Julia and John McLeod
(‘The significance of being skilful’, pages 26–29)
cover
The big issue
How can therapists
people with long COVID? asks Catherine Jackson
Welcome
News round-up
CPD and events
From the Chair
Reactions
The month
The big issue
Catherine Jackson explores the mental health impact of long COVID
The big interview
David Weaver on his achievements and legacy as BACP President The significance of being skilful Improving counselling skills is not just for trainees, say Julia and John McLeod Embracing impermanence and incompleteness
John Hills explores a pluralistic approach to working with existential experience Difference and belonging Sarah Morley on the benefits of mixed-gender therapy groups for sexual abuse survivors Opinion
We need to be wary of ‘mind-body’ theories that see illness as a psychological choice, says John Barton Bridging the gap
How can therapy help Afghan refugees cope with living in UK hotels? ask Jude Boyles, Jessica Ross and Kathryn Townley
‘Reflection on skills and ongoing skill development are essential components of effective practice for
...is what your colleagues willfeel whentheyseeyournew
Dealing with ethical dilemmas is one of the most challenging aspects of our work, but we can also learn a lot from the tricky stuff. The support and insight of fellow professionals in helping us decide on a course of action can be invaluable. So it’s perhaps no surprise that, according to membership surveys, the ‘Dilemmas’ section in Therapy Today is one of the most valued by readers. For confidentiality purposes, all questions are composite, but they are inspired by common dilemmas brought by members to the BACP Ethics hub. In its first evolution, dilemmas were answered solely by members. The next version consisted of responses answered by the Ethics Team based on the Ethical Framework. The latest iteration, introduced in the September issue last year, takes a hybrid approach that includes both Ethics Team and Therapy Today reader responses. We hope we’ve now got the balance right! This month’s dilemma tackles the perennial question of the ‘six degrees of separation’ factor that we often face with clients, especially if we work in our local area. The upcoming dilemmas are flagged at the end of each section and you don’t have to be an ‘expert’ to respond – if any resonate with you, please don’t hesitate to email your reflections – brief responses or longer ones (up to 350 words) are welcome.
A dilemma many of us face is when to move on to new challenges. Stepping away from work that has been part of our lives for a long time is never easy, especially if we believe we can make a difference. It’s with this in mind that we pay tribute to BACP’s outgoing President David Weaver in our ‘Big interview’ in this issue. David has done so much to raise awareness of cultural and racial issues in our profession during his time as President, Vice President and Governor, and I have personally gained much from working with him on our Black History Month issues. Also stepping down this month is Nancy Rowland, Vice President and previously Deputy CEO and a member of the Board. Nancy has given so much to the profession over the years, driven by her passion to establish a research culture in therapy. It’s a reminder that our profession stands on the shoulders of many giants.
A dilemma many of us face is when to move on to new challenges. Stepping away from work that has been part of our lives for a long time is never easy, especially if we believe we can make a difference
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As a nation we’re going through another period of change, with our new Prime Minister Liz Truss recently entering office and King Charles III ascending to the throne following the sad passing of Her Majesty Queen Elizabeth II in September. We’ve called on the new Prime Minister to ensure the nation’s mental health is a priority and to continue with plans for a 10-year mental health strategy. For more about our priorities for the new Prime Minister, see page 7.
I’m delighted to share that our mentoring scheme for trainees from marginalised and racialised communities has exceeded our initial expectations. We originally hoped the scheme would match 20 pairs of mentors and mentees. However, following a successful application process, we’ve been able to match up to 30. We’ll keep you updated with the scheme’s progress and I’m looking forward to seeing how their relationships develop over the coming months.
Finally, I attended the 2022 Labour Party Conference with Dr Rosena Allin-Khan, Shadow Mental Health Minister, who spoke about the incredible job you do while making the case for more investment in mental health. The event enabled us to promote the role and relevance of counselling and psychotherapy. You can read more about it on page 7.
Fiona Ballantine Dykes, Deputy Chief Executive
There’s still time to sign up for this year’s AGM on Friday 11 November. It’s a hybrid event so you can attend in person at the Mercure Hotel in Leicester or join us live online. The AGM will feature a round-up of our year and we’ll announce the results of the resolutions and motions before welcoming the new Governor who’ll join our Board, as voted for by you. Attendees can also watch a CPD
presentation, network with other members and receive a CPD certificate. Bookings will also include access to the on-demand service, where you can catch up on anything you miss during the day. The programme runs from 9.30am–4.25pm and members can join or watch for free. To find out more, see: www.bacp.co.uk/aboutus/about-bacp/governance/agm/ agm-2022
Our annual Mindometer report is an in-depth look at what therapists are currently experiencing in their practice and reflects the mental health and wellbeing of the nation. Surveying 2,983 of our members, this year’s report saw a sharp decline of the public’s mental health in comparison to last year. As we emerge from the
COVID-19 pandemic, a range of social, economic and global issues are having a compounded negative impact on the population’s wellbeing, resulting in therapists reporting that demand for therapy is over capacity. You can read more results here: www. bacp.co.uk/about-us/about-bacp/ mindometer-2022
We’ve recently launched a new series of resources designed to support you to use research in your practice. The good practice research resources cover seven topic areas: critically appraising research, developing methodology, presenting at conferences, research ethics, using routine outcome measures in practice, writing a research proposal and writing for publication. They
consist of panel discussions, member interviews, a presentation and a written information source. The resources are suitable for all members and have been developed by our research team. We hope the resources will help you to understand, undertake and use research more confidently. Find the resources at: www.bacp. co.uk/events-andresources/research/ good-research-practice
• We’re calling on Prime Minister Liz Truss to ensure the nation’s mental health is a priority as she begins her tenure. We believe everyone who is struggling with their mental health should be able to access a choice of psychological therapies when they need to. We’ll be engaging with the new Health Secretary and Minister for Mental Health at the earliest opportunity.
In order to further make the case for counselling, psychotherapy and therapeutic coaching, our Policy team attended both the Labour and Conservative Party Conferences this year. The team hosted a fringe event at the Labour Conference, which featured a Q&A panel with Shadow Mental Health Minister Dr Rosena Allin-Khan and BACP Deputy CEO Fiona Ballantine Dykes.
• We recently conducted a survey of members and found that two-thirds list cost of living concerns as a reason
for Britain’s mental health decline. The results also showed that 60% of therapists say their clients are anxious about whether they can afford to pay their household bills; 49% say their clients are cutting back on activities that benefit their mental health, and 47% say their clients are cancelling or pausing therapy sessions because they can no longer afford them.
Martin Bell, BACP Head of Policy, said: ‘Our research shows people are already making difficult decisions about what they choose to pay for, and this will have devastating consequences on their mental health and wellbeing.’ We’re continuing to push for increased investment in mental health support to combat the impact of the cost of living crisis.
• For more details and to keep up to date with BACP’s policy news, see www.bacp.co.uk/ news/news-from-bacp
BACP President David Weaver steps down this month after five years in post. We would like to thank David for his dedication to the counselling and coaching professions during this time. David’s presidency followed more than a decade of service as a BACP governor and also a vice president. He said: ‘I am proud to have led on the issues of entry to the profession and better representation within the profession. There’s always something to be learned, and there is always more that can be done. I think that when you put yourself in a role like this, you have to do something with it. You don’t just sit there and put it on your CV.’ You can read more about what David achieved in his time as President and his ongoing legacy in our ‘Big interview’ feature this month, which starts on page 22.
We would also like to thank Vice President Nancy Rowland who steps down this month after four years. Prior to that, Nancy was BACP’s Deputy CEO and in that role served as a member of the Board of Trustees. Nancy originally joined BACP as the first-ever Head of Research, and played a pivotal role in establishing a research culture within the organisation. She said: ‘I am most proud of enabling and supporting significant research projects by Mick Cooper and colleagues that were instrumental in getting counselling into schools, as well as the work with Michael Barkham and the late Mike King that has seen counselling being recommended as a treatment for depression in the recently published NICE guidelines.’
Confirmation of our new President will follow by member e-bulletin.
Promoting our members and our profession through the media
BACP Deputy Chief Executive Fiona Ballantine Dykes contributed to a BBC Online feature, Let’s talk: ‘Therapy is not weak or unnecessary’, on the increasing demand for counselling and psychotherapy, the need for investment and access to therapy for the public.
• Anthony Davis also contributed to the feature and spoke about how he’d seen an increase in men coming to therapy. Anthony also featured in an article in Marie Claire magazine advising people on how to find a therapist. Results from our recent member survey about the impact of the cost of living crisis on clients’ mental health were included in a Press Association (PA) article used by more than 160 newspapers and online news sites. It included comment from • Martin Bell, BACP Head of Policy and Public Affairs. Lindsay George • also spoke to PA for an article about how the cost of living crisis was fuelling retirement anxiety.
• Lina Mookerjee spoke to BBC Radio Nottingham about the Queen’s death and how to talk about it to children. The Independent featured comments from Jackie Roberts • in an article examining why people mourn public figures, following the death of the Queen. Louise Tyler • contributed to the Annalisa Barbieri column in The Guardian, which addresses family-related problems. A feature about addictions in Your Fitness magazine featured comment from • Dee Johnson.
Routine outcome monitoring or measurement (ROM) is the practice of regularly using outcome measures or questionnaires with clients during therapeutic work. It allows you and your clients to track the progress of your work over time. ROM questionnaires are extremely varied and can focus on a wide range of issues, such as psychological distress, depression, anxiety, self-esteem, wellbeing and personal goals. Research shows that using ROM can have a number of benefits both for practitioners and clients, such as providing a focus and structure, allowing the client to feel more involved in defining their own outcomes and promoting higher engagement in the therapeutic work. Many practitioners and clients find collecting measures useful, but they may not work for everyone. Barriers and challenges to using ROM include concerns over confidentiality and the collection of ROM becoming a bureaucratic exercise.
• If you’d like to find out more about ROM and how you could measure, collect and analyse data, see our dedicated ROM webpage: www.bacp.co.uk/events-and-resources/ research/routine-outcome-measures
In June we announced the launch of our new mentoring scheme for trainees from marginalised and racialised communities. We initially set out to match 20 pairs of mentors and mentees, primarily driven by the needs of the mentee, to form two-way learning relationships where the mentor can also learn from the relationship. We launched the scheme to ensure we offer current trainees the support to progress and succeed in the training environment. Following an exceptional response to the recruitment process, we’re delighted that we’ve been able to increase the number of pairings by 50% and match up to 30 pairs of mentors and mentees to take part in the scheme. All pairs are now working together and meet every four to six weeks to provide and receive support and gain opportunities and new insight from the shared relationship. We’ll bring further updates on the progress of the scheme over the coming months.
mInutes with…
Tim Patrick
Tim Patrick
BACP People and Organisational Development Officer
Describe your role at BACP: My role is to support the delivery of the people plan and to grow our staff’s confidence to be the best that they can be in their roles. Some of my current duties include developing BACP’s inclusive recruitment, onboarding and induction, updating our staff policies to be accessible and being on hand to provide people with advice as and when needed.
What’s the best thing about working at BACP? I’ve been given an incredible opportunity at BACP to influence positive change through my work. Every day I can be brave, bold and accountable with what I’m doing. BACP has so many great staff initiatives and being part of the process to better communicate these is hugely satisfying.
I’m a bit of a health freak and I enjoy the grind that I put my mind and body through daily. I have to warn you that entering into a conversation with me about nutrition or fitness might get you stuck for a really, really long time.
What advice would you give to your younger self? Don’t take anything personally and if you’re not failing,
Public Protection Committee
then you’re not trying hard enough.
Best advice you’ve been given? You’ll never know what others are truly dealing with and how things could affect them, so learn to really listen and to be aware of your surroundings.
What was the last book you read? The Little Book of Buddhism by His Holiness the Dalai Lama.
What’s your go-to karaoke song?
I have a few! But my most memorable performance was in a karaoke bar in Tokyo and (in my opinion) I absolutely slayed the stage with Cyndi Lauper’s ‘Time after Time’.
Your proudest achievement?
In a karaoke bar in Tokyo (joking!). I’ve always stayed true to myself and have always known when to say no in all aspects of work and life.
I would like
What would you like to achieve over the next year? I would like to see my current work projects through to completion, take on new ones and, above all, continue to grow as a person.
If you’re looking for affordable, high-quality and varied CPD content, don’t miss out on the CPD hub. Regularly updated with new resources to help you continue to develop your competence and knowledge, the CPD hub currently has more than 300 hours of online resources on a variety of topics. You'll find a mix of video and audio recordings; themes include abuse, bereavement, diversity, older people, self-care, students, suicide, trauma and more. Access to the CPD hub costs just £25 per year and you’ll receive a downloadable CPD certificate for each completed resource. To find out more, see www.
There’s still time to book onto our event ‘Working with soul: Creating a healthy culture, demystifying spiritual abuse within therapeutic practice’, to learn how to work with clients who are experiencing spiritual abuse. It will appeal to anyone who would like to improve their confidence when faced with spirituality-related safeguarding issues. It’ll help you to gain an understanding of varying perspectives of abuse within a religious or spiritual context. You’ll also learn how to support clients who are experiencing spiritual abuse, and explore and reflect on issues that are important to your clients. This online event includes
two presentations, followed by Q&A sessions with the facilitator. They’ll support you in integrating your learning from the event with a focus on safe and ethical practice, including self-care. The online event takes place on Friday 18 November, 9.30am–1.00pm. It costs £30 for BACP Spirituality division members, £35 for BACP members and £70 for non-members. To book, see www.bacp.co.uk/events
The focus of this event is the relationship between finances and poor mental health, with those in debt or financial hardship frequently experiencing stress, anxiety and depression. One in two adults with debts has a mental health problem. One in four people with a mental health problem is also in debt. Debt can cause and be caused by mental health problems. Bringing together a panel of experts working in and around welfare advice, therapy and research, the
session will explore key issues including the relationship between ethnicity and financial hardship and working therapeutically with clients in debt/financial difficulty. Attendees will also learn about the debt advice landscape and where to signpost clients for free, professional support. This online event takes place on Wednesday 18 January 2023, 9.30am–1.00pm, and costs £35 for members and £70 for non-members. To find out more and to book, see www.bacp.co.uk/events
Bookings are open for our next Children, Young People and Families (CYP&F) conference: ‘Trauma, healing and hope – breaking the cycle and promoting healing’. Presentations include: ‘Linking principles of polyvagal theory to clinical work’, ‘The fragile interplay between learning and healing’, ‘Trauma and eating disorders’, ‘Working with refugees as a school counsellor’, ‘Grief and loss’ and ‘The context for trauma in parents of children with special educational needs and disabilities (SEND)’. There’ll also be keynote presentations from Claire Harrison-Breed and Dr Renée Marks. This will be a hybrid event, so you can attend in person or online on Saturday 18 March 2023. It costs £40 for BACP CYP&F division members and £50 for BACP members to join online. This full-day event will include two livestreamed strands and a chatroom to network with peers, vote on interactive polls and engage with the live Q&A. In-person attendance at the event in London costs £60–£120, depending on membership status, for four strands of content, networking opportunities, lunch, refreshments and the chance to engage with exhibitors and BACP staff. For more information and to book, see www.bacp.co.uk/events
I’m writing after a period of huge historical change when we paid tribute to the late Queen Elizabeth II and welcomed a new monarch, King Charles III. As I watched history unfold on television, I observed the intensely solemn mood of the many thousands of people who lined the streets to watch the funeral cortège, paying tribute to a sovereign and telling their stories of what her 70 years of service meant to them. Whatever the reason people were drawn to watching the procession, a sense of change was almost certainly felt.
Transition is about moving out of one phase and into another, and as the time for BACP’s Annual General Meeting approaches, we reflect on the work of the Association over the past year. This year I note the step-change in our achievements for long-term success. Our Association is in a unique position offering a plurality of skills that are drawn together to focus on the progression of its core work –membership, professional standards and the wider profession. This work could not be achieved without the service of BACP officers and the commitment of volunteers over a span of several years. As we review our progress, we gain a greater understanding of the factors that have contributed to that achievement –a coherent voice, working in partnership, not isolation.
Over the years there has been much hard work and commitment to change
how our Association is seen and how we operate externally, along with continuing strategic work to evolve our internal structures. We are able to demonstrate what we have done internally with our new committee structures as well as communicate our purpose externally, with the support of dedicated staff who help members and the public access resources and understand the different areas of our strategy.
As with any transition, we make decisions about what we want to hold on to as we move into the next stages of our development, assessing what serves and what no longer serves us. What I have also witnessed is a shift in thinking that
acknowledges that what we do as a membership body will influence the wider profession. This approach underpins our work with the Professional Standards Authority, the National Institute for Health and Care Excellence, and the Governments of the four nations. Our continuing work on SCoPEd with our five partner membership organisations is further evidence of collaboration for the benefit of our collective members.
BACP members may have also recognised several changes over the years as a result of our technological and membership engagement strategy. We have listened to and responded to members and through collaborative creativity, we have delivered an enhanced equality, diversity and inclusion strategy.
This is an exciting time for our Association – a time of change that should be embraced. The Board is currently focused on writing a new strategy and, while we are still in the embryonic stages, we recognise that our organisation has a real opportunity to develop structures that will take us through the next five years and beyond.
Natalie Bailey Chair, BACP Board of GovernorsAt the AGM, we’ll be welcoming new trustees and saying goodbye to several colleagues, who have invested immense time, energy and commitment in the Association. I want to pay special tribute to and thank all those who have given selflessly and have contributed to the growth of our Association. ■
It was interesting to read about Patrick Vernon’s ‘The Ties that Bind’ project exploring the trauma experienced by families affected by the Windrush scandal (‘The big issue’, Therapy Today, October 2022).
For me, the scandal felt very personal – my grandfather was a passenger on the Windrush, coming to Britain from Jamaica in 1948. He had been deceased for almost two decades when the Windrush scandal took place. The thought that, at 94 years old, he could have been faced with deportation, leaving behind a life he built, a British-born wife of more than six decades, seven children, 10 grandchildren and five greatgrandchildren, was both angering and saddening.
I was a counselling student at the time, and at times I found myself with low-grade depression from the oppressed feeling that followed me. There was no mention of the scandal on the course from my fellow students or tutors. My so-called ‘racially ambiguous’ look, due to my mixed-race heritage, could be the reason for them not bringing it up, perhaps not knowing that I am of Afro-Caribbean descent. It’s possible they just didn’t know what to say. However, I believe this left me and other black students feeling unseen, disregarded and unsupported. Speaking up and saying as little as ‘I am here to listen’ or ‘It’s wrong what is happening’ would have been enough and even powerful. But speculating isn’t what is important here, and nor is bashing the educators or students. It’s important to put the onus on the systemic issue of the lack of diversity training and thus a lack of sensitivity needed to support and facilitate the development and emotional robustness of trainee black and mixed-race counsellors. Through education and training, we can work together to make sure that we are all included, protected and seen.
Today we are over-saturated with ‘representation’, which is useful as an unconscious message for inclusivity and diversity. However, this is just symbolism –the legwork must continue, like owning, breaking down and challenging our own unconscious bias. In other words, representation is merely an introduction to diversity. Embracing multiculturalism, the real work, is in our day-to-day lives in thoughts, feelings and actions.
Rochelle Armstrong MBACPRe ‘On the right platform?’ (Therapy Today, September 2022), I too have received those invitations to join various online platforms. Every email seems to be centred on the financial opportunities that signing up would offer, with little to no emphasis on what therapy is actually about. It is obvious that the marketing of some therapy platforms is solely based on
attracting practitioners, without any consideration for their therapeutic modality and the question of whether it would fit the platform.
As a psychodynamic psychotherapist, not being available 24/7 is a key part of the therapeutic process. It is through exploring the feelings around breaks in the work or days between sessions that we gently set the boundaries within which the therapeutic
alliance develops. To be contacted to join a platform where I would be expected to work against my own modality shows me that no time was taken to investigate who I am. The ethical value of ensuring the best service to clients seems to have been overlooked. Therapists are not being sought out for their experience, ethos or specialism because the end goal – an emotionally healthier client – does not matter as much as the financial gain of growing a successful business.
Therapy platforms that prioritise profit over care can only serve to tarnish what most of us have worked hard for many years to learn to do. Aaron Balick beautifully demonstrates this by sharing the ethical dilemma his team was faced with when attempting to scale up their platform. Aaron put ethos above anything else, thus remaining true to the core principles of psychotherapy. Florence Nadau MBACP, children, adolescents and families psychodynamic psychotherapist in private practice
Having read ‘On the right platform?’ in the September 2022 issue, I wanted to share my experience of working for BetterHelp. I joined the platform to top up my low income over the summer as many of my private practice clients were away. I was shocked from the start: I wasn’t interviewed at all for the role, they just asked me to provide my qualification certificate.
There was no training and a very limited introduction around what to expect and how the platform works. I was just asked if I had read the therapist guide. I received my first referral very quickly, with a limited questionnaire that served as some form of an assessment.
I wasn’t asked if I had any training or experience in message-based counselling and I had quite a difficult experience with a client wanting this form of therapy. I had to gently get them to rematch themselves with another therapist.
It feels unboundaried and not at all containing. I have stopped taking on any more clients through the platform. Perhaps I would feel differently with a bit more experience and
practise of working in this way, but for now, I don’t feel I want to take part in what seems to be a money-making scheme.
Liz Hills MBACPI recently read Sally Brown’s article, ‘On the right platform?’ I am a director of Turning Point, a large national social enterprise that has been established for 60 years and supports 130,000 people per year, predominantly those with drug or alcohol issues. A few years ago, we launched a therapy platform called ‘livelife’, Turning Point’s first venture into private pay or services direct to the consumer.
The article mentioned that BetterHelp comes up first on therapy-related Google searches – it also comes up second, third and fourth. However, it did not outline the implication of this, which is that, if you don’t have a considerable Google Ads budget, you will not be seen in a Google search. Talkspace and BetterHelp completely dominate this area. Like the assertive recruitment of therapists, such as the direct emails from ‘Will’ described in the article, the approach BetterHelp has with clients/customers is similarly domineering. As a venture capital-backed company, it has a very clear target to dominate the market.
Most large, scalable therapy services use affiliates, as referenced in the article. We don’t – we only employ therapists on permanent contracts. The large platforms are based outside of the UK. We are based here. We are not looking to increase shareholder profits –as part of Turning Point, any profits go to this social enterprise/charity. As great as the debate is about platforms, and I completely appreciate that you have to focus on the most common types, it feels like the smaller, more ethical services were missed out.
I signed up for the BetterHelp platform, having been lured to it by their direct messaging and popularity on social media. As a relatively new counsellor (I graduated in 2020), I was still
going through the ups and downs of developing my private practice and was keen to get work where clients are referred to me.
However, I’m concerned about the working practices that the platform offers to the therapists. First, the payment scheme based on escalating rates incentivises therapists to work with large numbers of clients but doesn’t seem to be concerned about therapists’ wellbeing and self-care, which inevitably are impacted by taking on such a high caseload. For example, they don’t offer supervision or even require therapists to be in individual or peer supervision outside the platform.
Second, as mentioned in your article, if you decide to take on a client and realise during the first session that you are not a good fit – because, for example, you don’t have the right experience to work with that client – you can’t refer them on. The platform gives the ability to terminate the work solely to the client. It is also down to the client how much information they reveal about themselves in the initial form, which for you is the only basis for deciding whether you will accept to work with this client or not. Clients can also decide not to show up for a session, which leaves you with no payment for any last-minute cancellations.
Offering a safe and non-judgmental space in counselling is key, but therapy is more than this. It is an opportunity to build a relationship – a relationship that, when properly held, can be truly therapeutic and, as a result, creates change for a client.
Unfortunately, platforms such as BetterHelp don’t do that. They are disrupters to therapy in the same way as Uber, Airbnb or Amazon were disruptive to other market sectors, but like these companies, they treat therapy as a commoditised service rather than a place to build a distinct and personalised therapeutic relationship. By placing too much ‘power’ on the client’s side, they damage the clienttherapist relationship, which can actually be detrimental to the client.
John O’Dowd, Acting BACP Registrar, makes no mention in his response to the point raised by David Waite (‘Reactions’, Therapy Today, July/ August 2022) of the complaints process being a ‘trial at a hearing with the complainant as witness/accuser/prosecutor – someone who may have some serious emotional issues and who can say anything they want with impunity’.
Waite says: ‘We need an inquisitorial process instead to discover the overall competence of the practitioner and whether the complainant is expressing some of the mental/emotional imbalances they brought to therapy.’ Rather than an ‘inquisitorial process’, there perhaps needs to be an understanding of the nature of what is hoped for by the client and also the counsellor within the imperfect world we live in. These expressed and unexpressed emotions and thoughts, and what is being shown in the whole therapeutic encounter, need to be taken on board by the Professional Conduct team.
In the language of internal family systems therapy, there are ‘protector parts’ that protect our ‘vulnerable parts’. When these vulnerable parts come through into therapy sessions in an uncontained way, they can leak out as a ‘complaint’ if we are not very careful. If this is not acknowledged appropriately and contained, splitting may ensue and a complaint be made against a counsellor. How much is this taken account of during the Professional Conduct process, I wonder?
Gavin Robinson MBACP (Accred)
Zadie Xa is a Korean-Canadian visual artist who uses masquerade, play, costume and storytelling to investigate social and political issues and recreate narratives that have been erased or repressed by the Western world. Her work draws inspiration from fields as disparate as ecology, science fiction and ancient religions to explore themes of belonging and self-identity within society. ‘House Gods, Animal Guides and Five Ways 2 Forgiveness’, her latest UK exhibition, exemplifies these inspirations. Here, she has created a specially commissioned immersive installation using hanging sculptures and fabric creations to turn the space into a colourful dreamscape. This bewildering and beautiful installation must not be missed –at Whitechapel Gallery, east London, until 30 April 2023.
In 1950s London, straightlaced and shy civil servant Mr Williams (played by Bill Nighy) has spent his life in a soul-crushing office job, ‘not happy, not unhappy’. After receiving a terminal diagnosis, he faces the challenge of finally ‘learning to live’ in the time he has left. It’s only after a chance meeting with young, sparky former colleague Margaret (Aimee Lou Wood) that it begins to seem possible. Drawing energy from their unconventional, platonic relationship, he devotes his final days to the development of an inner-city children’s playground that has been needlessly stalled by paperwork generated by him and his colleagues. With a screenplay written by Kazuo Ishiguro, adapted from the 1952 Japanese film Ikiru (To Live) and originally inspired by Tolstoy’s The Death of Ivan Ilyich, it’s a quietly beautiful reminder that we shouldn’t need a terminal diagnosis to live with the end in mind.
On general release from 4 November.
• Michelle Obama tackles ‘change, challenge and power’ in her new book, The Light We Carry. She says: ‘I’ve learned it’s OK to recognise that selfworth comes wrapped in vulnerability, and that what we share as humans on this earth is the impulse to strive for better, always, no matter what.’ (Penguin, out 22 November)
• A Heart That Works, from acclaimed writer and comedian Rob Delaney, grapples with the fragility of life, the experience of death, and the question of purpose for those left behind. It’s a warm and heartbreaking love letter to his child, who died, and to fatherhood itself. (Coronet, out now)
• I’m Glad My Mom Died by Jennette McCurdy is a no-holds-barred memoir from a former child star about her childhood of abuse and exploitation at the hands of her mother. Offering reflections on whether we always have to forgive people, it’s a raw but readable account. (Simon & Schuster, out now)
Know
In August 1972, Idi Amin, President of Uganda, announced that all Asians living there must leave the country within 90 days. Some 80,000 people were forced to leave with only what they could carry or wear, and £50 in cash. Many had British citizenship, and nearly 23,000 came to the UK, of whom 10,000 settled in Leicester, where there was already an established Asian community. This exhibition tells their stories to commemorate the 50th anniversary of the expulsion – the chill of the autumn weather when they flew into Stansted, the strangeness of English culture, and the racism and hostility they faced. Leicester City Council even took out an advert in the Uganda Argos warning them not to come, reportedly prompting many to go there anyway to see what made Leicester so special. The exhibition charts how they rebuilt their lives from almost nothing, and their contributions to local and national economic and cultural flourishing. At Leicester Museum and Art Gallery until 2 January 2023.
Juliet Stevenson reprises her award-winning 2019 role in this brain-bending play about medicine, ethics and identity politics. This is a radical revision by Robert Icke of Professor Bernhardi, a 1912 play by Arthur Schnitzler, which was mainly focused on exposing antisemitism in contemporary Viennese society. In this 21st-century rewrite, Ruth Wolff is a secular Jew who runs a prestigious institute specialising in Alzheimer’s disease. Her decision to prevent a Roman Catholic priest giving the last rites to a 14-year-old girl admitted to her hospital dying from a self-administered abortion goes viral on social media, provoking outrage among the twittering classes, petitions and TV debates, and threatening massive repercussions for Wolff and her institute. The rewrite tackles not just religion and medical ethics, but also race, gender, class, dementia, abortion, suicide... The ‘trigger warning’ list is extensive. Do a doctor’s sex, race and religious beliefs matter in such decisions? Should a medical decision be influenced by sanctimonious trolls? Who decides? At the Duke of York’s Theatre, London until 11 December.
Podcast picks
• As partners, therapist Angela Dierks and fellow therapist Tom MacKay make ideal co-hosts for a relationship podcast. The Relationship Maze explores everything from loneliness and attachment styles to mentalisation, trauma and more. www. therelationshipmaze.com
• Ever wondered what psychosexual therapy really involves? Or what we mean by systemic therapy? Aimed at clients, Finding Psychotherapy by therapist Carla Vercruysse is also a useful therapists’ guide to modalities. On Spotify and Apple podcast platforms.
• Therapist Tracy Northampton, who answers the ‘Analyse me’ questionnaire in this issue, discusses body dysmorphic disorder in This Food Thing, Jemma Richards’ podcast on how our relationship with food affects our behaviour. www. lovethisfoodthing.com
We are living in a world of denial. Everyone wants COVID-19 to be over; of course we do. But it isn’t, and I think it’s irresponsible that those with the power to prevent its spread aren’t doing more. Hundreds and thousands of people are becoming chronically ill after exposure to a virus that they are being told is no worse than the common cold.’
So says integrative counsellor and writer Elizabeth Turp, who specialises in working with people with long-term chronic illness and pain, and describes herself as an ‘expert patient’. Her concern is the growing incidence of long COVID, which is affecting people even after the mildest of experiences of COVID-19. ‘I could foresee this coming right from the start of the pandemic. All pandemics bring post-viral long-term health impacts. People are experiencing what may prove to be permanent disability and no one at Government level is taking it seriously,’ she says. ‘And in terms of chronic conditions, long COVID is particularly complex because of the multiplicity of symptoms involved.’
What might seem at first reading to be an overly apocalyptical vision surely needs serious consideration when you look at the numbers involved.1 COVID-19 cases in August 2022 totalled some 944,700 across the UK, well down on the 3.7 million of January 2022, but not so far off the 1.1 million recorded in January 2021. People are still getting COVID-19. They may be dying in fewer numbers, but every case is someone who is at risk of developing long COVID, the effects of which are multiple, hugely complex and varied, potentially very disabling, and
mostly still mystifying medical research as to their causes and, therefore, how to treat them. Omicron is proving just as likely as other variants to lead to long COVID, and long COVID rates are rising rapidly, from almost 1.3 million in January to two million in July.2
And this is when people may turn to counsellors and psychotherapists for help, says Turp: ‘They’ve tried everything else and it isn’t helping. Often they are pretending so hard that everything is fine, but it isn’t. Our job as therapists is to make space for all the mess – the fear, the loss, the guilt, the shame, the frustration and the anger – so they can begin the work on adjusting to disability and learning how to manage their symptoms.’
Long COVID can manifest as any and many of a long list of symptoms, often in combination. They include chronic fatigue, shortness of breath, chest pain, problems with memory and concentration (‘brain fog’), difficulty sleeping, heart palpitations, dizziness, pins and needles, acute joint pain, depression and anxiety, tinnitus, ear ache, feeling sick, diarrhoea, stomach aches, loss of appetite, a high temperature, cough, headaches, sore throat, changes to sense of smell or taste and skin rashes. And there’s more – hair loss, erectile problems and higher risk of stroke, heart attack and Alzheimer’s.
Says Turp: ‘Energy levels are low; you can’t think straight or concentrate; you may have pain in strange places; your sleep may be poor when you need it most; your appetite and guts don’t feel right; you are on an emotional rollercoaster. Much of this is normal following a viral infection as the body recovers and rebalances. The body
needs rest.’ Not resting can lead to the condition becoming chronic, she warns.
She believes that some of the symptoms of long COVID may be due to our natural, instinctive threat-survival system, which is largely controlled by the amygdala. This is the part of the brain that sends us into ‘protect and survive’ or ‘fight, flight or freeze’ mode, overriding the more logical thinking of our frontal lobes. ‘When we experience a serious threat, our brain responds to protect us – it scans for threats. The amygdala may become over-alert or hypervigilant, and this can contribute to physical symptoms in the body such as digestive problems, pain and sleep difficulties,’ she says.
The official advice from the NHS is to contact your GP if any of these symptoms are still present four weeks after you have had COVID-19, and you may then be referred on for further tests and possibly an assessment at a specialist long COVID clinic. There are 68 of these in England, where a multidisciplinary team of specialists with expertise in the various aspects of the syndrome, sometimes (but not always) including psychological symptoms, will be able to assess you and recommend treatment. But there’s nothing currently available that will lead to a cure. Long COVID remains a medical mystery – no physiological cause for its symptoms has yet been found. And it remains ‘long’ –some people who had COVID-19 in the first wave are still bed-bound by the symptoms.
According to Government data, some two million people are living with selfreported long COVID – two per cent of the population.2 But, given the ongoing rates of COVID-19 infections, the numbers are inevitably accumulating. For some, the
symptoms are lasting a year and more; for 67%, they affect their day-to-day lives, and 20% are affected severely. Those most at risk are in middle age (35–69 years), female, living in deprived areas, working in frontline public sector occupations – teachers and health and social care workers – and have coexisting health conditions or disabilities. Essentially, they are those exposed to the highest viral loads because of their work, those rendered more vulnerable by disadvantage, and (arguably) those carrying the greatest burden of caring for others – who are often mid-life women.
However, research has so far failed to track down the causes of these symptoms, beyond COVID-19’s known effects: damage to cardiac and lung function, blood clots and other physiological symptoms that can be identified through scans and medical tests. So, as members of the ME and chronic fatigue syndrome (CFS) community warned early on in the pandemic, people with long COVID are facing the same battles as they did to have their symptoms recognised and treated compassionately and appropriately.
Listen to the experts Lesley Macniven caught COVID-19 very early on, in March 2020. A leadership development and management consultant and work coach by profession, she cofounded and volunteered to co-moderate a Facebook support group (longcovid. org) for people who were developing the symptoms that have come to be called long COVID. The group has since grown to more than 55,000 people worldwide, primarily based in the UK and US. ‘What we want is recognition that we exist, research into why people aren’t recovering and into treatments that work, and rehabilitation – there are hundreds and thousands of people severely disabled by this; there needs to be changes at every level to accommodate it,’ she says.
It is the case that the majority of the research projects into long COVID funded by the National Institute for Health and Care Research (NIHR) are looking for causes and medical treatments. Only one is explicitly concerned with rehabilitation – working with people with long COVID
themselves to explore what helps them live with and manage the condition. This is the aptly acronymed LISTEN study (long COVID Personalised Self-managemenT support- co-design and EvaluatioN), led by Fiona Jones, Professor of rehabilitation research at St George’s Hospital and Kingston University, London. Researchers are exploring in partnership with people with long COVID what works for them, and from this will develop and trial a programme to help them self-manage their symptoms. ‘Long COVID is similar to other conditions where people feel they’re not being listened to by healthcare professionals, or the symptoms that they’re experiencing can’t be explained by standard investigations, so they get referred to different departments. There isn’t this ongoing support, so there’s not only the experiences you’re feeling but the anxiety that you’re not getting the support that you need as well,’ Professor Jones says.
But it’s a small trial, with nothing like the budget of others. Do we not need more investment in helping people to live with a condition that is disabling so many?
Macniven agrees: ‘There are things patients are finding that work for them but we just aren’t being listened to. So listen to what we have to say, and we will listen to what you have to say, and we will get the best of both worlds.’
Sarah O’Connell has had ME for nine years; her 11-year-old daughter has had ME for more than three years, and more recently her son, aged seven, got long COVID, combined with PANS (inflammation of the brain that causes a lot of neuropsychiatric symptoms, such as separation anxiety, obsessive compulsive behaviours and emotional dysregulation),
so she knows all too well what it is like to be faced with medical gaslighting. ‘You can be consulting for something quite other than ME, but as soon as you mention the diagnosis, there’s this vacant stare and you know what’s going through their minds. You just feel helpless and hopeless – hopeless because you realise there’s no connection and you can’t trust this person and the care you will receive because of their response to the diagnosis; helpless in that you can’t educate this person, there isn’t time to explain it – you just have to do what you can to get the care you need.’
Professor of biological psychiatry at King’s College London, Carmine Pariante has devoted his career to researching the links between mind, body and brain and diseases and disorders like CFS and long COVID that sit at the interface between them. He says, if a patient comes to a doctor saying something is wrong, then there is something wrong. The problem is that medical science hasn’t yet caught up with the causes of illnesses like CFS and ME. ‘Every psychological phenomenon has a biological substrate. Most psychological mechanisms are driven by biological changes in the brain – brain cells communicating. We know from research into pain that it is profoundly influenced by the cause – the tissue damage – but also by our mental state, our environment, how we interpret the pain, what the pain means for our health,’ he says.
‘But none of this takes away from the reality of the experience or implies that people invent these symptoms. Accepting that psychological and psychosocial factors influence your experience of the symptoms of your illness does not in any way imply the illness does not exist. It is just that we are behind with the science.’
Says Macniven, ‘I would love everyone to have 10 minutes with a therapist just to hear the words, “You are not well but you are not broken.” It would be like a drink of water in the desert. If only GPs would simply say: “I believe you and I can understand and I have noted your symptoms on your record and classified you as having long COVID and put you on a waiting list for a clinic, and meantime, what do you find helpful and how can we support you to self-manage the symptoms?”’
‘I would love everyone to have 10 minutes with a therapist just to hear the words, “You are not well but you are not broken”’
Counselling and COVID Turp argues that every specialist long COVID clinic should include counsellors in the team. ‘Everyone with a chronic long-term illness has psychological effects. Of course they do,’ she says.
Kim Patel, also an integrative therapist specialising in working with chronic pain and long-term health conditions, summarises the main talking therapies offered in multidisciplinary pain management and chronic fatigue programmes: ‘Mostly it’s CBT and looking at issues like fear avoidance, and boom and busting; acceptance and commitment therapy (ACT) that’s about finding valued goals and working towards them even in the presence of continuing pain or fatigue, and compassion-focused therapy (CFT), where again you are, for example, looking at boom-and-bust behaviours and the threat and drive systems, and bouncing between the two. And there’s also the person-centred approach, which is more about self-awareness and self-acceptance.
‘These are all approaches that counsellors can offer if someone isn’t getting the multidisciplinary support from a long COVID or chronic fatigue clinic,’ she says, ‘but they must have specialist training first. And I strongly believe these complex conditions need a multidisciplinary approach, to ensure the complexity of needs is properly explored and addressed.’
It isn’t work that a generic counsellor without specialist knowledge and experience of working with chronic conditions should take on, Turp says. So much harm can be done if the counsellor’s attitude is negative – and it is common even among counsellors, she says, to believe that the unexplained symptoms of chronic fatigue and brain fog are ‘all in the mind’. If a client is led to believe that all they need to do is what amounts to graded exercise therapy – gradually push themselves beyond what they feel is a manageable level of activity – the evidence shows that it can result in even worse longterm illness, she says. ‘Some therapists are COVID deniers; some are COVID minimisers – we are human beings, we are no different from the general population, where these beliefs are common.’
Sarah O’Connell is a firm advocate for counselling. ‘It has definitely helped me. It is such a tough thing to go through, when you have a chronic illness that affects your body and your brain. I used to be this articulate person with a career and something to say for myself, and now there are days when I can’t even string a sentence together. You are not just losing what your body can do; you are losing what your brain can do – it is a complete loss of self. There is a huge grief – I am still processing it after nine years. It’s so helpful to have someone there that you know you won’t push away by talking about anything you want to and helping you to prioritise what you can do with your limited energy.’
Karen Rawden, a psychosynthesis psychotherapist, co-founded the Facebook group ‘COVID-19 UK & Ireland Sufferer & Survivor Support’ in March 2020. She experienced ME in her teens, so knew what was happening when, after contracting COVID, she found herself once more struggling with familiar, continuing symptoms. She started the Facebook group because she realised, having also survived cancer, that what she needed to help her through long COVID was contact with other people in the same situation: ‘I had to find others who were going through this, to get solidarity, support and connection.’ The group offered weekly peer support meetings, which Rawden facilitated. ‘Each session lasted no more than 1.5 hours, with a set format for sharing, connecting and bearing witness to one another without judgment. No one offered advice or suggestions unless it was asked for. Being simply heard gives people who have suffered a sense of autonomy, agency and value.’
Her message to those with long COVID and those working with them is to listen
to their body and trust what it is saying. She says counsellors and psychotherapists have a key role in helping clients to grieve and develop a new relationship with their changed self, including with their body. ‘Through therapy, people can find it easier to reconcile their experience on their healing journey,’ she says. ‘Very often with COVID, at the beginning when people are immersed in the illness, it is like your emotions fade away. But there is a moment around four months after when the emotions come back in full force – anger, rage and then a low depression, and a feeling of general discombobulation that can look like anxiety – a sort of churning inside. You may experience physical symptoms – increased heart rate, sweating, symptoms of a panic attack. So often clients come to me not realising that what they are dealing with is the aftermath of COVID, whether it’s long COVID or the reconciliation of what they’ve been through.’
For Anu Garg, keeping foremost in mind that long COVID is essentially a physical condition is fundamental to how she works. She is an integrative counsellor/ psychotherapist and accredited EMDR practitioner, and she draws on all these skills in her work with people with long COVID. She sees her role as akin to that of a rehabilitation psychologist: ‘I regard what I do as providing the psychological rehabilitation alongside the physical and medical rehabilitation the client is getting elsewhere.’
The main focus for the work is loss, she says – loss of capacity, loss of functionality, loss of identity, loss of social role, loss of friendships, job, career, relationships – and, unlike bereavement, this loss is continual, gradual and cumulative.3 ‘It is a gradual, continual loss, going on and on. But while working with loss, we are also working with transition. People are constantly comparing who they are now with who they were before, and they generally don’t like themselves now. So, we need to explore what they can do now that they value.
‘Fortunately, many people do have some other skill or occupation they can still do within their reduced capacities, like
‘You are not just losing what your body can do; you are losing what your brain can do – it is a complete loss of self. There is a huge grief’
painting or writing. Some find that their relationships are better because they are not working full-time, so they can spend more time with family and partners. In our work, I will emphasise their improved relationship and how they are perhaps better able to listen and engage with their loved ones. Overall, my aim is to consolidate all that they see value in now, thereby enlarging their value system, but without them devaluing what they were.’
Session lengths may need to be flexible to accommodate the person’s capacity to engage with the work, or she may see them once a fortnight or every three weeks, rather than weekly. ‘Even half an hour can wipe someone out for the whole day,’ she points out. ‘You are gradually transitioning them to the new them. It’s a slow process because it’s two steps forward and one back. They like the new them, but then again, they don’t like it because they are still mourning the old them. Once they accept and adapt to the new them, then you can start to focus on the future and how they can maintain a healthy and better quality of life.’
Another important feature of what she offers is pluralism. ‘Be very multimodal – don’t be precious about your area of expertise, and if you don’t have the skills, refer on,’ she says. ‘Draw on other resources and other professions –occupational therapy resources can be very helpful. Provide them with practical information and resources that they can explore and use.’
Lesley Macniven strongly concurs. ‘For people with long COVID, counsellors should always be thinking “Where else can I direct my client?”,’ she says. She has established an offshoot campaign group that is looking at the implications of long COVID for people’s employment. ‘We need psychological support but there’s also practical support needed urgently around issues like employment and welfare benefits, especially with the cost of living crisis,’ she says. The group (longcovidwork.co.uk) is campaigning for changes to the benefits system and assessments for Employment Support Allowance to recognise the needs of people with episodic conditions like long COVID. Wherever possible, Macniven
says, employers should take steps to enable people with long COVID to stay in their jobs rather than resign or retire early.
Values – identifying and valuing what matters, while also acknowledging what has been lost – also drives the work of Chris Hutchins-Joss, team lead and CBT therapist at DHC Talking Therapies (DHC). DHC delivers IAPT services across Surrey and offers an eight-week groupwork course on ‘Living Well with Long COVID’, in addition to the usual IAPT offer of oneto-one talking therapy with either a CBT practitioner or a person-centred therapist, or guided self-help. Initially, the specialist long COVID clinics generally included a psychologist in the team. This seems to have fallen away and some local IAPT services have stepped into that space by expanding their existing specialist support for people with long-term conditions to include long COVID.
Around a quarter of people presenting with symptoms of long COVID attend the eight-session group, which is based on ACT. The aim of the group is to encourage people to explore what they are struggling with, physically and emotionally, what they are doing to cope with these symptoms in the moment, and how effective those coping techniques are: ‘People talk about worrying about the future, withdrawing from and snapping at loved ones, substance use and overeating – these are all common and very understandable responses to struggling with long COVID. Our role is to help them figure out what is working well and what isn’t, with a view to continuing with what is effective,’ Hutchins-Joss says.
‘We talk a lot on the course about how we hurt where we care – and that is because we do really care.’ So they will explore what participants miss most that long COVID prevents them doing, and what they can do that might serve that same function and meet those needs.
‘You can see the light-bulb moment when they realise there is another way of achieving that same important ingredient in their life. A lot of the work is about shifting our expectations to finding something more practical and feasible in the short term that can achieve it,’ he says.
It is also about rescripting their lives. ‘We all have certain stories about ourselves that we are hooked into – the story we tell ourselves and others about who we are. So the work is about finding how to unhook from those stories and create new ones about how we are dealing with the way that story is changing because of the effects of long COVID.’
As someone who is disabled, counsellor Emma West believes the profession has much to contribute to the multidisciplinary approach to long COVID. ‘I think there is a twofold role. One is helping people manage what is going on at this moment in time and exploring strategies, techniques, lifestyle changes and selfmanagement techniques that work for them. And the second, for long COVID in particular where we know so little about its long-term outcomes, is helping people maintain hope. I am concerned that telling people, “It’ll never get better, and you have to live with that,” could become a self-fulfilling prophecy. Yes, it’s potentially a life-changing loss, so there’s some psychoeducation to be done about the effects of loss and how it’s normal to go through the stages of anger, denial and so forth and come to that place of acceptance. But they don’t have to stop there, and people often need support, such as from a counsellor, to then come up with creative ways of doing things differently and living differently.’
Words like ‘acceptance’ and ‘recovery’ are highly loaded within the ME/CFS and now long COVID world. Says Elizabeth Turp: ‘Acceptance is not the same as resignation. It’s not about accepting
‘Once people accept and adapt to the new them, then you can start to focus on how they can maintain a healthy and better quality of life’
that your problem is permanent. It’s acceptance of where you are now: “This is what is happening to me at the moment, and I am going to stay with that and process it.” I think it’s only when they accept that this is where they are that people with long COVID can begin to learn how to self-manage the condition to make their quality of life better or start to heal.’
Kim Patel has personal experience of living with chronic pain: ‘Acceptance is courageous, because you have to be courageous to actively accept that this is how your life is now and live accordingly,’ she says. It’s what former occupational therapist Lydia Rolley calls ‘living with the new normal’. She is retired now but worked in a regional chronic fatigue service for 15 years, and latterly trained as a systemic family therapist. She has just published a book about recovery for people living with chronic fatigue, which she hopes will also be helpful for those with long COVID who are struggling to manage fatigue.4
The book is a very practical guide to pacing – how, in the early stages, to live within your energy resources and balance your wish to do more with a realistic appraisal of your capacities.
‘The whole concept of “new normal” is a good illustration of this whole condition,’ she says. ‘A lot of people can improve and recover. Where they get to isn’t necessarily where they started but it will be better than how they have been. I use the phrase “reasonable hope”, coined by Kaethe Weingarten – we want people to have hope but not to ask too much of themselves initially.’
‘Just sitting with a professional who believes you is very healing,’ says Turp. ‘You have to learn how to pace yourself,
how to put yourself first and how to ask for help. That is what acceptance is – when you stop fighting, accept that what you are going through is terrible; that it is what is happening to you and there is no point fighting that. But it can take years for some people to get to the point.’
Jan Rothney has recently published a book on recovery from chronic fatigue5 that is based on her hypothesis that it is the body’s response to an overload of stress, physical and mental, and its way of keeping safe. A former health and social care lecturer who has worked with children with behavioural difficulties, she has had ME twice and so brings personal experience and professional knowledge to formulating her Reset to Thrive recovery programme, which she originally ran as a clinic for many years and now online.
Like Turp, she argues that CFS is a result of the malfunctioning of the body’s autonomic nervous system (ANS) – the system that governs how the body responds to threat and danger, whether through fight or flight or immobilisation. The problem is that, when the person is able to start being active again, the ANS has reset the threshold for shutdown at a much lower level, as a safety mechanism to prevent total collapse happening again, she argues. It is then up to the individual to consciously override that new instinctive, self-preserving cut-off, Rothney says.
‘We need to train the amygdala that we are safe – we humans have the capacity to activate the higher brain to override the malfunctioning system. Some people are full of self-loathing and frustration – you need to find emotional detachment, to become this little Buddha that just watches what is happening and is curious about it but knows it’s your instinctive survival system running amok, stopping the polyvagal system from producing normal healthy functioning.’
She too thinks it is important to nurture hope: ‘People need to believe they can recover. Helping them is about introducing them to that belief in recovery, finding excitement in making progress, becoming resilient and changing their expectations of themselves. There is nothing wrong with giving people hope. Without hope, you fall into learned helplessness.’
It is inevitable that, where medical science fails us, people will seek alternative answers. Not knowing and uncertainty about the future are intensely destabilising, as is feeling you have lost control over your life. Concern has been voiced at some of the more experimental, unproven medical treatments that are being sold (at high prices) to the desperate and credulous, such as ‘blood washing’.6 By encouraging and nurturing people’s ability to accept where they are and feel compassion for their changed self and the many losses they have experienced, counselling and psychotherapy can perhaps provide a safe space where they have more chance of finding ways to live within the capacities of the ‘new normal’ for them.
• For further information about pacing for wellbeing, fatigue and post-viral recovery, see www.elizabethturp.co.uk
1. Gov.UK. Coronavirus (COVID-19) in the UK. [Online.] coronavirus.data. gov.uk (accessed 20 September 2022). 2. ONS. Prevalence of ongoing symptoms following coronavirus (COVID-19) infection in the UK: 1 September 2022. [Online.] Office for National Statistics bit.ly/3Um4vVX (accessed 20 September 2022). 3. Garg A. When ‘old Mark’ meets ‘new Mark’. BACP Workplace 2022; 1: 22–26. 4. Rolley L. The fatigue book: chronic fatigue syndrome and long COVID fatigue. Practical tips for recovery. London: Hammersmith Health Books; 2022. 5. Rothney J. Breaking free: a guide to recovering from chronic fatigue syndrome and long COVID symptoms. Glasgow: Arkbound Foundation; 2022. 6. BMJ. Long COVID patients seeking experimental ‘blood washing’ abroad. [Online.] BMJ Newsroom 2022; 12 July.
Catherine Jackson is a freelance journalist specialising in counselling and mental health.
‘People need to believe they can recover. There is nothing wrong with giving people hope. Without it you fall into learned helplessness’
About the author
David Weaver talks to Catherine Jackson about his achievements and legacy as he steps down as BACP President
What counsellors do in the counselling room must be informed by what is going on within the wider society
Catherine Jackson: Although you are not a counsellor, you started working with BACP back in 2004, first as a vice president, then as a governor and then as President from 2017. What inspired and motivated you to give so much of your time and energy to the counselling profession?
David Weaver: Counselling changes lives. That’s BACP’s mantra and I’ve experienced that in my personal life, in my community and for friends and relatives. And it wasn’t always from trained counsellors. Sometimes it has been from ordinary people using counselling skills that I have seen first-hand the impact of counselling.
I was invited to speak at a BACP conference on counselling in the workplace, and I gave a challenge to the Association on issues around social justice and discrimination – to really make itself accessible and relevant to ordinary people, right across the board. I said that my experience of therapists was that what they offered was often not appropriate to many sections of the community – black, working-class and minoritised groups in particular.
CJ: So they promptly invited you to come inside the tent?
DW: They did! And I thought, why not? I felt that I could be of value as an honest broker, or at least an honest critic, if I were inside the profession saying, ‘OK, let me understand what some of the perceived constraints might be to making some real changes’ and issuing a call to others to work together and make things happen. Because I recognised that there were others inside the profession saying much the same things, much more articulately than I could. So there were allies. And I thought I could use my position as a vice president, then governor and President to see if holding up a mirror to the Association could work as a spur to action. I guess the people involved at that time felt they needed that.
CJ: You mentioned that you had counselling? May I ask when and why?
DW: It was in my early teens. I was a victim of a racial attack, and the authorities gave me no support whatsoever. In fact, I was suspected of being the perpetrator. The counselling was arranged through my school, which was predominantly white, although it was done so well, I didn’t actually realise it was counselling until some years later. My father was a social
worker so I had a sense of what therapeutic support was, but if I’d thought it was counselling at the time, I would not have done it, because it would have been an admission of weakness, and along with that comes a stigma. What helped move me forward was this black counsellor’s ability to have a conversation that was culturally appropriate, informed by an understanding of what the issues might be for me, as a young black boy. He tapped into something that both of my parents drilled into me: ‘Only you can make yourself inferior; do not accept that you are anything other than equal to others.’
When the authorities who are there to support you dismiss your experience and more or less accuse you of wrongdoing, and the school doesn’t support you – like Child Q recently in Hackney – that can have major mental health implications. Thankfully for me, that was nipped in the bud through this counselling intervention. Looking back, I realise
I had a lot of anger, and talking to the counsellor helped me process what that was all about and build it into the social justice gene I think I have always had. But still, to this day, when I walk through that neighbourhood in Nottingham, for a millisecond I have two emotions – one is anger and the other a sense of total frustration that white bystanders continue to witness racism and do nothing. Could this happen now, some 40 years later, in the same area? Probably yes!
CJ: What were your main aims when you became President?
DW: My first aim was of course to support the strategic aims of the Association, but critically, for me, that was also about social justice. As well as the important focus on the relationship between the counsellor and the client in the
room, there was a need to make the case for counselling within a social justice framework. It is vital that counselling is made accessible and available to ordinary people as a right and free at the point of delivery.
I also wanted to place race firmly on the agenda. After George Floyd’s murder and the emergent prominence of the Black Lives Matter movement, we are of course in a very different place today. Given the challenges we were facing at the time – austerity, Brexit and then COVID-19 – we needed to recognise the issue of race within its overall social justice context.
In this country, we are quite good at recognising intersectionality, and this is important, but there is a difficulty with highlighting race issues with a level of specificity and focus. I wanted anti-racism to be seen as business-critical to the profession and to its practitioners, in terms of them seeing the potential for making counselling more relevant to today’s society. The learning gained from tackling the issues afflicting the most disadvantaged in society will have enormous benefits for the profession and the wider communities we serve.
Thankfully, mine was not a lone voice calling for change. What I was calling for could only gain momentum through collaboration and alliances. I wanted to use the President’s role as a convening power of itself. Working with and through others to achieve BACP’s aims has planted seeds in the organisation that have set down roots that will be hard to dislodge. There were so many good people in the profession who were able to hold a mirror up to themselves and say, ‘We aren’t doing enough if we don’t have a deeper understanding of what is going on in communities, whatever their ethnicity.’ From this analysis comes the recognition that what counsellors do in the counselling room needs to be informed by what is going on within the wider society – recognising we must be social justice advocates.
George Floyd’s murder was not the first –there have been many other such seminal moments, such as Stephen Lawrence’s murder. I was involved in supporting the Lawrence family at that time. I remember the wringing of hands and declarations that we needed meaningful change, but then the further you move away from these legacy moments, there’s a tendency to default to talking about race and racism in whispers. So, for me, it was about how you get people first to speak about these painful
‘He tapped into something my parents told me: “Only you can make yourself inferior; do not accept that you are anything other than equal to others”’
matters and then to follow through by searching for solutions. Leadership requires followers, so it was about how to engage people who don’t usually show up at meetings to talk about race. We can’t get away from the fact that the profession is needed because inequalities exist, and the greatest need resides at the margins of society.
CJ: Has that been sustained, that initial surge in emotion and commitment to tackling racism following George Floyd’s murder?
DW: People are now talking much more about race. There’s a question as to how much has trickled through in terms of systemic changes throughout the profession. There’s the initial outpouring of anger and disgust and declarations of the need to change, but then organisations are faced with having to deal with serious business challenges such as finance, and, unless there is a systemic push to change the way people are thinking, they revert to type. They fail to prioritise the things they said they would. I think that has happened within counselling training – many conversations have taken place but very little has changed in terms of the curriculum. I still get no end of correspondence from black students saying they feel ‘othered’, that their lived experience counts for nothing, that they’ve been marked down when they’ve brought forward legitimate conceptual frameworks that are outside the Eurocentric way of looking at things. The dropout rates speak to that experience.
If we want to achieve systemic change, we need to provide support for the next generation of people who are training or wanting to develop within the profession. It’s vital that academic institutions look at the curriculum and make it relevant across all the intersectionality issues. Indeed, there is a dissonance between the intellectual content of the training being
delivered and the society around us, which inevitably impacts on the experiences of the clients in the room.
There are many people who aren’t professionally trained counsellors who actually have the potential to make the profession relevant to ordinary people. My barber has saved hundreds of lives in my opinion through applying naturally acquired counselling skills and techniques. People have come to him feeling suicidal and he has turned them away from it – people bringing their family problems, domestic relationship problems, housing and debt problems and so on. I spotted his talent and convinced him he’d make an outstanding counsellor and he decided to apply to train. He didn’t get in – he was told he didn’t have the requisite skills. The profession has got to look at how it attracts and fosters the talents of diverse people and properly evaluates aptitude and different life experiences.
CJ: Is BACP doing enough? Has it continued to push forward systemically on the issue of race?
DW: BACP’s commitment to the black student mentoring and bursary scheme is such a major step forward. The challenge for all our institutions and professions is how to elevate race equality from being a short-lived project to becoming systemic to institutional culture and practices. BACP has started that. But this is not just about BACP – it’s about leadership across all parts of the counselling professions and professional bodies in the health and social care sector.
CJ: On the other hand, how many other such bodies have a black President and a black Chair?
DW: Not enough I’m afraid, and BACP and its members must be given credit for this. It is important that this becomes much more the norm as organisations need to attach more significance to the value of lived experience as an essential criterion for leadership in this country. Black faces in high places are important but it should not just be about that. There is an onus on all leaders to be specific about race equality, and this should be central to their organisation’s strategic agenda.
CJ: In your time as President, what was the biggest challenge you faced?
DW: I think here it’s more relevant to talk about the challenges BACP has faced. There is the continuing challenge around ideology. I think some institutions, professions and individuals have lost sight of their noble cause – keeping the end in sight. Sometimes that means setting aside short-term interests and widening participation in the debates we are having. Everyone needs to look at themselves in the mirror. Changes in the profession and how people perceive it require professional humility, hearing people out and suppressing the knee-jerk reaction to vilify the messenger – whatever the positions you take.
CJ: And what is BACP’s noble cause?
DW: The noble cause is what counselling can do to improve people’s lives and how it can help to change their circumstances for the better. That means giving consideration to the cultures of people who show up in the counselling room and what that means for training and for therapeutic approaches. As a younger man, I was involved in the anti-apartheid movement, where there were massive differences between different factions. But what brought us all together was that compelling vision of our reason for existing. BACP needs to continue to crystallise that for itself and get buy-in from its members to the emerging rallying cry. While we remain infighting on intra-professional issues, people are suffering for the want of what we can offer. It’s people’s lives being blighted – people in pain, people not realising their potential. Social neglect costs lives. It is our duty to get governments, funders and policy makers to recognise that cost.
CJ: What is your proudest achievement?
DW: I am proud that I’ve been able to use the convening influence of my role as President to get different people around the table to address
‘The noble cause is what counselling can do to improve people’s lives and how it can help to change their circumstances’
‘When you get race right, you get so much else right too for other minoritised groups and for the mainstream’
a wide range of issues in positive, solutionsfocused ways. This has involved support as well as challenge for the organisation and profession. On another level, I am proud to have led on the issues of entry and better representation within the profession. The bursary and mentoring programmes are a particular source of pride.
Early days into my presidency, I remember responding to two requests from members, one friendly, one much more challenging, demanding a black issue of Therapy Today. It was good to make that happen, with you, Catherine, as editor at the time, and the editorial advisory team. I am proud that, when I first started banging on about social justice, there was a lot of discomfort around me, but that has dissipated and become part of the mainstream discourse within the Association. Finally, I am immensely proud of continually placing race on the agenda. The downside of that is that some people may see me as a single-issue president. That is a reductionist view of me. I have worked on a significant range of issues across the counselling, mental health, social care and political spectrum. However, if that is my enduring legacy, so be it! Like I said, so much flows from the principle: when you get race right, you get so much else right too for other minoritised groups and for the mainstream population.
CJ: Is there anything you would have liked to achieve and ran out of time?
DW: There is work still to be done in really bringing race in from the margins to the mainstream. It is not just a matter of principles, morals and values; it is business-critical too. We’re making progress in terms of our vision, strategic thinking and our priorities in this area, but there is still more work to be done to take it from theory to reality. My dad’s generation would say, ‘That is for the next generation to do.’ Maybe every generation thinks that there is more we could have done – in that regard and many others, I fall in line with Dad.
CJ: And it’s for the next generation to take what they’ve learned and do it their way?
DW: Absolutely, do for self – organise for yourself, decide on self-determination as a way of achieving what you think is right. During the COVID-19 pandemic, I attended numerous online meetings, initiatives and events, some through churches and mosques – it reminded me of the power of doing for self out of
necessity. The profession could learn a lot from some of those approaches.
CJ: What has most helped you in achieving your aims?
DW: Collaborating with people who are committed to the profession. I have been lucky to experience real passion and commitment from people who have been called to do this work – that’s motivated me. I’ve been fortunate to learn from people who come my way with a request asking me to put forward this or that because no one else is listening to them. Listening to people wanting to get stuff done provides opportunities to harvest the extraordinary talent that is out there. It can be challenging but listening to ‘honest critics’ can also be fulfilling. I confess, sometimes you go to meetings, and you think, there’s just no pleasing some people! But it’s important to listen – there’s always something to be learned, and there is always more that can be done.
CJ: As a professional coach and mediator yourself, what would you say are BACP’s greatest strengths to take it forward into the next presidency? And its weaknesses?
DW: I think it represents the profession well. There is a constancy to its purpose, and it has increased its membership, which doesn’t happen by accident. I think it’s beginning to think of itself not just as a membership body but as a membership body that operates within a wider professional and health and social care arena and has a social purpose. It has good staff who understand political considerations; it is good on the evidence base for what its members offer. But – and this is a challenge, not a criticism – it needs to continue to work on how it harnesses different opinions and work to build higher levels of trust. It can’t just be three or four individual officers doing that well. It needs to develop an approach that the whole organisation understands is how things are done within BACP values, regardless of who is in those significant roles.
And it needs to draw some bottom lines in terms of acceptable behaviour within the profession. It needs a code of practice like the Ethical Framework that liberates rather than constrains but is clear about how members are expected to behave towards the Association and each other and how they can expect the Association to behave.
CJ: And last, you will have all this time on your hands (I’m joking, of course!) – what do you plan to do with it?
DW: I will still be busy with my own organisation and commitments, but my mother died a few months ago, and I want to be able to spend more time with my grieving father, family and close friends. And I need to lose a bit of weight! But I will still be around in the political leadership, health and social care arenas and in the background at BACP, supporting the bursary and mentoring initiative.
And to end, I want to give particular thanks to the Board, staff at BACP and the vice president team, who have all shown real commitment to the work of the organisation. I would also like to pay a special tribute to Nancy Rowland, who steps down as a vice president at the AGM. Nancy was previously a deputy chief executive of BACP, has been incredibly supportive to me throughout, and has made a tremendous contribution to the profession.
David Weaver is a former social worker, university lecturer, local authority senior manager and political advisor to senior government minsters. He is a senior partner in DWC Consulting, a leadership and change management organisation working with public, commercial and not for profit organisations.
Catherine Jackson is a freelance journalist specialising in counselling and mental health.
For a client, an important aspect of the helpfulness of therapy lies in the capacity of their counsellor, psychotherapist or other provider of emotional support to use counselling skills in an effective manner. Clients value moments when a counsellor listens in a way that allows them to know they are being heard, shares a relevant reflection, or asks a question that makes it possible to see an issue from a different perspective. By contrast, the hope that counselling might make a positive difference may be terminally undermined by selective or inattentive listening, awkward or self-serving personal disclosures or interrogative lines of questioning.
Counselling skills represent a creative and embodied dimension of therapy. The implementation of a skill in a real-life situation requires a capacity to improvise in response to what is happening in the moment. In occupations that involve these elements – for example, being a tennis player, violinist, surgeon, carpenter – there has always existed a strong tradition of routine, regular engagement in skills practice and skill learning/updating across the whole of a career. As therapists and as counselling educators and researchers, we believe that a similar approach has the potential to be beneficial for our own profession.
The idea that it could be valuable to regard counselling and psychotherapy practice as being grounded in a set of
interpersonal skills emerged from the work of Carl Rogers, Robert Carkhuff, Charles Truax and colleagues, in the context of the development of training programmes for client-centred counsellors in the 1940s. Since that time, almost all therapists, as well as many practitioners in allied fields such as healthcare, education, social work, clergy and the police, have had the experience of learning to use core skills such as listening, summarising, challenging, questioning and self-disclosure. The capacity to use counselling skills in a responsive and facilitative manner has been supported by a range of skills models and taxonomies, and research.1
At a professional level, competence frameworks and procedures for
Recent theoretical shifts in the way that therapy is understood confirm the importance of counselling skills, say Julia and John McLeod
accrediting training have been established by BACP and Counselling and Psychotherapy in Scotland (COSCA).
However, despite the fact that there exists a broad understanding of the importance of counselling skills, it can be argued that there has been a tendency to regard this aspect of practice as something that is important in the first few months of training but can then be taken for granted. Our aim in this article is to illustrate some of the reasons we believe that reflection on skills and ongoing skill development, backed up by relevant research and critical inquiry, are essential components of effective practice for all counsellors and psychotherapists.
Counselling skills are grounded in interpersonal, communication, relationship and social skills that operate in everyday life. In evolutionary terms, the capacity of human beings to survive and thrive was dependent on a capacity to share information and work together in groups, using such skills as storytelling, listening, sensitivity to emotional states, planning and conflict resolution. These capabilities continue to operate as the common ground of contemporary social life – counselling skills can be understood as comprising the application of generic interpersonal and communication skills for a specific purpose. Practising listening skills in a counselling training setting is not a matter of learning something for the first time; students in skills classes draw on a wide range of experiences of both helpful and unhelpful listening – and being listened to – from an early age. By creating opportunities for revisiting deeply ingrained ways of relating to others, the process of developing counselling skills can be experienced as both emotionally challenging and life-enhancing for students and trainees, particularly in respect of an ability to be open to painful emotions.2,3 Participation in this kind of learning process also builds an appreciation of what it can be like for clients to change their ways of interacting with other people in their life,
and the likelihood of encountering situations in which you are pulled back into earlier ways of being.
Important research into the links between interpersonal skills and effectiveness as a therapist has been carried out by Timothy Anderson and colleagues at the University of Ohio.4 These studies found that the majority of individuals who entered therapy training possessed good interpersonal skills. However, what made the difference in those who turned out to be more effective in their work with clients was a capacity to maintain skilful and responsive contact with clients in situations of emotional pressure, such as the client becoming demanding, angry with the therapist or withdrawn. By contrast, less effective therapists exhibited a tendency to become defensive and less empathic when what was happening in a session took them out of their comfort zone. These studies also found that, to a large extent, a pre-training measure of the ability to exhibit interpersonal skills under pressure, based on a brief role-play exercise, strongly predicted success with clients at the later internship or placement stage of training.
Further evidence for the significance of interpersonal and counselling skills can be found in studies that compare the effectiveness of minimally trained helpers, who possess counselling skills and relevant life experience, with the client outcomes observed in fullytrained professional counsellors, psychotherapists and psychologists working with comparable clients. Such studies have consistently reported
that similar outcomes were recorded by practitioners using interpersonal and counselling skills and those who had received several years of specialist training.5,6
Learning to use counselling skills in a way that facilitates productive client understanding and change does not occur only – or even mainly – during initial training. Rather, it takes place across the whole of a therapist’s career. In a recent study, experienced therapists were interviewed about their experience of learning to make effective use of the skill of therapist self-disclosure, purposefully sharing biographical information or stories from their own life with clients.7 These practitioners described a series of learning episodes that tracked back across the whole of their professional careers. For example, many of them reported that their initial training had highlighted a basic rule for using self-disclosure – avoid doing it. At later points, they periodically revisited this skill and refined their implementation of it, in response to experiences in supervision, personal therapy, work with specific clients, working in different settings, training and reading research studies. For example, some participants in this study talked about how the experience of offering online therapy during the COVID-19 lockdown – a situation in which it was obvious that both their clients and they were affected by anxiety and uncertainty arising from the pandemic – called for reflection around how to acknowledge this shared reality in an appropriate and therapeutically helpful way.
There is a growing body of evidence that the most effective practitioners, in all occupational groups, are those who engage in deliberate practice – being open to feedback in relation to occasions when their responses have been ineffective, devising an action plan to remedy this skill deficit, and devising situations in which they could engage in repetitive practice of the target skill.8,9 A deliberate practice perspective can be integrated into routine supervision, making it possible for the therapist and supervisor to identify and then work
‘Reflection on skills and ongoing skill development are essential components of effective practice for all counsellors’
together on specific instances when counselling skills have broken down under pressure.10
One of the great strengths of the counselling and psychotherapy professional community is its level of innovation and creativity around new ways of making sense of how therapy works. New ideas are constantly promoted through books, articles and CPD workshops. To make a difference to practice, therapeutic theories and ideas need to be translated into specific skills that are enacted in sessions. For example, in recent years there has been a lot of interest in the principle of feedback-informed practice, in which clients complete routine outcome measures on a regular basis to enable their therapist, and themselves, to monitor whether therapy is helping them to reduce their symptoms and distress. What has become clear in a number of research studies is that, while sometimes this approach can be helpful for clients, in other cases it has no effect.11
These contrasting outcomes arise from several factors, of which the most significant is the skilfulness, responsiveness and sensitivity of the therapist in introducing and explaining the purpose of completing symptom and satisfaction measures, and then being able to facilitate a conversation that draws out the implications for how to realign the therapy process in order to achieve better results. This line of exploration can place a heavy demand on therapist skills. It represents a classic example of exhibiting skills under pressure – in this instance, the potential discomfort of the therapist in being open to being told that aspects of their way of responding to their client have been unhelpful.
A major theme in the current therapy literature has been a growing appreciation of the importance of acknowledging the extent to which cultural diversity influences the interaction between a client and therapist. For example, many therapists have worked hard to develop an
understanding of how racism, colonialism, white privilege and intergenerational trauma have shaped their own lives, and the lives of their clients. The skill of broaching – the therapist taking the initiative and engaging in appropriate modelling to invite the naming and exploration of the possible relevance of differences in life experience, standpoint and identity – has emerged as a practical skill that makes an important contribution to working constructively with a range of diversity issues.12,13
A further significant theoretical shift in the way that therapy is understood is reflected in increased interest in seeing therapy as a collaborative, co-created process. From such a perspective, skills in using dialogue and shared decision making have the effect of promoting the client’s active engagement in therapy, to enable them to draw on their personal strengths and resources in order to navigate their own recovery journey. Adopting such an approach involves the cultivation of specific collaboration skills.14 Some of these skills operate at a micro-level of fluency word choice, such as sensitivity to the implications of using ‘we’ rather than ‘you’, or an appreciation that starting a response with the phrase ‘So…?’ can be a form of conversational control.15
Therapy tends to be a boundaried and contained activity that involves limited involvement of practitioners from other occupational groups, such as social
workers, healthcare professionals and teachers. This approach makes sense if therapy is considered as a specific intervention that aims to have an identified effect or impact on a client, such as reducing anxiety or depression. However, it runs the risk of failing to recognise that the reality for many clients is that their recovery from adverse life experience is supported by contact with helpers from many different backgrounds, in a range of settings. An important challenge for counselling and psychotherapy professionals is to learn how to build points of connection with colleagues from other occupational groups.
Training, research and practice around counselling skills represent a potentially highly productive area for interprofessional collaboration across all those involved whose work aims to promote mental health and wellbeing and sustain networks of emotional and social support. Many entry-level counselling skills programmes comprise groups of learners from a wide array of occupations. Some of these individuals go on to develop emotional support and embedded counselling services within their pre-existing work roles as teachers, social workers, nurses and clergy, grounded in their capacity to make use of counselling skills.16 There is a lot to be learned from the experiences of colleagues in other occupations around how to exhibit facilitative interpersonal and counselling skills when under pressure. For example, the police service has developed skills, strategies and training around how to support individuals who are in a state of extreme crisis. Social workers and call-centre responders have a deep understanding of how to work with clients who are hostile. Doctors, nurses and pharmacists have devised ways of facilitating productive therapeutic conversations within brief windows of opportunity.
Counsellors and psychotherapists are not the only practitioners who possess skills to help people who are struggling to cope with emotional, behavioural and interpersonal difficulties. The knowledge and experience of social workers, nurses, doctors, teachers and
‘One of the strengths of the counselling and psychotherapy community is its innovation around making sense of how therapy works’
many others who respond to the emotional and psychological needs of service users comprise a bridge between counselling and other professions that could be further developed in mutually beneficial ways. An important example of the relevance of skill-sharing and interprofessional collaboration can be found in a review of the relative effectiveness of mental health support for people affected by COVID-19 in different countries.17 This study found that, on the whole, countries in the Global South that had limited specialist mental health provision were able to respond rapidly and effectively in offering emotional support through creative and flexible services delivered by health and social care practitioners using counselling skills. By contrast, countries in the Global North, where there were well-funded psychology and mental health services, often did less well because they relied on protocols and procedures that were slow to adapt and change.
We believe that it would enhance both the social relevance of the counselling profession and the effectiveness of individual therapists if there were more discussion and research and more CPD and supervision opportunities around the topic of counselling skills. In advocating such a position, we are not suggesting that other aspects of therapy practice – theory, self-awareness, ethics, commitment to social justice – should be ignored. Effective therapy requires an ability to draw on all of these areas.
Developing facilitative and responsive counselling skills is essentially about sharing our experiences of what works and does not work – our practical, craft-based understanding of ‘how to’ do things in therapy.18 This process of refining a skill requires actual practice in a situation where it is possible to obtain feedback, preferably from a client, or someone in the role of client, around the helpfulness of one’s response to them. Skills development also requires critical reflection. Skills are complex –their helpfulness is highly dependent on context, and barriers to their effective
implementation are often rooted in significant themes in the therapist’s life experience and cultural identity. Critical reflection makes it possible to see that what may appear to be highly skilful practice may have unintended negative consequences.19
The field of counselling training has generated a substantial repertoire of structures for supporting skills learning, encompassing modelling, practice in triads, video feedback and activities adapted from art and drama.1 Skills learning can be highly emotionally demanding, because it involves trying out unfamiliar ways of talking and responding, and learning from mistakes. It can also be extremely satisfying, by making a tangible difference to your resourcefulness and helpfulness with clients. Skills practice activities provide unique opportunities to learn something new about ourselves and our work.
Julia McLeod is Lecturer in Counselling at Abertay University Dundee. Her publications include books, articles and chapters on counsellor training and development and the use of counselling skills by practitioners in human service occupations. Her latest publications include the third edition of Counselling Skills: theory, research and practice and Embedded Counselling in the Helping Professions: a practical guide, both co authored with John McLeod and published by Open University Press.
John McLeod is Visiting Professor of Counselling at the Institute for Integrative Counselling and Psychotherapy in Dublin. He has published books, articles and chapters on a wide range of topics in counselling and psychotherapy theory, practice and training, and is committed to the development of flexible, co-produced and pluralistic approaches to therapy.
1. McLeod J, McLeod J. Counselling skills: Theory, research and practice (3rd ed). Maidenhead: Open University Press; 2022.
2. Mackenzie A, Hamilton R. More than expected? Psychological outcomes from first-stage training in counselling. Counselling Psychology Quarterly 2007; 20(3): 229–245. 3. McLeod J, Lumsdaine S, Smith K. Equipping students to be resourceful practitioners in community settings: A realist analysis. European Journal of Psychotherapy & Counselling 2021; 23(4): 496–525.
4. Anderson T et al. A prospective study of therapist facilitative interpersonal skills as a predictor of treatment outcome. Journal of Consulting and Clinical Psychology 2016; 84(1): 57. 5. Stein DM, Lambert MJ. On the relationship between therapist experience and psychotherapy outcome. Clinical Psychology Review 1984; 4(2):127–142. 6. Tandon SD et al. Comparing the effectiveness of home visiting paraprofessionals and mental health professionals delivering a postpartum depression preventive intervention: a cluster-randomized non-inferiority clinical trial. Archives of Women’s Mental Health 2021; 24(4): 629–640. 7. Webster B. An exploratory study of pluralistic therapists’ views and lived experiences of therapist self-disclosure. Dundee: BACP Research Conference 2022; 19 May. 8. Ericsson A, Pool R. Peak: Secrets from the new science of expertise. London: Bodley Head; 2016. 9. McLeod J. How students use deliberate practice during the first stage of counsellor training. Counselling and Psychotherapy Research 2022; 22(1): 207–218. 10. Rousmaniere T. Deliberate practice for psychotherapists: A guide to improving clinical effectiveness. Abingdon: Routledge; 2016. 11. Solstad SM, Kleiven GS, Moltu C. Complexity and potentials of clinical feedback in mental health: an in-depth study of patient processes. Quality of Life Research 2021; 30(11): 3117–3125. 12. King KM. ‘I want to, but how?’ Defining counselor broaching in core tenets and debated components. Journal of Multicultural Counseling and Development 2021; 49(2): 87–100. 13. Lee E et al. Microskills of broaching and bridging in cross-cultural psychotherapy: locating therapy skills in the epistemic domain toward fostering epistemic justice. American Journal of Orthopsychiatry 2022; 92(3): 310–321. 14. Sundet R et al. A heuristic model for collaborative practice –part 1: a meta-synthesis of empirical findings on collaborative strategies in community mental health and substance abuse practice. International Journal of Mental Health Systems 2020; 14(1): 1–6. 15. Hollingworth A. So, you think your counselling practices are collaborative? Psychotherapy and Counselling Journal of Australia, 2017; 5(1). 16. McLeod J, McLeod J. Embedded counselling in the helping professions: A practical guide. Open University Press; 2022. 17. Kola L et al. COVID-19 mental health impact and responses in low-income and middle-income countries: reimagining global mental health. The Lancet Psychiatry 2021; 8(6): 535–550. 18. Doherty B. On crafting the perfect therapy opening. Psychotherapy Networker Symposium Keynote 2013. Available at: bit.ly/3TW19Jj 19. Margolin L. Rogerian psychotherapy and the problem of power: A Foucauldian interpretation. Journal of Humanistic Psychology. 2020; 60(1): 130–143.
A pluralistic approach allows therapist and client to collaboratively reflect on existential experience, says John Hills
We reach significant turning points in our lives which might be described as ‘existential crises’ where stark realities come into the foreground of our experience.1 We might experience a wondering about why we are living this specific life and not others. Why this partner? Why this place? Why these friends? Why this job? (Or, more generally, what the hell are we doing?) It may involve a questioning of the meaning of things – why does this matter? Why should we care? It may also involve an acute awareness that we and/or the people we love are going to die. Often it’s at these points that clients seek out therapy.
There are diverse routes through which client and therapist might work collaboratively to turn into and reflect on existential experience, allowing clients to uncover different strategies through which to re-realise connection and continuity. This diversity makes a pluralistic approach a naturally good fit for responding to existential crises.2,3
Existentialism may be thought of as a middle-class concern for those of us with the luxury to ponder such things. Nonetheless, in this article I’m going to explore the idea that we are all confronted with the same perennial conditions of life, which I identify here as impermanence and incompleteness.
In his essay On transience, Freud recalled a summer walk with a poet through the countryside, with flora and fauna in full bloom.4 The poet was mournful, not able to enjoy that moment for the knowledge that everything there, just like all nature, art, beauty and civilisation, would one day perish. Freud countered that the finitude of things made their transient beauty all the more precious and meaningful: ‘A flower that blossoms only for a single night does not seem to us on that account less lovely.’4
Impermanence is the idea that everything, everywhere is forever in flux, ever changing. No state of affairs will go on unchanged –whether a personal experience of happiness and actualisation, a relationship that seems to answer all our questions, a home we’ve worked so hard to maintain, or indeed life itself. This too shall pass. We know impermanence when we cling on all the tighter to those we love, knowing that one day one of us will die. Impermanence is implicit in the first of Yalom’s ‘four givens’ – the inevitability of death.5 As Yalom observed: ‘Life and death are interdependent; they exist simultaneously, not consecutively; death whirs continuously beneath the membrane of life and exerts a vast influence upon experience and conduct.’5
Impermanence sits at the heart of Buddhist thinking too. These words from Sogyal Rinpoche in the Tibetan Book of Living and Dying speak to its permeating of all life: ‘Every time I hear the rush of a mountain stream, or the waves crashing on the shore, or my own heartbeat, I hear the sound of impermanence. These changes, these small deaths, are our living links with death. They are death’s pulse, death’s heartbeat, prompting us to let go of all the things we cling to.’6
Parallel and intimately related to impermanence is a perennial sense of incompleteness. By incompleteness I mean that, aside from transient moments where our lives feel complete, these moments are always on their way to somewhere else and, as such, our lives are ordinarily experienced as incomplete. The way I see incompleteness is to think of a cyclical pattern, like a physics textbook diagram of the swinging of a pendulum, or a little pocket book of tide times such as would be useful to a local fishing community. At what point within the cycle is the cycle complete? Any point in the cycle is always on its way to somewhere else. Likewise, when is a family complete? Members are ever joining, transitioning and leaving. And at which time in my life was I living the life I was born to live? Moments
of satisfaction are typically followed by an ‘OK, what next?’ orientation. Or a moment of apparent completion may feel empty and dissatisfying when arrived at. I am reminded of the Peggy Lee song ‘Is That All There Is?’, which speaks to repeated experiences of disillusionment with life. There’s more fun in the song than I’m making it sound here, and Lee’s consolation comes through in the chorus line: ‘If that’s all there is, my friends, then let’s keep dancing.’
I think we also experience that sense of incompleteness when we become aware that with every choice we make, we exclude the possibility of other lives we might have lived. This might be about the place we live or the people in our lives. We have a taste of this feeling too, knowing that there is not enough time in one lifetime to read every book or travel to every place that you would wish to. The reality is that, to pursue this certain life, we let some of our potentials wither on the vine, but they linger like phantom limbs in the internal concept of self.
Expressing these ideas matters because it reframes instances of dissatisfaction, disillusionment, loneliness or meaninglessness. These may not be indicators that something has gone wrong psychologically or socially; rather, they might be seen as impermanence working within and between us, natural and true. There is hope, where we can respond to those feelings as a calling towards reconnection and renewal.
As therapists, we may meet with our clients in a state of existential crisis – moments when it feels like the veil has been lifted to expose a cold, painful or absurd reality. Martin Adams observed that ‘clients come to us when they feel their autobiography is not making enough sense, or has ceased to make enough sense’.7 Our clients might arrive with a feeling that they have plateaued, or with a disappointment with what they have. They may report a senselessness: ‘Why should I care?’ or ‘What is the point of any of this if we’re all going to die?’
Berra identified some of the symptoms of an existential depression as insomnia, boredom and hopelessness. However, from the inside, an existential crisis may be experienced as ‘an excruciating state of suspension in the void, in the total absence of
‘We know impermanence when we cling on all the tighter to those we love, knowing that one day one of us will die’
any certainty […] a painful and perilous state of emptiness and suffering, not easily tolerable’.8 The therapist’s response, as far as Yalom is concerned, is relatively straightforward – our clients are challenged to discover their own wisdom, their own intuitions about the meaning of life.9 Importantly, however, according to Bugental, the ‘growth alternative’ to an existential crisis necessitates a ‘leap in the dark’ – into territories previously unknown and uncharted by the client.1 This theme appears to be taken up by contemporary theorists informed from a dynamic systems perspective that identifies the client’s experience of novelty as a crucial ingredient in therapeutic change.10,11
A core therapeutic aspect of a person’s presentation may be the ways in which they are avoiding confronting the existential realities of their lives. Some examples of these styles of avoidance include: ■coasting by passively going along with life or others’ agendas ■self-sabotage, such as procrastination, mindless habits, debt ■addictive behaviours, such as alcohol, exercise, shopping, video games ■symbolic means of taking control, such as self-harm, restrictive eating.
And some that might be experienced keenly in the therapeutic space are: ■grievance and victimisation (externalisation of the problem) ■lurching from one drama to the next ■pretend mode – the client appears to be reflecting but nothing vital is being reflected on.
These patterns may also, of course, be presented by traumatised clients, and with some it may be more appropriate to think of trauma than existential crisis. My therapeutic response to encountering these patterns is to gently observe them taking place, either within the session or within the client’s reports, and be curious about when they seem to become super-charged. I enquire either implicitly or explicitly about what may be being hidden or obscured by these patterns. In an accepting and trusting therapeutic relationship, this tends to enable us to start to make contact with the core concern.
Wong argues that, since existential psychology is concerned with human existence, it is relevant to all people, and he therefore recommends existential competencies for all psychotherapists.12 He advocates therapy that is pluralistic in nature, departing from psychology’s ‘tribal or silo mentality’ and, instead, emphasising the importance of collaboration and drawing from the wisdom of diverse psychologies. As a pluralistic therapist, there are some core therapeutic dynamics that I have found essential to working existentially. These include:
■therapeutic exposure – our clients being able to recognise and confront that which they’re afraid of in an accepting and containing therapeutic space.13 This may also involve exposure to the therapist’s relative existential clarity ■‘towards and away’ observations within sessions, such as ‘I saw you light up when you spoke about that’ or ‘I feel like we’re not quite connecting just now’, often mirrored by the client’s towards-and-away moves out in the world.14 This can help to uncover and work with potential experience avoidance ■the metatherapeutic current – the parallel reflective thread between client and therapist, which is concerned with the nature of the therapy itself: what our purpose is, where we’re heading, and how we get there.15 This can help the client to feel they have ownership and responsibility in the therapeutic work.
Here are three psychological processes that I have found frequently come into play when working existentially:
1. Making active decisions rather than passive ones. Where clients appear to be coasting along or otherwise living inauthentically, they may come to recognise the idea that they have made passive decisions about their lives. A helpful therapeutic approach might be to model to the client
their own free will versus a sense of fatalism. We can often feel paralysed by the burden of making decisions, when either ‘path’ seems fraught with pitfalls and dangers. So sometimes it can be helpful to model the principle that, the decision having been made, it’s then their own responsibility to make it work. Therapeutic activities might include helping the client to identify their values and consider what committed action in the service of those values might look like.16 Indices of change might include the client’s clarity about their own needs and wishes, purposeful action and a greater sense of control.
2. Acceptance of our ‘unacceptable’ parts. Sometimes clients might report the occasional appearance of ‘out-of-character’ behaviours. Or they might present with shame or even the experience of living a ‘double life’: ‘If only they knew what I was really like…’ The concealment of the shame is typically exhausting work. A helpful therapeutic approach might be to introduce the idea of parts: for example, ‘It sounds as though a part of you feels… while another part…’ Attempting to identify the good intent of the different parts, even those that originally seem rotten, can help towards acceptance of multiplicity. Therapeutic activities might include encouraging the client to name and personify their different parts. Perhaps there is a motto that a part lives by. Perhaps dialogue is possible between the parts. Indices of change might include a greater awareness and acceptance of different parts and, in that, sometimes a sense of greater freedom and physical lightness.
3. Empathy for self and others. Here I mean an empathy particularly informed by ‘our ultimate aloneness’, another of Yalom’s ‘four givens’.5 We locate ourself as someone seeking connection in relation to others. Clients might present with avoidant behaviours, with the objectification of others, or misunderstanding others’ intent or even egocentrism. It can be helpful sometimes to
‘Where clients appear to be coasting or living inauthentically, they may come to recognise that they have made passive decisions about their lives’
model the idea that we each seek connection in our own diverse ways, which might be akin to ‘love languages’.17 Therapeutic activities might include journalling or writing exercises; a decentred curiosity about how a situation might be experienced by others; narrative and constructivist approaches, or creative representations of self, others and the world. Indices of change might include the client making more ‘I’ statements, rather than ‘you’ or ‘they’ statements, having more realistic expectations of self and others, greater compassion and the discovery of new strategies of connection and continuity.
My argument therefore is that we seek to sublimate our experiences of impermanence and incompleteness through connection and continuity, and that there is a plurality of strategies through which we re-realise connection and continuity. I see these as falling into four general families:
1. Attachment to life. Reconnection might mean a renewed commitment to healthy living; it might mean clarity in our career, or doing work that is more personally meaningful. The attachment to life might mean reconnection and renewal in one’s core relationship(s), fighting for a cause in the time that we have, or a devotion to some form of creativity.
2. A stake in the world beyond one’s lifespan. Continuity might be achieved biologically through the children that we have, nephews or nieces that we support or as teachers in the footholds we create for our students. It might mean a conscious modulation of an intergenerational legacy –repeating in this generation the positive ways in which we were parented and resolving to do other things differently. It might mean a sense of connection with ancestors and descendants through the generational continuum, or a commitment to a certain traditional life that we wish to keep alive in our generation and pass on to the next. Alternatively, continuity might be experienced through the good works that we perform that become a legacy that survives us. It might also simply mean making sure those we love know they’re loved before we are parted.
3. Spiritual perspectives. We may also seek to reconnect through a religious faith, which might include, for example, a personal relationship with God or with spiritual beings and a belief in an afterlife, whether a destination such as heaven or a belief in reincarnation. Others may assume a more pantheistic attitude towards the world; they may take their lead from ‘the universe’ and apparently meaningful synchronicities.
4. Embracing impermanence. Finally, we might embrace the impermanence of all things, finding meaning in a non-attachment to people and situations while remaining loving and compassionate in that non-attachment, or otherwise expressing ongoing gratitude for the world just as it is. It might mean a sense of communion with an eternal now, and it might mean a sense of homecoming as we return to the same elemental and recurrent nature that we were born into.
Of course, it isn’t for us therapists to determine which of these strategies is the ‘correct’ one for our clients. The strategy in any case typically feels more like discovery than design. However, we may continue to offer wonderings about how well, or otherwise, a strategy enables a client to re-realise connection within the totality of their life. In this way the existential crisis may pass, like a storm that rains itself out, as the person emerges into reconnection and renewal.
Dr John Hills MBACP (Accred) is a teacher and trainer at Leeds Beckett University, also working in private practice. John’s PhD centres on the meanings and patterns of therapeutic change. He is currently researching the social determinants of mental health and their implications for counselling and psychotherapy.
1. Bugental JF. The existential crisis in intensive psychotherapy. Psychotherapy: Theory, Research & Practice 1965; 2. 2. Cooper M and Dryden W (eds). The handbook of pluralistic counselling and psychotherapy. London: Sage Publications; 2016. 3. McLeod J. Pluralistic therapy: distinctive features. Abingdon: Routledge; 2018.
4. Freud S. On transience; 1915.
In: The standard edition of the complete psychological works of Sigmund Freud, volume 14. London: Hogarth Press; 1957 (pp303–307).
5. Yalom ID. Existential psychotherapy. Minneapolis: Yalom Family Trust; 1980. 6. Rinpoche S. The Tibetan book of living and dying. London: Rider & Co; 1993. 7. Adams M. Human development and existential counselling psychology. Counselling Psychology Review 2014; 29 (2).
8. Berra L. Existential depression: a nonpathological and philosophicalexistential approach. Journal of Humanistic Psychology 2021; 61(5).
9. Yalom ID. Staring at the sun: overcoming the dread of death. London: Piatkus; 2018. 10. Bonn E. Turbulent contextualism: bearing complexity toward change. International Journal of Psychoanalytic Self Psychology 2009; 5(1): 1–18.
11. Trop JL, Burke ML and Trop GS. Psychoanalytic theory and psychotherapy: a dynamic systems view of change. Clinical Social Work Journal 2013; 41: 134–142.
12. Wong PTP. Existential positive psychology and integrative meaning therapy. International Review of Psychiatry 2020; 32 (7-8): 565–578.
13. Carey TA. Exposure and reorganization: The what and how of effective psychotherapy. Clinical Psychology Review 2011; 31(2): 236–248. 14. Harris R. ACT made simple: an easy-to-read primer on acceptance and commitment therapy. Oakland, CA: New Harbinger; 2009.
15. Blunden N. The metatherapeutic current in pluralism. [Online.]
Pluralistic Practice 2022; 31 March. bit.ly/3xanXLz 16. Hayes SC, Lillis J. Acceptance and commitment therapy. Washington DC: American Psychological Association; 2012.
17. Chapman G. The five love languages: how to express heartfelt commitment to your mate. New York: Northfield Publishing; 1992.
It was usual for the women being assessed for the single-sex therapy groups we run at Sheffield Rape and Sexual Abuse Centre (SRASAC) to ask, ‘Will there be any men in the group?’ I would find myself reassuring the woman sitting opposite me, as it seemed ‘normal’ that our female clients (the majority of whom have been abused by men) would be understandably nervous about entering an arena where they may feel vulnerable again in front of a man. It was much more of a surprise to me, in my naivety, that when we began offering men-only groups, the men were reporting the same fears.
‘What could happen in the group that would put you off coming again?’ I asked Frank.
‘If I get left on my own with only men,’ he said.
‘But it’s a men’s group.’
‘Yeah, but my biggest fear is being in a group with men.’
For the first three sessions of our men-only group, the other female therapist and I would take turns to go for a loo break, as at least one man in the group had made it a condition of their attendance that they would not be left alone with just men.
By the time the group came to an end, the bond between the men was strong. The group gave men who may have endured horrendous sexual abuse from multiple male abusers, often in childhood, a chance to have respectful, bonding and nourishing conversations with other men. It was an honour to witness how they supported each other and watch them respond so movingly to being with other men who ‘got it’. We wondered whether our singlesex groups meant we were denying women the chance to experience men as fellow survivors rather than just perpetrators, and experience healing with them?
The second indicator that mixed-gender groups should be part of our regular offering was the many overlaps we saw in terms of recurring themes in the groups. One Thursday evening, Graham was tentatively asking the group, ‘Does anyone else struggle with relationships? You know, close ones.’ He went on to report how he finds it excruciating to be touched and often had to get high to manage it. ‘Maybe it’s better not to bother. I just don’t think I’m normal.’ Others in the group could relate and were able to share their experiences and offer him support. The next morning, the chairs were still laid out from the night before in the usual circle, awaiting the women’s group to arrive. Gina began crying in check-in as she told the group how ‘freakish’ she felt. She couldn’t have a ‘normal’ sex life with her husband because she couldn’t bear him to touch her. She breathed out, as the rest of the group could relate to what she was sharing. They offered comfort and support.
This synchronicity of topic was common in our single-sex groups. The men’s group all nodded sagely as Ben expressed how he would ‘never wear sandals’. They all understood his shrinking back in horror from the vulnerability of showing an open toe. The women’s group all felt they couldn’t wear tops that showed their upper arms, no matter that it was boiling outside. It was just understood between them
that this would be ‘crazy, risky behaviour’. At times, the topic had a slightly different slant depending on gender, but often the issue was the same and common to most survivors of sexual abuse. Group members often report that the best thing about the groups is meeting others who make them feel ‘normal’. Rather than the therapists being privileged to learn how common a survivor’s experience is, cutting across gender, class and racial boundaries, why not offer that opportunity to the clients?
The shared awareness of overlaps between different survivors’ experiences can do much to lift the stigmatising shame that goes handin-hand with being abused. Knowing that another reacted similarly or is left with the same ‘symptoms’ can be useful to help the healing from such an alienating experience. In the face of such commonality and solidarity, the gender of the ‘other’ becomes, potentially, less important.
Shared gender also does not eliminate other differences. One client from a single-sex group gave feedback that she’d felt different to others in the group, as her abuse happened in childhood, whereas all the other members had been assaulted as adults. There are additional complexities when abuse happens in childhood
‘The shared awareness of overlaps between different survivors’ experiences can do much to lift the stigmatising shame that goes hand-in-hand with being abused’
and belonging
at the hands of trusted loved ones. Many incest and childhood abuse survivors may find it harder to relate to the experience of a survivor of ‘stranger rape’ who is the same gender as them than they do to that of a childhood abuse survivor of a different sex.
Previously a women-only service, SRASAC opened the service to support all genders in 2016. We are a member of Rape Crisis England and Wales, which historically has been a place for women to find solidarity with other women and heal from the impact of sexual abuse. But, as our definitions of gender changed along with our awareness of who was enduring sexual abuse, Rape Crisis centres needed to change how they worked and who they worked with. This also informed our decision to tentatively introduce our first mixed-gender therapy group in April 2021. It was an online mixed-gender, post-therapy group that met for 12 sessions.
In our ‘normal lives’, we often inhabit echo chambers, where what is fed to us from the algorithms of our omnipresent smartphones are views we already hold and subject matter we are already drawn to. We often mix in social groups with like-minded others. A therapy group is an opportunity for people who may have otherwise never met to talk and compare notes. Our supervisor talked about how, in her groups, she invites ‘the cleaner to sit with the politician’.
Group participants are chosen on how ready each person is to share space with others, rather than how similar they are to other participants. The first mixed-gender group at SRASAC could have been seen as a contrived advert for ‘diversity’. The eight members included three women and five men (two of whom were trans), five of whom were white, one Asian-British, one black Caribbean and one of mixed heritage. The group ranged in age from 22 to 50. One member of the group was Muslim and two identified as gay. However, the diversity was not by design as the group was self-selecting, and for every person who said ‘yes’ to the idea of a mixed-gender group, there was at least one who said ‘no’.
Interestingly, the process that this group went through was similar to what we typically observed in our single-sex groups. There was a sense of nervousness in our first sessions, as well as open expression of relief by group members at finding others with whom they
expected to feel understood. Groups of survivors often unite and find belonging with each other around their experience of being misunderstood by the world at large. This group was no different. However, the real sense of togetherness often develops at around the mid-point when people begin to feel more genuinely comfortable with each other.
We noted in our first session that this group was marked by the theme of transitions. We were emerging from lockdown, two people in the group were at different stages of gender transition, new jobs were being started, medications being stopped, and for SRASAC, this was a transition into a mixed-gender group offer.
Just as in single-sex groups, bonding was aided by shared experiences. In one of the early sessions, the group members were virtually leaning into their cameras to send love and support to George, who was explaining how his mother must have known about his abuse as a young boy because he remembers her stroking his head and telling him it would be OK after it happened. How do we square the knowledge that the person who should love and protect us above all others tolerates (or worse) our abuse? This group of very different individuals all ‘got that’.
A difference that emerged in this group compared with our single-sex groups was that this group could not bond around the idea of having a ‘shared enemy’. This group didn’t have the luxury of being able to demonise the different gender or an ‘other’ group of people. They had to bond almost exclusively around their many shared experiences. Shona, a woman in her 40s, felt the group offered an antidote to what she described as ‘toxic solidarity’: ‘[This is] something I have experienced many times before, particularly in groups of women. I think groups of samesex or like-minded people can sometimes demonise a person/object/phenomenon over and above reality.’
Shona also reflected that the mixed-group therapy sessions added ‘diversity to collective
experience. I found that I could recognise my own past experiences or stages of instability –looping unhealthy thoughts in particular – in others, and that helped me reflect on why, when and how they are not healthy. The diversity in the group reinforced both the understanding that this is a human condition not specific to me, my phenotype, or my type of trauma.’
In session six, the mixed-gender make-up of the group was directly addressed. Interestingly, both a man and a woman expressed finding it helpful to hear the other gender expressing themselves openly. This helped reduce fear and heal some of the ways they’d pigeonholed the different gender due to bad experiences. The group reflected that ‘compassion can come in all forms’ and ‘evil people don’t care about gender’.
Initial anxieties about whether group members would offend each other by saying the ‘wrong thing’ soon dissipated. In the opening session, when Mike – a white man in his 50s – was asked what his preferred pronoun was, he answered, ‘I don’t know. I don’t really mind.’ He had never given it much thought and seemed slightly bemused to be asked. So, it was surprising and heartening to watch the relationship develop between Mike and Craig, a trans man in his 20s, as the group progressed. We wondered in supervision whether Craig’s protectiveness of Mike came from his experience of being an oldest sibling, looking after the younger ones. Mike had been a youngest sibling and was certainly in need of care and protection.
Craig later shared: ‘Throughout the sessions, I was able to see myself and my own struggles in someone older than me, someone of a different ethnicity to me, someone who was a different gender to me. I could see my trauma in so many different people that it helped me to stop viewing the world as full of people who could never understand. I stopped feeling so afraid of every person around me. I stopped viewing the strangers on the street as me versus them, because in them I could see my fellow group members.’
‘I stopped viewing the strangers on the street as me versus them, because in them I could see my fellow group members’
As well as the beauty of the connections that emerged, as with all groups, there were several points of conflict and difficult processes to manage. What surprised us was how little the points of conflict related to gender or differed from the conflicts that emerge in single-sex groups. A typical example happened in session nine. We noticed a very fractious energy in the group –there was a lot of moving around and people looking disconnected and sighing or eating crisps. When we reflected this to the group, it seemed we got nowhere, with one person reporting she ‘couldn’t be bothered with the drama’. One person left the group early, obviously distressed. I had recorded in my notes that it felt the group was in a ‘storm’ and I was wondering how we would ‘rebuild our boat and make sure everyone was comfortable again within it’.
In a therapy group, people are invited to share with each other their vulnerability as well as their power, and this can lead us to feel raw. We began our next session by showing the group a bag that was bursting full with ‘stuff’. We explained that the bag contained the ‘Achilles heels’ of this group. We asked the group to think about what of theirs was in the bag. They were then asked to share what belonged to them in the bag if they wanted to.
This group all chose to share. It was a moving session and a reminder of how vulnerable we all are and how healing it can feel to have others hold our vulnerability with care and attuned attention. It was a good way to remind the group to be careful with each other’s bruises and scars – whatever our gender – especially when we may push on them due to the intimacy of a therapy group.
As a society, we are catching up with new ways of defining ourselves, so we need to be allowed to make mistakes, as long as we notice how this feels to others. When, in one session, both my co-therapist and I misgendered one of our group members, we wanted to make
sure we gave space in the following session for that person to say how that felt. We wondered about asking someone else in the group to speak up for him, so he could just watch from the sidelines and say if they’d understood the impact accurately or not, so it wasn’t just him having to always point out the same old insensitivities. We didn’t do that in the end, as the group got more interested in discussing labels in general and how they are so often a simplification of the much more complex states of being we find ourselves in.
Increasingly, there is an awareness that we don’t fit neatly into boxes any more. This must be reflected in the types of structures and spaces that we as therapists offer. Following the end of the group, Craig reported that, ‘As a trans man, the concept of single-gender groups gives me discomfort. I often feel out of place in men-only groups, given that the first 22 years of my life were experienced as a woman, but as a trans man, I do not want to butt into women-only groups as it is their space, not mine. Given that much of my community includes people outside the binary system of gender, such as genderfluid, agender and non-binary individuals, singlegender groups are often not applicable to people.’ He continued, ‘I certainly do not claim that mixed-gender group therapy is appropriate for every situation. Single-gender group therapy has its place and has helped a lot of people to feel safe. I feel that there should however be an option for people to choose between single-gender and mixedgender groups.’
We wondered afterwards whether the fact that we met online reduced the tension of the initial meetings. It may have done for some, but we reflected it’s also important for us not to collude with the idea that, if we’re online, it will be ‘safer’ somehow. Group members shouldn’t have to be ‘safely’ behind a screen to be reassured that the group won’t hurt or humiliate them. To risk revealing yourself to another and that ‘going well’ (either virtually or in person) can be an important part of the experience of healing from abuse. As Yalom
says, ‘The act of revealing oneself fully to another and still being accepted may be the major vehicle of therapeutic help.’1 Avoiding and mitigating the clients’ fears of each other may also avoid that important part of healing.
The overall success of the group means that mixed-gender groups are now part of SRASAC’s offering, subject to the availability of members. We need groups that are welcoming to all people. For some people, this may be within their own gender. For others, this may be among a mixed group. Whatever the group, at SRASAC we believe that our therapy spaces need to be as diverse as the people who need them.
The potential of therapeutic groupwork is that it encourages connection among groups and individuals who may never get to talk or interact at depth in ‘normal’ circumstances. In our fractured society, where we are encouraged to polarise ourselves into competing groups, what better way to heal than to get together, listen to each other and compare notes?
This article has been written in collaboration with the members of SRASAC’s mixed-gender group, who have given consent to this being published. With special thanks to Jen Ayling, senior counsellor, who co-ran this group, and Lesley Ali, counselling support worker, without whom the groups would not run. All client names and identifying details have been changed.
1. Yalom ID. The gift of therapy: an open letter to a new generation of therapists and their patients. New York: Harper Perennial; 2003.
Sarah Morley is a personcentred psychodrama psychotherapist and supervisor. Alongside her work at Sheffield Rape and Sexual Abuse Centre (SRASAC) with survivors of abuse, she works in private practice with groups and individuals.
‘We don’t fit neatly into boxes any more. This must be reflected in the types of structures and spaces that we as therapists offer’
Igrew up in a theatrical family where my material needs were well cared for; I attended convent schools from age four and boarding schools from age seven, but I found no resonance in the adults around me for my inner life. My mother, a most compassionate human being and an exceptionally talented character actress, told me that she had suffered a ‘nervous breakdown’ aged 12 when she believed her family were trying to poison her. By the time she had me, she had attempted suicide twice and had received the diagnosis of manic depression.
At a certain point in our sessions, the counsellor leaned forward and asked, ‘Caroline, has it ever occurred to you that your parents are doing their best?’ It hadn’t. In later years, I appreciated the wisdom of that question, but at the time it didn’t help me very much. The therapy lasted for several months and was a lifeline amid the pressure of my student days. It also sowed the seeds for wanting to pursue this kind of reflection.
When I left university, I returned to London to live for a while in my childhood home in Shepherds Bush, before moving to rented accommodation. My confidence was through the floor and, instead of pursuing a career congruent with my newly acquired 2:1 degree, I worked for several agencies, cleaning flats. I knew that I had to continue to pursue therapeutic and healing assistance for as long as it took to feel at ease with being who I was in the world.
I arrived at my first therapy session in London with a pile of correspondence between me and my parents – I had been agonisingly trying to find some clarity of communication between us and would ask them to send back my original letter with their reply, so I could check the relevance of how they had responded. When my
therapist had read the letters, I asked him, ‘Do you think I’m mad?’ ‘No,’ he replied, ‘I think you’re just asking to be understood.’
The sessions took place weekly for just over a year. Through them I was able to understand my dilemmas and difficulties more clearly, and also gained confidence in identifying and expressing emotion, but it was not until I discovered meditation that I experienced a whole new level of freedom of choice in my life. It was the combined influence of the experience of acting on stage and the exploration of emotional and mental states that therapy facilitated that paved the way for a lifelong interest in the human psyche and spiritual and meditative paths.
I stumbled on meditation by chance at a summer school run by the Association of Humanistic Psychology, in south-west France. There, answering a small notice in the dining room – ‘Meditation on the grass at 10pm, bring a blanket’ – I met John Garrie, a British actor with a background in Taoist and Buddhist practice who became a meditation teacher, and later that year I entered a sevenyear intensive training in insight meditation. Since then, I have run many workshops and retreats, and written a meditation workbook for children, Making Friends with Ourselves.
Early experiences of therapy helped me become much clearer about what I was actually feeling and experiencing, and meditation offered approaches and methods to deepen and integrate those experiences and place them in a wider context, beyond the exclusive view of a ‘personal self’.
Over the years, it has become clear that the family of origin into which I was born was perfect (you could say tailor-made) to provide exactly the grist for my evolutionary mill that was needed. I remember my parents warmly now, with the deepest respect, love and gratitude.
About the author Caroline Sherwood is an author based in Cheltenham. Following a seven-year intensive training, she has taught meditative and spiritual life skills for 40 years. Her memoir, Following a Thread of Gold, is published by Crumps Barn Studio
Ihave something called Charcot Marie Tooth (CMT). It is named after the three neurologists who identified it in 1886. You lose strength and feeling in your feet and hands, but it usually progresses very slowly. Aside from having terrible balance, I was not really affected by CMT until my mid-40s. As part of my doctorate, I decided to research the experience of progressive disability through the voices of people who have CMT. Nine days before I presented my research proposal to my training institute’s approval panel, in September 2013, I was diagnosed with an entirely unrelated and better-known neurological condition – Parkinson’s.
Why do I have these conditions? According to the medical model, which presents a mechanistic, technical, clinical view of disease, I got CMT because a genetic mutation, a duplication of a segment of chromosome 17, was passed on to me by my father, who in turn received it from his father. Beyond that, the ancestry of our peculiar family heirloom is unknown. I got Parkinson’s because, at some point in my 40s, for reasons unknown, the cells in the substantia nigra region of the brain that manufacture the neurotransmitter dopamine started to take early retirement and shut down.
When you get ill, along with your diagnosis, you are given a new identity too. OK, you’re a patient now, an ill person. Parkinson’s? You are that little old bent-over man, the one in the illustration that’s in every textbook and encyclopedia (he seriously needs a makeover – the illustration was first published in 1886). Take your pills, don’t make a fuss. Nothing more is expected of you. Shuffle off home and sink into the warm embrace of the sofa
or under the duvet of depression. Keep out of our way. One of my mum’s old nursing books states categorically that mental changes from Parkinson’s will include ‘resentful attitude with emotional lability, depression, lack of concentration, intellectual changes, which may lead to dementia and paranoid delusion. Becomes miserable and over-sensitive’.1 Such a bleak, oppressive discourse creates and sustains what Foucault calls a ‘regime of truth’, one that removes any agency, power or hope from the patient while reaffirming the authority and power of the medical system.2
Yes, we get it. We realise that Parkinson’s is an unfolding horror show. Physical decline, cognitive decline, and the possibility of dementia and psychosis – these are common occurrences in Parkinson’s patients (though by no means a certainty).
All medical model approaches are focused only on alleviating and ameliorating deficits. No one ever talks about living a soulful life with them, let alone at times transcending them. People with health conditions can use them to live great lives and do great work. Parkinson’s didn’t stop Thomas Hobbes from writing Leviathan, for example, although it presents a rather grim, feral view of human nature – it was he who described life as ‘nasty, brutish and short’. Beethoven did his
best work while fighting deafness; similarly for Monet with blindness. Franklin Delano Roosevelt contracted polio at 39 and lost the use of his legs. He thought his political career was over – instead he became one of America’s greatest presidents, steering his nation through the Great Depression and World War II.
At 21, in his final year at Oxford, Stephen Hawking was diagnosed with motor neurone disease, also known as amyotrophic lateral sclerosis or ALS. He was told he had two years to live. But Hawking’s was a rare early-onset and slowly progressing form of the disease. He was gradually paralysed over his lifetime. He lost the use of his legs, his body, his voice. But how his mind soared. He became a brilliant physicist, cosmologist and writer. He lived a full, rich life with his disability. ‘Don’t be disabled in spirit as well,’ he said. I’d just turned 50 when I was diagnosed with Parkinson’s. In many ways, this is when I began to live. Ill health is brutal, horrific, desperate at times. But it is not always a tragedy – sometimes it heals.
The medical model isn’t the only choice on the menu. Another view, from the other side of the Cartesian divide, is that illness is a deeply psychological process and therefore something of one’s own making.
We need to be wary of ‘mind-body’ theories that see illness as a psychological choice, says John Barton
‘When you get ill, along with your diagnosis, you are given a new identity too. Take your pills, don’t make a fuss. Nothing more is expected of you’
This worrying trend, fuelled perhaps by Western flirtations and interpretations of Eastern thought, the 1960s and a spiritual hunger born of a surfeit of materialism, leads the conversation towards a pernicious victimblaming kind of New Age quackery that can sometimes become dogmatic and extreme. I call this ‘psychofascism’.
For some evangelical positive thinkers, angel therapists and other self-appointed psychics, faith healers and meta-physicists, individual power and responsibility are inviolable – they see health and illness as a psychological choice.
One such is Gabor Maté, the widely respected Hungarian-Canadian doctor, writer and public speaker. He declares on his website, drgabormate.com: ‘It’s my belief that diseases like cancer, ALS, multiple sclerosis and so on, that cause so much suffering for people, all come along to teach something – and that if the lesson is learned, with compassion for oneself, then the “teacher” has done its job
and can then take a hike. That’s not a guarantee, but I’ve seen many examples of people who have taken on their illnesses in this way and either survived or far outlived what medical science would have predicted, or at least greatly improved their own quality of life while alive.’
So show me some of those people who got Parkinson’s, learned their lesson and then got better. It has literally never happened.
Writes Susan Sontag in Illness as Metaphor: ‘Psychological theories of illness are a powerful means of placing the blame on the ill... Nothing is more punitive than to give a disease a meaning – that meaning invariably being a moralistic one.’ 4
The high priestess of psychofascism is Louise Hay, whose book You Can Heal Your Life has sold more than 50 million copies. ‘I believe we create every so-called illness in our body,’ she writes.5 If you only have joyous, loving thoughts, you will stay healthy, she says. If you already are ill, fear not – you can
heal yourself. Hay claims to have had cervical cancer in the 1970s – the diagnosis has never been corroborated – and to have cured it exclusively with her thoughts.
In her book, Hay also claims that diabetes comes from ‘longing for what might have been. A great need to control. Deep sorrow. No sweetness left’. ‘Accidents,’ she opines, ‘are no accident. Like everything else in our lives, we create them.’ Moreover, the ‘probable cause’ of Parkinson’s, according to Hay, and based on no evidence at all, is ‘fear and an intense desire to control everything and everyone’. She suggests a ‘new thought pattern’, presumably as a cure: ‘I relax, knowing that I am safe. Life is for me, and I trust the process of life.’
I have of course entertained psychological explanations for my Parkinson’s. My first therapist described me as ‘metal man’. I pushed myself. Metal man was embraced by the capitalist machine. False selves can achieve much. But there is anxiety in a suit of armour. I felt disconnected. So maybe metal man literally got on my nerves, for a long time, and my nerves got fried, creating some kind of short-circuit in my brain that precipitated Parkinson’s. Perhaps it’s a uniquely human disease of disconnection. No other animals get it. Children do not get it either. Nobody ever gets better. Men are 50% more likely to get it than women – a ratio that is in line with the statistics on suicide and addiction. One twin study found that people with challenging jobs involving complexity are more likely to get Parkinson’s.6 There are even pronouncements of a Parkinson’s personality, as reported by Luca and colleagues: ‘Since 1913, patients with Parkinson’s disease have been described as particularly industrious, devoted to hard work, inflexible, punctual, cautious, and moralist. These psychological characteristics have been so constantly reported that the concept of “Parkinsonian personality” emerged’.7
Your body perhaps gets tired of being told what to do and harangued and neglected. Parkinson’s might be an embodied manifestation of an intrapsychic schism, a lifetime of super ego-ordained fragmentation. Some of history’s most fragmented people succumbed to Parkinson’s, including Hitler, Franco and Mao – truly a monstrous trio of metal men.
At some point, the brain cells that create dopamine – the neurotransmitter of love –
simply give up. Perhaps they feel they are not needed – love is not wanted here.
But such an explanation strays into the realm of psychofascism. Any healthcare professional – especially a non-disabled one –who makes pronouncements like these when working with a patient is committing an act of violence.
Cancer is the disease whose victims are most commonly subjected to this kind of judgment. They are told they brought it on themselves by being too emotionally repressed; it is then demanded that they think positively and be ‘strong’ to beat the disease. Ehrenreich eloquently describes her experience of this in Smile or Die 8 Ten million people around the world died from cancer in 2020. Did they all fail to learn Maté’s ‘lesson’ that had been offered? How many people with cancer have died believing their death was down to personal weakness?
We don’t actually know precisely the reasons for the arrival and progression of cancer, or of any other disease. Cancer is common in all mammals, too, with a few exceptions – mole rats, for instance, almost never get it.9 Are we to assume they are better at expressing their anger than their fellow rodents? Did they have better attachment experiences in their youth? This is not to deny psychological processes, but sometimes we are ‘thrown’ into disease and there is no reason. With life comes disease, disability and death. No one is to blame.
Hay, in an interview with The New York Times, was asked if she really believes that people are responsible for their own deaths.10 Did victims of genocide, for example, or people killed in the Holocaust, get what they deserved? ‘Yes, I think there’s a lot of karmic stuff that goes on, past lives... it can work that way,’ Hay said. ‘But that’s just my opinion.’
The medical model generally ignores the mind. People resist any discussion of psychological contributions to physical difficulties because they fear being judged
as weak or accused of malingering.
A decade ago, doctors and researchers who even suggested that there might be a psychological aspect of chronic fatigue syndrome, otherwise known as myalgic encephalomyelitis or ME, received death threats and hate mail. Some were physically attacked. So now doctors have an almost complete aversion to exploring anything psychological at all (beyond the usual cursory ‘How’s your mood?’ question).
But those rejecting the medical model too often embrace its antithesis, psychofascism. What is needed is synthesis. I reject the black-and-white thinking of Cartesian dualism. Merleau-Ponty says Descartes was mistaken –living, our sense of the world and who we are, our subjectivity, these are deeply embodied experiences. Of course they are.
1. Koshy KT. Revision notes on psychiatry. London: Hodder & Stoughton; 1977.
2. Foucault M. Power/knowledge: selected interviews and other writings, 1972–1977. New York: Pantheon; 1980.
3. Dreifus C. Life and the cosmos, word by painstaking word. The New York Times 2011; 9 May.
4. Sontag S. Illness as metaphor. London: Penguin; 1977.
5. Hay L. You can heal your life. Carlsband: Hay House; 1984.
6. Valdés et al. Occupational complexity and risk of Parkinson’s disease. PloS One 2014: 9(9): e106676.
7. Luca A et al. The Parkinsonian personality: more than just a ‘trait’. Frontiers in Neurology 2019; 9: 1191.
8. Ehrenreich B. Smile or die: how positive thinking fooled America and the world. London: Granta; 2010.
9. Pennisi E. Why naked mole rats don’t get cancer. [Online]. Science 2013; 19 June. bit.ly/3d3BZb5
11
Says Merleau-Ponty: ‘The body is our general medium for having a world.’
The mysterious marriage of mind and body does not submit to certainties. In the words of Suzuki and colleagues: ‘Our body and mind are not two, and not one... Our body and mind are both two and one.’12
Writes Oken: ‘Psychological and biological factors are involved in all aspects of human function – healthy and disordered. All disease and health are psychosomatic; there are no “psychosomatic disorders” because there are no “non-psychosomatic disorders”.’13
I know that my physical symptoms go hand -in-hand with my overall psychological state at any given time. They affect each other. They are intimately intertwined. They are, perhaps, indivisible. Rather than just doling out pills, a health service could offer genuinely holistic, multidisciplinary treatments for chronic conditions, which could become a springboard for a whole new life – perhaps a life of healthy living, growth, community, creativity.
And spiritual, too. Disease can be like life itself: chronic, degenerative, incurable. And transcendent. In life you may find yourself. In death, may you get over yourself. Extracted with permission from The Humanity Test by John Barton (PCCS Books). www.pccs-books.co.uk
10. Oppenheimer M. The queen of the new age. The New York Times 2008; 4 May.
11. Merleau-Ponty M. Phenomenology of perception. Abingdon: Routledge; 2010.
12. Suzuki S et al. Zen mind, beginner’s mind. Boulder: Shambhala; 2010.
13. Oken D. Evolution of psychosomatic diagnosis in DSM. Psychosomatic Medicine 2007; 69(9): 830–831.
About the author
Dr John Barton MBACP (Accred) is a therapist in private practice specialising in working with neurological conditions and somatic symptoms, health anxiety and death anxiety. His new book, The Humanity Test, is published by PCCS Books.
‘People
I’m a psychodynamic psychotherapeutic counsellor specialising in working alongside transgender, non-binary, gender-diverse and queer people (LGBTQIA+ communities) and those closest to them. I work with over-16s in private practice, and I deliver training to therapists and organisations on improving their confidence when working alongside these communities. I also have a growing interest in the impact of race on therapeutic practice, and I work with many racially minoritised queer people.
I use the word transgender as an umbrella term, encompassing a myriad of experiences of people who do not identify wholly or solely with the gender they were assigned at birth. More broadly, I see my work as being about centring ‘the othered’, beginning with the acknowledgment that very strict ideas about gender, sexuality, race and normativity were created and continue to be upheld by the mechanisms of white supremacy, racism and coloniality. I’m learning how these things continue to shape our external and internal landscape, and am working towards decolonial and anti-oppressive thinking and practice.
I started my training as a psychotherapeutic counsellor before I transitioned (I use the term ‘trans man’ to describe my experience) and began my social and medical transition halfway through the course. I didn’t see anyone in this profession who was, like me, working class, young, brown and queer, and I could certainly feel the impact of being an outsider. I now manage this otherness by delivering my own training, creating my own spaces and connecting with other marginalised folks where I can.
With clients, I try to work without expectations of what being transgender might mean for them. I resist pushing them to find a true or authentic version of themselves as I think this is an unequal burden placed on trans people, wanting them to be 100% certain and to provide proof of that certainty by expressing it in ways that others find understandable or acceptable. It also provides little space for fluidity, which may be a crucial aspect of someone’s (everyone’s?) experience.
The question about whether or not to transition is often completely clouded by the abject fear of how others will respond, so I try to bring clients back to a more internal locus of reference when making decisions about their lives, however big or small.
I try to do this while also holding the knowledge that being trans in the UK is becoming increasingly dangerous. This often means sitting with grief, rage and despair about how our lives may be shaped by others and the expectation of rejection, isolation and loss. Alongside this, I make space for excitement about gender and optimism that things can be and feel better – I make space for celebration, and expression which feels more joyful, more peaceful, or simply less painful.
I don’t see being trans as an inherent trauma or disorder, any more than living as cis (cis is the Latin prefix meaning ‘on the same side’) – this serves to depathologise transness and queerness in all their forms, while acknowledging the impact of living as transgender in our current climate. This is probably influenced by the fact that I did not feel there was anything inherently wrong with me – my transness was a simple fact, or a naming of what was always there. I think being trans is the most natural thing in the world, which makes it very easy to believe my clients when they tell me who they are. I think this is the basic tenet of affirmative practice, particularly when contrasted with conversion practices.
People may also be surprised to learn that lots of trans clients come to me not because they want support in deciding whether to transition or not, but to have the luxury of talking about things that are broadly unrelated to their transness – it can be a huge relief not to be expected to talk about gender!
Working with trans, queer and racially minoritised clients is a practice not only in tolerating the unknowns but also in unknowing and undoing coloniality, which is to say, unknowing and undoing all the things we have been taught about what it is to be human. No wonder people find it daunting! But I think wider society has a lot to learn from people who transgress these social norms.
Ellis J Johnson is a psychodynamic psychotherapeutic counsellor, supervisor, trainer, consultant and group facilitator. He delivers training in trans inclusion and anti-racist practice to organisations and therapists across the UK and internationally. www.ellisjjohnson. com; www. transcounselling. co.uk
In May 2022, the United Nations High Commissioner for Refugees reported that the number of people forced to flee war, violence, human rights abuses, and persecution had passed 100 million for the first time.1
Approximately 16,500 people were evacuated from Afghanistan to the UK in August 2021, following the seizure of Kabul by the Taliban. Afghan adults and families were brought to the UK via the Afghan Relocations and Assistance Policy. Despite the Government’s commitment to resettle 5,000 Afghan refugees annually via the Afghan Citizens Resettlement Scheme, smaller numbers continue to arrive via this scheme.
The authors of this article all work for the Refugee Council in Yorkshire. Jude is a therapist working with adults and manages a therapeutic service for resettled refugees. Kathryn is a child and family therapist, and Jess manages a resettlement service. The Refugee Council is a national charity offering a range of services to refugees and people seeking asylum in the UK. It has provided support to those who arrive via resettlement programmes since 2004.
Many of the Afghan families arriving in the UK from summer 2021 onwards were offered temporary accommodation in what are known as ‘bridging hotels’. More than a year later, many of these families are still living in these same hotels.
The authors are all working with Afghan families who have been granted indefinite leave to remain and are housed in these hotels. We want to share our learning about the impact on refugees’ mental health of living for prolonged periods in these places
and in similar settings, as well as explore what can be helpful therapeutically to individuals and families.
It is not new for the Home Office to accommodate refugees in hotels, but the practice of using this type of accommodation for sustained periods of time has increased in recent years. Currently, the Government is also using hotels to house people seeking asylum, along with former military barracks. For those seeking protection, being accommodated in a hotel for long periods adds to the stress inherent in the asylum process, which has been described as ‘incomprehensible, prolonged and degrading’.2
Hotels are not an appropriate setting for refugees fleeing conflict and persecution, and especially those who are traumatised or distressed. A recent report by the independent humanitarian organisation Doctors of the World declared such contingency accommodation ‘unsafe’ for asylum seekers due to ‘the lack of access to adequate and appropriate healthcare services and the nature and conditions, which risk directly harming service users’ health’.3
We have witnessed how significantly this environment impacts on the mental health of those who arrive in the UK requiring a safe, stable and calm environment in which to start some form of recovery. The Afghans we are working with in Yorkshire will have lived in hotels for more than a year by the time this article is published.
Bridging hotels were commissioned by the Government as a temporary solution until suitable housing could be found in the community. Hotels are not designed for long-term stays, and Afghan families share small bedrooms with little space other than for sleeping. Hotels are particularly unsuitable places to accommodate children and women at risk of exploitation. This intense environment can lead to conflict within and between families and between ‘guests’ and hotel staff. There is little privacy in the hotel, and rumours and misinformation can spread rapidly. Refugee Council staff in the hotels have often witnessed people being ostracised because of perceived differences.
Most families have not been told when or where they will be offered housing. They are unable to settle and find it difficult to seek employment as they may be required to move to another part of the country at short notice. When families are moved out of the region, bonds made during a crisis are broken and children’s education is further disrupted.
The loss of relatives and friends weighs heavily in the hotels. People who were not evacuated to the UK are often facing deprivation or persecution in Afghanistan, and this causes significant concern for those living here. They are frightened for their elderly parents who cannot access medical care, their siblings who cannot feed their families, or their female relatives who cannot leave home without a male chaperone. The earthquake in eastern Afghanistan in June 2022 killed more than 1,000 people, destroyed hundreds of homes and left families destitute.
Therapy has a role in helping Afghan refugees cope with life in UK ‘bridging hotels’, say Jude Boyles, Jessica Ross and Kathryn Townley
People are distressed and sometimes traumatised by the experience of the crush at Kabul airport, and think often about those who did not make it onto the planes. Some lost relatives in the bomb blasts outside the airport. People describe feeling guilty about having escaped, leaving others behind.
In addition to the pressured and unpredictable atmosphere that can occur when accommodating large groups of families in crisis, people have faced racism and hostility from the local community, press, hotel security staff and other hotel guests.
Despite this, a community of support has built up within the hotels. Although families may not have known each other prior to the evacuation, their shared experiences bring them together. The Refugee Council has established women’s groups and provides different activities where people meet regularly and offer mutual support. Refugees have also talked about how they have made friends and found comfort in the normalising and collective experience of being accommodated together at such a difficult time. This was especially helpful soon after arrival. However, almost a year on, it has become harmful for many.
The mental health impact of living in an overcrowded and noisy environment has been immediately apparent in our therapeutic work with adults, children and young people.
The mother in a family that had been accommodated in a hotel before being resettled to Yorkshire described to us how, following their evacuation from Kabul, they arrived at the hotel distressed and shocked. Both parents were anxious to stabilise the lives of their four children and settle them into school, as well as re-establish some familiar family routines. They described the chaotic and pressured setting of the hotel and how it exacerbated their sense of panic at being in a new country. The father explained that the anxiety among families in the hotel almost felt contagious to him, and he shared how alarmed they were by the level of distress they witnessed around them, as well as being triggered by the sense of panic. They described feeling separated from the host community and wondered if being housed in a hotel had meant it took them longer to adjust and orientate as a family than if they
had been able to move into a house soon after their arrival.
Once the family had moved into their own house, despite the multiple challenges of the resettlement process, they spoke of re-establishing a sense of control over their environment. The parents could introduce family rituals around cooking and mealtimes, as well as other helpful routines around schoolwork and bedtime that were harder to maintain in the chaotic setting of a hotel.
The removal of the opportunity to make decisions as a family to change the situation they found themselves in was experienced as disempowering and impacted on both parents’ confidence. They felt it had affected their ability at times to reassure and contain their children’s distress, as well as manage the normal concerns children and families have during the resettlement process.
For the father, witnessing the distress and disturbance of others had exacerbated his existing mental health distress. He had struggled to find a space within the hotel setting to be upset and felt that his anxiety had affected his family. He described feeling guilty that he had been unable to protect his children from his tears.
The secondary school children referred to our service have usually exhibited high levels of distress and are self-harming, feeling suicidal or having panic attacks. Many are withdrawn. Sadly, there is little psychological support available for Afghan children and adolescents, and barriers to accessing statutory health services are multiple for our refugee clients.5
There is huge diversity in the groups of people who are being accommodated in terms of pre-flight experience, family make-up and the resources they have to manage their
current situation. Family therapy aims to consider the systems the individual children or families are part of and recognises that these play a huge role in how relationships change and conflicts can arise. Most if not all young people in the bridging hotels have experienced a sudden family separation and the associated sense of loss, worry and guilt. Family dynamics have shifted overnight and siblings have had to take on parental roles. Young people who speak and understand English are suddenly given the responsibility of translating for parents when no interpreters are available.
Most of the young people continue to attend school each day and manage to concentrate and learn, and this has often been helped by the schools’ commitment to welcome refugees and create a sense of safety. For most of the young people we are working with, school is their haven, away from the intensity of hotel life and the inevitable conflicts between and within families.
With little to do in school holidays or weekends, the young people spend a lot of time online. Anxieties about the developing situation in Afghanistan have led families to closely monitor the daily news and also lead to frequent distressing conversations (or overhearing them) with relatives who are in unsafe and precarious situations. Children are more likely to soak up the distress and anxiety their parents are understandably feeling in such confined settings.
Although many therapy services have continued to offer therapy online, our local experience tells us that offering in-person therapy is helpful for this client group. Given the overcrowded conditions and lack of privacy in the hotels, having the choice of a therapeutic hour away from the hotel in a separate and confidential setting is important. Many clients are anxious for therapy to be away from the hotel in order to maintain their privacy. When family members are still at risk in Afghanistan, an online session can be interrupted by a call from home. Offering clients a separate room where phones are turned off can protect the therapeutic space in a more direct way.
As therapists, there is much we can do to psychologically assist any newly arrived refugee that is common to any individual who
‘The mental health impact of living in an overcrowded and noisy environment has been immediately apparent in our work’
has experienced sudden change and extreme events. But specifically in relation to hotels, it is important that we normalise clients’ distress and collectivise their responses to this unjust situation, reassuring them that living in a hotel setting for long periods is affecting the psychological wellbeing of everyone. It is also important to be realistic about what might help individuals in these settings, given there is so little they can do to improve their environment.
Refugees are unlikely to be familiar with the UK’s social, legal and cultural systems, so it is important that we respond to questions when we can. Alongside this, refugees often do not have the opportunity to raise any concerns they have with a qualified interpreter present. Listening to practical problems or responding to questions can feel unfamiliar to therapists unused to working with refugees, but responding to these concerns can play a helpful role in building a therapeutic relationship, contribute to establishing safety and provide reassurance and containment.
It is helpful to slow up the assessment process to enable people to adapt to a different kind of conversation that can feel exposing and unfamiliar. We take time to describe what therapy is, what it isn’t and how it can help, avoiding mental health terminology or jargon. In some Afghan families, attending therapy suggests mental illness and so there can be a stigma in approaching a professional for help. Despite this, our experience is that the Afghan clients referred to us have been open to trying therapy, despite it being unfamiliar to most of them. Our clients have used the sessions in a variety of ways but, importantly, they have reported that therapy has helped them regain some control over their lives.
The structure of attending school and college has been important for children and young people, and so continuing to offer in-person or online/telephone sessions during school holidays has been helpful, given that much of our therapeutic work with children has been delivered within schools. In general, we have seen an increase in hopelessness during school breaks. Making sure they are prepared for the breaks is very important for these young people, for whom structure, continuity and certainty about the future are diminished.
Bearing witness to accounts of what is happening back home and listening to their worries, as well as exploring ways to regulate exposure to disturbing online content, are part of a typical session with a young client. We find that most of the young people in the hotels know how to look after themselves online and understand how devices may interfere with sleep and/or become unhelpful. However, for the young Afghans we are working with, their devices serve to distract from otherwise upsetting thoughts and worries. There is a need for open dialogue to support young people to manage this tension.
We work with a small team of Pashtu and Dari-speaking Afghan interpreters who are qualified and have had additional training in working in therapeutic and mental health settings, including in child and systemic family therapy. They receive regular training to enhance their skills and are offered a monthly supervision group. This is crucial in ensuring they can manage the impact of session content and are helped to manage the challenges and difficult dynamics that frequently occur in the triad/system. This has been especially difficult during the Taliban’s return to power, where interpreters often share the same concerns as their clients about family members left behind.
Anxieties about the confidentiality of the interpreter and security of the information being shared are common concerns for clients. This can be helped by a slower-paced assessment that gives space for the client to build trust with the interpreter as well as the therapist. Continuity by using the same interpreter is vital.
In online settings, using qualified interpreters who are present on the screen and empathic and warm is vital if therapy is going to be helpful. Some therapists have been concerned that the therapeutic alliance is more difficult to build online with an interpreter present. Some have asked the interpreter to keep their video off during video calls. Our experience and feedback from clients is that this can leave the client feeling anxious about whether the interpreter is judging them, as there are no physical cues to provide reassurance or connection. Clients can also worry that the interpreter is not alone and the conversation can be overhead.
Therapists have rarely been given training on working with interpreters, and even less so when working online. BACP updated its Good Practice in Action 091 Fact Sheet: Working with Interpreters in the Counselling Professions in 2021.6 Interpreters can help a client unfamiliar with therapy to feel at ease as they witness the positive and containing partnership of an interpreter and therapist working well together. The presence of the interpreter can enhance the therapeutic relationship as well as play a significant role in gaining clients’ trust and initial openness to try out therapy.
The need for support is clear, but it is extremely difficult for refugees living in hotels to access mental health services.
A report by the Refugee Council in 2021 accurately predicted that ‘while they continue to live in these circumstances, their distress is more likely to deteriorate than improve’.7
Despite this knowledge, few counselling services offer support to people living in this setting for long periods. Therapists working in organisations in areas where refugees and people seeking asylum are in bridging hotels need to reflect on what they can offer. Ensure your agency is proactive and open to receiving referrals from these hotels, while remembering that the hotel itself can be a complicated environment to find a private space to talk. For therapists in private practice, refugee therapy services are always in need of volunteers. For therapy teams new to this work, we would recommend attending training in working alongside interpreters and on the asylum and refugee context.
The impact on the therapist of working in this setting can be significant. Managing
‘The presence of the interpreter can enhance the therapeutic relationship and play a significant role in gaining clients’ trust’
Amena has been living in a hotel for eight months, having been evacuated from Kabul in August 2021. She lives with her husband and four children, all of whom are under 10, and she is pregnant. Amena’s family are still in Afghanistan. Her mother is unwell, and the family are barely managing to eat most days. She feels guilty at leaving them behind and powerless to assist. She is angry at the situation she finds herself in and is struggling to manage her children in a hotel setting without the family support she would have had at home. She isn’t sleeping well and feels anxious and agitated. Amena was recently physically assaulted by a disturbed young man in the hotel, and she is frightened and uncomfortable at being in such proximity to men she doesn’t know.
Amena met the therapist away from the hotel and described immediately how different she felt away from the noise and chaos of her room. A slow and paced assessment over three sessions enabled Amena to experience being supported and attended to. The interpreter was slightly older than Amena and it was apparent that her presence was reassuring. Talking in this undisturbed and quiet setting felt familiar to Amena, as she often spoke alone to her older sister when overwhelmed. The therapist was able to gain a picture of Amena’s early life experiences and her resources. The therapist was able to validate her strength in managing a distressing and shocking series of events prior to and since the evacuation. Amena did not initially see herself as strong but was able to recognise how capable she was, having supported her family through these experiences. The therapist normalised her distress at her current situation and Amena described feeling less ashamed that she had been struggling to cope. As well as sharing information on the impact of acute stress and sudden change on mental health in a culturally congruent way, the therapist was able to explore with Amena how she might find opportunities to rest and find time to herself. They discussed Amena speaking with her husband about her need for rest, which was productive, and he became more attentive and proactive with the children.
Amena was a highly sociable person in Afghanistan and missed the company of women, and so she was encouraged to join the women’s activities in the hotel, which she found helpful. The connections she made with other women reminded her of her social self and became another resource for her in the hotel.
Amena began to go for short walks and encouraged her husband to do the same. She tried to spend some relaxing time away from the hotel with the children in a local park and began to introduce a few routines from home to family life, which wasn’t always easy, but it helped the couple feel more in control. She also talked to the Refugee Council staff in the hotel about the assault and they responded quickly to the risk. She learned a breathing and relaxation exercise and decided to spend less time on her mobile phone, especially before bed. It was still difficult, but she was able to sleep a little better.
* Name and identifiable details have been changed.
our own frustration and anger at the social injustice embedded within our work with refugees is a continuous challenge. Working in close partnership with interpreters can mitigate some of this impact, as can accessing the usual clinical and management support systems. Often the opportunity to immediately debrief with a like-minded
colleague is the most helpful source of support. These sometimes brief and kind conversations by the kettle can be sustaining.
Our role as therapists is to bear witness and recognise the strengths and capabilities that these people have arrived with – strengths and capabilities they continue to have to draw on in the face of systemic neglect. ■
1. UNHCR. Ukraine, other conflicts push forcibly displaced total over 100 million for first time. [Online.] Geneva: The UN Refugee Council 2022; 23 May. bit.ly/3yqhlse 2. Yeo C. Welcome to Britain: fixing our broken immigration systems. London: Biteback Publishing Ltd; 2020. 3. Jones L et al. ‘They just left me’: asylum seekers, health, and access to healthcare in initial and contingency accommodation. [Online.] Doctors of the World 2022; April. bit.ly/3RQmrpA
4. Sands L, Cursino M. Afghan earthquake: At least 1,000 people killed and 1,500 injured. [Online.] BBC News 2022; 22 June. bbc.in/3BnZnt4
5. Kang C et al. Access to primary health care for asylum seekers and refugees: a qualitative study of service user experiences in the UK. British Journal of General Practice 2019; 69 (685): e537-e545. 6. BACP. Working with interpreters in the counselling professions. Good Practice in Action fact sheet 091. Lutterworth: BACP; July 2021. 7. Refugee Council. ‘I sat watching life go by my window for so long’: the experiences of people seeking asylum living in hotel accommodation. [Online.] London: Refugee Council 2021; 23 April. bit.ly/3Pe5bcF
Jude Boyles MBACP (Snr Accred) specialises in working with refugee survivors of torture/war and human rights abuses, including gender-based abuse. She is the co-author of Groupwork with Refugees and Survivors of Human Rights Abuses: the power of togetherness, recently published by Routledge.
Jessica Ross is area manager for the Refugee Council Resettlement Team. After qualifying as a social worker, Jessica has worked with resettled families since 2009.
Kathryn Townley is an accredited psychological therapist specialising in systemic family therapy with refugees who have been resettled in South Yorkshire.
Written by doctors for doctors, this 754-page volume is a comprehensive encyclopaedia of the mental illnesses that occur at moments of reproductive transition in cisgender women. As such, it excels; it is systematic, well organised and rich in data and vignettes. Part one covers reproductive health across the lifespan and part two focuses on the perinatal period of pregnancy and postpartum. If, for example, you want to find out which antidepressant is safe to take in pregnancy, this information is easy to access here.
However, as a psychodynamic counsellor, I struggled with the focus on diagnostic criteria based on DSM-5, and the treatment sections of each chapter where counselling is barely mentioned. Even CBT is only recommended where evidence of efficacy is strong and ideally in time-limited and manualised formats. But this book is the first of its kind, and it was written in order to put reproductive psychiatry on the map. Twenty years ago, women with reproductive mental health issues fell between psychiatry, obstetrics and gynaecology and paediatrics. Indeed, most psychiatrists in the US still receive no training in reproductive medicine as it is not an accredited speciality.
Of course, the information here will quickly need updating, as the section on abortion sadly already does, following the overturning of Roe v Wade. My hope is that, as reproductive psychiatry finds its feet, future editions of this text will expand on the value of counselling for women at the reproductive transitions, as chapters 12 (parent-infant relationships) and 18 (trauma) bravely begin to do. Jane Cooper is a former senior counsellor at the University of Cambridge
I’m all for curiosity and was enticed by the title. The author is a psychoanalyst and organisational consultant who qualified at the Tavistock, which, to my mind, sets the concept of curiosity within a very particular context. The first three chapters are psychoanalytic-heavy, with discussions about love, hate, knowledge, paranoidschizoid and depressive positions. Without a psychodynamic training, readers might get very lost very quickly. I persevered.
I found chapter four,
‘The myth of the healthy organisation’, both a helpful reminder of group theory as well as an interesting perspective on the roles we take in groups and why. Chapters five to nine explore practical applications of psychoanalytic theory to individuals, organisations and politics, with examples from Stokoe’s long and varied career. The title of chapter 10, ‘Love in Shakespeare’, was a welcome surprise. My initial thought, that it might be lighter than the preceding chapters, was dashed by the introduction, which reminds us that adults move continually between paranoid-schizoid and depressive positions, and civilised society occurs when hate is expressed with knowledge in the service of love. This is exemplified through Romeo and Juliet, Antony and Cleopatra and Hamlet, making it (slightly) more accessible.
The highlight, for me, came in the final chapter, ‘The problem with curiosity’, which tackles religion, culture, climate and ‘alternative’ therapies such as bodywork. The writing was more playful and the discussion felt new and interesting. I was curious to discover more. The danger of curiosity, according to Stokoe, is the expectation of finding meaning. I think that was the danger for me of judging this book by its title. I didn’t find meaning, but I remain curious.
Jeanine Connor is a psychotherapist and supervisor
Jessica Collier and Corrina Eastwood (eds) (Jessica Kingsley Publishers, £14.99)
The term intersectionality, coined by Kimberlé Crenshaw in 1989, is often unhelpfully confused with identity politics and frequently overlooked as a valuable methodological tool. This tool enables critiques of capitalist, neoliberal, economic and social welfare systems that contribute to the divide between rich and poor – the lamentable tapestry of contemporary life. Looking back on how certain populations have been at increased risk of getting sick and dying from COVID-19, there has never been more urgency required in recognising the need to expose the power structures that produce and reproduce difference.
This is not an easy book to read but it is an important and timely one. Through this collection of essays, we are shown how arts therapies can be enriched by engaging in a framework that ‘challenges the potential within our profession for colluding with neoliberal ideology’. Through vivid exploration of race, class, misogyny, survivorhood, disability and their tenacious veins of power, writers describe their courageous client work –I will carry Eastwood’s ‘snakey crazy lady’ with me for quite a while. However, the greatest poignancy lies in the detailed self-reflection that the practitioners undergo to reach an understanding about themselves.
The book is illustrated with images from practice that bring the reader back to the complex elegance of arts psychotherapies in their work with human expression beyond words. Begun in the post-war period, but with roots in the moral treatment movement of the 18th century, arts psychotherapies are about exposing what has caused us damage. This book makes a powerful case for looking at the complex webs of injustice and discrimination that imbue our biographies, silence us and make us ill. Olivia Sagan is a counsellor, psychologist and academic
Even in counselling and psychotherapy circles, Freud can sometimes exist more as an idea, a trope, even a caricature, than the deeply influential, complex and constantly evolving theorist who provided the foundations for psychotherapy. This book represents a fantastic opportunity to address this.
It is not a long book but it covers a lot of ground with welcome clarity, precision and many suggestions for further reading. Silverstein doesn’t assume prior knowledge but equally doesn’t patronise. By taking the reader through the historical context that led to Freud’s theories, then the evolution of his theoretical understanding over several decades, we learn about a complex figure who built on scientific underpinnings as he sought, in vain, for a unifying theory of human psychological development and the treatment of neuroses. It is fascinating to see the development of his theories, the false starts, the partnerships, the fallouts, the frustrations, the progress, the stumbles and the epiphanies.
It is striking both how much some ideas still seem fresh today, while others are conspicuous for their (to modern sensibilities) outlandishness. Most surprising of all, perhaps, is the way Freud interpreted hidden meanings from his patients’ conscious thoughts, based on his own theories, and then declared these interpretations as facts. Patients were obliged to either accept ‘the truth’ of these hidden symbolic meanings – thus validating his theories – or, if they refused to accept them, he interpreted this as repression and resistance. A reminder to us all that trying to make our clients fit into our preferred theoretical dogma validates us rather than them.
This set consists of a picture book and an accessible guidebook, to be used alongside it. The author uses the image of a house to represent the self, with trauma and subsequent dissociation creating shut-off or split-off rooms. This metaphor is also used to explain how environmental and systemic factors can have traumatic repercussions.
The picture book has a section explaining the basic metaphor, followed by further information about DID treatment and recovery. In layout and style, it resembles a children’s storybook. I wondered whether its appearance could be experienced as infantilising. The guidebook contains sections on trauma, treatment, support for practitioners and extensive up-to-date references.
For therapists, there are sections on transference, boundaries and vicarious trauma. We are reminded that feelings of failure are a normal response to navigating the territory of extreme pain and suffering. I appreciated the differentiation between dissociation and the now commonly used language of ‘parts’: for instance, ‘a part of me’ or ‘my inner critic’. I would have liked more about how to recognise DID in the therapy room.
The approach is non-pathologising and sensitive. Thorough explanations of DSM criteria and different types of dissociative experience are included, drawing on contemporary approaches such as the structural dissociation model and the work of Janina Fisher. We are frequently reminded that dissociation is a solution to trauma, and survivors’ voices are included throughout. One says, ‘Don’t confuse your degree with our lifetime of knowledge’ – worth remembering.
Sam Clark is an integrative psychotherapist
I was a counselling trainee and perplexed by the sometimes contradictory theories and claims being taught. I understood what I was learning but little of it made sense. Searching for answers, I chanced on this unique book. I read with discomfort as our field’s many scientific claims – and the associated status and authority such claims afford – were rigorously upended. Situating psychotherapy in its historical context, Fancher uncovers and analyses the underlying assumptions of four giants: psychoanalysis, behaviourism, cognitive therapy and biological psychiatry. This book shed me of the conceit that psychotherapy operates outside of culture. I began to examine and wrestle with my own practice’s hidden ideas and values, and wonder whether I had been undermining client autonomy through my conception of change. I dropped any pretensions to technical expertise along the way. This book remains an illuminating read.
Chris Davis is a counsellor and supervisor in private practice
Nick Campion is an integrative psychotherapist
Our House: making sense of dissociative identity disorder/ Understanding Dissociative Identity Disorder: a guidebook for survivors and practitioners Lindsay Schofield (Routledge, £12.99/£24.99)
I am very interested in applying for a job as a part-time staff counsellor with a local charity, as it deals with an issue that I am passionate about and have extensive experience in working with. However, I see from the charity’s website that one of its trustees is a former client of mine, who came to see me for six months while they were going through a relationship breakdown. They stopped working with me around three years ago. Given that time lapse, is it OK for me to apply for the job? And if I do, do I need to alert my former client? Financially, I am very much in need of a paid role to boost my private practice and jobs like this do not come up often in my local area.
Whether to apply for the job or not depends largely on the boundary established between you and your former client. The Ethical Framework (Good Practice, point 33) requires us to ‘establish and maintain appropriate professional and personal boundaries in our relationships with clients by ensuring that: a. these boundaries are consistent with the aims of working together and beneficial to the client
b. any dual or multiple relationships will be avoided where the risks of harm to the client outweigh any benefits to the client.’
Hopefully that boundary was drawn when you first contracted with your client. It may be that post-therapy contact was discussed at the time or when the work ended. You might, for example, have made explicit whether, and if so how, you would acknowledge each other if you happened to meet locally.
Your decision will also depend on your particular therapeutic modality. Some would say ‘Once a client, always a client’, and would maintain that the transferential relationship never ends. In the interests of non-maleficence, they would avoid any contact with a former client, otherwise some of the gains made in therapy might be lost. For others, the time
lapse of three years may be deemed long enough to allow for a new beginning, without causing any harm to the client. This will need careful thought and discussion with your supervisor. You indicate that you are in need of a paid job, and that this is a rare opportunity, so there are valid practical considerations too, but such needs should be weighed against other factors. Whatever your way of working, your responsibilities towards a former client can never be totally dispensed with.
You would always have information about your client, some of which is likely to be deeply personal, which you cannot ‘unknow’. Therefore you would need to be careful to bracket your prior knowledge and to ensure that you never made reference to information previously entrusted to you in confidence. This would be a new relationship, in which
you would both have redefined roles. There would be a change, maybe a reversal even, in the power balance. You would now be colleagues and it is possible that your former client, now a trustee, would have some kind of authority over you, if you are to be accountable to the trustees. How might it feel to be appraised or called to task or disciplined by them? Could you find out, discreetly, how involved the trustees are within the organisation, and to what extent your paths are likely to cross? Would you be expected to meet socially? It would be important, of course, not to disclose the former relationship to anyone else in the charity.
As to whether or not to alert the trustee to your job application, what would be your motive for doing so? Are you wanting ‘special treatment’, perhaps? What if they were to discourage you from applying? Would you be wishing to give them advance notice of your application, so that they are better prepared and less surprised to meet you in this new context? Seeing that they have chosen to hold a position within a counselling organisation, they are probably already aware that they may well come across a former counsellor of theirs, so that will always be a risk on their part. However, they might not wish to be reminded of that episode in their life and would rather leave it in the past, and may not welcome being approached by you. What if they were to ignore you and to treat you as if you had never met before?
You explain that the original therapy was at the time of the client’s relationship breakdown. Did you have a sense at the time that the work was complete, or was there any unfinished business? Was the ending planned? What if they now want to update you on their situation, or even expect to pick up where they left off? Might they still see you as their counsellor? Or do you believe that they could cope with the change in relationship and easily manage to see you in a different role? Could
Some would say ‘Once a client, always a client’, and would maintain that the transferential relationship never ends. In the interests of non-maleficence, they would avoid any contact with a former client, otherwise some of the gains made in therapy might be lost. For others, the time lapse of three years may be deemed long enough to allow for a new beginning, without causing any harm to the client
,,
you see yourselves coexisting happily within the same organisation? You won’t know the answers to all these questions until you actually meet, but they would be worth thinking through. Bear in mind that your paths may not cross until further down the line, perhaps when some kind of difficulty or crisis arises within the organisation.
The outcome isn’t entirely in your hands, as your former client will need to accept a degree of responsibility in this. If they come across your name on the list of applicants, they can exercise their autonomy by deciding what action to take. There might be an organisational requirement for the trustees to declare an interest if they know any of the candidates applying for a job, and perhaps to withdraw from the interview panel. If the trustee has decided to disclose the connection between you, you may be contacted to ask if you are happy for them to be on the panel. How would you feel about that?
As with most ethical dilemmas, a number of questions are raised but perhaps two of the most pertinent here are: ‘Whose issue is it?’ and ‘What is likely to do the most good and the least harm?’
This column is reviewed by an ethics panel of experienced practitioners.
‘When we start to do things because we need the money, we have to be careful’ I have two reactions to this. On the one hand, the counselling world is small and it’s not uncommon to cross paths with people we have worked with in the past. Only you and your client know what the work entailed but, assuming that there are no complicated transferences left from the original counselling, we might think that this could be explored further. After all, in the day-to-day running of an agency, a part-time staff counsellor might not be so involved with a trustee.
On the other hand, and in this case, I was interested in what the agency deals with that arouses your passions. You might have to be careful that passion doesn’t overrun your capacity to evaluate the situation. Similarly, in my experience, when we start to do things because we need the money, we have to be careful. Money can stimulate complex
You can find more information and guidance in the following BACP
Good Practice in Action resources, which are available online at www.bacp.co.uk/gpia
Ethical decision making in the context of the counselling professions (GPiA 044)
Ethical decision making in the context of the counselling professions (GPiA 033: Research overview)
Dual roles within the counselling professions (GPiA 077)
Making the contract within the counselling professions (
Boundaries within the counselling professions
Boundary issues within the counselling professions
unconscious dynamics, push us around and interfere with our judgment. These are things that I suggest should be discussed in your personal therapy and supervision before you pursue the position.
If you decide you still want to apply for the post, then I suggest being transparent about it, while being respectful of confidentiality. I would let the agency clinical lead or counselling director know that you have had prior contact in a professional capacity with one of the trustees. You want to be open about this from the start and not risk it coming to light later and appearing that you had not thought about the potential consequences, which may give the impression that you are cavalier with boundaries. I think it would be appropriate to let the former client know of your interest in the position and see how they feel about it. Again, if they are not perturbed, then it might be possible to pursue it further. But in all of these ideas, the difficulty with this kind of dilemma is that it is hard to predict what problem may arise from it in the future.
Things tend to become more complicated when we ignore them, and we don’t want to create problems for ourselves or others. Letting the clinical director know that you are thoughtful and careful when it comes to matters like this might be something that would encourage them to help you find work in another agency that they know of where you have no existing contacts.
Having tried to think this dilemma through, personally I wouldn’t apply for the post. Toby Ingham is a psychoanalytic psychotherapist and clinical director of South Bucks Counselling
We have to focus on the impact on the former client in this situation. Three years after they finished therapy, you reappear in their life as a member of staff in the charity where they are a trustee. I wonder how that would be experienced by them? Whether or not they told you about the trustee position they held at
It’s also worth considering whether the trustees of this charity would become part of the decision-making process, should there ever be a complaint made against you. Some trustees are effectively the employers of staff in charities. The dual relationship here could be very difficult – if they are involved in the process of awarding staff promotions, for instance, how would your former client be able to separate their possible loyalties?
,,
this charity during their work with you, what might they feel and think when your name appears at a trustee meeting out of the blue?
It’s also worth considering whether the trustees of this charity would become part of the decision-making process, should there ever be a situation where a complaint was made against you.
Some trustees are effectively the employers of staff in charities. The dual relationship here could be very difficult – if they are involved in the process of awarding staff promotions, for instance, how would your former client be able to separate their possible loyalties?
Two things are clear – without a doubt, you should inform your former client about your application. Second, at your interview for the application, would you be able to hold your former client’s confidentiality? You certainly would have to hide this piece of information from the charity managers.
I fully understand the disappointment you might feel about not applying for this attractive position, for the reasons you outline. It’s also always possible that this situation could have happened the other way round, with the trustee having the dilemma of joining a charity where a staff member used to be the would-be trustee’s therapist! However, that would be a choice that the former client would be free to make. That way round, there isn’t an ethical dilemma.
I’d say don’t touch this situation with a barge pole – it’s way too risky and full of potential for harm to a former client. Elaine Leonard MBACP is a counsellor and supervisor in private practice
I am trying to imagine how I would feel or react if my former therapist had been one of the candidates put forward for a job position at the local counselling charity when I was sitting on the board of trustees. The board was usually involved in employment selection – as, I would imagine, would be the case in many agencies and charities.
The first challenge would have been remaining neutral and assessing my former therapist’s application on its merits rather than my prior knowledge. The second would have been deciding if I was OK with the prospect of regular interaction with my former therapist. Whatever my regard for
their professionalism and abilities as a therapist, as I imagine this scenario, my gut is telling me it would have never been comfortable. So it’s worth bearing in mind that, should you proceed, it’s highly likely that is the position in which you are putting your former client.
We all have to deal with the ‘six degrees of separation’ factor if we work as a therapist in our local community. My friends and family are now used to me saying, ‘We’ll have to go somewhere else’, on entering a café or restaurant when I see a former or current client there. I’ve also had to abruptly leave yoga classes, and drop out of a ‘school mums’ social group when a former client started coming to events. One of the attractions of moving my practice online earlier this year was opening up the possibility of working with
clients I won’t meet when I step out of my front door – for their sake, as well as mine.
Obviously, the inconvenience of having to find somewhere else for coffee isn’t on a par with not being able to go for a job, particularly if, as you say, such positions don’t come up very often, it fits your interests and skill set and you are seeking the security of paid employment. Contacting your former client and asking them if they would be OK with you applying for the job is also not a simple solution – would they feel in a position to say no? Walking away from this opportunity may sting at first, but in turning it down, you are also gaining something – the peace of mind that comes with knowing you have done the right thing.
Sally Brown is a therapist in private practice and editor of Therapy Today
We welcome members’ responses to these upcoming dilemmas. You don’t have to be an ‘expert’ – if a question resonates with you, do share your experiences or reflections with your peers. The word count is 250–350 words, and the deadlines for each are given below. Email responses or any questions to therapytoday@thinkpublishing.co.uk
I have been with my supervisor for eight years and really feel that they understand me and the way I work –so much so that my supervision session is one of the highlights of my month. However, recently a participant at a CPD event commented that we can risk ‘coasting’ and missing out on potential growth when we stay with the same supervisor for too long. If I am happy where I am, do I really have to change?
(Deadline for responses 30 November 2022.)
One of my clients has been coming for help with low self-esteem after a difficult divorce. During a recent session, she said she had found someone on a dating app who she would like to meet. As she described him, alarm bells started ringing for me as I realised she was talking about my former partner, whom I had left because he had become controlling and abusive. Where do I stand – would I need to stop working with the client because of the boundary issue? Also, if they did end up dating, would it be within my remit as her therapist to warn her about his behaviour? (Deadline for responses 5 December 2022.)
The dilemmas reported here are typical of those worked with by BACP’s Ethics Services. BACP members are entitled to access this consultation service free of charge. Appointments can be booked via the Ethics hub on the BACP website.
Robert Elliott and Anna Oldershaw will be delivering Level 1 Emotion-Focused Therapy (EFT)training in Tunbridge Wells. This intensive four-day training will offer an exciting opportunity for delegates to learn directly from one of the founders of this psychotherapeutic approach.
Robert Elliott, PhD, is Emeritus Professor of Counselling at the University of Strathclyde. He has led EFTtraining in 15 countries.
To registerand for more info:
E: gaynor. mccracken@ca nterbu ry.ac.u k
T: +44 1227 927076
W: canterbury.ac.uk/eft-training
1 Meadow Road
Royal Tunbridge Wells Kent, TN 1 2YG
Coursefee: £800
Before 30 Nov 22:
Canterbury Christ Church
University
Qualifiedaccountant Availabletoassistfellowcounsellors andpsychotherapistswithtaxreturns, accountsandotherfinancialneeds. PleasecontactPaulSilver-MyerFCCA, UKCP(Reg),02074860541; psm@simonsilvermyer.com Low-costCPDworkshopsfromACPNL Wecoverawidevarietyoffascinating subjectswithexcellentspeakersand trainers.Fullprogramme at www.acpnl.org.uk/events
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For those who want a deeper understanding of psychodynamic and psychoanalytic concepts, with a particular focus on the couple. The course also serves as a foundation for applying for our clinical trainings. Apply now.
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What Makes a Contented Couple?: a Workshop for Clinicians presented by Anne Power
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Online live series: Lectures from the Tavistock Relationships Model
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A 10 day Certificate course for those working or looking to work with children and young people. The course will equip you with the tools and confidence to work with this group. The course is run by a respected, experienced therapist and supervisor in the area of children, young people and families. Get in touch on the details below for more information
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'WORKING WITH SHAME' 'WORKING WITH RELATIONAL TRAUMA' 'CHILD SEXUAL ABUSE. HOPE FOR HEALING' 'WORKING WITH SUICIDE & SELF-HARM' 'TRAUMA & THE BODY· SOMATISATION & DISSOCIATION' 'DISSOCIATION & DID: THE FUNDAMENTALS' 'WORKING WITH DISSOCIATIVE DISORDERS' 'MENTAL HEALTH & THE BODY: TREATING TRAUMA'
Brainspotting trainings teach the latest scientific Trainings Online and Beyond theory in relational neuroscience and the neurobiology of trauma informed therapy. Brainspotting is an embodied approach that removes obstacles and enhances the ultimate resource of transcendent attunement to realise the immense power of eye positions to access and process trauma. In these current times, we have the chance to adapt and evolve in terms of delivering the most effective therapy to those who need it most Brainspotting has been used successfully both face to face and online for some years, as the principles of
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Ten live dialogues between Prof Ernesto Spinelli and International Existential Therapists based on case studies tbat illustrate key existential topics. A group experience facilitated by Barbara Godoy and Guest Teachers to reflect on how clients are affecting, disturbing and inspiring our own relationship witb Being.
28Jan "Space" with Prof Ernesto Spinelli,
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Chrysalis NFP Ltd offer the following one-day, online, certificated, tutor ledworkshops for_professionals. These eacFi provide seven hours of recognised CPD. All workshops are Quality Checked by The National Counselling Society or The National Hypnotherapy Society and meet the CPD requirements of the Professional Register. EMAILcpd@chrysallscourses.ac.uk to request a booking form for your chosen workshopls. Thecost of each workshop Is £90.00.
'Eachworkshop Is limited to 20 students.Pleaseenrol ASAPto secure
place.
3rd November 2022 CHRYSALISCERTIFICATEIN MENTAL HEALTHAWARENESS
This workshop will introduce you to mental illness and their definitions, concepts, labels and stigma and how to foster positive mental health and psychological wellbeing.
In this workshop you will learn NLP philosophy of how the mind works, the difference between the conscious and unconscious mind and the representational systems that we use through the 'Communication model'.
This workshop will introduce you to discussion on the concepts of trauma, Post-Traumatic Stress Disorder and Complex-PTSD.You will learn how our brains protect us: intrusions (flashbacks), avoidance (of reminders/ dissociation); hyper-arousal and hyper-vigilance (anxiety/ reactivity) and the effect on memory.
In this workshop you will explore the understanding of the environmental and physiological factors that tell our body it's time to sleep. Identify unhelpful habits and behaviours and create new ones. Addressing different approaches that can be used with clients.
28th January, 2023 Chrysalis Certificate in Working with Self Harm
This workshop is for therapists who want to develop their understanding of self-harm and be better able to help clients who self-harm.
www.chrysaliscourses.ac.uk
MA in Child and Adolescent Psychotherapy and Counselling
Can lead to UKCP Registration and BACP Individual Accreditation
Duration: five years part-time
MA Conversion Course
Leading to UKCP registration and Middlesex University
MA in Child and Adolescent Psychotherapy and Counselling
Duration: two years part-time
Diploma in Child, Adolescent and Adult Psychotherapy and Counselling Supervision
Duration: one year part-time, eight weekends
Introduction to Therapeutic work with Children
Duration: four and a half days
For more information about training with Terapia
Call:
Join renowned trauma expert Gabor Mate and experience how to quickly get to the core of client suffering-to achieve profound, lasting transformation.
As clinicians, we need to be able to identify and understand our clients' issues at their deep and complex roots. That can be incredibly challenging and time-consuming, often requiring therapists to search, week after week, in the hopes of uncovering the true source of pain.
Renowned speaker and physician Gabor Mate is an expert at achieving rapid breakthrough results with even the most difficult mental health problems.
After spending decades working with drug addiction and mental illness from an up-close, personal perspective, he developed Compassionate Inquiry-an approach that takes the simple act of asking questions and transforms it into a powerful intervention that gets to the heart
of client suffering more quickly and effectively than you likely ever imagined possible.
Now in this unique online course, you'll experience Gabor Mate's Compassionate Inquiry approach in action with multiple, real client scenarios.
Get a front-row seat as Gabor demonstrates his method by working with dozens of audience members, one at a time, without any prior awareness of their struggles.
You'll learn the methods he uses to address substance abuse, infidelity, relationship issues, trauma, childhood attachment wounds, and so much more -while establishing a healing environment that even includes dance, laughter, and music.
profound
practice every day!
What motivated you to become a therapist? In my early 20s, during the 1980s, I was working for British Airways as a stewardess on long-haul flights, and the company had a crisis counselling service for the crew. Getting involved in this was my first step into the field. I didn’t really know what counselling or therapy entailed, but I knew I wanted to help my fellow colleagues and was struggling with my own mood.
Do you have a specialist field of practice? Eating disorders, body image and body dysmorphic disorder- (BDD) related issues. I suffered from an eating disorder from my late teenage years to my early 20s. Going into personal therapy at the age of 27 helped me navigate through this challenging period in my life. Following my core psychotherapy training at the Metanoia Institute, I went on to study trauma training with Pia Mellody at The Meadows in Arizona. This really helped shape my practice, particularly in the area of trauma and relationships.
Where do you see yourself in five years’ time? Currently, alongside my London-based psychotherapy practice, I am developing a wellness centre with my husband at The Falcon Hotel on the Castle Ashby estate in Northampton. I am truly passionate about offering a space where anyone, including clinicians and those in the field of mental
health, can come for rest and renewal – taking time out in nature, with open-water swimming and yoga.
How has being a therapist changed you? It has helped me to be more conscious in the world, particularly in terms of taking responsibility for my own actions. It has also helped me to assess a situation from the other person’s perspective and be more tolerant and compassionate.
What do you find challenging about being a therapist? Working with eating disorders can be very challenging. Resistance to change in eating disorders is common, and being patient with individuals who see themselves in such a punitive way can be hard.
And rewarding? My 30 years as a therapist have made me grateful for all the people who have allowed me into their world. To see people change against the odds gives me huge pleasure.
What is the most recent CPD you’ve undertaken? Was it worthwhile? ‘Shame and the Body: body image, eating disorders and embodiment – learning to love our bodies at any age’ – an online training with Sheila Rubin from the Center for Healing Shame in California. It was very worthwhile and gave me the tools to help clients with body shame.
I am a qualified hatha and kundalini yoga teacher, so yoga is a true passion of mine, and I also have a daily meditation practice. I also love running – it keeps my mind clear and focused. I’ve become a huge fan of open-water swimming and we are blessed to have a lake on Castle Ashby estate.
What book/blog/podcast do you recommend most often? For many clients with eating disorders and body-related issues, I recommend Fat is a Feminist Issue by Susie Orbach, which inspired me on my own journey. I also recommend Facing Love Addiction and Facing Co-Dependency by Pia Mellody, for those facing relationship challenges.
What is your favourite piece of music and why? I love anything by Jai Uttal, an extraordinary Kirtan musician. The track ‘Guru Brahma’ from the album Shiva Station really opens my heart.
What is the meaning of life? To evolve through experience in the service of others.
What would people be surprised to find out about you? In my mid-20s, I took a sabbatical from British Airways to work for an independent record company, and managed rap bands such as Run DMC.
Who is your counselling/ psychotherapy hero(ine)? Back to Susie O again! She has done great things in the field of eating disorders and women’s issues. I appreciate her psychoanalytic thinking and have attended many of her invaluable trainings over the years. My own therapist, Dr Roger Kennedy, also has to be a hero.
Now: BACP and UKCP accredited psychotherapist working in person in London and online, offering short- and long-term therapy, as well as supervision and coaching to therapists and trainees. Once was: Long-haul cabin crew for British Airways. First paid job: At age 15, a Saturday job working in Woolworths, Plymouth, behind the cosmetics and records counters.
Who would you like to answer the questionnaire? Email your suggestions to therapytoday@ thinkpublishing.co.uk
Introduction to Counselling (part-time)
Certificate in Humanistic Integrative Counselling Spring 2023
BACP Accredited Training Programme in Humanistic Integrative Counselling (two years, part time)
Diploma Year 1 Spring 2023
Advanced Diploma Year 2 Spring 2023
CPPD is one of the UK's leading humanistic integrative counselling schools, offering tuition responsive to the needs of each individual student.
We value each student's existing life experiences and skills within our friendly and creative environment.
