it in the allocated sessions that employees typically receive, which can be as few as four. There are some clients I feel uneasy saying ‘yes’ to for this reason, but I want to stay on the right side of the EAPs and make sure work continues to be sent my way as I rely on the income. I tell myself that at least the clients get a positive experience of counselling and that I can offer them some signposting for longer-term work. However, I do wonder whether in some circumstances (processing the impact of childhood trauma for instance) short-term work may do more harm than good. How can I ensure clients are safe but also keep the work?

the decision to do this always rests with the EAP and not you, the client or employer, regardless of funding. You should always follow the relevant processes and protocols regarding session allocation, even if the client’s issue feels ‘bigger’ than first assessed.

Therapy may be an unknown territory for an EAP client. They may have high expectations of how a handful of sessions can help. Management of client expectations is key, so it’s important you know what clients are told about the service so this can be checked against your understanding.

Now, focusing more closely on your dilemma, here are some questions that might be helpful to think about:

AKaren Stainsby replies:

I have worked for more than 20 years as an affiliate with a number of EAPs and offer my perspective and experiences from this work. Before addressing your dilemma, it’s important to acknowledge that while many commonalities exist between how different EAPs work, some practices do differ influenced by, among other things, the service arrangement each has with the organisation purchasing support for its employees.

As happens in other contexts, it’s not unusual that a therapist expecting a specific presenting issue finds a far more

complex or completely different picture when the work gets going. Therapists can see assessments differently from each other, and it can be hard for some EAP clients to disclose information, fearing their manager will be given details. So sometimes you may accept a referral you initially thought could be managed within the allocated sessions.

In general, you are expected to work within the session allocation. In my experience, very occasionally this allocation may be increased by one or two sessions, for example, following a sudden close bereavement. Nevertheless,

● Can every presenting issue be effectively and safely managed? Can the client be helped given the number of sessions available? Your antennae are picking up that it doesn’t feel right to accept some clients and you feel uneasy. Over the years I’ve learned to trust what my antennae might be telling me and regretted occasions when I haven’t tuned into that particular form of wisdom.

● Do you ever decline EAP referrals? Even if affiliates don’t rely on the income or particularly want to keep in the EAP’s good books, they may worry about refusing too many referrals, especially one after another, just in case they

cease altogether. Turning down a client evokes feelings in us. We want to help people in distress so might feel guilty or uncaring. Unless we work in person in a geographically isolated area, we are unlikely to be the only therapist available. If I’ve declined a referral from an EAP the next appropriate affiliate has been contacted from the affiliate pool. I’ve never been pressurised to accept any client referral l wasn’t happy about.

● What does staying on the right side of your EAPs mean? I imagine there feels a bit of a power imbalance. Most EAPs would freely acknowledge that they wouldn’t exist without affiliates. The good ones use their power well while valuing collaborative relationships with affiliates.

● Are EAP clients your only income source? It’s probably best not to become financially over-reliant on any one income stream. Maybe you also have a private practice. If there’s a fee differential, how much do you rely on each? Other sources of income to consider, if you’re interested, competent and see no conflicts of interest, include offering training, coaching, writing, teaching or examining.

There are also good practice areas to consider:

Always do your own assessment. If you accept the case, don’t rely solely on the EAP’s assessment no matter how detailed it is – do your own.

Talk about signposting. A brief intervention service, EAPs support employees in the short term, which may involve signposting to other services and springboarding to more appropriate help. It’s important the client understands why this might be necessary to help them. Mentioning in the first session that it’s part of the service is helpful. A client is less likely to see themselves as having opened up to someone only to be offloaded.

Research where to refer. To be able to confidently and effectively refer, you’ll have a local, national and

internet-based bank of referral information that includes private practitioners, voluntary and other organisations, and helplines. It’s important to check organisations still operate and therapists haven’t retired or moved. Carefully selected apps can also be useful. If the services you would like to refer to have waiting lists, a step-wise approach involving interim signposting might be appropriate.

4 Set a clear focus. Let’s say you accepted a client wanting to work on childhood trauma. You recognise

HOW DO EAPS USUALLY WORK?

● Employers have a duty to respond to legal responsibilities involving the health and safety of employees, so some offer an employee assistance programme (EAP)

● Therapy is usually provided through the EAP via self-employed therapists, known as ‘affiliates’, a process managed by a named EAP case manager or case management team

● Free at the point of delivery, employees are usually allocated between one and eight sessions

● Having received brief details, affiliates evaluate whether they can safely and effectively work within the allocated number of sessions, and if not should decline the case

● Working with an EAP involves a three-way contract between the affiliate, the EAP and the client’s employer. This contract is separate from that agreed between the therapist and client, although they must be compatible (Good Practice, point 31f). As therapists we speak of ‘our client’, but it’s important to remember that although affiliates have responsibilities, the EAP provider holds overall clinical responsibility for the client

● It’s not unusual to receive very brief client details at referral, sometimes one or two words. If more information is required, affiliates might contact the EAP before accepting or declining the case. However, they will be required to decide within a short time frame and may worry the case will be given away if they delay too long

● Along with the Ethical Framework, BACP’s Workplace counselling competence framework can be used to assess your competence to work with the ‘situations, ethical decision making, boundary issues, knowledge areas and legal areas that are unique to workplace counselling’.

that you could do more harm (Ethical Framework, Principles: ‘non-maleficence’) than good (‘beneficence’). You might open up areas that probably stand little chance of being processed and resolved during your limited number of sessions. But if that same client also wanted to focus on managing work/life balance, you might agree to work with that, holding in mind that the traumatic childhood experiences could well influence the work. You’d demonstrate accountability and candour by explaining the boundaries of the work and, if appropriate, may also recommend that after the EAP work they consider longerterm specialist support (Commitment 6a, Good Practice, point 51).

5 Get to know your case manager.

A good EAP is one where its affiliates don’t feel on their own throughout the process of seeing a client, especially when the work gets tough. The person who knows how their EAP works inside out is the case manager. When deciding whether to work for a particular EAP I’d suggest therapists find out how, if necessary, they would contact a case manager. This is not just in times of emergency, although they’ll only know whether the system works once they are an affiliate. If they work for an EAP for several years, systems will change and the affiliate may wish to review, among other things, levels of support, including how quickly someone gets back to them about a query.

As with all of our work as counselling professionals, building good relationships is important (Good Practice, point 56). Apart from enhancing services to clients, this will help when having any robust discussions. Good EAPs respect the fact that their affiliates want to practise ethically, safely and effectively; they’ll want to retain them and work collaboratively.

6 Is your current supervision enough? Hopefully supervisors are key supporters of the affiliate (Good Practice, point 60). It’s important they understand about working with time-limited therapy and the modality

used. If they’ve worked within a workplace context and are used to dealing with organisational dynamics, service levels, accountabilities, responsibilities and potential conflicts of interest, even better. You may wish to review your supervisory relationship and, if necessary, arrange separate supervision (Good Practice, point 60). Affiliates within peer supervision groups can be an additional source of support. Some EAPs run free or low-cost training events. Also, don’t underestimate the importance of self-support and self-care (Principles: ‘self-respect’, Good Practice, point 91).

Final thought

When working with colleagues or organisations in the counselling professions it’s important we feel ethically aligned. Only then can we feel settled in our day-to-day work – a feeling worth its weight in gold.

KAREN STAINSBY MBACP is senior accredited as both counsellor and supervisor and practises in Surrey. She also provides various professional services to BACP.

READER RESPONSES

Keep an open mind

AThis column is reviewed by an ethics panel of experienced practitioners.

Is it possible to support a client to achieve genuine and long-term therapeutic change in a small number of sessions? From my experience as an EAP affiliate therapist, the answer is a definite yes. However, contrary to the implication in the question, it is not necessarily the seriousness or otherwise of the client’s problem that is the determining factor. We will all have worked with clients who come to therapy highly motivated and ready to explore painful history and emotions and make rapid progress. We also have clients with apparently far less complex presenting problems whose progress is slow. I have learned therefore to keep an open mind when accepting a new referral. However, it’s important –and a key element of keeping the client safe – to have open and honest dialogue. Clients need to know, for example, how many sessions are available to them, even where the EAP discourages sharing this. It’s important to establish the client’s priorities, and you may need to contract to work on one particular issue – not ideal since it’s often not as clear cut as this in real life, but this includes the client as an equal participant.

SUPPORT AND RESOURCES

You can find more information in the following BACP Good Practice in Action resources, available online at bacp.co.uk/gpia

● Self-care for the counselling professions (GPiA 088)

● Four-way contracting between training providers, placements, trainees and supervisors within the counselling professions (GPiA 114)

Further resources:

● BACP Workplace counselling competence framework (bit.ly/3WdEmKS)

● UK Employee Assistance Professionals Association Counsellors’ guide to working with EAPs (bit.ly/4cm9heB)

Having said that, the four-session model referred to in the dilemma is very restrictive and, in my experience, not typical. Working with four EAP companies, I have rarely had clients who come for fewer than six sessions; some have more, and sometimes there is an option to request extra sessions. With six sessions there’s more scope for deeper work and time to consolidate and review – for example, by scheduling more of a gap between the later sessions.

Very occasionally I have a referral where alarm bells ring and I have real concern about embarking on short-term counselling. On these occasions I have contacted the case manager to explain this and received an acknowledgment that the referral for short-term counselling should not have been made. So yes, there will be rare occasions where the ethical thing to do is to turn work down.

ANNE LEE MBACP is an experienced EAP affiliate therapist. She is a member of the Psychotherapy and Counselling Union Executive Committee and the lead for its A Fair Deal for Affiliate Therapists campaign.

Stop worrying about staying on the right side I always conduct the first session as if I have been given no input. If a client comments I say that I have read the notes but that I prefer to hear their story from them directly. This also means that I have more input into what we choose to commit to. I tell clients upfront if the allocated sessions – and any additional ones granted – might turn out to be insufficient.

Most clients I meet are relieved to be with a therapist in a safe and held space where they can start the process of addressing their challenges. If we agree that the work isn’t likely to reach a planned ending in the allocated sessions, then we discuss all the options and signposting. It’s important to note that many EAP contracts state a therapist cannot accept a client as a private client after EAP sessions have ended without written permission. Having said that, it has been a very long time since an EAP provider offered me a referral of only four sessions. All have been open to extra

sessions, and a justification request from me in writing has never been refused.

In the early days after qualification, I too rarely said no to an EAP referral because I felt referrers would be more likely to allocate to those therapists who are always available. This may be true, though I have learned over the years that, in fact, most EAPs tend to send a referral to several therapists and see who responds first. I’d suggest to stop worrying about ‘staying on the right side’.

MARK

STANCOMBE

MBACP (ACCRED)

is an EAP affiliate and private practitioner.

Four sessions can be a holding space

AI have also often wondered about the implications of offering clients only four sessions when they have deep-seated issues or complex trauma, for fear of them falling into crisis and not having enough sessions left to process this and recover.

But gradually I have grown more confident in the usefulness of short-term contracts, even with complex and enduring trauma. As a person-centred therapist I trust in the client’s capacity to guide their own recovery, and that through a safe, nurturing environment and trustworthy relationship with their therapist, clients will feel empowered to make healthy choices in a safe, growthful direction. This includes their choice of how deeply to engage during their short-term sessions.

I trust in the client’s deeper wisdom to intuitively sense how much of their trauma they can safely connect with in this limited time. I do of course explore ongoing support options with each client as well as offer information about the chance of emotional triggering and flashbacks that can occur once therapy has begun. I also spend time sharing ideas for self-soothing and calming techniques. My experience so far confirms this trust in clients is well placed. Sometimes clients

will use their sessions as a contemplative space where they keep a safe distance from their deeper pain. Sometimes a client’s trauma has been so ready to erupt that four sessions have provided a vital release valve and helped them understand what has been happening to them. Four sessions can sometimes be a holding space for clients to consider their longer-term recovery options. I believe we can trust in each client’s process.

SARAH WOOD MBACP (ACCRED) is an EAP affiliate, therapist and supervisor in private practice.

I wouldn’t take this work

My experience of working for an EAP provider was that first and foremost these are businesses. If EAP providers really were acting in the best interests of the client as they claim, clients like this would never be referred for a limited number of sessions. What worries me is that the client will think these sessions will be enough to help them. In reality it’s likely you’ll not even scratch the surface within that time, and potentially delay and disrupt the client’s therapeutic journey to getting the help they really need. You won’t even be in a position to offer to carry on working with the client privately, as most providers have a clause preventing affiliates from continuing to work with clients after their allocated sessions, and if you’re found contravening this you’re dismissed.

Morally and professionally, you must consider this seriously because, as you have said, it could cause further issues for the client in the long run. The fact that you don’t want to say no through fear of losing work from the EAP speaks volumes in itself about the power balance here. Personally I wouldn’t take on this work or any work for this provider, as I couldn’t sleep at night with the moral and ethical dilemmas that happened on a daily basis.

‘Itrustintheclient’sdeeperwisdomtointuitivelysense howmuchoftheirtraumatheycansafelyconnectwith inthislimitedtime’

SHARON WILLIAMS MBACP is a private practitioner specialising in working with emergency services.

‘Partofourresponsibilityisnotonlytocreateasafe spacebuttoensurethatweareallowingpotentialclients tomakefullyinformeddecisionsabouttheprocess’

Take on the client but be transparent

In my work as an in-house counsellor I offer members of staff six sessions of counselling within a 12-month period. My priority in all cases is to empower clients to enter sessions with realistic and supported expectations. Part of our responsibility as counsellors is not only to create a safe space once therapy has begun but to ensure that we are allowing potential clients to make fully informed decisions about the process they are entering into with us. We can do this during an initial assessment with an EAP client by highlighting when it seems that longer-term sessions may be beneficial for the work they are bringing, explaining that trying to look at larger pieces of work in a short space of time can sometimes be counterproductive. This can be worded in a way that does not evoke judgment around the ‘severity’ of their issues but rather broadens their awareness of different types of therapeutic support.

A ?

HOW WOULD YOU RESPOND?

We welcome members’ responses to these upcoming dilemmas. You don’t have to be an expert – if a question resonates with you, do share your experiences or reflections with your peers. We welcome brief or longer responses (up to 350 words) by the deadline below. Email your response or any questions to therapytoday@thinkpublishing.co.uk

Is it OK for a client to eat in sessions?

November 2024

A client recently brought his lunch to our session to eat as he had had ‘back-to-back meetings’ all morning and hadn’t had a chance to eat. I was taken by surprise so allowed him to eat but wondered afterwards if I should have asked him to wait and eat after the session? Deadline: 10 September

Is it OK to work from home with children in the house?

December 2024 /January 2025

The inner tension of ‘should I take this client or not?’ can be eased by knowing that you and the client are working with the same awareness and information, allowing the motivation to shift from the uneasy internal conflict of ‘I need this work’ to ‘the client has chosen to do this work’. This transparency also opens up space for the client to ask questions and seek guidance about the support available, sets the scene for a trusting and honest therapeutic relationship, and empowers the client to take accountability for the approach they feel is best for them.

An alternative could be to offer to focus the sessions on cultivating self-care strategies and looking at what practices the client can support themselves with to bolster their resilience to the impact of the concerns they are facing. In my experience, supporting the client to create a foundation of resilience is beneficial whether or not they move on to deeper therapeutic work elsewhere.

ROWAN PRING MBACP is an in-house integrative counsellor for an organisation calmertides.co.uk

I would like to run my private practice from home to save money and could use our family living room as a counselling room as it is right next to the front door. I have invested in a white noise machine to sit outside the room for confidentiality but it’s likely that early evening and Saturday morning clients may hear the sounds of family life as they enter and leave (my two school-age children and partner). I will ask them to keep the noise down but I don’t think I can expect them to be completely silent. I wonder what the implications of this may be? Deadline: 10 October

Is it OK to supervise a former therapy client?

February 2025

A therapy client I worked with for around 10 sessions came back to me three years later for therapy as a counselling student. I discussed the boundary issues in supervision but as the work had been short term and ended some time previouslywe decided it was OK. I saw him for around two years during his training and he qualified 18 months ago. He recently approached me about supervision. I would like to take him on but wondered how I ensure I am his ‘supervisor’ rather than ‘therapist’ given our history? Deadline: 10 November

The dilemmas reported here are 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 BACPwebsite.

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It's designed to support you in your practice, plan and log your CPD and access a wealth of learning resources for your continuous professional development.

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The placequiet

In counselling, silence is very far from an absence of sound, says Olivia Sagan

I’m sitting quietly, thinking about silence. As a meditator and introvert this comes easier to me than to some people. Yet it is less a question of ease for me than one of necessity, and one of mental and physiological reset. As counsellors, most if not all of us need silence; to recharge in, to work things through in, to fully listen to our clients in. And yet, through my research and practice, I hear more and more about the noise that we feel we can’t escape, and how much of the clamour resides in our very selves. Ross suggests that silence is our natural state, having been evolutionarily necessary for our survival – and noise is, in the history of our planet, a recent evolution.1 But it is also a choice. I’m not alone in feeling that a quarter of the way into the raucous 21st century, as we walk with headphones clamped to our ears at the same time as sales in soundmasking gadgets are rocketing, choosing silence has a new urgency. The World Health Organization would support this, arguing that our world is too noisy and that this is harming our health.

the mind, and most of us struggle to switch off from some incoming noise, for much of our day. Csikszentmihalyi pointed out that, ‘Contrary to what we tend to assume, the normal state of the mind is chaos. When we are left alone, with no demands on attention, the basic order of the mind reveals itself.’2

Silence nourishes, soothes and gives a much-needed space in between noise, a chance to face yourself and detach from external din and the internal monkey-brain chatter. But it is also a challenge and a provocation. Anyone who practises sitting quietly will attest to the babbling rush of noise that floods in when we try to hush

At the same time that we struggle to be in silence, a growing body of studies draws our attention to the harm done to our mental wellbeing by noise pollution with some findings indicating that noise is associated with impaired mental health, and others pointing to an increased risk of a range of physical health symptoms as a result of prolonged exposure to noise.3 Attention is also being drawn to the damage wreaked by anthropogenic noise on biodiversity with the ripple effects of this particular loss on our wellbeing.4 Educators are concerned about the lack

of silence in our children’s lives as, despite a rise in the popularity of mindfulness within education settings, being quiet is still largely counter-cultural, particularly in Western society where silence is invariably inflected in negativity.5 Maitland suggests in A Book of Silence that ‘the fear of silence is very deeply embedded in the Western psyche’.6 In Eastern contexts, perhaps most notably in the Chinese tradition, silence is of particular significance and ‘does not reside in the speech or saying of the philosopher, but primarily in the way he lives his silence’.7

Unskinning

In silence anything might turn up. And often does. Any thing. Some thing. That swiftly avoided, routinely evaded, invariably ignored thing will surface in silence. And this avoidance and its consequences were perhaps behind the philosopher Pascal’s

observation in the 1600s that ‘all of humanity’s problems stem from man’s inability to sit quietly in a room alone’.8 Silence ‘unskins’ us – one of the most controversial musical works of the 20th century, still unnerving to this day, is John Cage’s ‘4'33’’’. It consists of what the composer called ‘the absence of intended sounds’. Listen to it and marvel at the unskinning. In a now famous study from 2014, participants were found to not at all enjoy spending six to 15 minutes by themselves with nothing to do but think, with some even preferring to administer electric shocks to themselves instead of being left alone with their thoughts.9 There’s a message there for counselling and being a counsellor, about the inherent toughness, demand and complexity of what we try and do, and indeed what we ask of our clients.

Philosophers have grappled with the concept of silence, its practice and meaning since ancient times, their thoughts interfacing with ruminations in literature and religion with the significance of silence highlighted in practically all spiritual and esoteric traditions around the world since the very beginnings of time. For the philosopher Heidegger it was through silence that we may genuinely hear and listen to our own being-in-theworld and to the others we share that world with, rather than fall prey to the idle chatter of the day. For Wittgenstein, ever preoccupied with words, language, the said and the unsaid, ‘what can be said at all can be said clearly, and what we cannot talk about we must pass over in silence’.10 For Sartre, writing about the French Resistance, silence was a heroic act, one of freedom. A knowledge of the historical context and construction of our human journey of self-awareness and our shifting responses to silence with all their attendant emotions is useful, but for counsellors and therapists what is important is an appreciation of how these interact and interplay in the counselling room.

Unspoken

Yalom noted that, ‘Beginning therapists must learn that there are times to sit in silence, sometimes in silent communion,

Clinical concepts

READING THE ROOM

Silence from the client, as any counsellor can attest, can test us and be interpreted in many ways.

● Dolores* was an intelligent, vibrant and deeply troubled client whose work with me began with a weekly tsunami of speech – deliberations, rants, interrogations, laments, recollections, jokes, anecdotes – until it stopped, and silence broke out. It was a troubling and resounding silence, one that gave us both so much food for thought. In the glacial shifting that ensued in that taut silence, I felt that Dolores was present in the room for the first time, as though she had just actually, finally, arrived. If the silence hadn’t fallen, hadn’t been held, hadn’t been recognised, we’d still be drowning in that thick tsunami of (arguably) thin words.

● Kate* was a young, ethereal woman who would look at me almost pleadingly, soundlessly, wordlessly, while ever so gently and abstractly touching the numerous scars of years of self-harm, as if they said it all. And in some ways they did. It took a long time for Kate to tell that story, quietly, almost inaudibly to begin with, as though the words and her voice themselves were tearing something fragile.

sometimes simply while waiting for patients’ thoughts to appear in a form that they may be expressed.’11 Most of us have been unnerved if not unskinned by silence in the counselling room, probably as novices but not only then. Part of our toolbox is a finely tuned sensitivity to facial expression, body language, barely uttered utterances – perceptibility of which is fine-grained during silent moments. In our work with clients, silence has come a long way from Freud’s view of it as the most powerful resistance, and deliberations of silence in therapy are enriched by therapists such as Bollas who drew our attention to the importance of listening to

the unspoken and that which is known but not yet thought.12

Many of us will have experienced the notorious awkward silence – the lingering, weighted, full-of-unspoken-words silence, the excruciating silence of fear, deep pain and grieving, the sticky silence of humiliation and shame. There is the expectant ‘help me please’ silence, the slow silence of thought, of regret, or the bright silence of awe and of hope. The silence of withdrawal and denial, of abandonment of faith, the impatient silence of ‘wait – I will find the words to say it’ and the seething silence of hatred, broiling anger, violence on a cusp of

‘Anyonewhopractisessittingquietlywill attesttothebabblingrushofnoisethatfloods inwhenwetrytohushthemind’

Clinical concepts

‘Ittakesquietcouragetositwithanotherhuman beinginsilence,andanunboundedcuriosity too,listeningoutforthehumanmessages thatcriss-crossinthatsilence’

eruption. There’s the silence of sudden forgiving, of a slither of self-compassion flooding the chest so fully it demands silence to enable breath to be taken. The silence of memory and remembering. The deep silence of injustice, powerlessness and despair. We know too that for some, silence comes as a ‘cold, pure blessing’.13

Silence is also culturally inflected –carrying different cargo as it moves about, having varying potencies and being received differently in diverse spaces and places – and by different people(s). Ronningstam notes that ‘cultural experience of silence and individual vicissitudes between talking and being silent influence the way individuals form an alliance and pursue the analytic process’.14 One study on the experience of refugees in therapy observed that the physical and psychological trauma the refugees have endured, combined with the experience of displacement ‘causes their sessions to be filled with silence and dissociative mental states’.15 The arts therapies are particularly attuned to the tunes of silence, and they have much to teach us who work primarily with spoken words.16

Unpacking

We will all have our experiences of silence in the counselling room – readers are pointed to Ladany and colleagues whose work begins with a useful review of studies mapping the ways in which silence can be used, interpreted and perceived.17 Therapists were found to use silence to convey empathy, facilitate reflection, challenge the client to take responsibility, facilitate expression of feelings, or simply to take time for themselves to think of what to say. Especially when clients have a history of others in their lives not allowing them space to sit with their feelings, silence can be a gift, cautiously but gratefully received. Those in the study

indicated that a sound therapeutic alliance was a prerequisite for using silence, but at times silence left uninterrupted could lead to harmful effects on clients, particularly those deemed fragile, or when the client experienced it as withholding. It was also recognised that silence was dangerous to the therapeutic process when clients came from families that used silence destructively – the terrible weaponised silence. Suffice to say, in counselling silence is very far from an absence of sound – it may be, in the counselling room, the deafening sound of someone silenced

Learning to tolerate, facilitate, ‘rest’ in and unpack silence in the counselling session, and enabling a silence for our client, modelling not just tolerating but flourishing in silence, is one of a range of vital counselling skills. Like most it takes time to learn. It takes quiet courage to sit with another human being in silence, and an unbounded curiosity too, listening out for the human messages that criss-cross in that silence. Dimitrijević and Buchholz map a fascinating terrain in exploring, interpreting, problematising and using silence that is a useful go-to for counsellors, therapists and indeed anyone interested in the social practices of silence and silencing.18

The poet Adrienne Rich reminded us that ‘lying is done with words, and also with silence’ and silence’s restless relationship with voice, agency and privilege must be kept in mind.19 It is never neutral and it is always a communication, but silence is also savagely open to misinterpretation, so let’s tread carefully. As counsellors working with clients from diverse backgrounds we need to be aware of the range of culturally inflected interpretations and uses of silence, alive to what types of silences are being activated by us and by our client, and

mindful of the power that circulates in our sessions. And perhaps the best way to ponder these provocations amid our chattering, networking and twittering may just be in silence. ●

* Names and identifying information have been changed to protect anonymity.

REFERENCES

1. Ross M. Silence: A User’s Guide. London: Darton, Longman & Todd Ltd; 2014. 2. Csikszentmihalyi M. Flow: the psychology of optimal experience. New York: Harper Perennial; 1990. 3. Passchier-Vermeer W, Passchier WF. Noise exposure and public health. Environmental Health Perspectives 2000; 108: 123-131. 4. Sordello R et al. Evidence of the impact of noise pollution on biodiversity: a systematic map. Environmental Evidence 2020; 9. 5. Lees HE. Silence in schools. London: Trentham Books; 2012. 6. Maitland S. A book of silence. London: Granta Books; 2009. 7. Tong LK. The meaning of philosophical silence: some reflections on the use of language in Chinese thought. Journal of Chinese Philosophy 1976; 3(2): 169-183. 8. Pascal B. Pensées [Thoughts]. London: Penguin Classics; 1995. 9. Wilson TD et al. Social psychology. Just think: the challenges of the disengaged mind. Science 2014; 345(6192): 75-77. 10. Wittgenstein L (trans. Pears DF, McGuinness BF).Tractatus logico-philosophicus. London & New York: Routledge; 2001. 11. Yalom ID. The gift of therapy: an open letter to a new generation of therapists and their patients. New York: Harper Perennial; 2009. 12. Bollas C. The shadow of the object: psychoanalysis of the unthought known. Washington: Columbia University Press; 1987. 13. McGregor J. Lean fall stand. London: HarperCollins; 2021. 14. Ronningstam E. Crosscultural meanings of silence. International Journal of Psycho-Analysis 2006; 87(5): 1277-1295.

15. Luci M, Kahn M. Analytic therapy with refugees: between silence and embodied narratives. Psychoanalytic Inquiry 2021; 41(2), 103-114.

16. Malchiodi CA. Trauma and expressive arts therapy: brain, body, and imagination in the healing process. New York: Guilford Press; 2020. 17. Ladany N, Hill C, Thompson B, O’Brien K. Therapist perspectives on using silence in therapy: a qualitative study. Counselling and Psychotherapy Research 2004; 4(1): 80-89. 18. Dimitrijević A, Buchholz MB (eds). Silence and silencing in psychoanalysis: cultural, clinical, and research perspectives. New York: Routledge; 2021.

19. Rich A. Women and honor: some notes on lying. Pittsburgh: Motheroot Publications; 1977.

ABOUT THE AUTHOR

Dr Olivia Sagan MBACP is Professor of Psychology at Queen Margaret University, Edinburgh. A former psychodynamic counsellor, Olivia has published widely on the interface of creativity, loneliness and wellbeing.

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strategies for a successful private practice 7

Ifound there is a freedom that comes with being an independent practitioner,’ says Elizabeth.* ‘It’s that kind of scary freedom of I make my choices here and these aren’t defined by an organisation. I think that’s both stimulating and scary.’

Like 68% of BACP members,1 Elizabeth works in private practice. Those who are already working independently or thinking about it might recognise the ‘scary freedom’ Elizabeth talks about. In private practice we are liberated from the organisational structures and constraints that can limit or change what we offer

There’s no manual for setting up in private practice but there are ways to improve the chances of success, says David T Morrison

clients. But it also means we have no path to follow and no safety net if we fall. I worked in business and management before my therapeutic training so there was something inevitable about my own journey into the independent sector. The ‘business of counselling’ has also been a central theme in my research as an academic psychologist. I’ve had the opportunity to use this business and

research knowledge to help others set up a private practice. While there is never any guarantee of success, I’ve learned some strategies that can improve the odds. Here are the seven most important.

1 Be clear about why you’re working privately

Successful private practitioners are clear about their motivations. Note the plural

here – there is rarely one single reason a therapist starts a private practice. Instead, private practice is the logical outcome of a series of personal and professional factors. These may be personal factors such as personality, flexibility and lifestyle. Or they can be professional factors such as career development, experience, availability of work, or goodness of fit with the therapist’s therapeutic approach.

These personal and professional factors interact to push people away from other sectors and pull them towards private practice. For instance, Elizabeth was pushed away from the NHS because of a policy that blocked her from achieving a promotion. At the same time she was pulled towards the independent sector because elderly parents’ care meant she needed freedom and control over the hours she worked.

Clients can detect a lack of commitment and motivation from their therapist and perceive it as unhelpful.2 This means that being clear about your reasons for working privately can help to convince and reassure both existing and prospective clients. In the medium term your motivation will help you to weather the inevitable challenges of private practice, such as an unexpected drought of referrals. In the longer term it will protect you from the loss of purpose and meaning that is associated with burnout in private practice.3

2 Allow your practice to evolve

Private practices evolve. As Nicole,* a practitioner in private practice, explained, it’s not ‘the same practice over and over again’. This might mean you eventually train as a supervisor, form a group practice with colleagues, offer training, or specialise in an approach or issue. Private practice is not a destination but a ‘lifelong endeavour’, as Owen,* another practitioner, described it.

This means that you don’t need to ‘get it right’ immediately because your practice is going to evolve anyway. The most successful practitioners are the ones who take a more provisional and flexible approach. They’re the ones who accept ‘this is what I’m doing now, but this may change in future’.

3 Figure out who you’re targeting

One consequence of private practitioners trying to ‘get it right’ first time is that they often fall into the trap of trying to offer everything to everyone. The problem with this is that it’s easy to become seen as a ‘jack of all trades, master of none’.

To illustrate this point, let’s imagine you want a delicious pizza. Do you go to the restaurant that offers pizzas, curries, burgers and steak, or the Italian restaurant with a specialist pizza oven? Most of us will pick the Italian place because we value its specialist expertise. Likewise, if someone wants counselling for their anxiety and is willing to pay for it, they’re going to choose a practitioner who has demonstrable expertise in anxiety.

Successful private practitioners are clear about who their target market is. This might be people who experience a particular problem like postnatal depression or social anxiety. A target market can also be based on demographic characteristics such as age, gender, occupation, location, relationship status or family type. It can also draw on psychographic characteristics like personality, motivation, lifestyle and attitudes. Any combination of 1) problem, 2) demographic characteristics and 3) psychographic characteristics is possible.

To identify potential target markets, reflect on your therapeutic experience. Ask yourself:

● What clients do I form the best relationship with?

● What clients do I get the best results with?

● What do colleagues and supervisors say I do well?

Make some notes about these and add to them as more ideas come to mind. You may find it helpful to discuss your ideas with your supervisor. Once you’ve got a more complete list, try to identify what

combination of problems, demographic and psychographic characteristics your ‘ideal’ clients have. These are your potential target markets. For example, you might have particular expertise in helping new mothers (demographic) overcome postnatal depression (problem), or couples (demographic) who have separated but want to try to make their relationship work (psychographic).

Instead of a large menu with everything on it, the most effective private practitioners offer a small menu with just a few items. Rather than appealing to everyone, they target a limited number of markets. This allows practitioners to be more focused in their marketing. Their website, blogs and social media posts begin to ‘speak’ directly to their target clients. Prospective clients feel seen and begin to engage.

4Understand what makes you stand out

Once you’ve established your target market(s), the next step is making yourself stand out. Professionally, you can think about how your style, philosophy, experience, past counselling outcomes and special training or techniques might be of interest to your target clients. For instance, a separated couple trying to repair their relationship will be particularly interested in a counsellor whose website talks about bringing couples ‘back from the brink’, or who describes specialist training in mediation and conflict resolution.

On a personal level, you can think about how your personality and experiences are relevant to your target market. Appropriate self-disclosure is usually experienced as helpful by clients and strengthens the therapeutic relationship.4 So in addition to your professional experience, let your prospective clients see why you’re the right person to help them.

‘Themostsuccessfulpractitionersaretheoneswho takeamoreprovisionalandflexibleapproach.They’re theoneswhoaccept“thisiswhatI’mdoingnow,but thismaychangeinfuture’”

This blend of the professional and personal is what makes your unique selling point (USP). As private practitioner Anna* told me: ‘I think what’s going to end up distinguishing me from another colleague may not be so much about my knowledge and skills but how I use those and how those are combined within my own character.’

Once you think of it in this way you realise that no two independent practitioners truly compete with each other, even if they’re targeting the same market. Our professional and personal stories combine to produce unique ‘products’ for clients to choose from.

5 Connect with others

Private practice can be a lonely experience. As Elizabeth put it, ‘You’re not part of a team. You don’t have the same rituals of walking into the office in the morning and all having a cup of tea together and catching up.’ This sense of teamwork is traded in for the flexibility and freedom of being your own boss. Nevertheless, I’ve yet to meet a private practitioner who wants to be alone. The most effective private practitioners find ways to overcome this isolation. They are active on private practice groups on social media such as LinkedIn or Facebook. They make the most of in-person networking opportunities like the BACP Private Practice regional events. They get involved in their local small business community. They keep in contact with counsellors they’ve worked with in other jobs or who they trained with. In some cases they forge reciprocal alliances with other independent healthcare professionals, such as massage therapists and physiotherapists. In short, successful private practitioners don’t suffer isolation: they actively seek out other people. There is one other ready-made solution to the isolation of private practice – group

FACTS IN FIGURES

68% of BACP members work in private practice1

practices. Instead of ‘going it alone’, group practices bring together a team of private practitioners. As Nicole,* who works in a group practice, explained to me, it can give a sense of teamwork and security: ‘You’re surrounded by this team of colleagues who are of the same qualification or a very similar qualification so there’s that unity, this sense of kind of safety.’

In addition to the human connection, group practices help to spread the

practical challenges and risks of working independently, as well as the costs of office space, equipment, administration and marketing. Each practitioner brings their distinctiveness to the team so that collectively they offer a wide range of expertise across psychological problems, client groups and therapeutic approaches.

6 Make peace with being a therapist and a business person Money is a tricky subject for counsellors. Most people enter the profession to help people rather than make money. However, as a private practitioner you have to reconcile your identity as a therapist and a business person. A private practitioner who undercharges or lets clients get away with missed payments will soon struggle to make ends meet

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or eventually burn out. It’s not just bad for business but bad for therapy too. For instance, a client who learns they aren’t being challenged about late payments may start to test therapeutic boundaries by arriving late. More broadly, undervaluing our time and expertise is a poor way to model self-worth to clients.

As a result of not thinking of ourselves as business owners, we also risk overlooking the support available to self-employed people. All four nations of the UK and many councils have excellent support services for small business owners. These services offer guidance and training – usually free –on important topics such as tax and marketing. You can find further information from the websites listed in the box above. You can find additional regional support services by performing an online search for your council or county name along with ‘small business start-up support’.

7 You have to learn on the job

Every single private practitioner I’ve met has said the same thing: ‘My training didn’t prepare me for this.’ In some cases counselling training on private practice amounts to a day or two. In others it’s just a couple of hours or not addressed at all. As a profession we need to get better at preparing graduates for working independently.

What this means is that you must be prepared to learn on the job, as Anna* explained: ‘It doesn’t come with a manual so you need to go through different phases, different emotions, stand on your own two feet, fall sometimes, but then you pick yourself up again, and be willing to learn from whatever comes your way, which is not always very pleasant – that’s a challenge.’

The most successful private practitioners try to reduce the trial and error by asking for advice from their supervisor, other private practitioners and business support services. This can go a

long way to making up for the shortcomings of core counselling training. There is no recipe that guarantees success in private practice. Like any business, a private counsellor is subject to unpredictable market forces. However, these seven strategies can improve your chances of long-lasting success. Whether you’re starting out or already in private practice, be clear about your personal and professional motivations. Be flexible about how you see yourself as a private practitioner, and allow your identity to evolve naturally. Identify your target market(s) and how you can persuade them you’re a good fit. Be prepared to network locally and regionally to develop your business profile. Recognise how your identities as therapist and business person are reciprocal rather than conflicting. And finally, be open to learning as you go because, as Anna said, it doesn’t come with a manual. ●

* Names and identifying information have been changed to protect anonymity.

REFERENCES

1. BACP 2022-2023 Workforce mapping report. [Online.] bacp.co.uk/about-us/about-bacp/6march-2022-2023-workforce-mapping-survey

2. Paulson BL, Everall RD, Stuart J. Client perceptions of hindering experiences in counselling. Counselling and Psychotherapy Research 2001; 1(1): 53-61.

3. Finan S, McMahon A, Russell S. ‘At what cost am I doing this?’ An interpretative phenomenological analysis of the experience of burnout among private practitioner psychotherapists. Counselling and Psychotherapy Research 2022; 22(1): 43-54.

4. Hanson J. Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients. Counselling and Psychotherapy Research 2005; 5(2): 96-104.

ABOUT THE AUTHOR

Dr David T Morrison is an independent practitioner psychologist and associate lecturer at The Open University. His doctoral research focused on counselling psychologists’ early experiences of working independently.

Making the internal visible

Self~exploration is not just for trainees ~ it’s an important part of every therapist’s ongoing development, says Sue Sweeney

Personal development I

It is only recently that I have come to fully appreciate the potential power of self-exploration to significantly enhance self-knowledge. As therapists we know that finding the words to talk about issues is not always easy for our clients. There may be difficulty in articulating thoughts and feelings, or an inability to identify and give voice to an underlying issue that may lie hidden from awareness. The same can be said of therapists, with many of us gaining experiential knowledge of self-exploration solely through participating in personal therapy during training. Yet even within and beyond that we may continue to hold experiences, including trauma, locked away within our defensive armoury. How then might we go about unlocking these experiences, untangling and peeling back messy layers to give them a visible, coherent form, and why is it important for us and those who we support? My own experience bears testimony to the importance of recognising and exploring the self as a powerful tool for healing, understanding and accepting personal experiences that will benefit client work. For me it was a process that provided the key to unlocking lifelong traumatic grief.

My story

When I was 19 my world fell apart. My dad died suddenly and unexpectedly of a heart attack. He was 52 and the most important person in my life. His loss rocked me to the core, and I thought that nothing else that happened to me in life would ever be as hard to get through. The unremitting grief was like a stranglehold around my young life, restraining, constraining, choking, always present. I was approaching the end of my first year of a three-year teacher training course at a college two hours away from home when it happened. Feeling lost, in deep distress and searing pain, I learned to navigate my way through the next two years to complete my studies while living with a gaping wound of unmanageable grief. Three years later the unthinkable happened when my only sister, aged 26, died in a tragic, preventable accident. Her

sudden and traumatic death left me reeling in disbelief that she was gone, wrenched from my young life, and we would never again share petty sibling squabbles or precious mutual lifelong support and love. The world was no longer a safe place to be in.

Four years passed, then my mum died suddenly from a brain haemorrhage. She was 56. The cumulative fallout of three sudden deaths compounded my fear of loss and left me in a state of terror at the prospect of losing another loved one. The knock at the door, the late-night phone call, seeing a police car pull up in the street all sounded alarm bells that this might herald more bad news that would knock me off my tenuous recovery axis during a decade of grief.

Life became a matter of survival, living one day at a time to get me through the working day. Change became a hallmark of my life, leaving teaching to work in recruitment, and later in the exhibition and conference industry, which brought travel, stimulating and engaging work, and success in reaching targets and delivering consistent outcomes. But it wasn’t satisfying, it wasn’t enough, and grief accompanied me in my daily life.

Wishing to do work that felt more meaningful and which would give me the opportunity to support others, I returned to university as a mature student and completed studies in art therapy and psychology. This new direction opened doors to fulfilling work supporting adults in hospital, community, military and humanitarian aid settings. Yet despite the personal therapy undertaken during my training, my ever-present repressed grief continued to haunt my daily life.

Turning point

I had been toying with the idea of doing research for several years, and decided

to embark on a professional doctorate in 2019 for personal and professional reasons. My initial idea was to focus on potential benefits of using art therapy with serving military personnel. Deep down though, there was a gnawing need to write about my personal experience of multiple sudden bereavements and cumulative grief. I hesitated because the subject felt too self-absorbed, too indulgent and self-focused. Despite that, its whispering insistence wouldn’t leave me alone, growing ever louder until I accepted that it was indeed valid as a research subject and of potential value to the bereaved and to those professionals who support them.

My bereavements happened decades ago when dedicated grief counselling was not commonplace, and resulted in feelings of abject isolation as I negotiated my grief alone. My research interest grew in exploring the contrasts and similarities of my historic grief with sudden, sometimes multiple bereavements and cumulative grief experienced by thousands during COVID-19, when grief became a shared and much publicised experience, in a ‘then and now’ context. This slowly took form to become my completed thesis (bit.ly/46hxCA2). I could not know at the outset that my deep exploration and immersion in the subject would be transformational for me.

Personal learnings

I learned much about myself through immersive thinking, reading, feeling and writing about my bereavement experience and the ensuing grief – that I need not feel shame for carrying grief throughout my adult life, and that I could feel proud for managing and coping with very difficult, traumatic loss largely on my own. I also came to realise that while grief lasts a lifetime, the effects can be

‘Myownexperiencebearstestimonytotheimportance

WAYS TO SELF-EXPLORE

There are many ways of making self-exploration a regular practice. As therapists we are well versed in self-care techniques to keep us safe and grounded when entering the realm of untapped information and feelings, and will need to employ these when necessary during periods of deep self-exploration. Here are a few suggestions:

JOURNAL

Keeping a reflective diary can bring perspective and understanding of the events, thoughts, feelings and reactions experienced during the day, as we examine our thoughts and reactions at a distance from the moment in which they occurred. Reflective writing helps to identify our trigger points, sensitivities and responses, all of which have relevance to how we engage and work with clients.

USE ART

Image-making is another useful creative tool for exploring and expressing our thoughts and feelings that each of us can do. The aim is not to produce a work of art but rather to promote a state of relaxation and flow that enables deep contemplation and insight to gain increased self-knowledge. Allow the mind to wander, start by making marks on paper or your chosen medium, and see where it takes your thoughts, feelings, memories and ideas.

SAY IT ALOUD

In addition to writing and image-making, the spoken word can also assist our self-development. Saying our internal thoughts out loud to ourselves, untangling the mesh that contains them, can be startling at times in its revelation and the emotions it provokes. Explore an issue, thoughts, feelings, response to something that is eluding you by talking into your device’s recording element and playing it back so that you hear what is being said, what you are feeling, the emphasis you put on the words, so that it reveals the inner meaning. Do this several times, speak openly and honestly – you are the only listener – and examine your response.

EXPLORE YOUR DREAMS

Keep a notepad by your bed so you can write down what you remember on waking. Explore if there is a repeat theme or common thread running through them, and record your thoughts, feelings and response.

MARIE MONTOCCHIO/IKON IMAGES

‘WeknowthatCPDis essentialandreadily participateinitbutdonot alwaysworkonourselves tothesameextent’

Iameliorated by seeking support at any time in the ensuing years. The same can be said for any issue, and this is hugely important for clients to know and tentatively explore while safely supported by a therapist.

In addition to the profound personal learning experienced, I gained valuable insight as a professional in my support of future clients. For example, recognition that the impact of sibling loss is sometimes overlooked when a family is grieving, with precedence being given to parental loss, and that addressing historic hidden grief may be pivotal to a client’s progress if it is an underlying issue impacting their current mental health. Perhaps most illuminating came the recognition that self-exploration is a valuable

key to the ongoing development of self-knowledge for therapists. We know that CPD is essential and readily participate in it but do not always work on ourselves, our own self-exploration, to the same extent.

Self-exploration

My in-depth self-exploration reaped unexpected insight and understanding through immersion in the process of writing extensively about my grief. Yet I almost didn’t write about my bereavement experience, feeling it was too self-indulgent. The events happened decades ago but here I was, still looking inwards, trying to make sense of it by myself. It was only by an extended process of bringing my thoughts, feelings, fears and shame out from

Personal development I

though knew from the outset it would provide many challenges, not least emotional highs and lows. It was indeed a rollercoaster and one I needed to remove myself from for periods of restorative respite at times. The unremitting search for sense-making, clarity and answers felt like wading through deep water before I was able to ‘come up for air’ and out the other side. Along the way I learned a great deal about myself and gained understanding about why I had held onto my grief for so long. With that understanding and self-knowledge came freedom from the mire of grief into acceptance and a peaceful calm not experienced before. This was not immediate and did not surface until completing the writing but once visible and apparent has remained with me. I can now view my sudden bereavements and grief in a more accepting and dispassionate way than ever before. That is not to say my grief has left me, but I can now live alongside it in a way that was not previously possible.

within, externalising and making them visible, that brought about the knowledge, understanding and insight that proved to be transformative.

In the same way that therapists have an obligation to work to ethical standards by engaging in CPD and supervision, I suggest we also have that same obligation to develop ongoing personal therapeutic selfknowledge that will benefit us personally and professionally.

It is deeper self-knowledge that clarifies and elucidates our relationship with self – knowing who we are and why we are – that impacts both the client and the work in the room.

When I started writing my thesis I did not know how I was going to navigate the exploration of painful memories

Making the internal visible to the external through self-exploration can bring unknown and untold knowledge and understanding to therapists that will benefit how we practise, and how we help our clients. When something within has nowhere to go we need to explore ways to enable it to find its way out. If it remains trapped and ruminating within we cover it up, suppress it, pretend it’s not there, but trauma and hidden, tightly held negative feelings will make their presence known. Self-exploration is an essential ongoing task for therapists to enable us to develop the best possible relationship with ourselves. ●

ABOUT THE AUTHOR

Dr Sue Sweeney MBACP is a counselling art therapist whose work has included therapeutic roles with UK serving armed forces personnel and veterans. She has a special interest in loss.

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Letters

Your feedback on TherapyTodayarticles

Person-centred

I was keen to read ‘Why Rogers is still relevant’ (Therapy Today, June 2024).

As a student coming to the end of three years of counselling training, I have become aware of the influence of this towering figure on the counselling profession. Reading the article was a useful update on some of the key issues.

I have often been reminded by my tutors and my supervisor to sharpen my focus on the client’s narrative, facilitating the conditions of the personcentred approach. These efforts have almost always served to deepen my listening, helping to unlock and generate new insights from my clients when our sessions seem to have become stuck. The familiar trio of empathy, unconditional positive regard and congruence continues to provide a touchstone in a rapidly expanding sector

with its increasing array of frameworks and approaches. But like many others, I find the conditions for change that Rogers identified simultaneously motivating and challenging concepts in today’s world. I agree with others quoted in the article that there are dangers in assuming that these can always be achieved. In any case, they all need to be practised with deep reflexivity. However, to castigate the personcentred approach for highlighting a set of qualities that are beyond the reach of practitioners seems to miss the point. To me these act as guide stars or beacons for both ‘doing’ and ‘being’ a person-centred counsellor. We need to be building on, not moving on from, Rogers’ work.

Ivan Kent MBACP

‘Why Rogers is still relevant’ in parts oversimplified the person-centred

From the Board

Having taken a rare moment while the sun is shining to read Therapy Today in my garden, I would like to express my gratitude for the open, authentic and human article by Sekinat Adima (‘From the Board’, Therapy Today, July/August 2024).

Her comments in relation to the experience as a woman of colour, of being scrutinised more readily than her white counterparts, actually ‘woke me up’. I was mindful that I had started reading her article with this same unconscious bias. Sekinat’s words landed home and enabled me to feel a warmth and sense of connection with her challenges as a human being, and recognition of the unfair differences that she faces as a woman of colour. I have always perceived myself as aware and supportive of equality, diversity and inclusion issues but this enabled me to challenge myself even further.

I wish her every success in her role and feel a deep sense of trust that with her open, authentic and unequivocal leadership I am in good hands with her on the Board of my professional organisation that has my back in this often isolated profession.

Karen James MBACP

Email your views on Therapy Today articles to therapytoday@ thinkpublishing.co.uk

MAXIMUM WORD COUNT 350

*Views expressed here are views of contributors, not necessarily those of BACP or Therapy Today’s editorial team

approach and did not capture the fullness of what it means to be a therapist committed to the approach today.

My work as a person-centred therapist is about understanding presentations of distress and socially ‘unacceptable’ behaviours as an adaptive survival mechanism. I recognise that societal, cultural and systemic oppression can cause people harm and impact an individual’s capacity for change –nevertheless the actualising tendency is always at work pushing towards growth. At the very least, this is why people in the most dire circumstances find the energy and courage to come to counselling.

As a human being I am judgmental and hold many assumptions. Unconditional positive regard is about acknowledging my own limitations and struggles to be OK with actions, choices, beliefs and values that challenge my ideas about people and acceptable human behaviour, so that I can

'I urge all members to af ply kindnes when using socia media'

‘The familiar trio of empathy, unconditional positive regard and congruence continue to provide a touchstone in a rapidly expanding sector with its increasing array of frameworks and approaches’

move them out of the way and get as close as possible to what it feels like to be my client, and to be in their world.

I believe that being deeply understood without correction encourages selfknowledge and self-determination that is transformative. An inner space is created where new possibilities can begin to emerge; a new confidence begins to incubate, fostering a change in the structure of self and the construction of a new self-concept.

Michelle Higgins, counsellor and supervisor in private practice

As a recently qualified person-centred counsellor I read with interest the various takes on the philosophy of Carl Rogers and its relevance today. Like Andrew Reeves, I see myself as philosophically person-centred. I would like to air a particular issue I have, though, in terms of Rogerian terminology, and would be interested to know if more experienced practitioners have thoughts on the matter.

I believe that one of the most well-worn phrases of the approach, ‘a way of being’, is inherently contradictory. It conveys a sense of stasis, of having arrived at a point or achieved a particular level. I see two issues – that of no longer moving or learning, and of a resultant disparity between client and counsellor (‘I am here, you are not’). John McLeod recognises the irony of teaching static dogma of a philosophy that preaches the movement ‘from fixity to changingness’. Similarly, Val Watson’s desire to take Rogerian philosophy and make it relevant to the 21st century emboldens me to put forward this point.

The person-centred philosophy as a living entity should continue to illustrate the actualising tendency. I know that the counsellor I am today is not the counsellor I will be in 10 years, as I continue to grow and learn. I conceptualise my person-centred philosophy as embodying ‘a way of becoming’, which tallies with my experience of continuous growth, development and change. We should be comfortable enough in our conviction to be able to reflect on what it means to be person-centred in the 21st century, and not be like the practitioners McLeod claims ‘fail to be self-critical’.

Despite being a new member of the person-centred family, I feel that it is incumbent on me as much as anyone else who subscribes to this philosophy to follow Watson’s lead, and critique, understand and take it further.

Jen Shanks MBACP

Anti-semitism

I’d like to respond to the ‘Experience’ article, ‘The tragedy you try to leave at the door will at some point follow you into the therapy room’ (Therapy Today, July/August 2024 issue). I have every sympathy with the anguish of the anonymous Jewish therapist whose

friends and family were victims of the horrific 7 October attacks. My first thought on hearing about the attack was for my own family in Israel.

However, I have to take issue with their characterisation of their client’s anger towards Israel as anti-semitic. I believe it’s important to distinguish between being critical of Israel, even seeing it as an oppressor, as the client did, and being anti-semitic.

As a British Jew I feel sympathy with the victims of the outrage perpetrated by Hamas against civilians, and at the same time I am horrified by the way Israel is prosecuting its war. I feel concern for the safety of the population of Israel while also seeing the oppression and dispossession of the Palestinian people. To be critical of Israel is not anti-semitic.

The client may be anti-semitic, I don’t know, but I would not judge them as such from the information given in this article. David Goldstein MBACP (Snr Accred)

I was pleased to see an article from a Jewish therapist on dealing with antisemitism in the therapy room. I read on eager to learn, particularly as someone who also holds a marginalised identity and believes we should all strive for an anti-oppressive practice. It soon became apparent, however, that the article was not what I expected.

The author makes explicit the conflation of anti-semitism with criticism of the state of Israel. What happens if we switch perspectives, from therapist to client? A client is expressing justifiable political anger to her therapist, who then pathologises that. Having done so, the therapist ‘hides from’ the client but several months later is still carrying it sufficiently heavily to report it to colleagues publicly.

The therapist earlier states, regarding their other clients’ silence on the genocide, ‘there should be little interest in that country unless you are Israeli, Jewish

TO YOU

‘Social media use is terrible for adults but it is worse for teenagers whose brains have not fully developed. It is worth considering that this epidemic of misery is global’

‘The tragedy you try to leave at the door will at some point follow you into the therapy room’

Anti-semitism is on the rise, so how should Jewish therapists respond when it shows up in clients?

How do therapists deal with their own personal tragedy in the counselling room? Many of us will have to answer this question at some rcareersAnd with something newsworthy and controversial and that so many people seem to have an opinion on? On7October2023myfamilyWhatsApp groupchat–usuallyfullofpicturesofdogs, childrenandsunsets–beganalertingmeto thingbadthatwasgoingonatIsrael’s border with Gaza. Si

or Palestinian’. This highly normative and in my opinion deeply individualistic statement leads me to question whether the therapist would also pathologise clients who expressed compassion for those suffering in Sudan, Democratic Republic of Congo or Ukraine?

Marc Mason MBACP

As someone who recognises and speaks out against the historic and present-day existence of anti-semitism I think first-hand experiences of anti-semitism are very important for readers to understand to facilitate empathy. However, I found the suggestion that only those connected to Israel and Palestine should have an interest in these countries problematic. Undeniably those who have a direct connection to Israel and Palestine are most likely to have an emotional connection that is hard to fully appreciate for those who do not. But with live footage currently reaching many people’s screens it is a tall order for people to have no opinion about the region. I believe there is much to learn from the

history of Palestinian and Israeli relations and the events that have led up to the current situation, especially for counsellors who are concerned with working with cultural awareness, and appreciation for the variety of human experience.

Nicholas Waters, trainee counsellor

I read with pride and hope the article on a Jewish therapist’s experience of anti-semitism. As the writer says, we are taught to stay with our clients’ feelings and to bracket our own, but it is all too easy to underestimate the impact of a sudden surge of hate from those we have listened to and supported perhaps for years. As a British Jew I have been wounded by the speed and ease with which the narrative has evolved. As an accredited therapist working for many years within a predominately non-Jewish environment, I too am yet to decide how I might respond to a client wanting to tear down an Israeli flag.

Sandy Leighton MBACP (Accred)

I felt compelled to email after reading the article about a Jewish therapist’s experience following the harrowing events of 7 October. The author writes movingly about the dismay they find themself in when their client talks so angrily about wanting to tear down the Israeli flag, and the inner conflict the author feels about revealing their identity. Reading it, I felt a familiar sadness but recognised that if I were in their situation I would have done the same. Facing racism is frightening, and it can come out of the blue in places that we least expect. I am grateful that the author had the courage to write the article in this current climate, and they should know that their candid words struck a chord.

Sharon Good

1ay they find themself in ,nt talks so angrily about r down the Israeli flag, and lict the author feels about identity. Reading it, sadness but ,t if I were in I would have 2. Facing racism ~nd it can come : in places that :t I am grateful r had the courage ticle in this current 1ey should know lid words struck

I just wanted to thank Therapy Today for publishing the article by the Jewish therapist about anti-semitism in the counselling room. I have encountered this myself as I am sure a number of Jewish therapists have since 7 October, the only consolation being discovering and joining a Jewish therapist group that provides incredible peer support at this terrible time. As the author says, many Jewish therapists neither ‘look nor sound Jewish’ or have Jewish-sounding surnames, and so it is often with trepidation that we greet new clients, or even regular clients, at this time, never quite knowing if they will bring this matter up. We pray hard that they don’t, together with the many other prayers that many are saying at this horrific time, in order that the therapeutic process is minimally impacted.

Name and address withheld on request

Generation Anxiety

I write to raise my eyebrows about ‘The truth about “Generation Anxiety”’ (Therapy Today, July/August 2024) and the claim that Jonathan Haidt says ‘the solution is simple – ban phones in all schools,

restrict access to the internet for all

is simple – ban phones in all schools, restrict access to the internet for all

Letters

Hero’s journey

In ‘The hero’s journey’ (Therapy Today, July/August 2024), a lovely reflection about the relevance of the hero’s journey in the counselling room, the author Philippa East generously shared the inspiration she found in this narrative framework.

In Western cultures we’re all familiar with the hero’s journey, whether we consciously realise that or not. We know that there’ll be trials and tribulations, but when all seems lost the hero will realise what is truly important and triumph over evil – the end. The problem is, we are so familiar with this story structure that we often subconsciously expect reality to follow the same rules, at least to a certain degree. But reality doesn’t follow the same rules as fiction.

I have encountered this phenomenon both as a client and counsellor. We often struggle with a problem, realise something important, change – and our struggle is not over. We have to keep working to implement recent insights into our lives, we slide into old behaviour patterns, and we have to relearn and rediscover that

under-14s and ban all social media for under-18s’. Haidt does not say that the problem is simple, and his book, The Anxious Generation: how the great rewiring of childhood is causing an epidemic of mental illness (Allen Lane), does not solely blame social media use. On the contrary, he very specifically blames the loss of play-based childhood and community, and states that social media is merely a part – the final, most comprehensively destructive part – of that equation.

Social media use is terrible for adults but it is worse for teenagers whose brains have not fully developed. It is worth considering that this epidemic of misery is global. It cuts across class, sex, wealth and race divides. The decline in mental health among teenagers happened in

We very much welcome your letters – the maximum word count is 350 and letters may need to be edited. NB these pages are dedicated to responses to recent Therapy Today articles only.

first important realisation. Those of us with a strong perfectionist streak may feel that this means we have somehow failed in our journey of self-discovery. I believe that it’s important to address this with gentleness and care, offering both an expectation check and assurances. As Dr East wrote, we’re all on a journey – perhaps instead of searching for a satisfactory end, we should learn to embrace the voyage.

Monika

Tomaszuk, trainee counsellor member

every single country at the same time, from the Nordic states to Australia to the US. If it were possible to put it down to the range of alternative theories that the article suggests, then why would the same response happen at the same time for every single country for which we have data?

Russell Long, BACP student member

‘The truth about “Generation Anxiety”’ presents young people’s anxiety as justified but seems to downplay the notion that smartphones or social media play a key role in their difficulties. As I write, police are investigating young girls who are victim to deepfake pornographic videos at school, and the Snapchat drug trade. In February the Government released guidelines for schools on

prohibiting the use of smartphones during the school day, and the Smartphone Free Childhood movement is helping parents come together in a collective attempt to opt out of the social norm to purchase a smartphone for their child at an increasingly early age.

As therapists, surely we are about promoting connection, play and resilience, all of which Jonathan Haidt is trying to put value to? Where is our understanding of the importance of early mirroring and attachment and the implications of screen-based interaction on these paramount areas of psychological development? There is nothing simple about it – this is an ethical and existential issue, which Haidt calls ‘spiritual elevation and degradation’.

Hannah O’Brien MBACP (Accred)

What I’ve learned

Michael Jacobs

Therapy takes time. If you can get hold of one thing in the hour, that’s great. If your client can, that’s even greater.

It’s OK to say no to clients. When someone wants therapy, is willing to pay for it, and yet from the initial assessment appears to be completely unsuitable for what the therapist can offer, it’s OK to say no. While it is true that every new client will teach us more about how to work, and that experience of new situations and new issues enlarges our knowledge and extends our skills, we should also try to avoid any learning from those mistakes which damage the client, or exploit the client just because we need the work.

Sometimes we have to forget what we learned. All our training has emphasised knowledge: theories about people, and knowledge of appropriate skills. This we draw on as we try to understand what the client is telling us. But if we wish to be as open as possible to what a client is telling or showing us, we may want to consider when we have to empty ourselves of everything we have learned, because in the end what probably contributes most to the value of a therapist is that they are someone who has listened, and worked with many people.

All therapists need a core. When we decide to train as a therapist, we are normally drawn, as if by a magnet, to a particular type of therapy, and that attraction normally stays with us in whatever direction we develop. It is important to have that solid core, that pole that runs from north to south through our practice and our thinking, to which we return, especially when we are confused or needing to check out our understanding. It has the ability to support us and help us locate where we stand.

We need to take the flak. We need to be able to take on ourselves, for as long as necessary, the angry feelings that the client is expressing or wanting to express. We do this whether the anger is aimed at ourselves or not, trying to make it safer for the client. We may ask whether the client is feeling angry ‘here’ and ‘with me’. Or rather more confidently, we may actually suggest to the client that ‘I think you may well be feeling angry with me too’.

And admit when we’ve messed up. It may help clients to address the mistakes we have made, our lack of understanding, or a response that we got wrong. Acknowledging our fallibility is another of those personal qualities we need to have on a par with being empathic and genuine.

Empathy is not enough. Empathy is central to counselling practice, and perhaps for some therapists this is the only way to be alongside a client. But empathy comes from knowing the client, and if we do not know enough about the client and the client’s way, then we risk harming them and ourselves. We need to learn from the client, and need to learn to distinguish our clients from ourselves. We really need to be saying more often than we do: ‘Can you help me understand what you are going through (or what you have been through)?’

Rules should be flexible. We have to have a structure for our work, and we seem to expect clients to fit the structure, without really involving them in the process of creating a structure with them. Do sessions have to last 50 minutes for everyone? There are some clients who would find a shorter session less threatening – I remember a client asking for two 20-minute sessions a week rather than one 50-minute session. It worked well in helping him cope with the stress of his disturbed inner world as well as enabling him to take the initiative for what he needed for himself.

We can’t rescue people. In therapy there are times which are just like those agonising moments on wildlife documentaries when we wish someone would step in and help. But they can’t. And we can’t. We have to let it be.

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ABOUT THE AUTHOR

Michael Jacobs is one of the pioneers of psychodynamic counselling and therapy in the UK and the author of many books, including Psychodynamic CounsellinginAction (Sage) and The PresentingPast(OUP).

• These edited extracts from Reflecting on Therapy, recently published by Karnac (karnacbooks.com), show some of what Michael has learned over a 50-year career.

Michael Jacobs