BACP Therapy Today July 2021 by Think Publishing

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JULY/AUGUST 2021 | VOLUME 32 | ISSUE 6 THERAPY TODAY

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I convinced myself being brutalised had done me good

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Page 27

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Fixing the male mind? How therapy can better support the mental health of men and boys

JULY/AUGUST 2021, VOLUME 32, ISSUE 6

The grounding power of walking // Working with OCD in a post-pandemic world How sibling relationships show up in therapy // Counselling with long COVID

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Contents, 1 VERSION

Contents July/August 2021

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Upfront

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Welcome News round-up CPD and events From the Chair Spotlight Reactions Viewpoints The month

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Main features

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‘Walking mindfully outdoors grounded me during recovery from addiction’ Mike Sands (‘The grounding power of walking’, pages 35–37)

Regulars It changed my life Talking point The bookshelf Dilemmas Supervision Analyse me

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The big issue Catherine Jackson explores what needs to change to make therapy more man friendly The big interview James Davies on how consumerism has fuelled – DQG EHQHƓWV IURP Ŋ WKH PHQWDO KHDOWK FULVLV Hostage negotiations Daren Lee explores CBT and psychodynamic approaches to working with OCD The grounding power of walking 'DLO\ ZDONLQJ KHOSHG 0LNH 6DQGV ƓQG KLV feet while setting up in private practice Allies and tormentors Don’t underestimate the impact on clients of sibling relationships, says Steve Heigham ‘Long COVID helped me re-evaluate my life’ Clare Pointon drew on trauma treatment research to overcome the impact of long COVID

Sometimes it’s hard to be a man Catherine Jackson asks if counselling needs to ‘man up’ to better support the mental health of men and boys (pages 22–26)

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From the Editor

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very single aspect of my life improved and, remarkably, continues to do so’, is how James O’Brien, LBC talkshow host, describes the impact of therapy in our ‘It changed my life’ column in this issue. At times, it can be hard to hold onto the conviction that talking therapy truly can and does make a difference to many people, particularly when it feels like every client you’re working with is ‘stuck’. Which is perhaps part of the reason why I devoured James’s new book, How Not to Be Wrong (WH Allen), in one sitting, as it’s a testament to the truly lifechanging power of talking therapy and being properly listened to. Although what drove him, reluctantly, to seek help in the first place was what he describes as his failure to be the husband and father he wanted to be, the work itself unravelled the lasting impact of the physical and emotional trauma he experienced at boarding school. That unpeeling of layers changed not just his relationship with himself and his loved ones but also the way he relates to every human being he meets. His memoir is a remarkably honest account of how therapy was the catalyst for changing his mind on everything from racial prejudice to emotional vulnerability, fatshaming and tattoos, because he learned to dismantle his defences and preconceived ideas and be open to truly listening to and hearing other people. If you’re looking for some summer reading that will renew your commitment and love for your work, I highly recommend it. For a taster, go to page 27. Part of what James questioned in therapy was the internalised belief that he and many other men grew up with – that vulnerability is weakness and being permanently primed to defend against attack is a smart and necessary way to live. Post-#MeToo, much has been written about ‘toxic masculinity’, but the question of nature and nurture, which ‘masculine’ traits are inherent and which are socially and culturally acquired, is complex. Catherine Jackson accepted the challenge to delve into that subject for our ‘Big issue’ this month (pages 22–26). As one

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of the interviewees, John Barry, currently Chair of the British Psychological Society’s Male Psychology section, argues, are we now pathologising masculinity to the extent that we are actively deterring men from seeking therapy? And are we, likewise, trying to force men into a way of being that just isn’t what men ‘do’? What is wrong with acting and thinking? Do men have to feel to be ‘good clients’? Through interviews with practitioners and academics, Catherine explores our understanding of the psychology of manhood, the positives Are we trying and negatives of traditional notions of to force men into masculinity and what we need to do as a profession to help them flourish. There a way of being that was so much to say on this subject that we had to cut Catherine’s article by just isn’t what men a third to fit the space in the hard copy “do”? What is wrong of the magazine. If you’d like to read the full version, you can find it online, on the with acting and Therapy Today pages of the BACP website. thinking? Do men If talking therapy doesn’t always meet men’s needs, then what could help them in have to feel? times of crisis? For Mike Sands, who writes our ‘Self-care’ article this month, it was walking. He describes how he used long, solitary walks to ground and stabilise himself while in recovery from active alcoholism and, later, while setting up in private practice. ‘Daily walking brings my consciousness and existence together like a compass and a map,’ he says. I would like to thank Mike for sharing his experiences (see pages 35-37). You may notice this is the ‘July/August’ issue. This is just a name change and it doesn’t mean we’re going bimonthly or dropping any issues – Therapy Today has never been published in August (or January). Sally Brown Editor

COVER IMAGE: ROBBIE PORTER/IKON IMAGES

Contributing to Therapy Today We welcome submissions from practitioners. To submit, please send a paragraph synopsis of your proposed article to the editor at sally.brown@thinkpublishing.co.uk. Please note, we currently do not publish poetry. For further guidelines,see www.bacp.co.uk/bacp-journals/author-guidelines Editor Sally Brown e: sally.brown@thinkpublishing.co.uk Art Director George Walker Copy Editor Catherine Jackson Managing Editor Marion Thompson Consultant Editor Rachel Shattock Dawson Reviews Editor Jeanine Connor Production Director Justin Masters Client Engagement Director Rachel Walder Executive Director John Innes Commercial Partnerships Director Sonal Mistry d: 020 3771 7247 e: sonal.mistry@thinkpublishing.co.uk Sustainability Therapy Today LV SULQWHG RQ 3()& FHUWLƓHG SDSHU IURP VXVWDLQDEO\ managed forests and produced using suppliers who conform to ISO14001, an industrial, environmental standard that ensures commitment to low carbon emissions and environmentally sensitive waste management. Both the cover and inner pages can be widely recycled.

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

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Disclaimer Views expressed in the journal and signed by a writer are the views of the writer, not necessarily those of Think, BACP or the contributor’s HPSOR\HU XQOHVV VSHFLƓFDOO\ VWDWHG 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 FRPSRVLWHV WR SURWHFW FRQƓGHQWLDOLW\

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

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Welcome, 1

Welcome

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News round-up

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

An exciting opportunity to work with BACP

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We held our 27th Annual Research Conference in May and were pleased to bring you the results of the PRaCTICED trial during the event. This landmark study, which was funded by BACP, found that person-centred experiential therapy (PCET) is as effective as cognitive behavioural therapy (CBT) and there’s no evidence of any meaningful difference between them when tested at either the end of treatment or six months after entering the trial. 7KHVH ƓQGLQJV DUH KXJHO\ LPSRUWDQW IRU the profession and will help us immensely as we continue to campaign for the provision of wider choice in talking therapies. You can hear Professor Michael Barkham talk about WKH ƓQGLQJV IURP WKH WULDO YLD RXU 5HVHDUFK Conference on-demand service, available at www.bacp.co.uk/events. There’s also a more GHWDLOHG XSGDWH RQ WKH ƓQGLQJV IURP WKH WULDO on this page. I’d like to thank everyone who has made a nomination as part of our Governor elections or has submitted a resolution or motion for consideration as part of our 2021 AGM process. This AGM is another important opportunity to shape the future of your Association and, as always, I encourage you all to get involved and ensure your voice is heard. Finally, you should have received an email about the launch of our exciting Learning Centre, the new home of learning at BACP. If you’re a CPD hub subscriber, you’ll now ƓQG \RXU &3' FRQWHQW KHUH DQG DOO PHPEHUV have access to the free CPD plan and log tool. Please take the time to explore the Learning &HQWUH WR ƓQG RXW PRUH LI \RX KDYHQōW DOUHDG\ and look out for the free resources being added in due course. There’s more information on the Learning Centre on page 10. Hadyn Williams BACP CEO

The Professional Standards team have developed several evidence-based FRPSHWHQFH IUDPHZRUNV DQG FXUULFXOD WR LQIRUP EHVW SUDFWLFH LQ VSHFLƓF areas of work. We have an exciting opportunity for a practitioner with experience of developing and delivering training curricula to join our team to work on the development of new competences and curricula. If you are passionate about the profession and would like the chance to contribute to the development of professional standards, we would like to hear from you. The Professional Standards Development Facilitator role is SDUW WLPH DQG KRPH EDVHG ZLWK JRRG UDWHV RI SD\ DQG HPSOR\HH EHQHƓWV <RX FDQ ƓQG RXW PRUH DERXW RXU FRPSHWHQFHV DQG FXUULFXOD DW www. bacp.co.uk/events-and-resources/ethics-and-standards/competencesand-curricula DQG ƓQG RXW PRUH DERXW WKH UROH DW www.bacp.co.uk/ careers/work-for-bacp

Support for the effectiveness of person-centred experiential therapy Results from the largest randomised controlled trial to date of person-centred experiential therapy (PCET) – also known as counselling for depression (CfD) and person-centred experiential counselling for depression (PCE-CfD) – found no evidence of any meaningful differences between it and cognitive behavioural therapy (CBT) as delivered in Improving Access to Psychological Therapies (IAPT) services provided by the NHS in England. Although at 12 months after entering treatment, the trial found that outcomes favoured the CBT group, particularly for clients who presented with more severe depression, when tested at six months after entering the trial or at the end of treatment, there was no VLJQLƓFDQW GLIIHUHQFH EHWZHHQ outcomes for PCET and CBT. The trial

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also found that there was no difference in cost-effectiveness between PCET and CBT treatments. The trial was led by a research JURXS DW WKH 8QLYHUVLW\ RI 6KHIƓHOG and funded by BACP. The results have been published in The Lancet Psychiatry. We believe the results will further strengthen the evidence base for the effectiveness of counselling as we continue to lobby the National Institute for Health and Care Excellence (NICE) to recommend a wider choice of talking therapies for mental health conditions. It also gives stronger evidence for NICE to recommend PCET as a front-line intervention on the same basis as CBT, for patients accessing IAPT services in England. This will, in turn, increase the number of opportunities for counsellors to work within the NHS delivering these services.

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2 2

mInutes with…

Jo Owen

Describe your role at BACP: I work with senior managers to identify priorities and opportunities that drive BACP’s strategy. I also support the teams to implement change across the organisation and measure the impact this change has on the members and the profession. This is my fifth year with BACP, although BACP has so many long-service staff, I sometimes still feel new.

What was the last book you read? The Henna Artist

by Alka Joshi. I set myself a challenge in 2020 to read 52 books, inspired by a blog by Jade Ingham-Mulliner from the BACP Events team. I smashed the challenge, but I think lockdown had a lot to do with that. What’s your go-to karaoke song?

What’s the best thing about working for BACP? The people make BACP such

a great place to work. They make you feel like you are part of something big and meaningful and the passion for what we do is contagious.

So many it’s hard to choose. I usually sing with my sisters and we go back to classics that we grew up with at home. The Beatles’ ‘Twist and Shout’ is a firm favourite.

What gets you up in the morning?

Usually a cat wanting food. I also like to exercise first thing, as it leaves me feeling really positive that I have ticked off something that’s important but can easily be derailed by life getting in the way. What advice would you give your younger self? Worry less about what

Jo Owen BACP’s Business Insight Manager answers our ‘getting to know you’ column. Look out for other BACP staff members in upcoming issues.

people think about you – everyone is different, so be different! Best advice you’ve been given? As children, we were encouraged to save our pocket money for the things we wanted, get a job when the things we wanted were expensive and never spend what we didn’t have. I thank my mum for instilling that in me from an early age.

PROFESSIONAL CONDUCT

Completing the ‘three peaks’ – Scafell Pike in England, Snowdon in Wales and Ben Nevis in Scotland. We did one peak a year, rather than all in the same day, but it still felt like such an achievement when we finished Ben Nevis. What would you like to achieve over the next year? I have a

large family, so it’s to have a gathering with all my family and to be able to hug the children. It’s the simple things that matter.

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

¢ BACP’s Public Protection Committee holds delegated responsibility IRU WKH SXEOLF SURWHFWLRQ SURFHVVHV RI WKH 5HJLVWHU <RX FDQ ƓQG out more about the Committee and its work at

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Your proudest achievement?

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

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News round-up

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Yasmine Clarke

Amrita Kaur Sohal

Dr Elvis Langley

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Research award winners

Members in the media ART PRODUCTION CLIENT

Claire Cox and Jacqui Cheetham were interviewed live on ITV Lunchtime News DERXW WKH EHQHƓWV RI FRXQVHOOLQJ DQG RXWGRRU WKHUDS\ LQ SDUW RI D VHJPHQW RQ 0HQWDO +HDOWK $ZDUHQHVV :HHN DQG WKH WKHPH RI QDWXUH Andrew Harvey ZDV IHDWXUHG RQ %%& 5DGLR 1RWWLQJKDP DV SDUW RI LWV FRYHUDJH RI WKH ZHHN Hadyn Williams %$&3 &KLHI ([HFXWLYH Fiona Ballantine Dykes %$&3 'HSXW\ &KLHI ([HFXWLYH Kris Ambler %$&3 :RUNIRUFH /HDG DQG Mark Fudge &KDLU RI %$&3ōV 8QLYHUVLWLHV DQG &ROOHJHV GLYLVLRQ ZHUH TXRWHG LQ DQ DUWLFOH in The Independent DERXW KRZ WR DFFHVV WKHUDS\ LQ ORFNGRZQ Justin Havens ZDV TXRWHG LQ The Sun and Daily Mirror WDONLQJ DERXW (0'5 DIWHU 3ULQFH +DUU\ VSRNH DERXW LW LQ DQ LQWHUYLHZ ZKLOH Wendy BristowōV FRPPHQW SLHFH LQ The Times VDLG WKH 3ULQFH VHHNLQJ WKHUDS\ FRXOG HQFRXUDJH RWKHU SHRSOH WR VHHN WKH VXSSRUW WKH\ QHHG %$&3 9LFH 3UHVLGHQW Julia Samuel ZDV DOVR IHDWXUHG LQ The Times WDONLQJ DERXW KRZ WR GHDO ZLWK JULHI Natasha Page FRQWULEXWHG WR D IHDWXUH RQ EEF FR XN DERXW WKH LPSDFW RI WKH SDQGHPLF RQ SHRSOHōV DELOLW\ WR KDYH VRFLDO LQWHUDFWLRQV &RRNLQJ DQG WKHUDS\ FDPH XQGHU WKH VSRWOLJKW LQ D IHDWXUH LQ WKH Daily Mail with Charlotte Hastings Nikita Amin VSRNH WR Vogue DERXW WKH FKDOOHQJHV SHRSOH RI FRORXU IDFH LQ DFFHVVLQJ VXSSRUW IRU HDWLQJ GLVRUGHUV The Independent IHDWXUHG LQVLJKW IURP Louise Tyler on how MXJJOLQJ KRPH VFKRROLQJ DQG ZRUNLQJ ORQJ KRXUV KDV FRQWULEXWHG WR D ULVH LQ EXUQRXW /RXLVH DOVR VSRNH WR The Guardian DERXW &29,' DQG \RXQJ SHRSOHōV OLYHV $OVR LQ The Guardian, Armele Philpotts FRQWULEXWHG WR WKH Ō$VN $QQDOLVD %DUELHULō FROXPQ Tasha Bailey GLVFXVVHG ZK\ EODFN ZRPHQ PD\ SUHIHU ZRUNLQJ IURP KRPH SRVW SDQGHPLF IRU 5HƓQHU\ $ Which? DUWLFOH RQ WKH FRQQHFWLRQ EHWZHHQ PRQH\ DQG PHQWDO KHDOWK LQFOXGHG FRPPHQW IURP Anthony Davis Lindsay George KLJKOLJKWHG WKH PHQWDO KHDOWK EHQHƓWV RI NHHSLQJ D MRXUQDO LQ Cosmopolitan 7KH %%& SRGFDVW Mindset RQ KRZ UHODWLRQVKLSV KDYH FRPH XQGHU SUHVVXUH GXULQJ &29,' LQFOXGHG Helen Knight and Katy Cossham DYDLODEOH RQ %%& 6RXQGV Emma Brand VSRNH DERXW WKH EHQHƓWV RI FRXQVHOOLQJ LQ D IHDWXUH LQ The Podiatrist If you are interested in becoming a BACP media spokesperson, email media@bacp.co.uk

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We’re pleased to let you know that we announced three research award winners during the 2021 Research Conference. J The winner of our BACP New Researcher Award is Yasmine Clarke, whose research paper explores from an integrative psychotherapeutic viewpoint the experiences of people who identify as mixed white and black Caribbean. Yasmine’s research also makes suggestions for practitioners working with this client group in clinical practice. Yasmine is an integrative psychotherapist currently working as a mental health practitioner at the University of York. She provides practice guidance and therapeutic support to students experiencing psychological and mental health difficulties. You can find out more about Yasmine’s research at www.bacp.co.uk/news/news-from-bacp J The winner of the CPCAB Counselling Research Award is Amrita Kaur Sohal. This award is designed to raise awareness of research that has important implications for counselling training or practice. Amrita’s research is titled ‘A Therapy for the Worried Well? A longitudinal analysis of the effectiveness of personcentred therapy within a sample of suicidal clients’. A film about Amrita’s research will be made later this year. J The winner of the PCCS Books Student Research Award is Dr Elvis Langley, whose research is titled ‘In the Same Boat Helping Each Other: a grounded theory of growth and emancipation in peer-led hearing voices groups’. Elvis’s research identifies a theory of how peerled hearing voices network groups impact people who attend them. It contributes to a greater understanding of how these peer-led groups benefit wellbeing and act as a fundamental support to those who hear voices. Elvis is a counselling psychologist and psychotherapist in private practice. You can watch Amrita and Elvis’s research presentations via our Research Conference ondemand service, at www.bacp.co.uk/events/ onlineresearch2021-research-online-promotingcollaboration-in-research-policy-and-practice

Congratulations to all the 2021 research award winners.

JULY/AUGUST 2021

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SCoPEd Does SCoPEd create a new hierarchy or distinction between counselling and psychotherapy? :H DUH DZDUH WKDW WKLV LV D FRQFHUQ RIWHQ UDLVHG DERXW 6&R3(G 6&R3(G GRHVQō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ƓFDWLRQ %$&3ō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ŌFRXQVHOORUō DQG ŌSV\FKRWKHUDSLVWō ZKLFK ZH NQRZ DUH XVHG GLIIHUHQWO\ E\

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Listening to our members Our next listening workshop on Friday 23 July is about ‘Creating a thriving profession through shared standards’. During this event, our expert panel will cover topics such as SCoPEd, the impact of COVID-19 on professional standards, and support and guidance for members in practice. We anticipate that this will be a popular event, so if you’re unable to attend, you can still send us your questions for the panel via our dedicated listening inbox and watch the event on-demand once available. If you’ve not been able to attend one of our live listening workshops so far, you can catch up via our onGHPDQG VHUYLFH 7KH ƓUVW ƓYH ZRUNVKRSV DUH QRZ available to view at: www. bacp.co.uk/listening As always, we’re keen to hear what themes you’d like to see covered in future listening workshops and ask that you share your ideas with us at: listening@bacp.co.uk

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CPD hub

SUBS ART PRODUCTION

Keon West’s presentation ‘Missed communications: errors we make when communicating across groups’ is a new addition to our CPD hub. Keon is a reader in social psychology at Goldsmiths University. His research focuses on prejudice, sexual orientation and sexual health. This presentation will help you gain an understanding of contemporary intergroup relations and the impact of race and gender biases. It ZLOO DOVR KHOS \RX UHŴHFW RQ WKHVH LVVXHV in relation to your own experience. We’re also pleased to include Victoria Nelson’s presentation, ‘Working with Deaf clients’, which tackles Deaf awareness and mental health. Born deaf into a hearing family, Victoria shares her experiences as one of the UK’s few Deaf psychotherapists, and provides tips on how to work with Deaf clients.

BACP Events/CPD, 1

The Learning Centre We’ve also partnered with PESI UK and Psychotherapy.net to bring you additional resources in the CPD hub, including interviews conducted by Irvin Yalom with experts on anger management and working with suicidal clients. There are also contributions from Kathy Steele, Janina Fisher and Dr Dan Siegel on attachment, trauma and PTSD. It costs £25 a year to subscribe to the CPD hub, giving access to more than 300 hours of CPD content and personalised &3' FHUWLƓFDWHV IRU \RXU UHFRUGV 6HH www.bacp.co.uk/cpd/cpd-hub

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Private Practice Conference When words are not enough – using creative approaches to therapy You’re invited to join our Private Practice Conference on Saturday 25 September, which includes two keynote speakers and six workshops on the theme of creativity. The programme will include presentations on metaphors, dream compilation therapy, creative supervision, music therapy and more. Speakers will join our hosts for live Q&A segments after their presentation. The workshops will span two strands, so you can build your own programme to meet your individual needs. It costs £25 to join and includes access to the live stream on the day and to the on-demand service for three months after the event. 7R ƓQG RXW PRUH VHH www.bacp. co.uk/events-and-resources/ bacp-events

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We’ve recently launched the Learning Centre, our new home of learning, which is available to all members. The Learning Centre includes a CPD plan and log tool, where you can plan all your CPD activities for the year ahead and log each time you complete a CPD activity. This could include reading a journal article, attending a network meeting, delivering a workshop, watching a video, listening to a podcast, and much more. The My CPD functionality in the Learning Centre aims to support registered members in meeting their membership commitment to plan, UHFRUG UHYLHZ DQG UHŴHFW RQ &3' activities in a structured way. The online tool replicates the original downloadable CPD template. Like the original template, the My CPD tool is designed to HQFRXUDJH UHŴHFWLYH SUDFWLFH and help you develop a cyclical process for your CPD. It provides sections for planning your CPD, recording your CPD activities (completed in or outside of the /HDUQLQJ &HQWUH DQG UHŴHFWLQJ RQ KRZ WKHVH KDYH LQŴXHQFHG your practice. <RXōOO DOVR ƓQG &3' FRQWHQW in the Learning Centre, which is available to view (depending on your subscriptions). All the Therapy Today podcasts can be accessed here too. Each content item has a SHUVRQDOLVHG &3' FHUWLƓFDWH IRU \RX to download for your records and a timeline to track your CPD over the membership year. 7R ƓQG RXW PRUH VHH www.bacp. co.uk/learningcentre

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The reporting of the success, following years of effort, of the ETHOS and PRaCTICED trials took centre stage. These two very high-profile randomised controlled trials are the result of BACP’s collaboration with distinguished research colleagues. Both trials will have enormous benefit for the profession. Other presentations from practitioners were equally important in exemplifying the significance of research to the counselling professions. As I watched the presentations and posters through the on-demand service, I had real appreciation for the hurdles that had to be overcome and personal sacrifices made in reaching the final stage of dissemination. The conference inspired me to continue on my own path of research, exploring the impact of serious youth violence. This research has taken me to new depths in recognising how this phenomenon impacts on people in black communities, affecting young people across genders and categorising young men and boys as perpetrators. The spotlight is also shone on men as perpetrators in domestic violence. Although it is recognised that men are victims too, they are a minority when compared with women. However, with approximately 800,000 reported male victims of domestic violence in England and Wales in the last year alone, this is a significantly large minority.1 Men’s Mental Health Awareness Week in June encouraged us to challenge the notion of gender-typical behaviours, stereotypes and assumptions that say it’s not ‘normal’ or ‘manly’ for men to express their emotions. Not feeling confident to access counselling because of these stereotypes may only serve to exacerbate crisis situations.

Considering the take-up of counselling by men is generally much lower than women, and that there are comparatively fewer male therapists in the profession, perhaps we need to ask ourselves, where do men go to express and address their fear, sadness, loss or rage, given the challenges they may experience within society today? Recent high-profile cases of attacks on women by men have quite rightly brought into focus the size of the problem women are facing. Campaigns such as #MeToo and End Violence Against Women have opened up debate and reflect changing attitudes. Many men have stepped up as allies and some have spoken out about their own experiences as victims. But placing our attention on men only as perpetrators may compound the difficulty they already face in accessing our services.

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We could perhaps also explore some of the factors that prevent men from accessing support, as discussed in our ‘Big issue’ article on page 22. Language is important; typical phrases such as ‘victims’ of abuse or violence could possibly prevent men from acknowledging difficulties, and might create barriers to asking for help. Exploring the significance of drugs, alcohol and/or violence by men and whether these are indications of coping with situations such as past or current abuse or threats of violence is important. Addressing our own biases as practitioners, and an awareness of the impact of labels and generalisations, may also be part of the change that needs to happen to allow men to feel confident to engage with our profession – one that is, after all, dominated by women. BACP’s work on its Equality, Diversity and Inclusion strategy is currently focused on race. However, in the longer term, as all the areas of diversity are addressed, considering the needs of men in that strategy, even though they may not be considered a minority in society, seems an important step. As a profession, we have been aware for some time that counselling is still a no-go zone for many men. We applaud the openness of certain celebrities and high-profile sportsmen talking about their mental health challenges and how therapy has helped, and there is no doubt that progress is being made in reducing the stigma. Yet the suicide rate in men remains unacceptable. More thinking and more research needs to be done to understand how we can shape our profession to be more male friendly, both for therapists and for clients.

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Addressing barriers to inclusion Meet the BACP members who have joined our new Task and Finish Group to improve equality, diversity and inclusion within our Association

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worked with many refugee communities and third-sector organisations. I have a special interest in bilingualism, culture and race, and the impact of these constructs on the development of the self. These topics excite and energise me. There is so much work to be done in addressing inequality, discrimination, power and privilege within mental health.

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JESSIE EMILION • About you: I’m an accredited counsellor, psychotherapist, supervisor and trainer, teaching on psychotherapy programmes in the UK, India and Malta. I was central to the introduction of cognitive analytic therapy (CAT) in Malta and India. In India, I have developed the model further by incorporating religious, cultural and societal values, making the model relevant to the Indian society and psyche. I am passionate about improving global mental health. I am currently CAT lead psychotherapist in Southwark, with South London and Maudsley NHS Foundation Trust, and consultant supervisor to Greenwich Cruse. My clinical work gives me a purpose and insight into the complexities of the human mind and the society we live in. Why join the group? I have extensive experience of working in the NHS both in primary and secondary care. As a trained interpreter and bilingual therapist, I have

What you hope to bring: I hope to bring both my personal and professional qualities – my expertise in the field but also qualities such as creativity, compassion and fun. We learn more and do well when we are having fun. With the pandemic and the Black Lives Matter movement, it is very clear that we need to address structural discrimination and close the gap in health inequalities, and I am committed to this. What might people be surprised to learn about you? I grew up by the beach but

MEL HALACRE • WHY AN EDI TASK AND FINISH GROUP? We truly believe that greater diversity will deliver a stronger profession; one that embraces different perspectives and new ideas and approaches. To this end, six BACP members were recently recruited to join a new Equality, Diversity and Inclusion (EDI) Task and Finish Group. It will report into an internal BACP EDI steering group and play a key role in the development of BACP’s EDI strategy, UHƓQLQJ WKH WDFWLFDO VWHSV WKDW ZLOO enable BACP to lead on EDI across the counselling professions.

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still cannot swim. One day I will get there! I am a committed rangoli (kolam) artist, and enjoy creating big pieces of floor art. I love watching EastEnders after a hard day’s work.

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About you: When I qualified as a counsellor, there were few organisations tailoring therapy for disabled people, yet my personal experiences and my research showed it was needed. So, in 2009, I set up Spokz People CIC, a non-profit organisation offering disability affirmative therapy. Why join the group? My aim has always been to improve therapy for disabled people and other marginalised groups. I have been encouraged by all the developments taking place within BACP these past few years. This was an opportunity to contribute to positive change. If we create more equality, diversity and inclusion (EDI)-aware therapists, we improve therapy.

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Spotlight BRYONY HARPER • About you: I’m a person-centred counsellor living and working in the East Midlands. I completed both my BA in humanistic counselling practice and my MA in trauma studies at the University of Nottingham. Since completing my training, I have worked primarily with young people and survivors of sexual violence, and I’m currently the counselling manager at Base 51, a charity supporting young people in Nottingham.

What you hope to bring: I am a pragmatist at heart and very much feel that organisations can learn a lot from the bottomup knowledge that is available. I’m not a huge fan of policies and procedures; I see them as important in terms of establishing a baseline, but what I am most passionate about is how these policies and strategies are actually implemented so they become alive and a reality. I hope to pass on the experiences of all the marginalised clients, therapists and students my organisation has had contact with and to offer practical, usable suggestions on how to improve inclusion. If we are going to move forward with EDI, we need to find a way to de-shame the conversation for all parties. We need to acknowledge what hasn’t happened and be proactive in reaching out to clients and therapists who have been marginalised, listen to them and value their insights. In the therapy field, we are trained to self-reflect and this self-reflective capacity offers us a unique opportunity around EDI: we can choose to offer marginalised clients and therapists a different experience. As a result, all of us can experience personal growth and healing from oppression. What might people be surprised to learn about you? Though I have a British accent, I lived in the Netherlands for 14 years and sometimes my words are ‘lost in translation’.

Why join the group? I have always been passionate about equality and diversity. Since my counsellor training, I have been mindful of opportunities to improve the accessibility of the counselling profession for clients, counsellors and trainees, so it’s an exciting opportunity to be a part of shaping BACP’s EDI strategy. What you hope to bring: I’m hoping to draw on my experiences of working to improve inclusivity, accessibility and diversity across multiple occupations, alongside my professional and personal experiences as a queer woman from a working-class background and my in-depth knowledge of the barriers impacting clients and counsellors from marginalised communities.

Why join the group? I have been aware of equality, diversity and inclusion all my life, even when I was too young to know what these words meant. I believe that the Task and Finish Group is a place where I can contribute to change and make improvements now and for the future within the profession. If I didn’t believe in what BACP could accomplish, I wouldn’t be here. The past year has highlighted the divide in understanding not just between individuals of different backgrounds but between the cultures of entire communities. I am not one for tick-box exercises and believe that organisations should do things because it’s the right thing to do, not just because it’s the ‘in’ thing to do. What you hope to bring: As well as my experience of being a member of a variety of EDI and therapist networks, I will bring my passion for counselling and EDI knowledge and lived experiences to the group. I hope to bring positive change across the profession to enable all members to feel listened to and supported by BACP. What might people be surprised to learn about you? I’m a big fan of Japanese culture and did a beginners’ course in the language following a trip to Tokyo. And I love practising tai chi.

What might people be surprised to learn about you? I’ve always wanted to be able to communicate with and understand as many people as possible. I first went to university to study German and Dutch but there were too many history exams, so I changed course and studied to be a counsellor instead.

NICK RENNIE • About you: I am going to cheat and blend ‘about me’ across all sections because you want to do yourself justice, right? Over the years, my jobs have followed the theme of helping others. My roles have included mentoring, community engagement, youth work, and youth and adult mental health work. I am now the founder/ director of You First Therapeutic Services, and also work part-time in the NHS as a patient equalities officer.

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What might people be surprised to learn about you? I spent a year living on a First Nations (Native American) Cree Reservation in the Canadian Arctic, learning to live in 24-hour daylight, 24-hour darkness, and temperatures below -50°C. It was a very long way from the closest town, and I learnt a lot about resilience, resourcefulness and how to read the night sky. It was also an amazing opportunity to live within another culture from another tradition, and that experience of being a cultural outsider has stuck with me throughout my career.

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About you: I qualified as a person-centred therapist in 2019 with a master’s in counselling and psychotherapy from Keele University. I trained as a therapist after nearly 20 years working in diversity and inclusion in the corporate world for international organisations. I often worked with individuals in highly stressful personal and professional situations, so therapeutic training felt like the next step for me. I now combine working as a therapist and coach with delivering diversity and inclusion training and consultancy work. Why join the group? It’s really important to me that diversity and inclusion sit at the centre of the organisations to which I belong. This group is an opportunity to really engage with the process of meaningful change for BACP, and an opportunity for me to bring my pretherapist work and experience into my current ‘day job’. It offers a chance to contribute to the change process, and it’s a journey I wanted to be part of. What you hope to bring: My knowledge and expertise of EDI, and a strong sense that diversity and inclusion work goes beyond what is covered under legislation. I have a lot of energy for EDI, and know there are no easy answers, but I hope that my experience means I can offer a broad holistic perspective that embraces all aspects of EDI.

About you: Since the millennium, my fading sight has confronted me with the reality of visual impairment. Having firsthand experience of the barriers that disabled people can face in living an independent life, I was drawn to counselling as a means of being supportive of others. Having worked my way through the accreditation process, I’m now both a senior accredited counsellor and supervisor, and work with a range of thirdsector organisations, and health and social care services to support the enablement, empowerment and rehabilitation of people with sight loss. Since 2010, I’ve also worked within BACP, including serving on the Professional Ethics and Quality Standards Committee and the Ethics and Good Practice Steering Committee. Why join the group? To ensure that EDI is at the forefront of how the profession evolves. There can be a risk that EDI is seen as a tick-box exercise, but by embedding EDI into BACP’s systems and processes and by ensuring it is reviewed, essential adaptations can be made and equality, diversity and inclusion can be made real. What you hope to bring: I hope to shine some light onto the reality of how inequality, discrimination and exclusion can be experienced. My fading sight has confronted me with ever more barriers to independence, some of which are proving to be insurmountable. It’s led me to become increasingly supportive of people and

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organisations focused on enablement and empowerment and it is this experience, at both a strategic and personal level, that I’ll be able to contribute to the group. What might people be surprised to learn about you? I’ve always loved going to the theatre but, as my sight faded, I stopped going as it just didn’t feel the same not knowing what was happening on stage. That was until audio description went live. It gave me back one of my great loves as it explained what was happening on stage without talking over the actors. I also get to explore the stage and meet some of the cast before a performance. I’ve been on a stage at the National Theatre chatting with a scantily clad Benedict Cumberbatch!

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Understanding the afterlife

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A warm thank you to Claudia Nielsen for her nudge towards a more thoughtful and informed understanding in counselling and psychotherapy of how individuals and cultures imagine and talk about what happens beyond death (‘Talking about the afterlife with clients’, Therapy Today, May 2021). As a psychotherapist for 50 years and a Catholic priest for 21 years, I have often come across priests and religious people who have referred themselves for therapy, only to experience their therapist as so keen to demonstrate that WKH\ FRPH IURP ŌWKH PDLQVWUHDP VFLHQWLƓF IUDPHZRUNō WKDW LW IHHOV OLNH DQ unprofessional attack on their belief system. Part of the problem is that many therapists who hold the mainstream view on the afterlife – ie that it doesn’t exist – are blissfully ignorant of other beliefs held by millions of the worldwide population and what they may mean for the client. I smile too as I think, have I ever met a client who, in the middle of a crisis of loss and bereavement, takes comfort from the thought that there is no afterlife? If you are looking for CPD on this subject, I would recommend The Hidden Freud: his Hassidic roots by Joseph Berke (Routledge). The book charts Freud’s life and struggle to present psychoanalysis as thoroughly Western DQG VFLHQWLƓF DQG WR OHDYH EHKLQG KLV +DVVLGLF EDFNJURXQG ,W SRLQWV RXW how he managed to establish an apparently new secular religion, but also to organise his own death so that he died on Yom Kippur, the day of atonement. Yom Kippur is the day when the soul has the best chance of being accepted and returned to the fold of the righteous for eternity. Food for thought, I hope. Fr Peter Marden MBACP (Snr Accred)

Dissecting intersectionality In response to the illuminating interview with Dr Dwight Turner (‘The big interview’, Therapy Today, May 2021), I salute his endorsement of protest movements, be they vigils, marches or, as he poignantly says, ‘whatever we are allowed to do these days’. At times like these – of jovial, buffoonish suppression of democracy – protest is the only shadow of democracy left. As a lower-middle-class southern Italian already deemed in my native country a ‘wog’ (before

being patronised and underpaid in every kitchen I worked in from the US to the UK), I gain from Turner a glimpse of what it might be like to experience a much higher frequency of repression, and one that I must urgently pay attention to and learn from. I too googled what it is that can be found under woodpiles. I had no idea what the saying implies and shuddered at my findings. Becoming a therapist was certainly a journey of self-discovery and great learning. It was also my ticket of admission into the English, white,

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middle class, with all its joys, sorrows and unreconstructed prejudices. For when I learned all about authenticity, dialogue, I-Thou and all things deep and relational, I also imbibed an ideology that assumes symmetry and equality between two people. But there is no such thing. The therapeutic encounter is deeply asymmetric; class, race, gender, sexuality, status and money – too many things get in the way of imagined symmetries. In courageously and movingly presenting his honest anger alongside his vulnerability and sensitivity as a man – in relation to his father and to his five-year-old daughter – Turner shows the way for all of us in our timid and compliant profession. All the same, I do not share his belief in heuristic research. In my view, quantitative and qualitative research methods alike perpetuate a knowledge/power dynamic that bolsters rather than dismantles the status quo and its inherent racism and hatred of otherness. There are other ways of doing research and one day the therapy world will catch up. Maybe.1 As for intersectionality, a term he endorses in the interview, the term has been hijacked and has lost its emancipatory meaning. Bland solidarity among identitarian groups is not the same as active solidarity against the common enemy – namely, neoliberalism. The same applies to ‘identity politics’, a term first coined in the 1970s by the Combahee River Collective, a group of black lesbian militants based in Boston. The way they saw it, ‘the major systems of oppression are interlocking’.2 It is also crucial to remember what Judith Butler said: ‘Identities are formed within contemporary political arrangements in relation to certain requirements of the liberal state.’3 Struggle on we must, and I am thankful to Dwight Turner for providing invaluable inspiration. Manu Bazzano, psychotherapist, supervisor and visiting lecturer REFERENCES 1. Bazzano M. Making love to your data. Therapy Today 2021; 32(2). 2. Haider A. Identity politics: race and class in the age of Trump. London: Verso; 2018. 3. Butler J. The psychic life of power: theories in subjection. Redwood City, CA: Stanford University Press; 1999.

Having sat in sessions with men who begin to reveal and acknowledge their situation at the hands of abusive partners, I am dismayed when their stories are not acknowledged in pieces on domestic abuse, keeping male victims in the shadows

Men are victims too The cover ‘Behind closed doors’ flagged up an ‘investigation’ into domestic abuse (‘The big issue’, Therapy Today, April 2021). The piece does briefly acknowledge that not all victims are women but, sadly, men as victims were not explicitly acknowledged. Having sat in sessions with men who begin to reveal and acknowledge their situation at the hands of abusive partners, I am dismayed when their stories are not acknowledged in pieces on domestic abuse, keeping male victims in the shadows. The ManKind Initiative charity does excellent work and runs courses that I can highly recommend to anyone who wants to expand their knowledge on domestic abuse to include male victims. According to their literature, one in six men will experience domestic abuse, more than 500,000 men every year, and every two weeks a man is killed by a partner or ex-partner.1 The figures are terrible, although not as high as the figures for women (two women a week), which I fully accept. I am not suggesting a male-versusfemale competition on suffering. I think the point I am trying to make is that a piece that is explicitly highlighted to be about clients and to be an investigation ought to cover a full spectrum. Like many counsellors, I am well aware of how domestic abuse impacts everyone of all gender identities. Perhaps if it had been part one of a two-part article this investigation would have been more farreaching and inclusive Gavin Conn MBACP, integrative counsellor REFERENCE 1. Brooks M. Male victims of domestic and partner abuse: 55 key facts. ManKind Initiative; 2021.

In praise of cold water I wish to thank Sam Milford for his article on the benefits of open water swimming (‘The healing power of open water swimming’, Therapy Today, June 2021). He says that ‘plunging into cold water produces a mind-

body connection that is hard to ignore’ and is beneficial in lots of ways. About a year ago, I started taking cold showers, running the shower on cold for a one-minute icy blast after my usual hot shower. The first time I felt I would die of shock but the endorphin high I experienced immediately after prompted me to repeat the experience. Feeling so good afterwards has made me want to keep it up and now I actually look forward to the icy blast. According to several studies, cold showers increase resilience to stress. What I notice is that I feel energised afterwards and I’ve become less sensitive to the cold generally. Your article is nudging me towards starting to swim outdoors. Nina Parker MBACP, integrative counsellor and energy psychotherapist

Responding to enquiries In response to Sarah Edwards’ daughter’s experience in seeking a counsellor (‘Viewpoints’, Therapy Today, June 2021), I too have known the same experience in counsellors not responding to enquiries. A client wanted counselling for her son but, obviously, I could not see him due to the conflict of interest. He agreed to therapy only with a male therapist for specific reasons. My client was unsure as to what specific experience of practice she should be searching for her son, so I offered to assist and passed on four counsellors’ details from a counselling directory portal. Only one replied within 24 hours. Two replied five days later, and the other she is still waiting on.

It may have taken the person making the enquiry a long time to build the courage to take up therapy. To be ignored just undermines our profession and makes it look like they are not valued

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I have been a counsellor for 17 years and when I receive an enquiry by email or text, I respond the same day. I acknowledge their enquiry and inform them I will get back to them later that day. I believe that this is being courteous and professional. I also acknowledge it may have taken the person making the enquiry a long time to build the courage to take up therapy. I respect that. To be ignored, to me, just undermines our profession and makes it look like the person making the enquiry is not valued. If they already have low self-esteem and low self-worth, being ignored will not help. Ann Holden MBACP, counsellor and relational coach

ICU trauma I was very interested to read the article, ‘Dreams, hallucinations and delirium’ by Laura Barnett (Therapy Today, June 2021). I work as an intensive care unit (ICU) nurse, as well as a counsellor in private practice, and have seen how patients are affected during their ICU stay. My ICU employs a clinical psychologist, who follows up post-discharge patients who have a diagnosis of PTSD, but there is nothing much at the moment for patients who are actually in ICU. We have a list of questions to ask patients to try to ascertain if they are suffering from hallucinations, panic or anxiety, which can help identify if a patient is struggling. We also have ICU diaries where hospital staff and family members can write about what has happened to a patient on a particular day. After their discharge, the patient can read their diary and start to piece together and understand their fragmented memories of ICU. One of the most overwhelming things I am aware of for ICU patients, which I didn’t see mentioned in the article, is that the majority of them have a breathing tube inserted down their throat, so they are unable to speak or communicate their needs. I believe that this is very traumatic for them. The nurses and doctors try desperately to understand what they are trying to communicate, but it isn’t always possible. It is a very lonely and

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frightening experience. So the delirium is definitely a part of the trauma, but there are other factors too that make it a distressing experience for patients. 5DFKHO 7UXPƓHOG 0%$&3 $FFUHG counsellor and psychotherapist in private practice and registered nurse in ICU

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I felt compelled to write after reading Laura Barnett’s article (‘Dreams, hallucinations and delirium’, Therapy Today, June 2021) as I found it incredibly moving to hear similar experiences to my own. When I was in my early 20s, I became very ill with a virus that attacked my nerve endings, leaving me temporarily paralysed. I spent around two months in the ICU at my local hospital. I had counselling afterwards to help me process the trauma of such a sudden and frightening illness. However, I never thought to share my experiences when in ICU, despite it being an incredibly disorientating experience. I very clearly remember – even almost 20 years on – hallucinations, such as someone trying to kill me by sitting on my chest, being moved around, walls and ceilings closing in, being tied down and held under water. At the time, I was on a ventilator and struggling to breathe. One night, I tried to pull my ventilator tube out, desperate to escape what was going on. Having someone like Laura to talk to and process these memories and emotions would have been hugely helpful. I was pleased to read that this experience is being recognised as a trauma in itself. (PLO\ (OOLRWW psychodynamic art therapist and therapist for CAMHS

significant scale in the UK – in other words, currently, as distinct from in the recent past. Moon cites from the Government’s 2018 LGBT survey, which is highly flawed, based on only four questions in an online, self-report survey. Legislation needs to be based on an accurate survey of the extent of the problem if it is to be at all effective. The term ‘conversion therapy’ is misleading in capturing oppressive practice towards LGBT people. The 2018 survey defines conversion therapy as: aversion therapy, pseudo-psychological treatments, spiritual counselling, surgical and hormonal treatments and corrective rape. None of these are consistent with ethical, professional practice by therapists. The survey is unable to tell us where these abuses occur, whether in the NHS, private medical care or unlicensed practice. Sometimes more law is simply not the right answer – rather like mending a clock with a hammer, it’s just the wrong tool for the job. The Independent Inquiry into Child Sexual Abuse (IICSA), led by Professor Alexis Jay, decided, for example, not to call for mandatory reporting of child abuse

Is more law the answer? Dr Igi Moon says, ‘It is beyond me to understand people who disagree with a ban on conversion therapy’ (‘The big interview’, Therapy Today, June 2021). Perhaps this puts me beyond their understanding, but I see five arguments against a legal ban on conversion therapy. There is no credible evidence that conversion therapy is practised on any

A ban could deter many therapists from engaging with LGBT clients as being ‘too risky’. We need more CPD and enhanced professional standards from BACP, not more bad law

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for this reason. The kinds of punitive and coercive practices inflicted on LGBT people are already covered by existing law, statutory regulation and professional disciplinary action. Aversion therapy and surgical and hormonal treatments are covered by the powers of the General Medical Council (GMC) and the Health and Care Professions Council (HCPC) to remove a practitioner’s licence to practise. Enforced spiritual counselling is covered by false imprisonment. Physical ill-treatment is covered by safeguarding legislation, and corrective rape by criminal law. If these measures are not being properly enforced, why would a new law be any better? There are serious problems with how to define conversion therapy in law. What does it mean to ‘suppress’ gender identity? What would be the lower age limit – two- and three-year-olds in play therapy? How will a legal ban enable us to work safely with clients such as Keira Bell [who took legal action against a gender clinic, on grounds that they should have been challenged more by medical staff over their decision to transition]? Do we really want the police outside our therapy rooms, courts seizing our records and higher insurance premiums? A legal ban is likely to have a widespread and not necessarily progressive impact on therapists working with gender issues. LGBT communities have already experienced the ill effects of poorly drafted, oppressive legislation. Section 28 of the Local Government Act 1988 prohibited the ‘promotion’ of homosexuality by local authorities. It had a chilling effect on youth workers and school counsellors, deterring them from discussing sexuality for decades. A ban could deter therapists from engaging with LGBT clients as being ‘too risky’, at a time when gender is clearly emerging as a priority area for our professions. We need more CPD, and enhanced professional standards from BACP, not more bad law. So, I don’t expect Dr Moon’s understanding, but there is a real debate to be had here. 3HWHU -HQNLQV 0%$&3 counsellor, supervisor, researcher and trainer

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1959-2021 It is with deep sadness that I write of the sudden death of my dear friend and former colleague Hazel Wilcock, in a house explosion in February. Hazel was an extraordinary person. She had a wicked sense of humour and had a gift for making you feel better simply for having been in her presence for a while. Hazel’s professional achievements were outstanding, and one of the tragedies of her early death is that her career was cut short when she still had much planned and much to offer. As a social worker for the Deaf, working in Lancashire in the 1980s and 1990s, she made a key contribution to the development of accessibility of services to Deaf people. She subsequently trained as a counsellor and worked in Blackburn as a primary care senior counsellor for some years, developing a placement scheme for trainee counsellors in the NHS that was recognised as a model LQ WKH ƓHOG Later, Hazel was able to combine two of her passions by developing WKH ƓUVW GLSORPD LQ FRXQVHOOLQJ IRU 'HDI SHRSOH )RU WKH ƓUVW WLPH HYHU 'HDI SHRSOH FRXOG WUDLQ DV FRXQVHOORUV RQ training courses designed for them. She also set up and managed the specialist Improving Access to Psychological Therapies (IAPT) service for Deaf people while working for the British Deaf Association and subsequently for the mental health charity SignHealth. While at SignHealth, Hazel also played a key role for many years in partnership with Deaf and hearing researchers at the University of Manchester, carrying out vital research into Deaf people and mental health. In the past four years, Hazel’s professional life took a different direction with her involvement with St Ann’s +RVSLFH VDWLVI\LQJ KHU ORQJ KHOG ZLVK WR ZRUN LQ WKH SDOOLDWLYH FDUH ƓHOG , NQRZ from our conversations that she was passionate about the clients and the work she was doing as a counsellor, and saw it as the place she would stay until the end of her career. I know her hospice colleagues feel her loss very keenly. , KDG WKH SULYLOHJH RI ZRUNLQJ ZLWK +D]HO ƓUVW DV P\ PDQDJHU DQG WKHQ DV P\ supervisor, and I owe a debt to her for my development as a counsellor and supervisor, simply because she was an amazing role model. Amid my huge sadness and feelings of loss, I consider myself incredibly lucky to have known her and been her friend. 3DXOLQH 6XPPHUV 0%$&3 $FFUHG counsellor

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I am part of a group of therapists who recently received an email from Public Health England asking for volunteers to help combat COVID-19 vaccine hesitancy among certain ethnic minorities. As the email says, ‘There appears to be a mistrust of the UK health system, with people preferring to return to their homeland for routine appointments (eg smear tests, pregnancy care, health checks). Hesitancy around the vaccine appears to be linked to a preference to receive the vaccine in their own country.’ The email says the Government wants to activate a UK network to encourage and reassure people to come forward for vaccination. Some of the counsellors very quickly engaged with this initiative. Asking counsellors and psychotherapists to join a network to ‘encourage and reassure’ members of these groups regrettably shows how little the Government knows about therapy. Personally, I am pro-vaccine, but is it up to therapists to act as advocates for or against? The danger is that, in doing so, our fragile alliance with our clients is put at risk. My experience is that vaccination very rarely comes up as a topic in my practice. If it did, I would first be curious to learn where the hesitancy and mistrust come from. The Government should probably do the same and explore where and why there are both hesitancy and mistrust and address its own contribution to this. Therapists offer significant help and support to clients, but it is not our place to be agents for the Government, effectively judging our clients’ autonomous choices. We should be respecting clients’ privacy and their right to be self-governing. Isn’t this what the Ethical Framework recommends? 6ODYLWVD 0LURYLF 0%$&3 $FFUHG

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The month Mental health and the human experience in the arts, media and online

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Brandon Kohrt is associate professor of psychiatry and behavioural sciences at George Washington University. His interest is in the mental health of SRSXODWLRQV DIIHFWHG E\ FRQŴLFW disasters and other humanitarian emergencies. In this essay, he is concerned with our growing use of emotional regulation WKHUDSLHV DQG VHOI KHOS DSSV and the way mainstream psychiatry and psychology, as ZHOO DV WKH VHOI KHOS PRYHPHQW focus on the mastery of self regulation skills to achieve mental wellbeing. While the psychiatrist in him understands how these cognitive approaches may be helpful, his anthropology training makes him ask, ‘Is emotional regulation something we’re really supposed to do alone?’ He describes instances in a range of settings across WKH JOREH Ŋ QDWXUDO DQG PDQ made disasters and tragedies, large and small – where he has seen healing offered and derived through simple human contact. ‘Emotion regulation to reduce distress appears to be a fundamental human behaviour that doesn’t just happen within us, but between us,’ he FRQFOXGHV <RX FDQ ƓQG WKLV remarkable essay on the Aeon website at bit.ly/3vGTYYD

BEYOND THE MASK Made entirely during lockdown, Beyond The Mask LV D QHZ GRFXPHQWDU\ IURP ƓOP PDNHU DQG %$&3 DFFUHGLWHG WKHUDSLVW -DQH +DUULV -DQH FR IRXQGHG WKH FKDULW\ 7KH *RRG *ULHI 3URMHFW ZZZ WKHJRRGJULHISURMHFW FR XN LQ ZLWK KHU ƓOP HGLWRU SDUWQHU -LPP\ (GPRQGV DIWHU WKH VXGGHQ GHDWK RI WKHLU \HDU ROG VRQ -RVK Beyond the Mask explores many aspects common to both grief and the pandemic Ŋ WKH LVRODWLRQ D VHQVH RI WLPH VWRSSLQJ WKH ORVV RI FRQƓGHQFH WKH FKDOOHQJH WR one’s sense of self, the damage to mental health and, of course, mask wearing and WKH YDULRXV ZD\V ZH DUH KDYLQJ WR DGMXVW WR RXU QHZ QRUPDO Ō7KRXJK JULHI FDQ EH D VRPEUH VXEMHFW WKH ƓOP LQ IDFW DLPV WR OHDYH WKH YLHZHU IHHOLQJ HQFRXUDJHG about our world,’ says Jane. Beyond the Mask is available to groups to share. For information and support in creating ticketed fundraising screenings, which can include Q&A sessions with Jane and Jimmy, contact info@thegoodgriefproject.

On modern love

• Millennial Love by Independent journalist Olivia Petter, based on her hit podcast series, offers insider insight into the challenges of modern dating and how it’s harder to meet someone than ever before, despite (or perhaps because of) dating apps. (4th Estate, out 8 July)

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• Comedian Rosie Wilby deftly blends her own experiences with insights from therapists, sociologists and scientists to explore why heartbreak can be so devastating in The Breakup Monologues: the unexpected joy of heartbreak *UHHQ 7UHH out now)

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• Conversations on Love grew out of journalist Natasha Lunn’s quest to understand the nature of relationships through honest FRQYHUVDWLRQV 7KH resulting collection of interviews includes therapists Philippa Perry, Stephen Grosz and Esther 3HUHO 9LNLQJ RXW -XO\

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

Don’t miss

THE END OF THE F***ING WORLD

Along a spectrum %ULWLVK ERUQ VFXOSWRU 9HURQLFD Ryan’s work draws on shapes, forms and objects from the natural world. Formative in her early years was a trip to Nigeria, where she was LQVSLUHG E\ WKH UH DGDSWDWLRQ RI everyday consumables, including food and waste materials, to create spiritual offerings and shrines. Her main focus is on the interplay EHWZHHQ FRQŴLFWLQJ RSSRVLWHV revelation and concealment, container and contained, absence DQG SUHVHQFH 7KLV PDMRU VKRZ RI new work at the Spike Island centre for contemporary art and design in Bristol deals with environmental and sociopolitical concerns, personal narratives, history and displacement, and the wider psychological implications of the current coronavirus pandemic. Until 5 September. www.spikeisland. org.uk/programme/exhibitions/ veronica-ryan

Based on a collection of minicomics by Charles Forsman and scripted by Charlie Covell, this is a dark comedy-drama in two series of eight episodes that will NHHS \RX RQ WKH HGJH RI \RXU VRID ,W WHOOV WKH VWRU\ RI WZR WHHQDJHUV ZKR ŴHH their homes together – Alyssa (played by Jessica Barden) has become surplus to requirements following her mother’s remarriage to the predatory Tony and the birth of twin siblings; James (played by Alex Lawther) is stuck in a state of traumatised dissociation after seeing his mother drown herself. Tentatively, they begin to reach out to each other and risk the giving and receiving of love and human contact, while being pursued across the country by the police. Touching, true, shocking, sad DQG YHU\ IXQQ\ DOO DW RQFH DQG ZLWK DQ DPD]LQJ VRXQGWUDFN LWōV DYDLODEOH RQ 1HWŴL[

Podcast picks

Lost and found • Annie Mac, the former Radio 1 DJ turned novelist, explores how changes punctuate our lives DQG GHƓQH ZKR ZH are. Changes with Annie Macmanus includes a diverse range of interviewees – artists, writers and academics. On most podcast platforms.

• 7HUUL :KLWHōV UDZ DQG honest memoir about childhood trauma, Coming Undone, is the springboard for her new podcast, in which she talks to others whose life has become derailed but who have come out stronger from the wreckage. On most podcast platforms.

• A Living Loss is a new podcast by Julia Samuel, a BACP YLFH SUHVLGHQW DERXW coping with the feeling of loss that comes from change we don’t have any control over, such as a relationship EUHDN XS RU D KHDOWK diagnosis. On most podcast platforms.

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Sometimes it’s hard to be a man

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mong its many impacts, COVID-19 has been widely predicted to bring major negative effects on mental health. As we (hopefully) move towards greater normality in our social and working lives and the death rates fall, there are repeated warnings that the economic impacts of the pandemic are likely to take a longer-lasting toll. And, say Samaritans, we should be very alert to the potential for rising suicides among the group already known to be most at risk – middle-aged men. ,Q D UHFHQW FRURQDYLUXV EULHƓQJ 1 Samaritans points out that the common risk factors for men in this age group have all been exacerbated by the pandemic. The main themes emerging in calls to the helpline from men during the height of the pandemic have been loneliness and social isolation, in part due to the closure of so many traditionally masculine opportunities for social contact such as sporting events and venues; feeling that they should be able to ‘put on a brave front’ in the face of the pandemic; fear and uncertainty about job and income loss and its implications, and relationship breakdown due to lockdown pressures. Male suicides have already returned to levels not seen since the early 2000s, according to the latest (pre-COVID) 2IƓFH IRU 1DWLRQDO 6WDWLVWLFV GDWD 2 Should

the counselling profession be asking itself searching questions about what it should do when men still aren’t availing themselves of what it offers, despite their evident need? Not a ‘man thing’ It is a paradox that, despite the fact that psychotherapy and counselling have largely been theorised and developed as therapeutic practices by men, men are least likely to seek their help. And it’s another paradox that what makes men more in need of talking therapies is (arguably) what stops them seeking them – essentially, the fact that they are men. Whether you subscribe to the biological, environmental or cultural explanations (or all three), what seems to bring men to the point where they need such help but stops them reaching the counselling room are the very attitudes, values, beliefs and behaviours that we, certainly in the industrialised West, generally associate with traditional norms of masculinity. These are issues with which psychologists have been tussling since the 1980s, and most recently following the publication in 2018 by the American Psychological Association of its Guidelines for Psychological Practice with Boys and Men.3 The guidelines have proved highly controversial within the psychology profession and the controversy revolves precisely around

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this central issue of whether and in what ways masculinity is pathological, or ‘toxic’: are the chief elements of what it is to be a man in and of themselves psychologically dysfunctional and in need of intervention and treatment? This, argues John Barry, currently Chair of the British Psychological Society’s Male Psychology Section, co-author of the recently published Perspectives in Male Psychology (Wiley, 2021) and co-founder of the Male Psychology Network, is exactly what the guidelines do – they pathologise masculinity. ‘They’re useful if your interpretation of masculinity is that it’s just a social construct or all about men’s power over women and being competitive,’ he says. Guidelines one and three particularly provoke his criticism: guideline one with its injunction that ‘Psychologists [should] strive to recognise that masculinities are constructed based on social, cultural, and contextual norms,’ and guideline three, which recommends that psychologists ‘understand the impact of power, privilege, and sexism on the development of boys and men and on their relationships with others’. ‘These guidelines are a really poor advert for therapy and won’t encourage men to seek help,’ Barry believes. ‘People get very entrenched in the nature/nurture debate when it comes to masculinity and it’s not only very unhelpful, it’s wrong, because it’s not one thing or another. Some aspects of masculinity are to do with biology or evolutionary psychology and some are to do with enculturalisation and socialisation – both sides have something to bring. But when a man loses his job and gets depressed, to say it’s because he has lost his role as the family patriarch is probably the least useful avenue to explore in therapy. These ideas don’t have much use VFLHQWLƓFDOO\ RU FOLQLFDOO\ ō +H DJUHHV that some expressions of ‘traditional masculine attributes’ can be harmful, both to men and to those around them, ‘but you have to be careful not to pathologise them. To say this is a problematic part of being a man is a psychological dead end’.

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Power imbalance For counselling psychologist Dr Michael Beattie, ‘it’s not masculinity but some aspects of patriarchy that need to be overhauled. Masculinity wouldn’t be a problem if there weren’t imbalances of power, or imbalances of privilege between sexes and between different masculine positions – men dominating women, white men dominating people of colour, cis-men dominating non-cis men and so forth. If we are to make value judgments, I would say what is problematic about masculinity, what is “toxic”, are some of the norms around how to be male, because they make life GLIƓFXOW IRU PHQ DQG ZRPHQ ō He points to research by Mahalik and colleagues4 WKDW LGHQWLƓHV WKH ŌQRUPVō necessary (for men or women) to ‘gain access to the tribe of men’: attributes such as winning, emotional control, risktaking, violence, dominance, primacy of work, power over women, disdain for homosexuals, physical toughness and pursuit of status. Being masculine is, Beattie argues, essentially a social

‘What comes from denying feelings and doing masculinity well is you get rewards, you get privilege, right from a very early age’ performance that is all about getting to the top of the power pyramid – and then ƓJKWLQJ WKH FRPSHWLWLRQ WR VWD\ WKHUH because having achieved the pinnacle, you have to defend it. ‘It’s exhausting for men,’ Beattie says. He acknowledges the views of fellow psychologists and counsellors OLNH %DUU\ EXW ƓQGV SOHQW\ RI HYLGHQFH to challenge their argument that men’s ways of being in the world are ‘normal for men’ and shaped by their biology. ‘There is research that little boys are very emotionally labile and that testosterone is a very irritable hormone – that little

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boys are not in fact naturally less emotional; they are socialised into this. I prefer to think about the value of emotions at a very basic level: they exist so we can connect with what we need. We have nerve endings so ZH GRQōW VWDQG WRR FORVH WR WKH ƓUH DQG get burned; we feel hunger so we know to eat; we have thirst so we know we need to drink; we feel loneliness so we know to seek company; we feel anger so we know to set boundaries – they are all feelings that connect us to what we need. I think the problems arise when we get emotionally stunted or cut off. ‘For me, one of the principal goals when working with men is enabling them to allow a certain amount of emotional discovery or reconnection. I am not saying all men or only men do this, but it does seem there is a lot more compartmentalisation of affect in men – putting things in boxes and hoping they will just go away – and that can come home to roost at a certain point.’ You can, he argues, see how this plays out in the suicide statistics. ‘Generally men act out feelings and generally they are socialised and encouraged to do so. It’s not biological destiny. There are aspects of gender role socialisation that we could be helping our children with more. As things are, what comes from denying feelings and doing masculinity well is you get rewards, you get privilege, right from a very early age, as research with primary school children shows. If you didn’t get rewards, you wouldn’t want to do it, because there is a cost.’ Doing emotions differently Paul Atkinson grew up in a working-class family in Nottingham and is a practising psychotherapist and co-founder of the Free Psychotherapy Network. His father was an electrician, a warm and loving man who, he says, never used the word ‘love’. Going out on a job with his father was a powerful bonding experience for all three sons in the family. ‘Mostly, for men, life is about doing,’ he says. Men externalise their experience of feelings through activity. But men do have their own, very creative forms of emotional

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expression. ‘In my world as a kid, and still as an adult, banter is a really major way for men to be intimate. It has a kind of avoidance of seriousness but also an extraordinary truth-telling, exposing, challenging quality to it. But on its own, it doesn’t get you to where you need WR EH WR SURFHVV PRUH GLIƓFXOW LVVXHV Things go toxic when there is a lack RI DELOLW\ WR UHŴHFW RQ DQG SURFHVV WKH emotional world and the internal world breaks out and gets acted out.’ Atkinson co-founded a men’s group VRPH ƓYH \HDUV DJR ZKLFK KH FR facilitates with another therapist. It is a closed group of some nine to 12 men, who meet regularly. ‘There is a terrible defensiveness and stuckness in a lot of men, to the detriment of themselves, their relationships and society in general. ,W LV VWLOO LQFUHGLEO\ GLIƓFXOW IRU D ORW RI men to open up and be vulnerable to other men about who they are. Traditional modes of masculinity are to do with strength, competing successfully and being rather cut off emotionally. Maintaining that is hard work but also very important because it is about ego. But it keeps you unsafe. I think a lot of men really would get a lot out of a men’s group. They learn over time how to grow emotionally. ‘My experience in every men’s group I’ve been in is that, on the whole, if you put a group of men together in a room to talk about what really matters to us, then things really begin to move and change. For the group leader, the main thing is simply to offer some encouragement to go beneath the surface bit by bit, to open up to more vulnerable feelings, to what really matters in men’s lives, which men can be very good at covering up.’ Beattie sees it as his job as a counselling psychologist to help men ‘soften the delineations’ between male and female and, in the Jungian sense, integrate all the parts of themselves that they have locked away in different compartments. ‘I think some part of therapy for men is about making friends with all the different bits of their self. I use a lot of compassion-focused work with men because it’s a very effective

way of working with shame, which is one of the key ways in which societies police men and women, boys and girls, into conforming to being appropriately male or female. ‘Practising self-compassion can be very powerful for men. You can start off in a reasonably psychoeducational way so there is an engagement with the client, normalising different aspects of his experience by positioning it within gender socialisation as something that happens to all of us. Then you introduce the notion that he has a choice, that you don’t have to try harder to get better at things and get back to being a more effective competitor in the race; rather, you need to understand and have compassion for yourself in how you are experiencing that competition and recognise you share that with your tribe. Therapy is about softening some of the very critical aspects of the self that might be driven by shame and holding aspects of identity more lightly.’ But, he says, the real work to be done is much earlier in our lives – in primary schools, teaching young children that they don’t need to follow their allotted lanes in the motorway of life. ‘A lot of these problems are social, and they are handed on. Regardless of what we may think of Prince Harry, what he said recently about his father’s way of dealing with life being handed down from his father, and in turn handed on to him, and how he wanted to break that chain with his own son ring very true for many men, regardless of their status or class. As mental health professionals, maybe we need to do something about trying to break that chain.’

‘A lot of these problems are social, and they are handed on... maybe we need to do something about trying to break that chain’ THERAPY TODAY

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Blasculinity Beattie’s conceptualisation of the transgenerational pressures on men to conform to a masculine stereotype are echoed by Dwight Turner, counsellor and psychotherapist and a senior lecturer at Brighton University. Earlier this year, his blog on ‘Love and the Black Man’,5 about how hard it is for black men to acknowledge love, whether given or received, struck a chord with many in the black community. &KLOGUHQ RI ƓUVW JHQHUDWLRQ PLJUDQWV of the Windrush generation, he argues, have been socialised by their own fathers into a semblance of unemotional, stoical endurance. Turner recalls only once being told by his father that he loved him – when, aged 14, he stood up in court as a witness in a trial after he and his friends were attacked by a white gang. His father wasn’t a bad man, Turner says; he was simply enacting the role that he had himself inherited: ‘You can’t talk about black masculinity without talking about the injunctions placed upon black men within the colonial framework – that idea about children being seen and not heard and the father being the patriarch of the family.’ And for black boys in the UK, there is also the injunction ‘to be an adult but not too much of a man’, Turner says. ‘Kimberlé Crenshaw has written about this in relation to Black Lives Matter. The George Floyd murder can be seen as white masculinity imposing its own domination over black masculinity and that’s nothing new for black men. And, when you are raised in a home with a father who has endured that, it compounds it. To be challenged within your own home is intolerable for a man who has already been defeated. The way one still has dominion in a white environment is by oppressing one’s own male kids. If you challenge the dominant male, you get thrown out. I’ve seen that with black male kids who’ve had to leave home at 16: “You’re a man now, get out.”’ So how might a therapist work with this in the counselling room? ‘By working to restore their sense of pride and identity,’ Turner says. ‘With my own clients, I will try to help them understand

‘It is possible for them to escape from those expectations. We are breaking down that idea that you just have to get on with it’ their internalised black father, how they have internalised those injunctions. Then, within our relationship, I hope they will internalise something from myself, explore what they can let go of within themselves, look to examples of strong black male people in their culture and the qualities they can identify with that they already have and discover they can choose how they want to be with their own kids.’ Changing cultural expectations Beattie’s argument that therapists need to get into schools to challenge and change the way young children are guided into and rewarded for certain JHQGHU UROH VWHUHRW\SHV LV H[HPSOLƓHG by counsellor Neema Fauvrelle. She works in a boys’ boarding school, where, by tradition, the English upper classes send their male children to learn to be men. That such a school would employ a counsellor, other than to tick a box, RSHQV D FUDFN LQ WKH HGLƓFH WKDW VKH LV brown, female and feminist widens that crack and, she hopes, means she is able WR LQŴXHQFH WKH VFKRROōV FXOWXUH DQG values and bring about a revolution in its expectations, and those of their parents, on its pupils. Fauvrelle says, ‘I’ve been working in that school for three years and I used to be sequestered away in an attic room; people barely liked to mention me out loud. And now I am reading The Huge Bag of Worries to Year 1. I see these boys, aged 11-13, and every week I’ll ask, “How are you doing?”, and every week they’ll say ŏ,ōP ƓQHŐ 7KH\ GRQōW IHHO WKHUH LV D VSDFH ZKHUH WKH\ DUH DOORZHG QRW WR EH ŏƓQHŐ they don’t know what that even means.

Sometimes I am desperate for a kid to throw a chair around the room so I can say, “You are angry, let’s work with that”. It can take weeks to establish that this is one such place.’ These boys are presented with very binary models of masculinity and femininity, neither of which work for them. With her, she hopes they can discover there are alternatives. ‘They have a mum who embodies sadness and sensitivity, and a dad who embodies strength, achievement and courage, but if you are sensitive like mum, does that make you female? Is that OK? But do you want to be like dad, because that can be quite scary? And there’s money and power mixed in with that – being like dad gets you wealth and power but what does it take to get there? I am one person who can say, “Of course you are homesick, of course you are sad. It’s OK to feel like that.” It is possible for them to escape from those expectations. We are breaking down that idea that you just have to get on with it. These boys have been able to cry and that is opening up this massive institution.’ In Bristol, Martin Bisp runs Empire Fighting Chance, a charity that works with youngsters, from deprived homes and areas within the city, using the archetypal male sport of boxing to get them to engage with therapy. This isn’t primarily about boxing, he emphasises; hardly any of the young people who come to the gym go on to box as a sport. Rather, it’s about providing a venue that is acceptable to them, that doesn’t have the stigma of a health clinic or mental health environment, and offers something they can do (skipping, hitting bags) alongside their therapist (who is also a trained sports coach) while talking about what’s going on in their lives. Moreover, boxing is, Bisp says, a sport whose stars are not afraid to admit to having emotions. He points to the current world heavyweight champion – arguably the toughest man on the planet – Tyson Fury, who has openly spoken about his own mental health issues, and to Frank Bruno. ‘For the kids who come here, there’s an element of feeling you have to hide the fact that you are struggling, or

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maybe there’s nothing you feel you can do about it so it’s easier to try to ignore it, or you are from one of those social or cultural groups that see it as a weakness, so you try to pretend that everything is great. We found sport was a way of cutting through those barriers and start working with young people. And, as a group, boxers are quite open to talking about that kind of stuff. People assume ER[HUV DUH WKHVH KXJH PDFKR ƓJXUHV EXW actually people like Tyson Fury and Frank Bruno deserve massive credit for being open about their mental health and wellbeing. We leverage the machismo of the sport to say, if boxers can talk about this stuff, why shouldn’t you? ‘Young people can discuss almost anything in the sessions and that starts to break down this ridiculous notion that men aren’t allowed to do anything except be tough. It challenges the stereotype of men as these onedimensional beings when we all have different elements in our characters.’ What works for men Australian psychologist Zac Seidler argues that the psychology and counselling professions need to change how they work with men, rather than expect men to change how they have been conditioned to be: ‘Men do want to seek help, and will engage in treatment, if they are given the right type of help,’ he has written. ‘Rather than focusing on what treatment is offered, attention should be directed to the how of treatment.’6 Seidler offers a set of principles for good practice when working with men – greater ‘gender-competence’ in the counsellor; an initial emphasis on goals and tasks and active problem-solving; a strengths-based framework that promotes autonomy over dependence; referencing ‘positive and pro-social masculine relationships’, such as ‘mates’, and ‘family protector’, and using ordinary language and purposeful self-disclosure to challenge the stigma and mythology around therapy. Barry has reviewed the research on the differences in the types of therapy men and women prefer. There are very

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few, but therapists should be aware of them, he says. ‘Men seem to like support groups more than women do, probably because they are more about sharing information rather than feelings. But I’d argue that what is more important than the type of therapy is how male-friendly the therapist makes it.’ This means being knowledgeable about male-typical communication styles, like banter, and male-typical experiences, such as stress response to relationship breakdown. ‘And good mental health isn’t just derived from therapy,’ Barry says. ‘In my own research I’ve found that, for men, important sources of mental health are job satisfaction and relationship stability. Playing sports or being a supporter can also be good for mental health.’ He says that too often the ways men express their emotional or mental distress through behaviour are not acceptable in the counselling room and can then become a matter for the criminal justice and forensic mental health systems. Instead of recognising the distress behind the behaviours, we judge and condemn the man: ‘Men tend to express their depression and trauma differently from women. It’s mirrored in how men approach therapy. They want D TXLFN Ɠ[ WKH\ WHQG QRW WR ZDQW WR WDON about their feelings as a way of dealing with their problems. Men also tend to stoicism and to self-medicate with alcohol and externalise their feelings in ways including aggression and violence. But we tend not to recognise these as symptoms of depression and trauma, other than in the context of PTSD in WKH SRVW FRQŴLFW DUHQD :H WHQG WR identify this as men behaving badly or aspects of toxic masculinity. And it’s a dead end when no one recognises that their behaviour overlays their suffering. It’s a massive challenge for everybody ZKHQ VRPHRQH LV YLROHQW LW LV D PDVVLYH challenge to help them. You just want them to be away from you, locked up. It’s a natural response but, as psychologists, if we want to do justice to our profession, we need to actually try to help them.’ Psychotherapist Sue Parker Hall argues that counselling and psychotherapy try to force men into

‘We tend to identify this as men behaving badly. And it’s a dead end when no one recognises that their behaviour overlays their suffering’ a particular mould that they innately GR QRW ƓW Ō, WKLQN WKHUH LV D GDQJHU RI feminising men, making them more like women. People say men need to learn to express their feelings but I say there are three ways of being in the world: one is thinking, one is feeling and one is behaving. A lot of men would more comfortably negotiate the world quite adequately through using their behaving DQG WKLQNLQJ WKHLU IHHOLQJV GRQōW KDYH a big role. The same is true for some women too. This push to get men into “traditional” therapy is misguided. ‘I also think there’s not been much modelling for men’s healthy aggression, as well as their gentler side. Healthy aggression is the life force with which we penetrate the world, that powers our mission in life. I think men’s aggression is misconstrued and managed too much – for example, with boys in school. They get blamed for being disruptive when it’s the system that is disrupting them by not allowing space for their healthy aggression and energy. As a profession, we ought to be way more respectful of men’s dealing with things in the way that they naturally deal with them.’ Parker Hall works relationally with all her clients, men and women. ‘Therapy for me is more about giving them an experience of being regulated in the therapy room that I hope they will LQWHUQDOLVH JLYLQJ WKHP DQ RSSRUWXQLW\ to tell their story in an environment that is respectful, caring, non-judgmental and receptive and takes them seriously.’ Interestingly, psychotherapist, Buddhist and author Manu Bazzano, who has written incisively and self-critically about the concept of masculinity, describes something similar. ‘There

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LV VXFK D Ɠ[DWLRQ DW WKH PRPHQW ZLWK identity. But, as Michel Foucault would say, it’s not about identity, it’s about practices. It is about how you act, how you speak, not how you identify with one gender or sex or another. So we start by helping a man be comfortable in his body, then say, let’s begin a journey and see what else is there, because the traditional masculine model doesn’t work – it brings pain to men and women. ‘Perhaps,’ he wonders, the solution to the ‘problem with men’ is for therapists to focus on providing spaces where men can free themselves from social and cultural expectations and risk trying out different ways of being in the world. ‘There aren’t many places where we can think aloud without being judged. So maybe we therapists can dare to offer that space.’

REFERENCES 1. Samaritans. Coronavirus policy brief: middle-aged men. Ewell: Samaritans; 2021. https://media. samaritans.org/documents/Middle_ Aged_Men_1.pdf 2. Suicides in England and Wales: 2019 UHJLVWUDWLRQV /RQGRQ 2IƓFH IRU National Statistics; 2020. https://bit. ly/3vsRzAH 3. APA guidelines for psychological practice with boys and men. Washington: American Psychological Association; 2018. www.apa.org/about/policy/ boys-men-practice-guidelines.pdf 4. Mahalik JR et al. Development of the conformity to masculine norms inventory. Psychology of Men & Masculinity 2003: 4(1), 3–25. 5. Turner, D. If I was your boyfriend: love and the black man. Dwight Turner Counselling Blog 2021: 3 March. 6. Seidler Z. Men’s mental healthcare – striving for better reach. The Psychologist (online) 3 May 2018. https://thepsychologist.bps.org.uk/ mens-mental-healthcare-strivingbetter-reach

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

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erhaps the only negative legacy of my life-changing therapy is an abiding belief that the people who would benefit most from similar treatment are the people least likely to believe that they might. I know this because I used to be one of them. Until relatively recently I subscribed, quite sincerely, to the school of thought that sees vulnerability as weakness and suffering as character forming. Worse, I would passionately contend that early experiences of mental and physical pain had helped me develop a robust and resilient personality – the kind of personality, I believed, that you needed to navigate the vicissitudes and casual cruelties of newspaper offices and, later, the worlds of TV and radio. Would I ever have sought help solely for my own benefit? In my work as a combative radio phone-in host, I would argue honestly and often that a healthy character could fight its way out of any situation, argue its way out of any problem. Weirdly, it worked for years in many ways, but I had subconsciously convinced myself that being brutalised as a boy had done me ‘good’, that it was perfectly normal to spend your entire life with your fists up and your armour on and that it was possible to argue, cajole and debate your way out of any negative situation. I thought it was perfectly normal to wake up every morning with a bolus of what I now know to be anxiety in the pit of my stomach, and that it was perfectly natural to spend every day chasing the adrenalin hits that would temporarily quieten its gnawing presence. When one of the people I love most in the world became catastrophically and, it seemed, irreversibly ill, I realised pretty quickly that this was a problem my personal toolbox was spectacularly ill equipped to fix. In fact, my tried-and-tested tactics for tackling troubles were making the situation worse – and finally admitting this to myself constitutes what was probably the most difficult moment of my life. When my wife suggested I try therapy, I was so broken and desperate that I agreed immediately. But I did so very sceptically, more, I think now, to allow myself to claim that I was

‘trying my best’ to be better, than in the expectation of any actual improvement. If she’d suggested that coffee enemas or drinking horse’s milk might help, I would have signed up for them too. And so I approached my introductory consultation with a heavy heart and next to no hope. I was James O’Brien, broadcasting bruiser and destroyer of the slickest politicians. Therapy simply wasn’t for people like me and, besides, there were no traumatic skeletons in my closet. Being adopted as a baby by the best mum and dad anyone could hope for had marked me out as special and wanted in a way that unadopted children could never be. Being sent to a boarding school near home at the age of 10 – and one 200 miles away three years later – was an act of love and sacrifice by parents who wanted me to benefit from advantages they had never enjoyed. How could this walking, talking ‘success story’ possibly be a ‘victim’ of anything? And then, sitting in a little garden studio in London, I began, at the gentle urging of a warm and wise therapist, to think about the abandoned, beaten boy I had once been. I baulked at the description and told her so. ‘If we decide to work together,’ she said, ‘you will soon be talking to your younger self and telling him that he’s safe now, that you will look after him.’ On the surface, I still found this a perfectly bonkers notion but something must have shifted because, just a week or two later, with a cushion playing the part of 13-year-old me, the floodgates opened and my life began to change. To my profound shock, I came to understand that I had been so desperate to protect myself from the pain inflicted on me by monks and teachers that, even before puberty, I had started to surround myself with a complicated framework of denial and weaponised debate. I had thought this framework was ‘me’ and had buried my authentic self beneath an aggressive, arrogant and often angry carapace. As we began working to shed it, every single aspect of my life improved and, remarkably, continues to do so.

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About the author James O’Brien is an award-winning writer and broadcaster. His ƓUVW ERRN How To Be Right – in a world gone wrong :+ $OOHQ ZRQ WKH 3DUOLDPHQWDU\ %RRN Award for Best Political %RRN E\ D QRQ SROLWLFLDQ +LV ODWHVW ERRN How Not to Be Wrong: the art of changing your mind :+ $OOHQ ZDV UHFHQWO\ UHOHDVHG LQ SDSHUEDFN

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Capitalism is very good at smelling out opportunity and suffering is a vast opportunity James Davies talks to Catherine Jackson about how the rise in consumerism has fuelled – and benefits from – the mental health crisis

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Catherine Jackson: You are well known for your work with the Council for Evidence-based Psychiatry, highlighting the harmful effects of our ever-growing dependency on psychotropic medication. Your previous book, Cracked H[SRVHG WKH ŴDZV LQ WKH VFLHQWLƓF HYLGHQFH XQGHUSLQQLQJ psychiatric diagnosis. How does your new book, Sedated, pick up and continue those themes? James Davies: Sedated goes further, to look at the social and political context that has allowed the biomedical model I critiqued in Cracked to become dominant, despite its poor outcomes. That was the mystery for me – why have outcomes dramatically improved in general medicine since the 1980s, while outcomes in psychiatry and mental health have at best flatlined and, according to some measures, have actually got worse? Why has this happened despite our spending around a quarter of a trillion pounds on services and research since the 1980s, and despite around a quarter of our population receiving some kind of intervention each year? I was bemused as to how a system that is clearly failing could continue to expand year on year. There had to be some other structural reasons, and that’s what I explore in Sedated – the conditions that have allowed a failing system to dominate and thrive. To explain this, I draw on an insight that was central to much sociological thinking over the 20th century – that the main institutions of society (religion, law, healthcare and so on) always adapt to what the dominant economic model of the day demands. I use this idea to explore how our mental health sector has evolved since the 1980s to broadly accommodate the needs of our neoliberal economy, but at the expense of obtaining good clinical outcomes. Thus, the health sector has colluded with neoliberalism in order to stay relevant and survive. Ironically, this servitude has come at huge social and human cost, whether we’re considering the harms of ineffective drugs, the waste of unnecessary prescribing, the costs to the economy of poor outcomes, or the rising disability and welfare spending, lost tax revenues, absenteeism and falling productivity that have been enabled or fuelled by our overly medicalised system – that’s the real mental health crisis of our time.

CJ: You quote an interview in 1981 with Margaret Thatcher by the Sunday Times journalist Ronald Butt, to mark KHU ƓUVW WZR \HDUV LQ RIƓFH DQG VHW RXW her plans for the future. She says to him: ‘I set out to change the approach and changing the economics is the means of changing that approach… economics are the method, the object is to change the heart and soul.’ And, in Sedated, you argue that this was her deliberate project – to use monetarism and neoliberal politics to change human nature itself. JD: Yes, I contrast this with an essay the economist Maynard Keynes wrote in 1930, ‘Economic possibilities for our grandchildren’. For Keynes, economics are the means by which you enable people to achieve their full potential. That is the purpose of the economy. You create circumstances that allow people to thrive and flourish emotionally, psychologically, relationally, intellectually, aesthetically and so on. And this isn’t an individualistic model. For Keynes, the more you evolved as a human, the better member of society you would be; the better you were as a husband, father, mother, sister, friend, whatever, the more embedded in your community you would be. It was about economics serving human flourishing. And that was very much in tune with humanist psychological thinking in the 1950s, 1960s and early 1970s. Carl Rogers, for example, was of that school. I don’t want to glamourise mid-century capitalism, as it did have other problems, but there was this synergy between the rise of humanism in psychology and the influence of Keynesian economics in the political sphere. What dominated at that time was the idea

‘The health sector has colluded with neoliberalism in order to stay relevant and survive. Ironically, this has come at huge social and human cost’ THERAPY TODAY

that being productive meant realising your full human and social potential. But, with the rise of neoliberalism in the 1980s, that shifts to a focus on how busy and entrepreneurial you are, how productive you are in the economy. This becomes the measure of what is good, healthy and proper. And, at the same time, you see that ideology permeating the mental health sector too, as it moves towards honouring economic indices – no longer serving productivity in the humanist sense, as defined for example, by Keynes, Erich Fromm and Rogers, but in the economic sense, as defined by Milton Friedman, Margaret Thatcher and Ronald Reagan. This can be seen very explicitly in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), which introduced for the first time the concept of ‘occupational dysfunction’ – an index that explicitly identifies underperformance at work as a symptom of mental disorder. So, not working at our economic optimum starts to be pathologised, which implies that optimum working, as conveniently defined by the corporation, is a key feature of mental health. The US psychologist Erich Fromm said something relevant when he contrasted what he called the ‘having mode of living’ embodied by capitalism – essentially, materialism – with the ‘being mode of living’ and the psychological harms caused by the former. He argued that, under the pressures of modern life, we had all variously succumbed to overvaluing buying and consuming things, deriving our identity and self-esteem largely through what we owned and possessed.

CJ: You cite the work of Professor Tim Kasser and his research into the psychology of materialism. Can you tell us a bit more about how that is relevant to your argument? JD: Tim Kasser is a US psychologist who was very influenced by Fromm and developed what is now known in psychology as ‘the aspiration index’. It’s a standardised questionnaire designed to assess, among other things, the relative importance people ascribe to materialistic values and goals. He has found that materialism has a significant influence on people’s emotional, relational and instrumental lives. His research shows that having a materialistic outlook on life is associated with a whole host of problems.

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‘Materialism is an attempt to correct the damage done by harmful social deprivations, and this is endorsed by society’

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People who are highly materialistic are more likely to have relational problems, less likely to experience deep social connection with others, more inclined to antisocial behaviour, less inclined to invest in social relationships, less able to show empathy, more inclined to physical and emotional health problems, and more prone to what gets diagnosed as depression and anxiety. But he isn’t saying materialism is causing our distress; he is saying that materialists use objects to compensate for other deprivations and neglected human needs. Initially his research revealed that acquisition of objects is a way of compensating for such people’s sense of personal inadequacy. But he went on to show that they also use consumption as a means of emotional self-regulation. It’s an attempt to manage emotional distress – another harmful coping mechanism, but one that consumerist societies encourage and exploit. I think this is a very interesting idea. Materialism is an attempt to correct the damage done by harmful social deprivations. And this attempt is endorsed by the society we live in, which tells us that consuming our way out of misery is a legitimate way to proceed – a message we imbibe from a very early age. The problem is that it may be good for the economy, but it isn’t good for the individual.

CJ: Is that what you mean by ‘turning distress into capital’? JD: Exactly, it commodifies distress, and capitalism is very good at smelling out opportunity and suffering is a vast opportunity – the global psychotropic drugs market alone is worth $70 billion annually.

CJ: And on top of that is the self-help, self-improvement market, I suppose, which resonates with neoliberalism’s

individualism that many see as so damaging to the individual and to society as a whole. But returning to mental health policy, you focus on two examples of how the mental health sector has swung into line to support the Government’s neoliberal agenda – mental health awareness training and the Improving Access to Psychological Therapies (IAPT) programme. JD: Mental health awareness training is very interesting. The theory is that if employers train a few members of staff to support people who are struggling mentally and advise them to seek out some kind of help and intervention, it’s going to be good for the person and good for the corporation, because it will bring down absenteeism and increase productivity. But if you look at it in any kind of depth, you will see it’s doing something very different, and the clue is in the fact that there is no evidence that such training, or any other kind of mental health consultancy, actually saves companies any money or makes the mental health of employees any better. So why is it so popular with employers? This training must be bringing something. And it is – it brings the employer control of the narrative as to why people in the workforce are distressed, unproductive, dissatisfied and disengaged with the work they do. Workplace mental health awareness training allows the employer to deflect attention from the fact that the work is meaningless, boring, underpaid, insecure or downright damaging, and recast employees’ understandable response to their circumstances as due to something going wrong within them – they have a mental health problem that requires some kind of intervention. Essentially, it depoliticises, medicalises and pathologises worker distress by default, and by doing so it exonerates the institution and political community from taking responsibility for this parlous state of affairs. But it also does something else – it’s helping stifle collective and community action because people’s suffering is dealt with in private; you don’t get an opportunity to share with others in your workplace the nature of your suffering and therefore to identify that you share common problems. If a community comes together around common adversity, there is an opportunity for collective action. Collective suffering properly channelled has always been a vital spur for change. We have

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seen that in the women’s liberation movement and most recently with the Black Lives Matter protests, but interventions like mental health awareness training interrupt that by favouring a highly medicalised approach, one that privatises people’s despair. In this way, political tribes are replaced with diagnostic tribes, as we identify with a given social grouping that is defined by our mental ill health rather than our affiliation to a particular social cause. Once suffering has been politically defused in this way, individualised and profitable treatments follow, emphasising dysfunction in the self over social reform. Similarly, IAPT was always all about employment. The reason why the Government went for it was because it was claimed to solve an economic problem, not a human one. But that has been its downfall, because when you put economic needs above human needs, those human needs remain unfulfilled. And that has happened with IAPT – the outcomes remain woefully poor. If you measure IAPT outcomes properly, on average, you’ll find you are probably better off not going to IAPT at all. It’s not set up for facilitating deep and meaningful human change and recovery. That isn’t its objective. You get two to six weeks of watered-down CBT that is all about getting you back to your daily routine and activities – the things that may have made you miserable in the first place. And, again, it identifies the individual as the problem. What is ironic is that mental health awareness training often refers people to IAPT and IAPT tries to get them back into work. Then, when they start putting IAPT counsellors into job centres, the narrative becomes, ‘Why are you unemployed? It’s not the economy or the zero hours contracts or because local factories have shut because the work has been outsourced more cheaply abroad. You’re

‘Our mental health sector has become the “new opium” of the people... it sedates us literally and ideologically’

unemployed because you’re not thinking correctly, you’ve not got the right attitude.’ And here comes IAPT again, to install the correct attitude. It all slots together to produce the desired outcome, which is not about making the person’s life more meaningful; it’s about serving economic indices.

CJ: Returning to the pharmaceutical industry, you explicitly compare Karl Marx’s assertion that religion is ‘the opium of the people’ with the use of psychiatric drugs to sedate political protest, as in the title of the book. Could you say a bit more about that? JD: Marx used the term back in the mid18th century to describe the role he believed religion played in teaching people – and usually the most disadvantaged people – to accept and endure their terrible living and working conditions, rather than fight and reform the harmful social realities oppressing them. So, in that sense, religion was sedating the distress that would otherwise galvanise people into political action. It was a sedative that was disabling the impulse for social reform. In Sedated, I argue that our mental health sector now serves precisely the same function, but for post-1980s neoliberalism. In other words, it has become the ‘new opium’ of the people, which is what the book was originally going to be called, to convey the idea that our mental health sector sedates us not only literally, through the chemical substances it excessively distributes, but also ideologically, by telling us that the origins of our despair are rooted in the space between our ears, rather than in the deeper social drivers of our circumstances.

CJ: So, what is all this to do with counselling and psychotherapy? JD: Essentially, I believe that we as a profession must repoliticise emotional discontent. I came to therapy via social science. My PhD was in social anthropology, so I have been schooled to look at social structures and their impact on how we think, feel and behave. It is something I have always done at a very primary level. But what struck me when I began training as a psychotherapist was that we weren’t being taught to think in that way. We were being taught to privilege biography and the immediate family as the primary drivers of who we humans become. While this perspective is, of course,

central to therapy, a lot of therapists don’t go beyond that. I soon learnt that only a minority are very sociological in how they think and practise. For me, becoming conscious of our social predicament and its social drivers should be seen as central to ‘becoming a person’, to use the Rogerian phrase. It is this awareness that equips you with what you need to make informed decisions about how and what to change in your life, which is why I feel every therapist would benefit from integrating some kind of sociological perspective into their work. Second, we as a profession need to be much more sociopolitically aware of the role our mental health sector plays in modern society – how it is culturally situated and what functions it serves as a social institution, both facilitative and problematic. We should be equipping young practitioners with a critical perspective on the social purpose of therapy. Because there are problems with it, as IAPT illustrates, and we don’t address that in our trainings. No social institution is entirely benevolent; everything casts a shadow. Third, I would like us all to think more about what I call ‘mobilisation therapy’ – at some point, the suffering person has to act if they are to recover. There is therapy in activism, and there’s therapy in supporting and working with people who’ve been through similar things to yourself. One of the dangers in medicalising mental health issues is that it refracts and diminishes this collective experience; it cuts you off from your fellow sufferers, and that is a real loss, to both the individual and the social group, as I mentioned before. In the end, then, whether we are looking at the medicalisation of worker dissatisfaction, at the rise of back-to-work therapies, at the alignment of materialist values and mental health treatments, at the pathologisation of the unemployed, at recovery being measured in terms of economic productivity, at pharmaceutical regulation that puts industry interests first, at the use of diagnostic labels to medicalise our children and plug school funding cuts, or at the widespread commodification and depoliticisation of mental distress, we are referring to a mental health system that has become handmaiden to the ideological needs and wants of new capitalism. That is why our system continues to expand, despite its evident failure. So that is what the mental health sector now needs to address.

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About James Davies Dr James Davies is a reader in medical anthropology and mental health at the University RI 5RHKDPSWRQ +H LV D TXDOLƓHG psychotherapist and co-founder of the Council for Evidencebased Psychiatry. Cracked: why psychiatry is doing more harm than good is published by Icon Books (2013). His new book, Sedated: how modern capitalism created our mental health crisis, is published by Atlantic Books.

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

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Daren Lee explores CBT and psychodynamic approaches to working with OCD in a post-pandemic world

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y experiences of obsessive compulsive disorder (OCD), both as a practitioner1 and a relative of a sufferer, have confirmed for me that it is both a sinister and a misunderstood disorder. For some people with OCD, their concomitant obsessional thoughts represent an analogical ransomer who issues threats and holds loved ones hostage. In the minds of such OCD sufferers, only their compulsive behaviours can save their loved ones from a catastrophic fate that they think about or visualise, time and

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time again. According to Veale and Willson, this is a reflection of their exaggerated sense of responsibility.2 The distress that OCD creates can be relentless. Catastrophic thoughts and images play on repeat, with only fleeting respite obtained by the completion of compulsive behaviours. OCD sufferers are burdened with a sense of pressure, a case of ‘complete the compulsion or else’. To compound this distress, according to Leahy, the mere presence of such intrusive thoughts results in clients assuming a moral responsibility to save their loved ones from

the ransomer that has the OCD sufferer’s loved ones in their clutches but, worse still, insists that only they can pay the life-saving ransom. People with these experiences of OCD do not compulsively clean their hands because they like to feel clean or check that they have properly locked the door to protect their material possessions; they fulfil their compulsive behaviours because, to them, it might be a matter of life and death.

’Clients are advised in no uncertain terms to break all contact with the ransomer as it is imperative to call their bluff’

The myth of being ‘a bit OCD’ My affinity with people with OCD has been reinforced by my observation that there is a tendency for their distress to be belittled. Over the years, I recall countless occasions in which people have quipped that they are ‘a bit OCD’ because they like to rank their fridge magnets or pride themselves by their organisational prowess, claiming the disorder as an amusing character quirk. But people who genuinely have OCD know it’s no laughing matter – as does any therapist who has worked with clients who experience obsessional thoughts and/ or compulsive behaviours, or anyone who has seen a loved one ravaged by its symptoms. The meaning that OCD sufferers attach to their intrusive thoughts compels them to complete their ritualised behaviours; they are at the mercy of the ransomer and, at its worst, this can invade every aspect of their lives. So, how do you work with a ransomer? From a cognitive behavioural therapy (CBT) perspective, the answer is simple – you don’t. Widely used cognitive behavioural protocols are based on a formulation by Salkovskis et al,4 which suggests that OCD is maintained through safety behaviours such as hypervigilance, reassurance seeking and compulsive behaviours. Clients are advised to systematically eradicate safety behaviours through a range of behavioural experiments – by ceasing their hypervigilant behaviours, dropping their attempts at reassurance seeking, and refraining from compulsive behaviours. In short, they are advised in no uncertain terms to break all contact with the ransomer as it is imperative for the client to call their bluff.

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Exposure response prevention This a big ask for someone who is convinced that a failure to adequately complete compulsions could jeopardise the safety of their loved ones. The enormity of what CBT requires of OCD clients is exemplified by

exposure response prevention (ERP). The technique necessitates clients being gradually exposed to increasingly demanding situations while insisting that they refrain from using safety behaviours. The rationale is that, with increased exposures, the client’s anxiety will decrease through habituation. My own clinical experiences with this intervention have been enlightening. I have worked with clients with obsessive contamination fears who, long before the COVID-19 pandemic, were incessantly washing their hands and applying antibacterial gel, as dictated by their ransomer. Their obsessional thoughts invaded their consciousness with such ferocity that ERP exercises resulted in them feeling intense anger. I recall clients staring at me as if they wanted to burn a hole through me, which felt unsettling, to say the least. But ERP is not designed to be comfortable for clients; it is, by its very nature, designed to create an anxiety-inducing situation that clients can get used to, which allows them to acquire evidence to dispute their obsessional beliefs.

Do no harm For practitioners, working with an ERP approach may present an ethical dilemma around their commitment to ‘non-maleficence’. Early on in my training, I recall being worried about the situation arising in a session where I would not know what to do or say. I recall soothing myself by thinking, ‘Just be with the person and do no harm.’ Yet here I was, doing that very thing, sat in a room with a client who looked terrified, or who seemed to be willing me to burst into flames. The complex nature of the ethics of such a situation has to be acknowledged: in the shortterm, clients were undeniably being exposed to a situation (invited by me) that they perceived to be harmful. But, as it worked, the ends appeared

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to justify the means. On both qualitative and quantitative levels, over the weeks, clients were experiencing less anxiety and could reduce their safety behaviours, and with each step, they were reclaiming a bit more of their organismic self. On a number of occasions, the client and I together called the ransomer’s bluff and survived to tell the tale. However, despite strong efficacy data,5-7 one has to wonder how ERP can be translated into a post-COVID-19 reality. For instance, deliberately exposing a client to unsanitised conditions to experiment whether they really will contaminate their loved ones was a possibility before, but this would be unthinkable now and would contravene published public health guidance.8 The days of clients being asked to knowingly touch the inside rim of a toilet (and not wash their hands) until their anxiety dissipates are long gone. Furthermore, many people with and without OCD symptoms may still be experiencing worrying thoughts about their loved ones’ risk in relation to COVID, so the boundaries between helpful and unhelpful reassurance seeking are less clear than they have been for generations.

A psychodynamic perspective It comes as no surprise that a psychodynamic approach to formulating and treating OCD is vastly different to that used by cognitive behavioural therapy. Far from ignoring the ransomer and their intrusive demands, psychodynamic practice requires that the client becomes intimately acquainted with them. The psychodynamic therapist offers an opportunity and space for the client to explore just who the ransomer really is and examine their motives. Bürgy has suggested that OCD can be seen as a manifestation of a structural egodeficit.9 To compensate for their ego-deficit, OCD sufferers seek reassurance from selfobjects by demanding confirmation and approval. This theory is consistent with my experience of previous clients who became aggravated when I had not been forthcoming with reassurance. Clients want to know that they are doing things ‘right’, as they believe the consequences of their decisions and behaviours are of paramount importance. To OCD sufferers, a failure to ‘pay the ransomer in full’ could have grave consequences for their loved ones. But could there be more to this hostile transference?

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Compulsive behaviours designed to protect loved ones could represent a form of reaction formation, defined by Lemma as ‘a disturbing idea that is transformed into its opposite’.10 On this basis, compulsive behaviours represent an antidote to rival the unconscious aggressive impulses that clients harbour towards their own loved ones. Perhaps the ire that I have detected in clients is stoked by the clients’ own latent aggression? This view has some evidence in its favour. Moritz et al11 suggest that the disproportionate concern for the wellbeing of loved ones reflects an ‘altruistic façade’, as clients’ compulsions reflect defences against their own latent aggression. Certainly, this accords with my own clients’ disclosures about the content of their graphic dreams and visualisations of violence befalling their loved ones. Despite the repulsion this evokes in clients, I would contend that it is more accurately described as wish fulfilment than nightmares. Clients diligently make ‘payments to the ransomer’ at considerable personal cost – they believe they have to if their loved ones are to be spared. But is this as heroic as it seems? Unsettling as it can be, part of the work of psychodynamic practice calls for us to invite the client to step out of the shadows and reveal themselves. The analogical ‘ransomer’ is not an enigmatic stranger with intent to exploit at all, but is all too familiar to the client – an embodiment of their own destructive impulses, realised through ego dystonic representations. Obsessional thoughts are described as intrusive: they feel like an invasion; something or someone is penetrating their thoughts and wishing destruction on their loved ones. To OCD sufferers, there are ransomers everywhere – in their thoughts, in their dreams, in their imagination. The common thread here, however, is looking back at them in the mirror. Having presented two conceptualisations of how practitioners work with ransomers, I will conclude with an example that marries the two. I once used a thought-action fusion behavioural experiment along with a CBT protocol with a client presenting with OCD symptoms. This required that I asked the client to verbalise an unpleasant thought or image in order to test whether thinking (and saying) something really would make that event occur in reality. The client verbalised that I would be hit by a car over the coming week, the idea being that

’The client had the RSSRUWXQLW\ WR ƓQG out once and for all whether they were really as dangerous as they suspected’ my attendance at our next session would offer evidence that it was safe to call the ransomer’s bluff. When I attended our next session unscathed, the client had their ‘evidence’. However, this represented much more. The thought-action fusion behavioural experiment presented the client with a platform to step out of the shadows and unveil themself as the ransomer. The client had the opportunity to verbalise their aggression, to think and say the worst and find out once and for all whether they were really as dangerous as they suspected. In sessions, I had withstood them staring through me as if they wanted me to burst into flames and their irritation when I would not offer immediate reassurance. I had even withstood their wish that I would be in a car accident, but I still came back. I could withstand their latent aggression and through that we knew that the ransomer was not so bad after all.

1. Lee D. A jolt of transformation. The Psychologist 2020; 21 July. https:// thepsychologist.bps.org.uk/jolttransformation 2. Veale D, Willson R. Overcoming obsessive compulsive disorder: a self-help guide using cognitive behavioural techniques. London: Hachette UK; 2009. 3. Leahy RL. Overcoming resistance in cognitive therapy. New York, NY: Guilford Press; 2012. 4. Salkovskis PM, Forrester E, Richards C. Cognitive behavioural approach to understanding obsessional thinking. The British Journal of Psychiatry 1998; 173(S35): 53–63. 5. Meyer V. 0RGLƓFDWLRQ RI H[SHFWDWLRQV LQ FDVHV ZLWK obsessional rituals. Behaviour Research and Therapy 1966; 4(4): 273-80. 6. $EUDPRZLW] -6 9DULDQWV RI H[SRVXUH and response prevention in the treatment of obsessive-compulsive disorder: a meta-analysis. Behavior Therapy 1996; 27(4): 583–600. 7. DiMauro J, Domingues J, Fernandez G, Tolin DF. Long-term HIIHFWLYHQHVV RI &%7 IRU DQ[LHW\ GLVRUGHUV in an adult outpatient clinic sample: a follow-up study. Behaviour Research and Therapy 2013; 51(2): 82–86. 8. UK Government. Staying at home and away from others (social distancing). www.gov. uk/government/publications/fullguidance-on-staying-at-home-and-awayfrom-others. 9. Bürgy M. The narcissistic function in obsessive-compulsive neurosis. American Journal of Psychotherapy 2001; 55(1): 65–73. 10. Lemma A. Introduction to the practice RI SV\FKRDQDO\WLF SV\FKRWKHUDS\ 2[IRUG John Wiley & Sons; 2015. 11. Moritz S, Kempke S, Luyten P, Randjbar S, Jelinek L. Was Freud partly right on obsessive– compulsive disorder (OCD)? Investigation of latent aggression in OCD. Psychiatry Research 2011; 187(1-2): 180-84.

Post-pandemic Sadly, it seems likely that the COVID-19 pandemic will heighten the perceived threat of the analogical ransomer for OCD sufferers. For people with OCD symptoms, past and present, I can foresee more ransomers lurking in the shadows. The rhetoric surrounding COVID-19 as an ‘invisible killer’ and the calls for us all to take responsibility for stopping the spread of the virus will surely be all too familiar to OCD sufferers. The need to maintain high levels of hygiene to prevent contaminated hands (or droplets) from becoming a mortal threat to others may well obstruct popular interventions used to treat OCD that call the ransomer’s bluff. But we can still dig below the surface to become better acquainted with the ransomer – after all, better the devil you know than the devil you don’t.

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About the author Daren Lee is a BACP accredited counsellor currently undertaking a doctorate in counselling psychology. He has worked in bereavement, alcohol and drug use support, and in primary and secondary NHS mental health services. His research interests include obsessive compulsive disorder, group therapy, promoting men’s mental health and people’s relationship with alcohol and drug use.

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The grounding power of walking Daily walking helped Mike Sands find his feet while setting up in private practice

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tarting out in private practice last year was quite destabilising. I felt uncomfortable about negotiating fees, accepting payments and marketing myself. At times, it still feels like walking across boggy ground – ‘You’re not cut out for this,’ my merciless inner critic tells me. I sometimes find myself continuing to occupy the inner worlds of my clients after their sessions have ended, and can feel ungrounded, with a curious loss of my personal solidity. Starting my practice in the midst of COVID-19 restrictions accentuated that ‘unreal’ quality of being physically rooted in a single location yet, paradoxically, lost in a mist where I am unable to feel the sustaining physical presence of close family and friends. How do I find a way back to my own reality and invest in my own care? By walking. There is something in the energetic quality of walking mindfully in the open air that is exquisitely beneficial. By daily walking,

and my grandson could put his footprint on the earth, alongside a painful awareness of my less-grounded times.

The ungroundedness of addiction

I re-establish contact with the reality of my body. Daily walking brings my consciousness and existence together like a compass and a map, in a profoundly restorative manner. I recently observed my grandson trying to stand, exploring being upright, testing his balance and perhaps imagining taking his first steps. On somewhat wobbly legs, with all 10 toes squeezing into the carpet, he was beginning the lifelong process of standing upright in the world. There was an innocence in his wholehearted engagement with gravity that deeply touched me. In that emotion was enormous gratitude that more than two decades of sobriety have created the stability in which my children could develop as adults

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As an active alcoholic, my life had been intrinsically ungrounded. In my emotions, thoughts, behaviour and relationships, I had the sense of drifting weightlessly through an intoxicated haze. I lacked any sense of a centre of gravity. Lowen1 described an alcoholic ‘high’ as the person having difficulty sensing the ground under his feet, alongside the sensation of floating, explaining this as withdrawal upwards of energy from the feet and legs – a familiar feeling to me. As a round-the-clock drinker, my connection with the ground had frequently been tenuous, and Lowen notes that ‘it makes sense to me that an individual who feels he has no control over his legs should also feel that he doesn’t know where he is going’.2 My life

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undoubtedly lacked direction and control and at that time, I walked very little. The long and arduous withdrawal from alcohol made my gait unstable but, after a time, I began to walk more steadily, although slowly at first and not very far. As the distance I managed to walk increased, I noticed the parallel emergence of emotional stability. I was unaware at the time of the concept of grounding, but I now believe that, by putting one foot in front of the other, I was spontaneously but unconsciously responding to a deeply embodied need to ground myself, which put me on the path to a new life chapter. Lowen has described static grounding exercises but I was experiencing the dynamic grounding of walking. In early sobriety, I learned to use walking to engage with the bare reality of a world without the emotional crutch of alcohol. At around this time, the Alcoholics Anonymous 12-step programme introduced me to the concept of mindfulness, and my walking became consciously mindful. I began to engage all of my senses as I moved along roads and paths, through fields and forests, experiencing a constant flow of sights, sounds, smells and weather conditions. Instead of alcohol, I began to use two walking poles for balance, and they continue to stabilise me. My old ‘hands-on-hips-forwardstilting-slump’ has become a more upright, four-limb activity. The more upright stance, even while walking uphill, allows me to breathe more naturally into lower areas of the lungs and into my back and shoulders, where

I don’t normally feel my breath while slumping. After 15 to 20 minutes of walking, I feel a steady, rhythmic, pleasing coordination of body and breath and an embodied, meditative calm settles within me. My felt sense is of being fully grounded. Maintaining long-term sobriety has been a process of reaching and holding onto that feeling. Perhaps my grandson’s spontaneous wish to walk and find his own solid ground mirrors my curious compulsion to walk from very early sobriety.

The action of walking So what happens when my grandson and I decide to get to our feet? Our bodies become upright and, within body psychotherapy, such vertical grounding has been seen as both an energy concept and psychological metaphor.3 In a bioenergetic sense, there is a flow of energy, allowing the body’s weight to pass down through the feet and legs and discharge into the earth, resulting in feelings of solidity and acceptance of reality. We feel both physically grounded and emotionally balanced. As we step forward, there is a momentary loss of balance as we release our firm, twofooted connection with the ground but trust that the ground will be there when we need it to meet our extended leg. Perhaps my grandson is also learning to trust, with his tentative tiptoeing steps. As our heels make contact with the ground again, there is an energetic discharge. We confidently transfer weight and begin to move forward. Physically balanced and emotionally grounded, we repeat this process of controlled falling, experiencing the ground as reality meeting our own reality. We develop an awareness of where we are in space, our relationship with the objects surrounding us, the air above us

‘I now believe that, by putting one foot in front of the other, I was responding to a deeply embodied need to ground myself, which put me on the path to a new life chapter’ THERAPY TODAY

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and the ground beneath us as we adjust to the varied terrain. My grandson doesn’t need to be taught the benefits of mindful walking – his delight in his conscious awareness of this novel process is written all over his face. Keleman4 described three bioenergetic aspects to grounding: ‘vibration’ – a resonating pattern of excitement displayed by cells in the body; ‘pulsation’ – the in-and-out of expansion and contraction; and ‘streaming’ – patterns of rhythmic pulsation along the axis of the body, which increase when the body is vertical. After a day of trekking across hills, my legs have a muscular tingle equivalent to Keleman’s ‘vibration’; the absolute aliveness I feel on a lengthy trek is ‘streaming’, and the sustained, rhythmic, whole-body movement with poles is ‘pulsation’. Salopek’s5 description of walking as ‘a two-beat miracle – an iambic teetering, a holding on and letting go’ elegantly captures the experience. There is a ‘peak experience’ quality to some of Lowen’s writing,6 as he notes: ‘When body, mind and movement coalesce in a moment of personal truth, the feeling is one of fulfilment.’ It is this form of almost transcendent experience that draws me back to long treks, in spite of the fatigue, blisters and aches. While mindfully walking, my body and mind become a coherent entity, with my senses relaying a steady stream of information on conditions underfoot to my legs, feet, hips, shoulders and arms, which adjust and respond. The mechanics and coordination of bone, muscles, blood and breath are the experience of alive embodiment – a feeling that can be intoxicating in its barrage of sights, sounds, smells and touch. This is far removed from automatic, mindless walking. Gros7 describes such experiences as recovering ‘the pure sensation of being… the simple joy of existing… the joy that permeates the whole of childhood’. Perhaps my grandson feels this. I have found space in my life for this new form of intoxication, which counters the oppressiveness of recent times.

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Walking as self-care So much for addiction, trekking and my grandson, but what therapist self-care lessons can we learn from considering walking as a form of grounding? We don’t need to walk through inspiring scenery to feel grounded. During the COVID-19 lockdowns, my outings were restricted, but mindful engagement with the reality of my body while walking through urban landscapes is similarly grounding. Simply walking outside, in contrast with the metronomic, enclosed and mechanistic quality of the indoor treadmill, allows our bodies and minds to work together, to develop a sense of place. Our psycho-geographic capacities can be nudged into action as we notice how buildings vary in age and design along a familiar street and ponder why. There can be a surprising variety of plants and animals in urban streets when we allow ourselves to notice them. Oxford’s suburban roads gave me early-morning views of anxious foxes darting between hedgerows, red kites hovering menacingly overhead and family cats prowling with their usual enigmatic air. Mindful presence brings awareness of the scent of fragrant bushes in gardens (sarcococca delivers abundantly, even in winter). There was an awareness of how quiet the usual rat-runs were during lockdown. Even walking a well-known path in the opposite direction can bring a completely new perspective. I grinned last week when I saw, for the first time, a smiley face etched in concrete at the bottom of a drainpipe. It had been there for decades. How had I missed that for so long? A curious contentment can be found in wandering and wondering through outer and inner spaces. I may even go so far as to call it happiness, which is quite a statement for one with noted ‘Eeyore’ tendencies. The relative slowness of walking in a world of dizzying complexity and change enables synchronisation of outer and inner worlds, and perhaps Solnit makes a similar point:8 ‘I like walking because it is slow, and I suspect that the mind, like the feet, works at about three miles an hour. If this is so, then modern life is moving faster than the speed of thought, or thoughtfulness.’ The sheer physicality of walking and repeated rhythmic contact with the ground brings clarity of mind. It is surely no accident that many great philosophers were committed walkers. Aristotle founded the Peripatetic School of Philosophy in Athens,

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‘Walking mindfully outdoors grounded me during recovery from addiction and continues to ground me in my career as a psychotherapist’ named after the walkways of the Lyceum where its members met. Rousseau, Thoreau, Nietzsche and Kant were also walkers. We must, of course, start from where we are. Bodies that we may have for too long ignored, neglected or abused will bring physical limitations into sharp focus. My 62-year-old body copes differently with walking than my 32-year-old body did, particularly when mountain walking at altitude (a pre-COVID reminiscence). The facts of geography and geratology cannot be ignored, and I sometimes feel that particular hills have become steeper over the years. And then there’s the weather – the Serenity Prayer reminds me to ‘accept the things I cannot change’, and I hold this in mind when struggling through rain, mud and mist and give silent thanks for the fact that I am still able to walk long distances. There is space amid these musings for gratitude, alongside compassion for those who are denied this simple pleasure. More than anything, walking grounds us in the reality of our own bodies. Buddhist monk and writer Thich Nhat Hanh9 draws attention to the body focus of mindful walking: ‘We can’t be grounded in our body if our mind is somewhere else. We each have a body that has been given us by the earth… In our daily lives, we may spend many hours forgetting the body. We get lost in our computer or in our worries, fear, or busyness… Only when we are connected with our body are we truly alive… So walk and breathe in such a way that you can connect with your body deeply.’ Walking means so much more for me than alternating lower-limb propulsion. Walking mindfully outdoors grounded me during recovery from addiction and continues to ground me in my new career as a psychotherapist. It feels more important than ever as we find our feet post-pandemic.

REFERENCES 1. Lowen A. Bioenergetics. London: Penguin Books; 1975. 2. Lowen A. The language of the body. Hinesburg: The Alexander Lowen Foundation; 1958. 3. Anagnostopoulou L. Vertical grounding. In: Marlock G, Weiss H, Young C, Soth M (eds), The Handbook of Body Psychotherapy. Berkeley: North Atlantic Books; 2015. 4. Keleman S. The human ground: sexuality, self and survival. Berkeley: Center Press; 1975. 5. Salopek P. To walk the world. National Geographic 2013; December. https://www. nationalgeographic.com/magazine/ article/out-of-eden 6. Lowen A. Pleasure: a creative approach. Hinesburg: The Alexander Lowen Foundation; 1970. 7. Gros F. A philosophy of walking. London: Verso; 2015. 8. Solnit R. Wanderlust: a History of walking. London: Granta Publications; 2014. 9. Hanh TN. The miracle of mindfulness. London: Random House; 1991.

About the author Mike Sands is an integrative therapist working in private practice in Oxford and London. He trained at the Minster Centre and, before that, worked in a range of senior management positions in a business career that began in the 1980s. His interest in human psychology was sparked during research for a PhD on the social consequences of coal mine closure.

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Allies and tormentors Don’t underestimate the impact on clients of the love-hate intensity of sibling relationships, says Steve Heigham

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ver the past few years I have become interested in looking at research about sibling relationships in psychotherapy, for a number of reasons. Many clients have openly talked about the impact of sibling relationships in their lives but, in other cases, I have also found it useful to consider that siblings may have been a background influence. For instance, there is evidence that having at least one sibling has a significant psychological effect on improving an individual’s conflict resolution skills.1 Clients are not usually very conscious of effects such as this – what they tend to be most conscious of is how unhappy or happy those relationships were and still are. But because sibling relationships are, for the majority of people, the longest relationships that they have in their lives, even if they are not the closest, they make a considerable difference. In directly relational terms, some clients’ experiences of their sibling relationships may be a big influence on the way they relate to us as therapists and the role they see us playing in their lives. This sort of effect is worked with more consciously in psychodynamic-style groupwork, where current relating to others in the group is often compared with original family relationship styles. The intention is to bring to consciousness feelings and thoughts that may be influential so that they may be accommodated and detached from if they are unhelpful. The same may be said about constellations groupwork. In this article I explore how we may work with this more consciously in individual work, where such feelings and insights can still be fruitfully discussed and lessons learned from them.

Distance and intensity When exploring the internal dynamics of their family in timeline work where the story involves childhood sibling relationships, there is often an intensity that is inexplicable in purely rational terms. This impression is also reflected in the way sibling relationships have tended to be written about in our culture, history and literature where two fairly distinct narratives tend to emerge: siblings as allies and siblings as tormentors. To quote an anonymous workshop participant: ‘If you don’t understand how a woman can both love her sister dearly and want to wring her neck at the same time, then you were probably an only child.’ What causes the relationship to have such intensity in the emotions felt around this? Dunn’s research2 has shed light on why sibling relationships are so intimate compared with those with peers and parents. Siblings spend long periods of time playing alongside, quarrelling, bargaining and recruiting each other into roles in projecting fantasies that are very personal. And they do this over many years and in changing circumstances, so that, over time, siblings assemble intimate knowledge of each other’s strengths and foibles, which are then used, for better or for worse, in each and every interaction. Thus

‘Some clients’ experiences of their sibling relationships may be a big influence on the way they relate to us as therapists and the role they see us playing in their lives’ THERAPY TODAY

these relationships are often highly charged, defined by intense, uninhibited emotions that often spill over in ways that puzzle parents and other onlookers. Dunn’s research also reveals demographic trends in sibling relationships that can be helpful in predicting how people’s lives may have been, and may still be affected by early sibling relationships. For example, she has found that, even though same-sex siblings tend to get on better, they also tend to argue and fight more. Siblings with less than four years difference in age also tend to be more intimate, but also more competitive – there may be more envy, guardedness, secretiveness or guilt about having been the favourite.

Emotional functioning This experience of intense interactions may have a considerable effect on clients’ mental health as adults, and their therapeutic process. For example, there is increasing evidence that several attributes help predict how quickly and well clients access insight and make progress in treatment. Among these, one quite promising line of research is into aspects of social emotional functioning – levels of empathy, self-awareness, trust and social skills or what has been termed in other literature ‘mentalisation ability’ or ‘psychological mindedness’. This has been shown in numerous studies to influence the therapy process, mostly in a positive way3 – psychologically minded clients tend to expect more of therapy and get more out of it. In the mental health field, mentalisation deficits are being increasingly researched in connection with a wide range of mental health conditions. Studies suggest that just having an older sibling can increase adult scores on the Empathy

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Quotient test,4 a key aspect of mentalisation. There is some suggestion that this effect is not universal, and is more emphasised for women, and may be reversed in the case of some men. That women tend to have higher Empathy Quotient scores generally and develop this trait earlier suggests that this difference in style of relating may start at an early age. Overall, having siblings seems to influence sociability in general: adults who have had sibling relationships tend to participate more in group activities and team sports and, interestingly, in practical activities in general. Of course, sibling relationships are not the only, or may not even be the most important influence on everybody’s level of psychological mindedness and sociability, but it may be fruitful to bear in mind sibling relationships when exploring how well clients generally understand and get on with other people in their lives – how well they are supported socially, for example.

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Sibling relationships may also play an important role in early attachment processes. In most Western theories of therapy, the quality of the parent-child attachment bond is seen as the most important, and ruptures and difficulties in this become the highest risk factor in psychological development, with many problems in life explained this way. But outside our present Western, nuclear family context, older sisters and brothers may be the most important attachment figures, especially when a mother’s time is very much taken up with her youngest offspring in a large family. We have seen this in the traumatic narratives of refugee children fleeing from war-torn areas: siblings may become the most vital connection where parents have been killed. Sometimes in therapy, clients remember ruptures in close sibling relationships that they had tended to minimise but that may have left them feeling unsupported in a way that is hard to define. This emotional remembering has often then provoked memories of changes in sibling relationships that sometimes coincided with other pivotal points in their lives. These may be unacknowledged, but are something that can be usefully picked up and developed in timeline work. In terms of the importance of sibling attachments, in some lines of research, it has

been found that older siblings do tend to be predisposed to be responsive to younger siblings. In attachment tests, they tend to show protectiveness towards them. In my practice, working with one client on his history of dysfunctional family relationships, we rediscovered how his older sister had been crucial in saving his sanity by playing a protective role, rescuing him from the worst excesses of their distraught parent going through a very difficult time in life. This had quite an effect on both the giver and receiver of this protection, sometimes encouraging victim feelings, rescuer tendencies and a pathological avoidance of conflict. Taking a broader perspective on the issue of wider attachment relationships, it is interesting to note that, evolutionarily speaking, humans are different from many other primates in allowing and encouraging a lot of alloparenting (parenting/childcare other than by the parent), and by a wide variety of other people; indeed an expression used in other parts of the world says that it takes a village to raise a child. Considered from this angle, it is not surprising that other relationships may have been very important to both survival and social and emotional development. Working cross-culturally, with more diverse populations, it becomes obvious that in the West we tend to be less conscious of wider family influences than of the direct influence we had from our parents, which is, of course, in keeping with the more fragmented, individuated norms that we live by. But among other cultural groups in the UK with more collectivist values and living in long-term extended family settings, familial obligations and roles still often play a much more important role in forming young people’s development, including their relationships with their siblings. Interestingly, even within Western cultures, research shows that the closeness and quality

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of sibling relationships can often vary by socioeconomic status and gender. Close companionship with siblings tends to be more common in working-class and lower middle-class families, and they often continue longer in life, with siblings more likely to live near to each other and be active in each other’s social lives.5 This may also be one of the factors that helps to explain why people in these groups tend to use counselling services less and have higher levels of dropout in treatment, as other forms of social support may be preferred to therapy, due to discrepancies in values and issues around unfamiliarity. With respect to gender, women in all walks of life tend to be more likely than men to maintain frequent contact with their siblings and, overall, affection seems to be stronger between sisters than between brothers or brothers and sisters.

Families as systems Looking at sibling relationships in the context of families as systems, it has been found that siblings who are securely attached to parents, in general, tend to get on with each other better, and these positive overall family relationships tend to stimulate healthy emotion regulation in later childhood. Thus, science seems to support the cultural stereotype of ‘happy families’ behaving in certain ways, which is the basis of much TV advertising. However, what is often borne out in systemic family practice is that the internal family ‘narrative’ of happy childhoods is often what is particularly sought after and reinforced, but that this may cover a multitude of more complex unresolved feelings. Another example of how sibling roles within the family system may be preserved into adulthood is how they may resurface at family gatherings, which can be reassuring for some, but may also be experienced as constricting and belittling by younger siblings. One particular client found it was liberating to acknowledge what was going on and develop assertiveness skills to challenge this unconscious assumption of roles. Studies in social learning also show that siblings may be very important models for imitation, particularly in the teenage years, and these may have some considerable effect on early adult development, such as support in starting work and choice of career. At a time when teenagers are exploring identity, siblings

may offer influential models, particularly if younger siblings have seen how their older sibling’s explorations have been responded to in the family system. It is also becoming clearer that many mental health conditions begin to emerge in mid-teenage years – clearly adolescence is an important developmental period in terms of determining mental health through the rest of the lifespan, and sibling relationships at this time may often play an important role. On the role of social support, research shows that sibling relationships do tend to become closer in later life, and become more important as a source of social and emotional support and a barrier to loneliness. Sibling relationships may also help us to preserve our memories and the feelings attached to them, through repeated sharing of memories and photographs – an important element in remaining cognitively coherent in later life. This would be a fruitful area for further research.

The darker side In research, negative sibling relationships are correlated with greater deviancy, substance misuse and criminality in adolescence, although it is often hard to tease out the effects of socioeconomic factors from sibling effects. Some research shows that negative sibling relationships produce a tendency to internalise problems later in life, leading to more serious depression and anxiety conditions. Looked at in more specific detail, it has been found that sibling bullying is not uncommon; in one study, 30% of respondents had been hit by a sibling, and 54% reported that they had suffered some form of bullying by a sibling. The effects of sibling bullying can be profound and complex, as how the experience is integrated into the personal narrative can be subtle. As Hermann says, people tend to ‘construct a system of meaning that justifies it’ to help them to assimilate their experience.6 This may influence clients to minimise their overt blaming of siblings in their story, and instead focus on the general lack of parental control or neglect, but still reveal very uneasy feelings in the retelling. I have found that this sort of non-verbal communication is often very fruitful and interesting to explore. It is interesting to note that in our Western culture there is a tendency for sibling conflict

to be over-normalised as ‘rivalry’, but this may sometimes, in my experience, cover up some deep hurts that have been experienced by the sufferers, and may have led to having their feelings dismissed as ‘petty squabbling’. For one particular client, this experience had been pretty annihilating: in a scenario of insecure/dysfunctional family relationships, the cruelty of her older sister had greatly affected her general level of trust and confidence and led to deep shame issues. These had been hard for her to identify as an adult, because the treatment was seen as fairly normal in her family. Having an opportunity to re-evaluate the experience was very cathartic. Another confounding factor in looking at sibling relationships is the belief that certain mental health disorders run in families: clients often seem to intuit and suggest this themselves. This ‘folk psychology’ can be hard to disentangle. I have sometimes found it useful to challenge some clients’ overdeterministic interpretation of genetic family influence – the research is not that simple.7 Transgenerational effects of attachment and trauma may be a more valid explanation for family members experiencing similar mental health issues. Dallos and Vitere8 found that people tend to react to their upbringing in two main ways: a script that replicates, or one that tries to repair or contradict it. Either way, many of the same issues become of greatest concern, which will tend to deeply affect them, and often come out in therapy. In my own practice, I try to look at as wide a range of influences on a client’s current functioning as possible, and I have found quite often that one of these influences may be sibling relationships. I hope I have helped readers to look at the subject in a new light and gain some confidence in exploring how this may be affecting some of their clients.

REFERENCES 1. Kitzmann KM, Cohen R, Lockwood RL. Are only children missing out? Comparison of the peer-related social competence of only children and siblings. Journal of Social and Personal Relationships 2002; 19(3): 299–316. 2. Pike A, Coldwell J, Dunn J. Family relationships in middle childhood. York: York Publishing Services/Joseph Rowntree Foundation; 2006. 3. McCallum M, Piper WE, Ogrodniczuk JS, Joyce AS. Relationships among psychological mindedness, alexithymia and outcome in four forms of short-term psychotherapy. Psychology and Psychotherapy 2003; 76(pt 2):133–44. 4. Perner J et al. Theory of mind is contagious: you catch it from your sibs. Child Development 1994; 65; 4. 5. BengtsonV L et al. Sourcebook of family theory and research. Thousand Oaks, CA: Sage Publications; 2005. 6. Herman J. Trauma and recovery. New York: Basic Books; 2001. 7. Pettersson E, Larsson H, Lichtenstein P. Common psychiatric disorders share the same genetic origin: a multivariate sibling study of the Swedish population. Molecular Psychiatry 2015: 21; 717–721. 8. Dallos R, Vitere A. Systemic therapy and attachment narratives: applications in a range of clinical settings. London: Routledge; 2009.

About the author

‘Adolescence is an important developmental period in terms of determining mental health, and sibling relationships may often play an important role’ THERAPY TODAY

Steve Heigham is a psychotherapist in private practice and a lecturer in counselling at University College Weston. He is a member and ex-Chair of the British Psychology Society psychotherapy section. His research interests are in evolutionary, community and climate change.

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Best practice

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‘Long COVID helped helped me me re-evaluate re-evaluate my my life’ life’

PRODUCTION CLIENT

BLACK YELLOW MAGENTA CYAN

Clare Pointon drew on trauma treatment research to overcome the impact of long COVID

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hen I fainted in the middle of a Zoom client session in November, missing by inches an iron fireguard as my head hit the floor, I had no idea how sick I was about to become. Nor did I have any inkling of the chance my ill health would give me to re-evaluate my life and priorities. Within days I was nauseous from the moment I woke up to the moment I fell asleep and so exhausted that I couldn’t walk more than a short distance without sitting down. My gut was in turmoil and I was intermittently passing out. I had first realised something was wrong eight months earlier, on the usual walk to my part-time workplace. I felt a strange electrical impulse in my body that left me dizzy. A couple of hours later, just as I showed my client out of the counselling room from her assessment session, I had my first faint. I was in bed for a few days with a low fever, body aches and fatigue but, as my symptoms didn’t fit the NHS profile for COVID at the time, I was advised there was no need to take a test. But the fatigue didn’t pass. Three weeks off work later, we were in lockdown and, working remotely with clients, I was trying to push through it. I started to notice other problems that were to continue over the next few months: episodes of dizziness, nausea, gut problems, breathlessness, sleeplessness and the scary experience of losing my words and forgetting what I had just said. My GP didn’t have an answer. Even when the term ‘long COVID’ began to emerge, there was a reluctance to use it. No one really understood what it meant or how to treat what seemed to be a growing number of people with this strange cluster of symptoms. I was sent for NHS investigations – every kind of heart test, monthly blood tests, a liver scan and a chest x-ray, all of which came back with no concrete explanation. My GP started to take an interest in my case, but there was no diagnosis or treatment. My best

hope, it seemed, was to be assessed by a long COVID clinic, if one opened in my area in the coming months. Things came to a head in October, after a surgical operation under local anaesthetic to remove a cyst on my back. The procedure was short and successful, but for the 10 minutes I was on the table, my body went into fight or flight mode – I was shivering uncontrollably, my heartbeat thundering in my ears. This, I believe, precipitated less than a week later the first of what were to become episodic fainting fits, constant nausea and a general sense of losing strength. No matter how much I rested, I woke up each day with the same symptoms. I was increasingly losing hope that anything would change.

Holistic approach A single mother with a part-time employed job and most of my income from private practice, I felt I was walking towards some kind of edge. I started seeing my Zoom clients while sitting on the sofa with my legs up; like this, I felt less likely to faint. I drank hot ginger all day to cope with the nausea. And, for the first time ever, I made a decision to disclose to my clients a few key facts about my health – that I appeared to have long COVID, that I had had a couple of blackouts and, if one were to happen during our session, I would come round quickly and there was no need for concern. Interestingly, having shared this, I felt less anxious about fainting and didn’t do so again during a session. My supervisor was supportive, empowering me by backing up my instincts, as well as my own journey

to research what I could about my condition, and signposting me to a holistic doctor. Gradually, as I trawled through scientific research on the internet, I found theories that would help me forge a path back to health. I discovered a theory – which I notice continues to gain credence among scientists – of a link between a condition called mast cell activation syndrome (MCAS) and long COVID.1 The treatment advocated is a strict low-histamine diet (avoiding an extensive list of foods) for several months, plus a range of daily supplements. With nothing else on offer via the NHS or the National Institute for Health and Care Excellence (NICE), I went for it. I started to understand my long COVID as an exaggerated inflammatory response where the memory in the body of the original (in my case, undiagnosed) COVID-19 infection – similar to the process of psychological trauma in the brain – had been retained and was available to be retriggered under the extreme stress of the minor procedure on my back. I realised that I needed – as do those who have undergone psychological trauma – to re-teach myself to self-regulate in order to reset my system. My online sessions with a holistic doctor supported this, spelling out the importance of a reset for my autonomic nervous system (ANS) to be able to move beyond its sympathetic ‘fight or flight’ response in order to activate the parasympathetic response that restores the body to calm. I appeared to be one of many long COVID sufferers stuck in dysautonomia, or dysregulation of the ANS. My task now was to improve the tone of the vagal nerve – the key part of the

‘I started to understand my long COVID as an exaggerated inflammatory response where the memory in the body of the original COVID-19 infection had been retained’ THERAPY TODAY

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Experience, 1

Experience

Experience, 2

Experience VERSION REPRO OP SUBS ART PRODUCTION CLIENT

ANS that moderates our physiological and emotional experience. Reflecting on my life, it made sense to me that this was, of course, something I had to really think about. My default tendency had always been to live on the edge, from my previous role in journalism, as a correspondent in a conflict zone, to my lifelong tendency to push myself right up to my limits and back in my familiar rhythm – from morning espresso to evening red wine. As I now mindfully recreated my routine, I found myself thinking of Babette Rothschild’s metaphor of learning to ‘apply the brakes’,2 in the same way that we teach clients with activating psychological trauma to slow down, check in and self-regulate. I reworked my diary and reduced the number of clients I could see, committed myself to half an hour of gentle yoga and meditation each day before breakfast, introduced calming breathing exercises to relax and help me sleep, used cold water exposure – in the shower and later in open water – and took daily 15-minute midday naps. All were activities I’d heard could improve vagal tone. I started to really listen to my body. And slowly my recovery began. I feel I am not quite the person I was before and it’s hard to say exactly what I mean by this. If I am careful of myself, as I am learning to be, I have the strength to work at full capacity while taking care of my daughter and living the active life I want to live. There are residual symptoms but, alongside the fatigue and forgetfulness, I am aware of moments of euphoria. I have an urge to connect to the best version of myself at 58 – an urge that has led me to create change that feels good. I have become better at identifying my limits and eliminating stress that is toxic for me. I have left a part-time workplace with high levels of organisational stress to make space to expand my private practice and return to writing. And I have experienced a strong desire to reconnect to the important people throughout

my life, many of whom are spread across the world. I now have regular video calls and I’ve even learned how to send – and have sent – a number of friend requests on Facebook.

Post-traumatic growth I have come to think of this as part of what psychologists Richard Tedeschi and Lawrence Calhoun call a phenomenon of post-traumatic growth (PTG).3 We know in our work that the experience of trauma doesn’t inevitably lead a person to post-traumatic stress disorder (PTSD). Depending on a variety of factors, many have the resilience to manage and integrate it. But, according to Tedeschi and Calhoun, trauma can actually give birth to PTG, which they define as an enhancement of five areas of a person’s experience: their appreciation of life, their relationship with others, new possibilities in life, personal strength and spiritual change.3 Peter Levine describes a ‘transformation through trauma’ as a process through which, he says, ‘the nervous system regains its capacity for self-regulation. Our emotions begin to lift us up rather than bring us down. They propel us into the exhilarating ability to soar and fly, giving us a more complete view of our place in nature’.4 Unsurprisingly, my client work of the past year resonates with similar themes. For one client, a traumatic parental bereavement from COVID-19, combined with an oppressive and uncaring workplace, led to a new connection to self, to specific skills and passions and, from this, a decision to move on and start a new career. For another, years of marital unhappiness and verbal abuse reached a crisis in lockdown, which sparked a clarity about deserving better, an understanding that this was about leaving and the courage to plan and communicate the first steps towards a new life. These are just fragments from the stories of people who have been through trauma and not only survived but overcome it and grown in their understanding

‘If I am careful of myself, as I am learning to be, I have the strength to work at full capacity while taking care of my daughter and living the active life I want to live’ THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

about themselves and their lives in specific ways. Confronting long COVID may not have been what I would have wished for myself at the start of 2020, but the experience has turned out to be a semicolon in my life. In the absence of concrete medical guidance, I was asked to empower myself to seek out new and alternative solutions. I was invited to tolerate uncertainty and embrace some changes that I had been avoiding. And, most significantly, I was reminded to reconnect to myself – to what I feel, what and who I want in my life, what is good for me and what I am good at.

REFERENCES 1. Peers T. Potential relief for those suffering from symptoms post COVID-19. www.drtinapeers.com/ longcovid 2. Rothschild B. Applying the brakes: in trauma treatment, creating safety is essential. Psychotherapy Networker 2004; Jan/Feb. 3. Tedeschi RG, Calhoun LG. The posttraumatic growth inventory: measuring the positive legacy of trauma. Journal of Traumatic Stress 1996: 9(3); 455-472. 4. Levine P. Waking the tiger. Berkeley, CA: North Atlantic Books; 1997.

About the author Clare Pointon MBACP (Accred) has worked as a psychotherapist for more than 20 years, including in the NHS, higher education, the voluntary sector and in SULYDWH SUDFWLFH ,Q KHU ƓUVW career in journalism, she lived and worked in London, Europe and the Middle East as a BBC radio correspondent and a newspaper journalist. She now writes and works in private practice.

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

‘I have reached a healthy compromise’

Lucky numbers

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What is your optimal client caseload?

‘Fifteen is the maximum number of people I can see in a week’ ART PRODUCTION CLIENT

When I entered private practice, how many clients to have was one of the big mysteries. I had heard of psychoanalysts seeing 40 people in a week and the more I spoke to other practitioners, there didn’t seem to me to be a standard number. For the first few months, I had four clients a week and I turned down new client enquiries until I felt comfortable with that number. I then looked at my finances and considered how I would like the rhythm of my week to be, and how many sessions I would need to do to pay my mortgage and bills. As I am also an artist, creative expression is a crucial part of my practice, so I also needed to factor in two days a week for this. Through slowly building my hours, I found that I could see up to five clients online per day. I have found that 15 is the maximum number of people I can see in a week as this gives me enough time between clients to reflect and rebalance. What makes this all sustainable in the long term is being clear with clients that I take regular breaks. This means a minimum of one week around Easter, two weeks at Christmas and two weeks over the summer. This is the key for me in terms of preventing burnout and I believe it’s important modelling for so many of my clients who struggle with internalised guilt and shame around rest and productivity. Since completing some training in ‘wild therapy’, I am now looking to take part of my practice outside to be alongside the other-than-human world. I am curious to see if and how this affects my capacity.

, FDPH WR WUDXPD LQIRUPHG FRXQVHOOLQJ DIWHU P\ WUDLQLQJ hours at HMP Styal, a closed women’s prison. When I was looking to start work in private practice, I was lucky to be introduced to a practitioner who had set up a thriving DQG ZHOO RUJDQLVHG SUDFWLFH DQG ZDV ORRNLQJ WR H[SDQG and take on freelance counsellors. My circumstances were such that I still needed a regular, guaranteed income, so , NHSW XS P\ SDUW WLPH ZRUN DV D SDUDPHGLF , KDYH DOZD\V understood that I could not bring the best of myself to my clients and to trauma work if I were to work full time. I now KDYH FRXQVHOOLQJ DSSRLQWPHQWV DYDLODEOH RYHU WZR GD\V Being able to compartmentalise my life, both personally and professionally, has always worked well for me; closing the door, literally and metaphorically, at the end of my two days of counselling means that the work takes up less emotional energy the rest of the week. Sharing a room with others helps PH FRQƓQH P\ ZRUN WR WKH GD\V , UHQW WKH VSDFH , ORYH WKH work and it is very tempting to expand but I think, as things stand, I have reached a healthy compromise. Fenella Foulis, counsellor

‘Getting the numbers right is an aspiration’ What is important to me in managing my client numbers is to ask myself before accepting any new appointments, ‘Is WKLV IRU PH"ō 7KDW LV VRPH FOLHQW SUHVHQWDWLRQV PD\ EHQHƓW from a team perspective to scaffold the best therapeutic intervention. I also ask myself, ‘Do I have the time for this?’ We know that accepting a new appointment has more to it than the contact hour. There is the related admin, reading, UHŴHFWLRQ DQG FXULRVLW\ WR FRQVLGHU DV ZHOO DV WKH DV \HW unknown issues that expand client or supervisee need and my own process of self and professional development. Then I consider my own resilience, asking myself, ‘Am I VHFXUH DQG ŴH[LEOH HQRXJK WR EH WKH EHVW WKDW , FDQ IRU WKLV new client or supervisee?’ Also, am I in a good place, and professionally, am I accessing and using my supervision as best I can? My practice has been both challenged and strengthened by the period of coronavirus restrictions, and LW KDV JLYHQ PH WLPH WR UHŴHFW RQ ZKHUH , PD\ GR WKLQJV differently in future. Have I got the balance right all the time? No! Does this alarm me? No! Getting the numbers right, for me, is an aspiration – I am a work in progress. Dr Raymond Dempsey, independent practitioner and supervisor

Gemma Autumn, integrative counsellor

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

JULY/AUGUST 2021

Justin 2.30pm

George 11.30am Jes 2pm Amanda 4.00

Sally 11.30am Rachel 2pm Cath 4.00

Gianni 3.20pm

Michael 11.30am Dionne 2pm Marion 4.00

Alex 3.20pm Ian 2.30pm

Juanita 10am

John 11pm

Juanita 10am

Sally 11.30am Rachel 2pm Cath 4.00

Luca 3.30pm

Bridget Toby J. 2.30pm 2pm

Maff 2.30pm

Zoe 3.30pm

Amelia 3.30pm

George 11.30am Matt 2pm Grant 4.00

Talking point

George 11.30am Matt 2pm Grant 4.00

‘Timing can be just as important as the number of clients’

Ishmail M. 3pm

Toffe e 11.30am Jeremy 2pm Winnie 4.00

JUNE 21ST

TUESDAY

ADD NIGEL!!! 4.00

Michael 11.30am Dionne 2pm Marion 4.00 DAY

CANCEL WEDNES George 11.30am Matt 2pm Grant 4.00

SHUTTERSTOCK

‘Seeing only three clients once a week feels a little frustrating’ As a trainee therapist working in a large primary school, my caseload is determined by both my current level of experience and demand, which even before the pandemic was somewhat high, to say the least. :LWK SOXV KRXUV RI FOLQLFDO SUDFWLFH QRZ XQGHU P\ EHOW , FXUUHQWO\ VHH three children one day a week for the children’s mental health charity , ZRUN IRU 7DNLQJ LQWR DFFRXQW WKH VFKRRO WLPHWDEOH ƓWWLQJ LQ WKHUDSHXWLF sessions of 50 minutes per child, with additional time needed for setting XS DQG SDFNLQJ DZD\ IRU HDFK FKLOG GXH WR FXUUHQW &29,' UXOHV RQO\ DOORZV IRU D PD[LPXP RI ƓYH FKLOGUHQ WR EH VHHQ SHU WKHUDSLVW SHU day. Thank goodness there are seven of us in our team to work with as many children as we possibly can. For someone who initially trained as a primary school teacher and was responsible for 30 children all day, ƓYH GD\V D ZHHN VHHLQJ RQO\ WKUHH FOLHQWV RQFH D ZHHN DV D WKHUDSLVW sometimes feels a little frustrating. But then I think about how the work DOVR LQYROYHV ƓQGLQJ WLPH WR PHHW ZLWK WHDFKHUV DQG SDUHQWV FRPSOHWLQJ necessary paperwork, setting up the room appropriately for each child, greeting them fully prepared and present, offering a full 50 minutes without interruptions and walking with the child back to their classroom. These are all part of giving each child my best, enabling them to fully EHQHƓW IURP WKH WKHUDS\ WKDW LV VR QHHGHG E\ WKHVH \RXQJ SHRSOH Cathy Bamford, trainee child and adolescent counsellor

THERAPY TODAY

Talking Point, 1

Sophie 2pm

Mr Brown 2pm

Since starting my practice, I’ve made many changes to the number of sessions I offer and I maintain an open mind as to how and when things may need shifting around. I used to offer very early morning sessions and some fairly late in the evening, which taught me that timing can be just as important as the number of clients we see. I currently don’t work evenings so I can offer more sessions during the day. I keep strict boundaries around working times, offering set available hours but allowing clients without fixed schedules to move around within my available time slots, and this works really well. I have a busy practice and so regular breaks have become really important for self-care. When considering client numbers, I advise being really honest about what your goals and needs are. Find out what will support you in managing your caseload and to maintain your health and wellbeing, so as to get the most from your practice and give the best of yourself to clients. Simone Ayers, person-centred counsellor and supervisor

THIS MONTH’S TALKING POINT IS COMPILED BY SALLY BROWN

Michael 11.30am Dionne 2pm Marion 4.00

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The bookshelf

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

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CLIENT

A Straight Talking Introduction to Children’s Mental Health Problems (2nd edition) Sami Timimi (PCCS Books, £12.99)

The Girls Within: a true story of triumph over trauma and abuse Gill Frost (Phoenix Publishing House, £29.99)

Closing the Asylum: the mental patient in modern society (3rd edition) Peter Barham (Process Press, £12.99)

Child and adolescent psychiatrist Sami Timimi examines the complexity of children’s mental health in this little book of 150 pages that packs a big punch. It is divided LQWR ƓYH FKDSWHUV Ŋ ‘The work of culture’, ‘Childhood in today’s world’, ‘Common diagnoses’, ‘Common treatments’ and ‘Getting help’. There is something provocative and enlightening in every one of them. Timimi’s mission is to make sense of why children are more likely than ever to be diagnosed with and treated for a mental health condition. He says diagnosis might ‘satisfy our understandable thirst for certainty’ but warns that it betrays a ‘more important need for truth and honesty’. Truth and honesty are what this straighttalking book delivers in abundance. 7LPLPL UHIHUV WR WKH ŌWULFNō RI FODVVLƓFDWLRQ DQG DUJXHV WKDW FODVVLƓFDWLRQ V\VWHPV DUH social constructs, rather than the result of biological knowledge. He argues too that, with a dominant ideology that says competition improves public and personal wellbeing, there are inevitably winners and losers. Losers display insecurity, performance anxiety, self-harm, eating disorders, depression and social phobia – disorders and dysfunctions arising from internal failings that require correction by health professionals. Cultural norms and social constructs are examined, leading to uncomfortable questions about the ‘value’ of children with mental health diagnoses in a society that is EDVHG DURXQG DQ HFRQRPLF QHHG IRU SURƓW Prescription drugs are put on trial; so too, rather uncomfortably but necessarily, are the talking therapies. This is a must-read for anyone interested in understanding more about children’s mental health problems and how to help them.

It isn’t often that we see the word ‘triumph’ in the same sentence as ‘trauma’ and ‘abuse’, let alone in the same book title. In this case, though, LW LV YHU\ PXFK MXVWLƓHG This isn’t an easy read, especially, perhaps, for people with a history of childhood abuse. The book tells the true story of Vivian, and ‘the two extraordinary girls living within her’ – Little Vivvi and Izzy. Vivian suffers from dissociative identity disorder (DID) and, despite the various technical terms and descriptions that exist for this little-understood condition, Frost uses her own sensitive, respectful and straightforward descriptions throughout the book. Indeed, there is very little reference to any theoretical underpinning at all, which both makes the book accessible to a wider audience and allows the reader to experience some of the deeply moving humanity of the therapeutic relationship between Vivian, Little Vivvi, Izzy and Gill. 7KH WKHUDS\ ODVWHG IRU ƓYH \HDUV DQG LV detailed in the author’s session-by-session UHŴHFWLRQV , HQMR\HG )URVWōV KROLVWLF DSSURDFK Ŋ VKH LQFOXGHV UHŴHFWLRQV RQ supervision sessions, phone calls, text messages and other extra-therapeutic factors throughout. As well as being an invaluable resource to enhance a greater understanding of a client’s (and a therapist’s) experience of DID, there is much food for thought on themes of self-disclosure, boundaries, therapist vulnerability and many more. I highly recommend The Girls Within as inspirational and deeply moving reading about working with clients with DID and the therapeutic relationship. To use the author’s own words, it is a lesson in ‘communication, compromise, cooperation and compassion’.

First published in 1992, this book should be history – literally. That so much of what it says is so pertinent to today’s experience of mental health care is a shocking indictment of the ‘care in the community’ initiative that is its subject. The book was written at the cusp of the asylum closures that were launched with Enoch Powell’s famous ‘water tower’ speech in 1961 and accelerated towards completion throughout the 1990s. The failure to SURGXFH WKH SURPLVHG EHQHƓWV IRU WKHLU inmates, due almost entirely to inadequate funding, was already becoming clear. The book charts this ably and clearly. But its focus is the ‘person who is the mental health patient’. What concerns Barham is the extent to which the former ‘patient’, their personhood now supposedly restored, can enjoy their full rights as a citizen, able to live in mainstream society with dignity, respect and decency. Which is far from the case in reality; they remain effectively incarcerated by the barriers of poverty, stigma and exclusion. People in need of mental health care and support are the victims of our ‘repair shop mentality’, writes Barham; our eagerness ‘to circumscribe and produce neat solutions to human problems’. And mental health ‘patients’ have failed lamentably to be repaired; they do not recover when given pills, ‘they hang around… messy social conditions seem to cling to their persons’. And so it remains – still, too often, we see the patient, not the person; still we fail to provide the necessary healing environments of hope, compassion and safety, and this excellent, trenchant book is a powerful reminder of that.

Jeanine Connor is a child and adolescent psychotherapist

Emily Harrison is an integrative therapist

Catherine Jackson is a mental health editor and writer

THERAPY TODAY

BLACK YELLOW MAGENTA CYAN

JULY/AUGUST 2021

The Bookshelf, 1

Reviews A Practical Guide to Working with Sex Offenders Diane Wills and Andrew Wills (Jessica Kingsley Publishers, £22.99)

Young Refugees and Asylum Seekers: the truth about Britain Declan Henry (Critical Publishing, £19.99)

This book is aimed at ‘safeguarding professionals’ and is consequently a broad-brush picture of the landscape around working with sex offenders. Therapists and counsellors may ƓQG VRPH RI WKH chapters a little heavy, especially those that go deeply into theories of risk and legal history. This is not helped by the workmanlike prose. At times, another run-through with the editor’s pen would have been welcome. That said, it is a useful primer for anyone planning to work with this group. Chapter eight in particular is interesting, looking at the history of approaches and debates in this arena. It is extraordinary just how many approaches have been tried and theories recruited to the cause – it’s an area littered with ideas, concepts and theories, most of which have fallen by the wayside. Frustratingly, one of the most promising programmes can’t attract enough funding to run. The authors are at pains to stress that sex offenders are not a single, homogenous group – all have different motivations, histories, proclivities, values and so on. While much of society may ƓQG WKH LGHD XQSDODWDEOH WKLV PHDQV WKDW the only way to really have a chance of success in working with these people is through a genuine, warm, compassionate and reciprocal professional relationship and by trying to understand the function and meaning of their behaviour. The book ends on an optimistic note, which is welcome but doesn’t feel overly supported by the evidence in the preceding chapters. But maybe it is the sincere and optimistic belief in the potential for all people – including sex offenders – to change that is the most essential ingredient of all.

This guide to understanding and supporting young people who have arrived in Britain as refugees is written by a social worker, primarily for other social workers. However, it will be of interest to anyone working with either young people or adults who have a history of displacement. Henry begins by challenging myths and misconceptions about the asylum system and about young refugees’ experiences. The scene is set by a foreword by Lord Alfred Dubs, who came to the UK on the kindertransport and has campaigned tirelessly for child refugees. There is a mine of up-to-date background about the countries that most young asylum seekers come from currently, along with case studies that explore individual stories, and practical information about the asylum system. For counsellors and therapists, though, the chapter on trauma is particularly relevant, and while it may not contain anything new to trauma-informed practitioners, it does invite us to think about trauma through the lens of young UHIXJHHV DQG DV\OXP VHHNHUV VSHFLƓFDOO\ Child refugees are likely to have experienced traumatic events in their country of origin, on their journey to the UK, and also in everything that might have happened since arriving. The very fact of being asked to repeat their story to various professionals over and over again can be retraumatising, as can language barriers and the uncertainty of waiting for Home 2IƓFH GHFLVLRQV (VVHQWLDOO\ WKRXJK WKLV book highlights the many ways in which the current system fails and harms the vulnerable young people who arrive in the UK alone to seek refuge and instead are often faced with indifference, or worse.

Nick Campion is an integrative psychotherapist in Derby

Emmanuelle Smith is a psychodynamic psychotherapist in training

THERAPY TODAY

The book that shaped my practice

The Transforming Power of Affect Diana Fosha (Basic Books, 2000) More than a decade after qualifying as an integrative psychotherapist, I chanced upon accelerated experiential dynamic psychotherapy (AEDP), and everything changed. This ERRN GHVFULEHV WKH ƓUVW LWHUDWLRQ of AEDP and introduces the concepts that form its foundational principles. Fosha is a theorist, master practitioner and gifted writer. Her humanity shines through the pages, particularly in the extensive transcripts from real-life therapy sessions. I felt as if my training to date had given me lots of different patches and AEDP sewed it together into a quilt, integrating humanistic, experiential, phenomenological DQG SV\FKRG\QDPLF LQŴXHQFHV Throw in an ongoing dialogue with transformational studies and neuroscience, and you have a 21st-century integrative psychotherapy model. Fosha’s model demands bravery, radical empathy and a willingness to judiciously self-disclose. At the risk of sounding like an acolyte, it has shaped my practice and it has also transformed my life. Sam Clark is an integrative psychotherapist in Margate

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Dilemmas VERSION REPRO OP

OUR ETHICS TEAM CONSIDERS THIS MONTH’S DILEMMAS:

THERAPIST SAFETY SUBS

Presumed threat

ART

I have recently changed from working in an organisational setting to working at home, and I am offering clients the choice of attending in person or working online. I have just had a phone conversation with a man requesting in-person appointments, and I hadn’t anticipated how uncomfortable I, as a woman, would feel at the prospect of seeing a male client in my own home. I explained that I am on my own, and said that in these circumstances I would prefer to work online. He then became very agitated, accusing me of assuming that he would be a threat. He said I had judged him to be guilty before I had even met him. He did not book an appointment, but I don’t know how I’d handle this situation differently another time, as I do need to take care of myself.

PRODUCTION CLIENT EVA BEE/IKON IMAGES

SELF-RESPECT, INCLUDING CARE FOR SELF,

is a core ethical principle. As stated in the Ethical Framework, ‘We will take responsibility for our own wellbeing as essential to sustaining good practice with our clients by taking precautions to protect our own physical safety’ (Good Practice, point 91a). It is good practice to have at least one phone conversation with a potential client before agreeing to see them in person, to give you a sense of who they are and establish why they need therapy, and also to assess whether you are likely to be able to help them or whether they should be signposted to a more appropriate service. Other precautions include asking the potential client for their address, GP details, how they heard about you, and their past experiences of therapy; sending them a registration form to be completed and returned; having someone else in the house when you first see a new client; setting up a ‘buddy system’ for checking in and out with a trusted friend or colleague; asking for a further assessment session before committing yourself,

and not disclosing to clients that you will be on your own. If you instinctively feel unsafe, it could be important to investigate those feelings. What was it about this particular client that made you feel uncomfortable? Were you fearing for your physical safety? Was it just the gender difference? Why should difference in gender be a problem for you? And are you ready for working independently from home? Such issues warrant exploring in supervision and, maybe, personal therapy. If you had agreed to see this client, the reasons for his reaction might have emerged and become fruitful material for exploration. Maybe he had been falsely accused in the past? With this client you may never know, but it would certainly be worth deciding in advance what you would say next time to a potential male client, so as not to be accused of discriminatory behaviour. Further guidance can be found in BACP’s guide to lone working – see Support and Resources on page 52.

Aggressive behaviour I work in private practice from my home, and usually I have the house to myself. I’ve just seen a client for an initial appointment. He wanted to explore his relationship with his partner and quickly began to describe the partner’s many alleged faults. As he did so, he got increasingly worked up and said that he QHHGHG P\ KHOS WR ƓQG ZD\V WR ŌVKXW WKHP XSō DQG ŌVRUW WKHP RXWō , WULHG WR explain that this was not my role, and asked if they had considered couples therapy. At this suggestion he became very aggressive, stood up and paced about the room, swearing aggressively and punching his hand and looking around as if searching for something to throw. He seemed out of control and I was worried about what he might do

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next. I asked him to leave, which, to my relief, he did, although not without shouting all the way to his car. I am still shaking and already dreading ever meeting him again. I don’t even want to contact him about payment for the attended session. Please tell me what I should do. THIS FRIGHTENING SITUATION in which you found yourself reminds us of the vulnerable position we are in as therapists, especially when working on our own. It’s easy to become complacent about our safety if we have never experienced anything like this before, but it pays to carry out regular safety assessments. For example, you may choose to remove from the room any items that could be used as weapons, and check on seating arrangements so that you have a clear exit pathway. For future reference, it would be advisable to carry out an assessment of the client’s needs and hopes for therapy before agreeing to see them. In the case you have described, an initial telephone conversation would have provided you with the opportunity to ask about the client’s reasons for seeking therapy, before entering into a contract. Even then, though, it is not always easy to predict how a client is going to behave in a session, or how they will react to your comments or interventions, or to be sure of their real motives. It is not clear whether you and the client had already entered into a therapeutic contract, but it does highlight the need to do the contracting as early as possible in the session. If not, it could prove difficult to ask for payment for the attended session, but you might still decide to seek payment, reminding him of the terms to which he had agreed. This could be incorporated into a written message, explaining that you are not prepared to see him for further sessions. If you are concerned that his partner is at serious risk of harm, or is the victim of coercive or controlling behaviour, you might consider contacting the police (overriding any confidentiality commitment ‘in the public interest’), although that would be a difficult judgment call to make on the basis of just one curtailed session. Your own self-care is key here, both in recovering from this incident and in making any necessary adjustments to your practice. This calls for an urgent supervision session, to restore your confidence and your own sense of psychological as well as physical safety.

Dilemmas, 1

As stated in Good Practice, point 18, ‘We will maintain our own physical and psychological health at a level that enables us to work effectively with our clients.’ Fortunately, this type of occurrence is rare, but it reminds us all to be vigilant and as well prepared as possible.

Sex talk I received a telephone enquiry from a potential client asking if I offered psychosexual therapy. I explained that , DP QRW TXDOLƓHG LQ WKDW ƓHOG DQG suggested that they try searching on a directory for therapists offering that specialism. Their language then became quite sexualised. When I said that I would need to end the conversation, the caller VDLG Ō'RQōW ZRUU\ , NQRZ ZKHUH \RX live’, at which point I hung up. Since then, I have received many phone calls from the same number. The caller says nothing, and all I can hear is heavy breathing. I don’t suppose the police would take me seriously if I reported this and I don’t have the caller’s name or address.

off outside working hours. It is also important that you consider the personal impact and take this to supervision.

Lone working YOU ARE NOT OBLIGED TO ACCEPT as a

client everyone who contacts you, and you are quite within your rights to decline a referral if you are not competent in a particular area of practice such as psychosexual therapy. In the words of the Ethical Framework, ‘We must be competent to deliver the services being offered to at least fundamental professional standards or better’ (Good Practice, point 13). As stated in BACP’s guide to lone working, ‘Be prepared to say no to offering therapy if you feel too uncomfortable, and don’t succumb to financial (or any other) pressure to take on every potential client.’ It must have sounded threatening to hear the caller say they know where you live. As soon as we make any of our personal details publicly available, such as in a directory or on a website, we run the risk of being contacted for inappropriate reasons. If you receive two or more nuisance or threatening communications, this could amount to an offence of harassment, so the police should take you seriously if you were to report this, even though you don’t have the caller’s name or address. It would be advisable to keep a record of these calls. You could also contact your phone provider and block that phone number, and many practitioners opt to have a separate mobile phone for business use, which can be switched

I am a volunteer counsellor at a local charitable counselling organisation. Because I have another job, I can only offer evening appointments for FRXQVHOOLQJ ƓQLVKLQJ DW SP :KHQ , started, there was always someone else LQ WKH EXLOGLQJ EXW QRZDGD\V , RIWHQ ƓQG that I am working alone. The entrance is at the back of the building, in an unlit area, with people often loitering near the building; cars left there are frequently EURNHQ LQWR 'HVSLWH P\ EULQJLQJ my concerns to the attention of the organisation’s management, nothing is being done about it. I know I could leave, but I enjoy the work itself and there are few other opportunities to practise. THE ORGANISATION YOU WORK FOR

has responsibility for the health and safety of its staff, volunteers and service users, so one suggestion would be to persist in bringing this issue to the attention of the management or trustees, reminding them of their responsibilities. There might be some simple improvements that they could make, such as installing security lighting, or ensuring that someone else is in the building until your last client leaves. Is there a lone working policy, and are any documented procedures being

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followed correctly? From your description of the premises, not only you but also your clients might be feeling vulnerable, especially in winter and if they have to wait outside before being allowed into the building. If you really are expected to work alone and if you are willing to do that, then there are several precautions you could take, such as carrying a personal alarm and checking in and out using a buddy system. This could take the form of a private arrangement with a family member, trusted friend or colleague, or a subscription service using an app on your phone or computer. BACP’s guide to lone working offers a useful ‘Personal safety checklist’.

Stalking I have been seeing a client for long-term FRXQVHOOLQJ DQG LW LV SURYLQJ GLIƓFXOW to end the therapy. I feel that we have gone as far as we can, yet the client is disappointed that she is feeling much the same as when we started, with no VLJQLƓFDQW FKDQJHV KDYLQJ WDNHQ SODFH Over the past few weeks, I keep bumping into the client (almost literally) when out walking my dog, although, as agreed at the outset, we do not stop to engage in conversation. I have also noticed her driving slowly past my house, and on two occasions I have seen her parked across the street and staring in my direction. I challenged her about this in our most recent session, but she totally denied it and said I must be mistaking her for

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Dilemmas, 2

Dilemmas VERSION

someone else. Is there anything I should do to address this situation? REPRO OP

THERE IS PLENTIFUL EVIDENCE here

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to indicate that you are being stalked. The Suzy Lamplugh Trust defines stalking as ‘a pattern of fixated and obsessive behaviour which is repeated, persistent, intrusive and causes fear of violence or engenders alarm and distress in the victim’. Stalking behaviours include following, contacting or attempting to contact, monitoring (including online), loitering in a public or private space, watching or spying. Stalking is an official criminal offence (Protection from Harassment Act 1997 – amended by the Freedom Act 2012), and you are entitled to report the issue to the local police. The UK Government website says, ‘Contact the police if you’re being stalked – you have a right to feel safe in your home and workplace… Call 999 if you or someone else is in immediate danger. Contact your local police if it’s not an emergency.’ Another source of support and guidance is the National Stalking Helpline on 0808 802 0300, operated by the Suzy Lamplugh Trust. As for the work with this client, the situation requires careful handling in close consultation with your supervisor. You have already challenged her, only to be met with total denial. This need not stop you from reminding her that there are boundaries around the therapeutic work, perhaps referring to your contract if it specifies that contact between you will be limited to the sessions, and emphasising that the relationship is a purely professional one. It would be understandable if you felt that you could not continue working with this client, in which case you should bring the work to an end. One suggestion would be to say that, if the unwanted attention were to continue (even though denied by the client), not only would the therapy end immediately but you would report her to the police, if you have not already done so. What is not normally recommended is to try to work therapeutically with the client on the issue of the stalking itself. A survey carried out in 2019 by the Suzy Lamplugh Trust on behalf of BACP reported ‘concern that some members said they had directly discussed personal safety incidents in therapy sessions with clients who were perpetrating the behaviours towards them. This could be a significant safety risk, particularly with stalking, but also for some

SUPPORT AND RESOURCES You can find more information and guidance in these BACP resources, which are all available online at www.bacp.co.uk/gpia:  Working in private practice within the counselling professions (GPiA 004)  Ethical decision making in the context of the counselling professions (GPiA 044)  Unplanned endings within the counselling professions (GPiA 072)  Self-care for the counselling professions (GPiA 088)  Safe working in the context of the counselling professions (GPiA 106)  Boundaries within the counselling professions (GPiA 110 and 111)  Working with unhealthy dependency within the counselling professions (GPiA 115)  Working with domestic abuse within the counselling professions (GPiA 116)

other behaviours. The attention and time spent with the therapist may be feeding the obsessive nature of the behaviour and increasing the likelihood of those behaviours becoming more dangerous.’ While empathy is considered an essential part of therapists’ work, it may also be a factor that increases the risk of being stalked by a client. It would appear that, for this client, it was the threat of the therapy ending that precipitated the behaviour. Having worked long term, you will probably have become aware of the client’s attachment style, her dependency and her likely responses to endings, so it is good to anticipate her reaction and to be prepared for her acting out. Have you, perhaps, continued for longer than is helpful, and colluded with avoiding the ending? It might seem obvious with hindsight, but there could be useful learning here to discuss with your supervisor. An experience like this can be extremely stressful, and even though you may be tempted to isolate yourself at such a time, it is important that you seek whatever support you need,

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 Practitioner self-disclosure in the counselling professions (GPiA 117) Dealing with inappropriate behaviour: www.bacp.co.uk/ events-and-resources/dealingwith-inappropriate-behaviour A quick guide to lone working (Parts 1-3): www.bacp.co.uk/ events-and-resources/ethicsand-standards/ethics-hub/loneworking-guide Findings of the lone working survey by BACP and Suzy Lamplugh Trust: www.bacp.co.uk/events-andresources/ethics-and-standards/ ethics-hub/lone-working-survey Suzy Lamplugh Trust: www.suzylamplugh.org

principally from your supervisor but also (within the bounds of confidentiality) from family, friends and specialist services such as the Suzy Lamplugh Trust. ABOUT THE AUTHOR Stephen Hitchcock is BACP’s Ethics Consultant. He is a senior accredited counsellor and supervisor with 20 years’ experience, and he has a private practice in the Lake District. Stephen previously worked with BACP’s Professional Standards department as an accreditation assessor and moderator. This column is reviewed by an ethics panel of experienced practitioners. The dilemmas and responses 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 BACP website.

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The answer to the above question is – it depends! As a qualified therapist, I carry the responsibility for my client work; my supervisor helps me reflect on it, and is responsible to me for delivering quality supervision. If my supervisor were to become concerned about my practice, it would be their responsibility to express those worries to me and help me work out how to remedy them. If I am unwilling or unable to improve my practice, my supervisor may have to take this up with my employer and/or my professional organisation. The situation is somewhat different with trainee practitioners, who typically gain their experience of client work within a placement and are usually provided with both a line manager and a supervisor. These are different roles, so ideally should be held by different people. It is the line manager who can be held accountable for the actions of their staff and who will therefore hold the clinical responsibility for the client. Some agencies use outside supervisors, but in both cases, who is responsible for what needs to be clearly set out in a four-way agreement between the trainee, the agency or service, the supervisor and the training organisation. A training supervisor is responsible therefore not only to the trainee and their placement, but also to the training organisation. It is crucial that they give accurate feedback on the trainee’s practice, not only to the student but also to the placement and the training organisation. If, for example, a final year trainee has not achieved the level of competence expected of a professional practitioner, it is the supervisor’s responsibility to be honest about this. Supervisees are responsible for what they bring to supervision. But it is the quality of the supervisory relationship that decides how well practitioners are able to use their supervision. Dr Els van Ooijen BACP accredited psychotherapist, counsellor and supervisor and author of Clinical Supervision Made Easy (PCCS Books)

I think much of this depends on the experience of the therapist. With trainees and recently qualified supervisees, I may have a more direct approach of ‘try this’ and ‘I wouldn’t do that because...’ I don’t actually take responsibility for their work but I would take responsibility for the consequences of any of my suggestions or directions. Once qualified, the therapist makes autonomous decisions. We can say to a supervisee, ‘Don’t do that’, in cases such as handing over client notes to the police without first discussing it with the client, but if they go ahead and do it, they have to take full responsibility for their actions. I trust they will bring into supervision the things that they need to explore. I don’t take responsibility for supervisees’ actions or decisions. I see my role as one of helping the supervisee to explore how to make strong, defensible ethical decisions, to understand how and why they have arrived at a decision or made a particular intervention. This supports them to be confident and autonomous in their work. I feel comfortable with others arriving at a different decision to me but if I felt a supervisee was not working ethically or I strongly disagreed with their ethos, I would discuss it with them and, ultimately, it may lead to ending the work. I oversee ethical responsibility to ensure quality of care to clients and the professional development of the supervisee in accordance with the core competencies of supervision, including equality, diversity and inclusion. I encourage self-monitoring of wellness and fitness to practise alongside raising this if I feel there is a need to. Competency, ability to assess and deal with risk and safeguarding issues, ability to make decisions that withstand scrutiny and ability to grapple with the ‘tricky stuff’ are all part of the process. Luan Baines-Ball (they/them) BACP senior accredited counsellor, psychotherapist and supervisor in private practice

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Supervision enables practitioners to maintain consistent ethical good practice and to sustain their own resilience, robustness and levels of self-care to engage in clinical work. With an objective or outcome of supervision being that supervisees work ethically and safely, there needs to be an explicit recognition that a supervisee’s own ability and level of self-reflection to be able to identify and offer ethical practice and process ethical dilemmas may develop in relation or proportion to their level of training and experience. Therefore the extent to which a supervisor is responsible for a supervisee’s client work will vary depending on the supervisee’s qualifications and clinical experience. When supervising trainees, supervisors have a responsibility to work with training and placement organisations, to ensure that trainee counsellors are working ethically and meeting professional standards. A trainee may not yet have developed a broad ability to be fully aware of ethical or practice issues. Therefore, the supervisor’s responsibility to the training and placement organisations for the trainee to be working ethically results in a proportionately greater responsibility falling on the supervisor for the supervisee’s client work. This also places a duty on the trainee to bring all their client work to supervision honestly and transparently, to ensure that their supervisor can support them to work ethically and safely. In contrast, when supervising experienced or qualified counsellors, the greater weight of responsibility for the supervisee to be working ethically and meeting professional standards sits with the supervisee. The roles and responsibilities held by the supervisor and supervisee should be discussed at the start of a supervisory relationship, to ensure safe, ethical and competent practice. Myira Khan BACP accredited counsellor, supervisor in private practice and founder of the Muslim Counsellor and Psychotherapist Network (MCAPN)

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To what extent is a supervisor responsible for a supervisee’s client work?

Supervision

Analyse Me, 1

The questionnaire VERSION REPRO OP SUBS

me Analyse

ART

Nemone Metaxas speaks for herself What motivated you to become a therapist? It was a yearning to

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understand more about our way of being in the world that led me to a foundation course in counselling and psychotherapy. I’d been periodically searching online for an appropriate route into counselling but it wasn’t always clear to me what extra training I would need (after my BSc in psychology from Manchester University and postgraduate work in mental health) and how I could transition across from my work in radio. Once I’d had children of my own, I wanted to understand more about how we become the people we are in adulthood, which led me to a master’s in integrative psychotherapy and counselling. I wrote my dissertation on finding a voice to talk about the death of my sibling, as I had been unnerved by the silence around death and illness at that time. What have you learned about yourself since becoming a therapist? I have learned how much

of an architect I am in the situations I find myself in, and that my desire to be busy is a blessing and a curse. I am beginning to notice what I miss when I’m rushing about. And I’m learning to enjoy, cherish and nurture the slower moments in life – so much so that they have become as

important to me as other more noisy and busy times. What book, blog or podcast do you recommend most often?

The On Being podcast hosted by US journalist Krista Tippett. A friend brought it to my attention and I’ve always been very grateful. It was invaluable during lockdown. I ran for my daily exercise, totally immersed, listening to Katherine May on ‘How wintering replenishes’, Alain de Botton on ‘The true hard work of love and relationships’, Christine Runyan on ‘What’s happening in our nervous systems?’ and Resmaa Menakem’s ‘Notice the rage; notice the silence’, and many other wonderful episodes. What is your favourite piece of music and why? This is like asking

me which is my favourite child – unanswerable. It changes with my mood, day of the week and decade you ask me in. It’s the question I dread most and the one I can agonise over for days. So right now, it’s a combination of Self Esteem’s new single ‘I Do This All the Time’; Janek Murd’s remix of Coco, Steel & Lovebomb’s ‘Queueing for Shangri-la with a Surprisingly Level Head’ and ‘Les Dance’, Jean Claude Gavri’s edit of ‘Let’s Dance’ by David Bowie, which singer-songwriter Róisín Murphy, a

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recent guest on my Journeys In Sound series on BBC Radio 6 Music, turned me onto. However, whenever you ask me, whatever the mood or decade, it will always be Prince’s ‘Purple Rain’. What do you do for self-care/ to relax? Wild swimming, running,

snowboarding and seeking out more natural environments at every possible opportunity. We live near the river in London and one of my greatest pleasures in the past year has been walking with my family on the riverbed when the tide is low and it is safe. I sense it’s connected to seeing more horizon during a period when our ability to travel and leave our home environment has been curtailed and our view has been limited. What gives your life meaning?

Learning something new and seeing life from a different perspective. My children are key to this. Working through an impasse or challenging time with a client, or in life more generally, gives me a great sense of my place in the world and how everyone and everything interrelates. What would people be surprised WR ƓQG RXW DERXW \RX" I have

appeared on Celebrity Mastermind and my specialist subject was the children’s books of Roald Dahl.

About Nemone Now: The host of BBC Radio 6 Music’s Journeys in Sound series and a BACP registered integrated psychotherapist in private practice, seeing clients in central and west London as well as online (nemonemetaxas.com). Once was: A presenter on Kiss 102 in Manchester, BBC Radio 1, BBC Radio 2 and BBC Radio 5 Live before finding my spiritual home at BBC Radio 6 Music, where I have curated a weekly specialist show, Nemone’s Electric Ladyland, for the past decade. First paid job: Doing the washing-up in a tearoom in Cambridge.

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

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