The Voice of the Counselling and Psychotherapy Profession

Therapy Today

The voice of the counselling and psychotherapy profession

May 2017 Volume 28 Issue 4

NB +++ indicates the start of a new section

+++ Contents

Welcome Publication information

Here and now:

In the news News feature The month Letters

The big issues:

Waiting for the Southsea busFinding meaning in life is just as important as we near its end, says Helen Kewell.

Women at the edgeSophie Livingstone describes her work with women with sexually compulsive behaviours.

Rethinking human sufferingStephen Joseph sees a place for person-centred counselling with people in severe mental distress.

I write, therefore I thinkLiz Cox explains how reflective writing can power professional development.

Regulars:

This much I don’t knowWisdom from experience.

Research into practiceLiddy Carver discovers how creative arts can help people with depression express their feelings.

DilemmasMatias’s difficult client wants to see his notes. Talking pointHow do you feel about working online?

Self-careTeddy bears with issues.

Analyse meWhat does your counselling room say about you?

Your association:

From the Chair BACP round-up

This is your journal. We want to hear from you. [email protected] +++ Welcome

Editor’s note

I love the way articles with no immediately apparent connection resonate with each other. Take March’s article on Redeen, the asylum seeker who could see no point in the future, and Helen Kewell’s article this month about her work with elderly people at the very end of their lives.

It is shocking that the emotional needs of older people are so frequently and thoughtlessly bypassed by the NHS, and that they are so rarely offered counselling. The assumption is that it’s too late now and, anyway, they don’t want it: ‘They would rather talk to the vicar/each other/have a nice cup of tea.’ What struck me is this article’s message that ‘it is still possible’ – that it is, indeed, crucial – to hold onto the belief that we can ‘challenge long-held life narratives and [...] dare to write new ones’, even, and perhaps especially, in very old age. The self-acceptance needed for change to occur can still be achieved at the end of life, and person-centred counselling can be the catalyst for that process.

This marries well with Stephen Joseph’s article on person-centred counselling with people in severe mental distress, for whom it is widely assumed to be useless. Not so, he argues: the Rogerian image of the potato seedlings in the cellar, growing towards the far-off light – that understanding of the damaging effects on the human psyche of thwarted and distorted potential – can explain most, if not all, forms of human distress. As Emmy van Deurzen points out in ‘This Much I Don’t Know’, you have to be willing to enter the client’s world (get on that bus to Southsea with them), ask them what stopped them going there before, and, by doing so, help them get there now.

Catherine Jackson Editor

Consultant editor’s note

The rapidity of the digital revolution has left therapists running to catch up. Are these wonderful new channels for communicating with clients, or a threat to our profession (and, indeed, to our own and our clients’ mental health)?

My own stance on technology is ‘love it, hate it, wouldn’t want to work without it’. Whatever we think, it’s here to stay, and the contributors to this month’s News Feature and Talking Point offer some interesting perspectives on how to use it so that it doesn’t use us.

A natural follow-on feature would be about how the so-called digital natives – our young adult clients – have been affected by growing up ‘on-screen’. How has this fast-paced, ‘always-on’ culture affected them? Has it changed how we relate and mate? Did the noughties, and the rise of Facebook, Instagram, Twitter et al, make us more narcissistic? Has the selfie generation become too self-focused? We know that anxiety and anxiety-related issues are increasing, especially in the younger generation. Has the digital revolution affected human evolution? Let’s press ‘pause for thought’...

Rachel Shattock Dawson Consultant editor +++ Publication information

Editor Catherine Jackson e: [email protected]

Consultant editor Rachel Shattock Dawson

Reviews editor John Daniel e: [email protected]

Media editor Bina Convey e: [email protected]

Dilemmas editor John Daniel e: [email protected]

Group art director Jes Stanfield

Chief sub-editor Charles Kloet

Production director Justin Masters

Group account director Rachel Walder

Managing director Polly Arnold

Group advertising manager Adam Lloyds d: 020 3771 7203 m: 07725 485376 e: [email protected]

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Case studies

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ABC total average net circulation

43,903 (1 January–31 December 2015) +++ In the news

Our monthly digest of news, updates and events

Counselling wins royal approval

BACP has warmly welcomed Prince William and Prince Harry’s recent backing of counselling. Prince Harry spoke publicly about his brother’s advice that he seek counselling after two years of ‘total chaos’ in his late 20s, having blocked his grief since his mother’s death. Prince William told charity publication CALMzine that he and the Duchess of Cambridge wanted their two children ‘to grow up feeling able to talk about their emotions and feelings’. BACP Chair Andrew Reeves said: ‘Prince Harry’s experience has shown that access to the right therapeutic support, at the right time, can have a positive and lasting effect.’ www.bacp.co.uk/media

Mental health and social media

Social media is a chief cause of mental distress among students, a report from the National Union of Students (NUS) says.

The report, Further Education and Mental Health, is based on the views and experiences of 22 further-education students aged 15–18 who attended an NUS roundtable event earlier this year.

The students said 24/7 social media made them vulnerable to online bullying at all hours, often made them feel ‘isolated’ and ‘neglected’, and meant they were continually seeking validation from other people.

They also spoke about the stigma attached to mental ill health, particularly in colleges, and about feeling ‘weak’ if they used mental health services, which, they said, were seen as being only for very serious cases. Many also said they didn’t know where or how to get help, either from their college or in the community.

The report sets out a ‘Charter for Mental Health in Further Education Colleges’, which says all colleges should have a student social media policy, and should build stronger links with local mental health services. bit.ly/2q4bp43

Call for national prescribed drug helpline

Members of the All-Party Parliamentary Group for Prescribed Drug Dependence (APPG for PDD) are calling on Public Health England to fund a national 24-hour helpline to help people hooked on prescribed drugs, including opioid painkillers, tranquillisers and antidepressants.

The call is backed by many professional and patient organisations and charities, including BACP, the British Psychological Society and the Royal Colleges of GPs, Physicians and Psychiatrists.

An estimated 770,000 long-term users of antidepressants could be taking these drugs unnecessarily in England alone, new research suggests. More than 250,000 people are taking benzodiazepines and/or z-drugs for longer than six months, even though NICE guidance says they should only be taken for two to four weeks.

Paul Flynn MP, Chair of the APPG for PDD, said: ‘Long-term users of these drugs can suffer devastating effects when they try to withdraw, often leading to years of unnecessary suffering and disability.’ prescribeddrug.org

Reporting child sexual exploitation

The Scottish Government has published new guidance for health practitioners on identifying and responding when a child may be at risk of sexual exploitation.

The guidance covers ‘spotting the signs’, barriers to disclosure, young people particularly at risk, how to respond, and the formal processes and procedures in place for practitioners to report their concerns.

A section on what young people want from health practitioners quotes young people themselves. One said: ‘No one ever asked me if I needed help.’ Another said: ‘I felt like that [the police] were getting really annoyed with me ’cause I didn’t have the words for a lot of the things.’ Another sought help for depression and self-harm and was told by doctors that she was ‘being silly and to go home and grow up’. bit.ly/2oFYJ1X

Report charts disability inequality

People with disabilities still face disadvantages and inequality in Britain, the Equality and Human Rights Commission (EHRC) has said. In a new report, Being Disabled in Britain: a journey less equal, the EHRC highlights the many disadvantages and inequalities still faced by disabled people in all spheres of life, including people with mental health problems.

Among the issues highlighted, the report singles out the wide variation in access to NHS talking therapies in England, Wales and Scotland. In England and Wales, the waiting time target for access to psychological therapies is now 28 days, but in some areas people are waiting more than 90 days, and the report also notes concerns about drop-out rates and whether the programme is reaching people who need help the most, such as those with chronic depression. In Scotland, it says, the majority of health boards have failed to meet the target to ensure access to psychological therapies for all patients within 18 weeks from referral to treatment. bit.ly/2nSeKm0

New veterans’ mental health service

NHS England has launched a specialist mental health service for armed forces veterans and service personnel who are leaving military service. The £9 million NHS transition, intervention and liaison (TIL) veterans’ mental health service will have the capacity to assess and refer on for further treatment, where appropriate, 17,500 people over the next three years.

Service personnel approaching discharge and veterans will be able to either self- refer or request referral via their GP, mental health provider or a military charity. An initial face-to-face assessment will be offered within a fortnight and, where appropriate, a clinical appointment two weeks later.

The service is intended to identify early signs of mental health difficulties, alcoholism, anxiety and depression, and ensure veterans get help for complex problems and psychological trauma before they reach crisis point.

Student stress in Northern Ireland

More than three-quarters of students in Northern Ireland have experienced stress or other mental health problems in the past year, a survey by the National Union of Students-Union of Students in Ireland (NUS-USI) has found.

Some 3,600 students took part in the research, and 78% reported mental health worries over the past year. Of these, 81% reported suffering from stress. Other common concerns were lack of energy, being unhappy or down, and anxiety. Forty- six per cent said their mental health problems had affected their quality of life, 44% said they had affected their studies and 43% said they had had an impact on their personal relationships.

The main causes were their studies and financial worries and pressure. Just one in 10 of those who tried to get help were able to get support on the same day. One in six got some help within a week.

NUS-USI President Fergal McFerran warned of a looming crisis in student mental health and wellbeing in Northern Ireland. ‘That is unacceptable,’ he said. bit.ly/2o5a6n8

Key stats 50% of children responding to a Department for Education consultation say they would like to be a mental health/peer supporter for other children. bit.ly/2ntYNlU

60,000 more people will be treated in IAPT services by the end of 2017/18, and 200,000 more by the end of 2018/19, NHS England has promised. bit.ly/2mURwhT

25.8% more young people in Wales sought counselling last year because they felt suicidal, up from 244 in 2014–15 to 307 in 2015–16. bit.ly/2oNJqpj +++ News feature

Tap and talk

Sally Brown asks if counselling is reaping the whirlwind of the digital revolution

We are in the midst of a digital revolution that is changing the way we communicate with each other and how we source and share information across the globe. The ubiquitous smartphone has created a 24/7 society where the boundaries between work and home have blurred, and there is an expectation that we are all instantly contactable. It amazes me how quickly we have normalised the seismic cultural changes of the last few decades. We no longer wonder that we can video-call loved ones on a different continent (for free!), or bat an eyelid at toddlers who can operate a tablet before they can walk or talk, or find it curious that we can ‘browse’ online for all our needs, whether that’s a new partner or a new pair of shoes.

For counsellors and psychotherapists, the digital revolution has extended our potential client pool worldwide, language and regulatory requirements permitting. We can market ourselves globally. We can offer face-to-face sessions from anywhere to anywhere, and be available at any time, if we so choose, at a press of a button. We have gained so much, including the ability to reach people who, for reasons of illness, disability, finance or geography, would not otherwise be able to access our services. We can even augment our work with, or be replaced by, apps.

But is there a price to pay in the quality of the work, for us, as practitioners, and for society in general? Are we seeing the advent of the therapy equivalent of Uber’s ‘tap and ride’?

Reaching clients

If we want to continue to reach new generations of clients, we have to do so on their terms, believes Sarah Worley-James, Chair of the Association for Counselling and Therapy Online. She is the creator and co-ordinator of the online counselling service at Cardiff University, which provides email, instant messaging and webcam sessions to its students. ‘In the 21st century, young people’s preferred means of communication is via a range of ever-changing online platforms and phone apps. It is reasonable for them to expect to be able to contact and work with professionals online in a similar way.’

In the US, clients can now subscribe to Talkspace, billed as ‘the leading online therapy platform’, and benefit from ‘therapy without travelling to an office – and for significantly less money than traditional therapy’. A monthly subscription of $128 allows them unlimited text messages with a therapist. For $276 a month, they get four video sessions and unlimited texting. Psychotherapists can earn up to $3,000 per month by counselling users via phone or text messaging. In the UK, Stillpoint Spaces similarly provides an encrypted video-conferencing platform, in addition to face-to-face therapy, worldwide.

Search for ‘mental health’ in an app store and you will find more than 2,000 apps, including those that claim to help you manage anxiety and the symptoms of post- traumatic stress disorder. Mental health has been described as the ‘next frontier’ for technology companies. In its 2016 report, Technology and the Future of Mental Health Treatment, the US National Institute of Mental Health (NIMH) predicts that behavioural health apps will increasingly incorporate ‘face-to-face counselling to provide a balance between technology and the human touch’. The World Health Organization has also backed the use of mental health apps to promote self-care.1

Studies suggest they are effective. For example, in a recent study of 99 adults with symptoms of depression or anxiety, or both, who used a mental health app called IntelliCare for eight weeks, 37% of those with depression and 42% of the anxiety sufferers reported a complete alleviation of symptoms at the end. However, the study lacked a control group, so the findings have only limited validity, and it’s worth noting that 64% of the group were also taking medication and 22% were also having psychotherapy.2

Emma Broglia, a PhD student at the University of Sheffield whose research is being funded by BACP, is currently studying the use of apps to supplement face-to-face therapy in a student counselling service. One of her research projects involves a highly rated app called Pacifica, a CBT-based programme that allows users to track moods and challenge unhelpful thoughts. Pacifica is one of 10 mental health apps recently recommended by NHS Choices.3

A group of 20 students were encouraged to use the app to map their mood and carry out relaxation exercises in between therapy sessions, with the option of discussing their experiences with their therapist. The therapists used a range of modalities, including CBT and person-centred and integrative counselling. ‘The study is still under way but results from an initial focus group have been positive – clients are reporting feeling that they have more control over their wellbeing,’ says Broglia. ‘The levels of depression and anxiety have been measured using PHQ-9 and GAD-7, and what has been surprising for the therapists is that even those at the severe end of the scale have experienced benefits from using the app.’ However, Broglia believes that the current ‘gold rush’ of mental health apps should raise concerns. ‘The issue is that these apps are designed by developers who do not have a therapeutic or clinical background, and very few have been the subject of clinical trials,’ she points out.

A different process

The mistake is to think that, just because we are comfortable using Skype socially, we are equipped to work effectively online, says Dr Gillian Isaacs Russell, psychoanalyst and author of Screen Relations: the limits of computer-mediation in psychoanalysis and psychotherapy. ‘In 2008, I closed a 30-year psychoanalytic practice in the UK and moved to rural South Dakota. A couple of previous patients and supervisees hadn’t realised I had moved and asked to work with me. I became enthusiastic about working online – this was going to be a magical solution to the problem! But I sleepwalked into the experience,’ she says. ‘It’s not just that we lose elements of communication; working remotely fundamentally changes the process. Therapists are resistant to thinking about this – we think we’re communicating in the same way, but the research shows many differences. We need to become familiar with the emerging research. It has serious implications for the way we practise, including the way we set our fees.’

She also found she needed a different kind of focus to keep the connection going. ‘The more you have to concentrate, the less you can relax into presence. It’s more cognitive – you can’t even approach that feeling of free-floating attention or reverie.’

Yet, despite this feeling of intense concentration, she found that her ‘state dependent’ memory – the memory on which we rely to access details of what was said the last time the client was sitting opposite us – was impaired, making it harder to remember the content of the sessions. ‘Sixty per cent of communication is non- verbal. That implicit, non-verbal communication that is central to what you do in the consulting room isn’t going to happen in the same way online,’ she warns.

But the most significant difference between face-to-face and online work is the loss of ‘presence’, says Dr Isaacs Russell. ‘Presence is a core neuropsychological phenomenon – it’s an organism’s capacity to locate itself in the external world, and the ability to interact with another in a shared physical environment enables the nervous system to recognise that it is in an environment outside of itself that is not a dream state or a product of its mind. The experience of embodiment in a shared environment is essential to our experience of being. Evolution prepared us to be embodied beings, sharing the same space, so all screen relations are simulations of this relational experience.’

Escaping the mess

One potential cost of the digital revolution may be the emergence of what is being tagged the ‘empathy gap’. According to a 2010 meta-analysis of studies by Sara Konrath at the University of Michigan,4 there has been a 40% decline over the past 30 years in the ability of students to recognise and identify other people’s feelings. In comparison with their peers in the late 1970s, students today are less likely to agree with statements such as ‘I sometimes try to understand my friends better by imagining how things look from their perspective’ and ‘I often have tender, concerned feelings for people less fortunate than me’. And the biggest decline has happened since 2000, when mobile phones became widely available.

‘Research shows that when people are together, say for lunch or a cup of coffee, even the presence of a phone on the table – even a phone turned off – does two things,’ says clinical psychologist Sherry Turkle, Abby Rockefeller Mauzé Professor of the Social Studies of Science and Technology at the Massachusetts Institute of Technology (MIT), and author of the book Reclaiming Conversation: the power of talk in a digital age. ‘First, it changes what people talk about – it keeps conversation light because the phone is a reminder that at any point we might be interrupted, and we don’t want to be interrupted when we’re talking about something important to us. Second, conversation with phones on the table, or even phones in the periphery of our vision, interferes with empathic connection. Two-person conversations that take place with a phone on the table leave each person feeling less of a sense of connection and commitment to each other.’

The shift towards online communication via Facebook, texts, email and platforms such as WhatsApp is part of a flight from the ‘messiness’ of spontaneous conversation, Turkle believes. ‘What people are fleeing is the kind of conversation that talk therapy tries to promote – the kind in which intimacy flourishes and empathy thrives. Online, we can curate the self as we want it seen. We can edit our conversation. We can cultivate the illusion that we can say the “right thing”. Contrast all of this with the simplest lessons of talk therapy: there, we quickly learn that, when we stumble and lose our words and are left in silence, this is when we may reveal ourselves most to each other.

‘We’ve always wanted to escape what’s most difficult in our relationships, and technology gives us a way.’

Online disinhibition

For some clients, this lack of ‘presence’ is a bonus: working online provides them with a ‘zone of proximal distance’, creating a sense of safety, says Worley-James. ‘Students on the autistic spectrum find the noisy, bright, intense sensory experience of entering a busy student support centre stressful and difficult to cope with. This may deter them from asking for our support, or, if they do, they may come to the session in a heightened state of anxiety. The environmental stressors of a busy building can also negatively affect students with mental health problems, such as social anxiety, creating a barrier to them accessing our service. I have also worked with transgender students who are used to accessing peer support through online forums. They may feel safe to be themselves in the virtual world, when face-to-face relationships can be fraught with uncertainty about the other person’s hidden opinion.’

There can also be a positive benefit from the ‘online disinhibition effect’ – the abandonment of the social rules normally applied to face-to-face communication, which is often associated negatively with cyberbullying. However, says Worley- James, ‘The effects of online disinhibition can be hugely beneficial and therapeutic for many clients. The anonymity of communicating by email or instant messenging allows some clients to explore sensitive topics without cultural or gender issues intruding and limiting their freedom to do so. I am struck again and again by how quickly clients open up online, and how effective the online therapeutic relationship can be.’

Turkle warns that therapists are in danger of slipping into digital therapy without ever really questioning its usefulness. ‘At first, treating a client by Skype is presented as “better than nothing”. Gradually, what you can do on Skype begins to be presented as equivalent to, or maybe better than, what you can do with the client in the room. Why are therapists so quick to abandon the body and what it brings to our understanding?’ she asks. ‘If you give up on the body, you open the door for treatment by programs, by robots, by all kinds of artificial intelligences that also don’t have bodies. This seems a stretch, but it is a stretch that is ready to be marketed to you.’

The answer is, of course, that we need to ensure that we make good use of what digital technology can bring to our work while ensuring it doesn’t dictate how we work, negatively affect the therapy relationship, or become misused as a cheap alternative to face-to-face therapy.

Return to embodied therapy

Isaacs Russell predicts that we will soon see a renewed valuing of talk therapy, and a need for it, by a generation who have become disillusioned with social networking: ‘My prediction is that young people growing up with technology will have a longing for something authentic and we will see a greater demand for embodied therapy.’

Turkle agrees: ‘Psychotherapists are experts at the kind of talk that digital culture needs most, the kind of talk in which we give each other full attention, the kind of talk that’s relational, rather than transactional. What therapists need to recognise is the reason we need to talk: to forge relationships that are the triumph of messy, breathing human connection over the cold instrumentality of treating each other as apps. This does not mean that virtual treatment doesn’t have a place. But it should not be allowed to sneak in as a substitute.

‘Psychotherapy has a moment to assert what it knows best: that the body does matter – that being in the room does matter.’

Boxout: Digital policy

We owe it to our clients to seek information and educate ourselves about digital life, says psychotherapist Aaron Balick, author of The Psychodynamics of Social Networking. ‘Most therapists start their training in mid-life, and they are trained by mid-life digital immigrants who are generally later to the table than these trainees themselves, so it is taking our field a while to catch up with the zeitgeist. I have come to a place where I think every therapist should have a digital policy because we don’t have the privacy we had 20 years ago.’

Balick’s digital policy includes an undertaking not to google a client or follow them on social media, and he suggests that his clients do the same for the duration of their work together. ‘I can’t stop clients googling me, but I can request that, if they do so and they find something out about me that they want to discuss, they bring it into the room. I tell clients that this is how I keep this relationship different from other relationships, and protect their confidentiality,’ he says.

We also need to think about the culture of ‘implicit immediate availability’ that smartphones, email and texting can create, he argues. ‘How will you cope if you find digital native clients are less boundaried about contacting you between sessions? I no longer receive emails on my smartphone. I realised that receiving requests for information or actions that I wasn’t in a position to carry out until I was back in my office was creating anxiety.’ He has also re-evaluated his relationship with social media. ‘I have come to view it as somewhat pernicious,’ he says; he has turned off all his notifications and now accesses it when he chooses to. ‘This is the ideal, of course. Just like everyone else, I’m liable to check more than I ought to and impulsively post things I probably shouldn’t. It’s a work in progress.’

Sally Brown is a counsellor and coach in private practice (therapythatworks.co.uk), a freelance journalist, and Executive Specialist for Communication for BACP Coaching.

Dr Gillian Isaacs Russell will be presenting at the Confer conference, ‘Providing Psychotherapy in a Digital Era’, on 24 June, in London (www.confer.uk.com).

References

1. www.who.int/mental_health/action_plan_2013 2. Mohr DC et al. IntelliCare: an eclectic, skills-based app suite for the treatment of depression and anxiety. Journal of Medical Internet Research 2017; 19(1): e10. 3. www.nhs.uk/Conditions/stress-anxiety-depression/Pages/mental-health- apps.aspx 4. Konrath S, O’Brien E, Hsing C. Changes in dispositional empathy in American college students over time: a meta-analysis. Personality and Social Psychology Review 2011; 15(2): 180–198. +++ The month

Our monthly round-up of film, theatre, the media and events

11,796 people viewed cricketer Freddie Flintoff talking about anxiety to musician Professor Green in this Heads Together campaign video: bit.ly/2oCIx5k

TV: Being Mum and Dad

The power of celebrity in helping to challenge male stereotyping was amply evidenced by the reaction to Being Mum and Dad, a BBC documentary featuring Rio Ferdinand, in which the former Manchester United player opened up about his grief following the death of his wife, Rebecca Ellison, from breast cancer in 2015. The programme was watched by 5.2 million viewers, and social media buzzed with praise in the days that followed. It’s no longer available on iPlayer, but let’s hope for a repeat soon. These were some of the tweets from affected viewers:

Dr Sarah Russell @learnhospice. ‘Think this should be mandatory watching in all health & social care curriculums, not just palliative care.’

Tony Shepherd @tonysheps. ‘In a world where the phrase “man up” is often used. So much respect for @rioferdy5 for doing this programme. Much love.’

Fara Williams MBE @farawilliams47. ‘Watching #BeingMumAndDad with a permanent lump in my throat. So much bravery shown by @rioferdy5 massive inspiration to so many.’

Radio: The Uncommon Senses

We know about the five senses, but what about the other 28 we are believed to possess? Not only do we have a multitude of senses, such as our sense of self and our sense of agency – the feeling of being in control – but we also have to contend with a predictive brain that second-guesses what it expects our senses to tell it. Philosopher Barry Smith and sound artist Nick Ryan explore the human multi- sensory world in The Uncommon Senses, a fascinating seven-part series broadcast on BBC Radio 4 in March and still available on BBC iPlayer.

Blog: Anxiety surge

A toxic combination of political upheaval and our addiction to 24/7 newsfeeds is driving the five-fold increase in traffic to the Mental Health Foundation’s online anxiety page, says Senior Media Officer and blogger Carl Strode. ‘The surge in traffic started last July, the month following the EU referendum vote…phones and social media keep us connected to the shifting currents of world and home political affairs, making it much harder to maintain boundaries and take healthy time out from anxiety-inducing news.’ Read more at huff.to/2o17hDO

Theatre: Good Grief

With a coffin stuffed with sympathy snacks, comedian Jack Rooke and his 85-year- old nan Sicely invite us to their world of grief. In this final run of his critically acclaimed show – a blend of sharp wit, storytelling and film – we follow the comedian’s experiences after the death of his father and his observations on grief more generally. Rooke applies his comic talent to this frank but gentle look at how we treat the bereaved and how we support the welfare of grieving families. Good Grief is currently touring until 24 June. bit.ly/2nvsW5Q

Video: If you only have two minutes…

Institutional racism has dogged the Metropolitan Police for many years, but a subtler subconscious bias is at play in society more widely, and it is highly relevant to our work with clients. In a funny and thought-provoking presentation (part of the 5x15 talks initiative) the Met’s highest-ranking Sikh officer, Chief Superintendent Raj Singh Kohli, challenges the everyday assumptions we make about each other. If unchecked, this natural human trait impels us to form networks with people just like ourselves and to make subliminal judgments, with potentially harmful consequences. bit.ly/2nGk6n2

Event: Gut-Brain-Heart-Brain

Many in the psychotherapeutic and complementary medicine communities have long held that emotional processing crosses the Cartesian body–mind divide, taking place not only in the brain but also in the heart and gut. Research into the ‘gut-brain axis’ is generating techniques to harness the powers of the bacteria and other micro- organisms in our digestive system to heal emotional pain and harm, particularly in trauma work. This one-day conference brings together experts in the field to explore the contribution of our physiological systems to affect regulation. They include nutritionist Michael Ash, clinical psychologist Janina Fisher, author of the forthcoming book Healing the Fragmented Selves of Trauma Survivors, and EMDR specialist and medical practitioner Art O’Malley. The Gut-Brain-Heart-Brain conference will take place on 1 July in London. bit.ly/2nLPlsM

Event: Blooming in Brighton This year’s Brighton Fringe arts festival (5 May to 4 June) offers the most events ever (970), including 300 premieres. Look out for Patrick Sandford’s Blooming. Sandford scooped three awards last year for Groomed, his show about his personal experience of sexual abuse. His 2017 performance is based on a survey that asked 100 people: ‘How do you know when you are happy?’ In what promises to be a provocative and kaleidoscopic performance, Sandford questions whether we can ever move on from trauma and if happiness is the key. Blooming will run on three consecutive weekends from 19 May. bit.ly/2ne8hRn

TV: Rehab

Surviving addiction is not only about the addict; it’s also about all the people and relationships around the addict that are affected. Phillip Wood’s first film, Chasing Dad: a life-long addiction, was an intimate and visceral documentary about his own survival in a household of addiction, and has been nominated for the 2017 Royal Television Society Breakthrough award. His new film, Rehab, explores addiction in young people, and promises to be equally powerful. Rehab will show on BBC Three at the end of May.

Know of an event that would interest Therapy Today readers? Email [email protected]

Read a new book we should list? Email [email protected]

Professional Practice in Counselling and Psychotherapy: ethics and the law Peter Jenkins (Sage, £24.99)

Structured around the BACP core curriculum – and including exercises, case studies and tips for further reading – this training and practice manual covers a wide range of topics to do with ethical and professional practice. Jenkins guides the reader through the BACP Ethical Framework, the relevant legal frameworks for practice, contrasting models and approaches to ethics, confidentiality and record-keeping, and working with key issues, including difference and vulnerable clients.

Essential Research Findings in Child and Adolescent Counselling and Psychotherapy Nick Midgley, Jacqueline Hayes and Mick Cooper (eds) (Sage, £24.99)

Experts in the field present current best knowledge from the research on neurobiology, attachment and trauma, and the development of mental health problems in children and young people. What works for whom? What leads to change? What can therapists learn from research? How can developmental and neuroscience research inform therapeutic work with young people?

What is Mindfulness? Tamara Russell (Watkins Publishing, £7.99)

Neuroscientist, psychologist and martial arts and mindfulness expert Tamara Russell demystifies the common confusions that get in the way of successful mindfulness training. In this short book, she seeks to answer our questions – what does mindfulness really mean and how can we get the most from it? – and to explain how mindfulness practice can be applied in our daily lives, using the right tools and the methods that most benefit our bodies and brains.

The Descent of Man Grayson Perry (Penguin, £8.99)

The nation’s favourite transvestite, the Turner Prize-winning artist, TV presenter and author Grayson Perry, explores how masculinity shapes the lives and expectations of men in Britain today and presents a new ‘Manifesto for Men’. Covering topics from power to physical appearance, this funny, honest and tender book is driven by the belief that, for everyone to benefit, men need to decide to upgrade masculinity for themselves.

Out of this World: suicide examined Antonia Murphy (Karnac Books, £19.99)

Murphy weaves together personal insight, professional practice and a review of the literature to provide an account of current understandings of suicidal states of mind. Suicide is explained as a largely unconscious, aggressive act, with its roots in a perceived or real experience of thwarted childhood needs. Therapy offers an arena where the suicidal fantasy can be worked through, rather than acted out, she argues.

First lines

‘Voices are waiting to speak to you. They know your name. They could call it from the surrounds of sleep, on a bustling street, or from your car back seat. Samuel Johnson, Sigmund Freud, probably you, and definitely me, have all had at least this fleeting voice-hearing experience.’

From Can’t You Hear Them? The science and significance of hearing voices by Simon McCarthy-Jones (Jessica Kingsley Publishers, £13.99)

A book that shaped me

An Evil Cradling Brian Keenan (Vintage, £9.99)

I read this book as I was travelling across India, often on buses or trains, for days at a time. With vast expanses of time ahead of me and nothing to fill them, I felt I was losing grip on my mind. Keenan’s account of being held hostage, with English journalist John McCarthy, for four years in Beirut, tells how he tried to retain a grip on his sanity. It’s the only book I’ve read in which one chapter provokes tears of sadness, and the next tears of laughter.

Nicola Strudley MBACP (Snr Accred)

What book contributed to making you into the person you are? Email a few sentences to [email protected] +++ This much I don’t know

My first full-time job as a psychotherapist was in a rather special psychiatric hospital in the Massif Central, in a small village called Saint Alban, where the patients lived in a castle, surrounded by mountains and beautiful countryside. This hospital was the pioneer of French revolutionary psychiatry, having taken down its walls and unlocked its wards in the 1940s and 1950s. Patients, doctors and nurses had created a community in which manual work and social activities were shared and discussed therapeutically.

I arrived there in 1973, aged 21, full of ideals and good intentions. I loved the shared vision of working together and I was proud to be getting rid of my white coat.

The very first person I met was Henri, known to all as Riquet. He became my guide and mentor, but was never my patient. Riquet had been a resident in the hospital most of his life, since he was brought there as an orphan with behavioural problems. He was a kind of prophet and representative for Saint Alban and had featured in a movie about it, where he spoke about asylums as places of protection from the outside world and its craziness.

He was in his early 50s when I met him and thus 30 years older than I. He liked to compare himself to the wild boy of the Aveyron, who had been found mute and savage in the countryside and who had been destroyed by human culture. Riquet had obstinately remained wild himself, and regularly went on long excursions in the mountains. Nobody bothered him or tried to confine him. He often looked like a vagrant.

Riquet taught me to listen to the words of people who are mad and to respect the personal world they have created. He taught me to find the value of their worlds and not to try to dominate, cure or destroy them. He taught me that my own depth of feeling was a precious resource, not something I had to control or shut off, and that it was this that allowed me to relate to people who were alienated and estranged from the world of other people, because they too felt so deeply.

My relationship with Riquet formed the basis of my growing understanding of psychotherapy, more than my training and supervision. He took me on walks, showing me the flowers and the mushrooms, naming them and telling me about their properties. He gave me unsolicited and sometimes harsh and rude feedback about my work, and never spared me. He challenged me on my privilege, even when I felt I was working very hard and being generous with my time. He encouraged me to take a political view of psychiatry and personal problems. He shamed me about everything I had taken for granted. He showed me great affection too, and made me feel I was talented and special.

Above all, Riquet taught me to stand away from conformity and normality. He showed me how important it was not to set myself above people, but to be with them in respectful reciprocity and plumb their depths to find their wisdom. Emmy van Deurzen is a philosopher, existential psychotherapist and counselling psychologist. She works in private practice and is founder of the School of Psychotherapy and Counselling at Regent’s College, the Society for Existential Analysis, and the New School of Psychotherapy and Counselling at the Existential Academy in London, where she is Principal. +++ Letters

We very much welcome your views, but please try to keep your letters shorter than 500 words – and we may need to cut them sometimes, to fit in as many as we can. Send your letters to the editor at [email protected]

Matriarchal Britain

I was intrigued by your thought-provoking front cover on the March 2017 issue, ‘Is counselling women’s work?’ I was hoping to read ideas on how to persuade men into our profession. I was very let down.

I question the continued assumption of a patriarchal society. I believe modern Britain is matriarchal. However, there is no monetary value in raising children and the majority of primary caregivers are women. Men expect to be the primary breadwinner? I suggest they are expected to be. I also suggest women are just as assertive as men, and wonder if their goals and techniques simply differ.

Overall, the article seems to focus on how to support women into management, and not men to be counsellors.

Mark Cuddihy Napier Counselling, Glasgow

Celebrate yin and yang

I was interested to read the article ‘Is counselling women’s work?’ in Therapy Today, March 2017, and its exploration of the possible reasons for many more women than men choosing this profession.

While a passing nod was given to ‘biological reasons’, the main thrust of the article focused, as is routine at the moment, on the ‘socialisation’ aspects of the difference between male and female choices.

It concerns me that there is an over-emphasis on ‘socialisation’ and an avoidance of certain hardwired, biological determinants that, in my view, we do not need to fear.

Yes, there will always be exceptions to the general rules about male and female difference, but, in my work as a couples counsellor, I can tell you that communication difficulties present constantly because men and women ‘speak different languages’ in their expression of their needs. Let us not fear these differences, but celebrate them and see how they can be a strength, in the same way that yin completes yang.

I even dare to say that there will always be more men than women attracted to the army or to the construction industry as professions – and it is likely that there will always be more female counsellors than male. I wonder why this should be a problem.

Jennie Cummings-Knight www.goldenleafcounselling.com

Women psychoanalysts

I write in response to a point made by Sally Aldridge in the article on counselling as women’s work in Therapy Today, March 2017. I was dismayed to see her saying, ‘While psychotherapy is rooted in the male-dominated world of psychoanalysis, women have “owned” counselling from its earliest days.’

I consider this remark as dismissive of the enormous numbers of women who have been leaders in psychoanalysis and who have contributed tremendously to the feminist cause. I cite Melanie Klein, Anna Freud, Karen Horney, Nancy Chodorow, Joy Schaverien, Susie Orbach, Christina Wieland, Julia Kristeva, and I could go on.

Karen Minikin MBACP (Snr Accred) Counsellor, psychotherapist and supervisor [email protected]

Subconscious prejudice

I was interested in Sally Brown’s article on ‘Is counselling women’s work?’ (Therapy Today, March 2017) and I was reminded of my very first training group with the Marriage Guidance Council in 2001, which I embarked on to create a second career. Inevitably, I was the only man in my group of about 10 women. Before the group had been going for more than 10 minutes, one of the women raised the subject of her menstrual cycle, which seemed to me a very clear signal that a man was going to find it tough if he wanted to break into the female preserve of counselling.

Fortunately, I had already been in a Robin Skynner group, and was not abashed, and went on to qualify and enjoy private practice, but I do wonder whether there was a subconscious prejudice against men in the profession and whether, maybe, that still exists.

Michael Dillon Weston

Unconscious bias

I would like to offer a further perspective on Sally Brown’s article in the March 2017 issue, ‘Is counselling women’s work?’.

In ‘Talking Point’ in the same issue, the discourse around women being better suited to counselling was fascinating: for example, women are ‘more available to… and more skilled at’ a certain kind of caring. Surely, if counsellors of both genders offer such opinions about the suitability, skill and aptitude of male counsellors, then it demonstrates unconscious bias in our own profession, and suggests that this also may contribute to a lack of male counsellor representation?

If we cannot grasp this particular nettle, and explore our attitudes and beliefs about counselling and psychological therapies in relation to gender, then everybody is going to get stung: clients, colleagues and all.

Richard Mason Reg MBACP (Accred)

Porn use does not mean child abuse

I am writing this because it was so disappointing to see featured an ethical dilemma around viewing pornography (‘Cautionary Tales’, Therapy Today, March 2017) that seemed to be written with no knowledge or understanding of either sexuality or good therapeutic and supervisory practices.

The dilemma makes clear that the image viewed was of two adults having sex, yet the article constantly talks of filmed child abuse. The piece claims that ‘the research linking abuse to the viewing of pornography is ambiguous’, yet offers no links to said research. However, readers are instead directed to an organisation that works with survivors of and perpetrators of childhood sexual abuse, clearly implying that those who view consensual adult sex are likely to also view filmed child abuse.

One of the first things we are taught as embryonic counsellors is that any strong reaction must be examined. If we have an emotional response to something a client brings, we need to be able to reflect on it. If we are not sure what has prompted the response, we take it to supervision, or to our own personal therapist. This is one of the ways in which clients are kept safe. It is the bedrock of good ethical practice.

It worries me a lot that, in less than one full sentence, the need for this kind of reflection was dismissed. There is no reflection at all on Marna’s part. One does not have to be a Freudian to wonder if Kevin had the role of a father figure in Marna’s life. Was this a moment of ‘walking in on daddy’? This would explain the strange leap to fears of child abuse, and the inability to treat with empathy and compassion someone who reveals their distress. This is, of course, speculation about a fictional scenario, but it is the type of challenging question one would expect to have posed if you disclosed that you were struggling with your emotions to the extreme degree that Marna is.

This directly leads to perhaps one of the most important questions that the piece ignores: is Marna safe to work with clients? Watching pornography is common; it is done by all genders, and, with the growth of the internet, is often a worry for clients. Can Marna work with a male client who tells her he watches pornography without expressing her clear disgust? Can she work with a gender- or sexually diverse client who expresses how much pornography has helped them understand themselves? Can she work with a female client who has discovered a taste for BDSM from watching porn? These are questions that should have been asked before anything else. Yes, we have a duty to ensure fellow professionals are working ethically, but first we have to ensure we are working ethically. The disconnect around sex that is being encouraged in this article, the lack of personal reflection, and the leap to judgment all ignore the building blocks of counselling – the core conditions.

Counsellors and psychotherapists who have not examined their own attitudes towards sex honestly and with a recognition of unconscious and subconscious reactions are a greater danger than someone in distress who ill-advisedly watches porn on a break in a private room.

Last, despite so many fine words about being more inclusive of LGBTQ+ people and different forms of relationships, the entire piece assumes heterosexuality as a norm.

Karen Pollock Counsellor in private practice working with gender, sexual and relationship diversity

Closed to men?

I approached counselling training in my early 30s from the position of becoming increasingly aware of my disconnection within myself and with others around me. I had hitherto been a ‘good male’: sailor, salesman and tree surgeon. I knew I needed to soften my armour and allow a sense of ‘flow’, which would allow myself out and others in. I needed to reconnect and give substance to my core. I needed to find meaning for my life and salve my wounds.

I needed three breaks from training because this journey was fraught with confusion, pain and overwhelm. As such, I was a member of four different groups. The first thing that grabbed me was that, in each, I was either the only male in the group, or one of two. This I found difficult because, while seeking a more empathic, compassionate way of being, I also valued much of my more ‘male’ way of being. I often seemed at odds with the group in this. It was a very hard process to learn that the attributes that worked so well (at least in certain areas) in my former life were so denigrated in counselling training. I was often left feeling inadequate, wrong and ostracised. I believed my maleness was not valued by my peers. I struggled to feel validated in my experience, my difference misunderstood by my peers and by me.

It was a hard journey to find the resilience to experience the tensions caused by this difference and keep coming back. I know of other men who just dropped out and did not return. I have come a long way to allow my softer, feeling side to flower. I still wonder how open to the male experience training courses and students are.

Nick Tarrant MBACP

Poignant and humane

I am writing to both compliment and express my gratitude to John Pasture for his contribution ‘No one can help me’ in the March 2107 issue. I experienced his story, both in content and style of narrative, as simply stunning in its quality of expression and descriptiveness, its poignancy and as a catalyst to reflect yet more deeply on such challenging work.

Thank you so very much for sharing this first-class account of therapy with its most unexpected turn and at its best!

For me, John’s story oozed the love and caring for humankind that is so profoundly touching and makes me feel proud and thankful to still be in this profession now some 20 years on. It also provides some balance by acting as a stark contrast to so much of the daily world atrocities that we are witness to and the shadow side of what it is to be human.

Jennet de Caresle, MSc, PG Dip Couns, MBACP (Snr Accred)

Registration still has credibility

It’s always sad to read a resignation letter from a member who has worked so hard for over 30 years with BACP (Christopher Murray, Letters, March 2017). With only 14 years of membership, I wish the writer well, and hope he will reconsider. Accreditation is not a gold standard. Human nature is what it is, and it will only take a moment’s reflection to recognise it is the individual’s responsibility to maintain standards as a professional, in any sphere working with fellow human beings.

The writer’s perception with which I disagree is that it is easier now to train, become accredited, and then practise privately as a counsellor, and that this is a lowering of standards. These validation procedures are still regulated by BACP and the standards have to be met. As more accredited private practitioners from a variety of modalities offer their services locally, this increases choice for the client, and equally increases competition between the services offered. There are other accrediting umbrella organisations for counsellors and psychotherapists, yet both of my previous NHS posts in primary and secondary care required BACP accreditation and registration. I am confident this perception of the organisation’s credibility will continue.

Paul Frazer Reg MBACP (Accred)

Efficacy of EMDR

The BACP News in the March 2017 issue of Therapy Today quoted a single recent research paper comparing the efficacy of Eye Movement Desensitisation and Reprocessing (EMDR) with Emotional Freedom Technique (EFT) or body tapping. EFT is a completely different approach that doesn’t have the same rigorous evidence base as EMDR, even though the research showed them both to be effective. I would have cited a more recent meta-analysis of 26 randomised controlled trials between 1991 and 2013,1 which demonstrated the effectiveness of EMDR in treating psychological trauma and post-traumatic stress disorder (PTSD). This is a substantial basis, which makes EMDR recommended by many organisations, such as NICE and the World Health Organization.

My own experience of introducing EMDR with over 100 clients (not all with PTSD) is that it can resolve deep-seated trauma within minutes, or certainly sessions. Of course, this doesn’t work with everyone, but that is the case for all approaches, and sensitive, client-focused work with attunement is just as important with EMDR as any other therapy approach.

Justin Havens MBACP (Accred)

Reference

1. Chen Y-R, Hung K-W, Tsai J-C, Chu H, Chung M-H et al. Efficacy of eye- movement desensitization and reprocessing for patients with postraumatic-stress disorder: a meta-analysis of randomized controlled trials. PLoS ONE 2014; 9(8): e103676. doi:10.1371/journal.pone.0103676

Speaking up for interpreters

As a therapist who manages a team working with refugees, asylum seekers and vulnerable migrants, I enjoyed reading John Pasture’s ‘No one can help me’ (March 2017), about working with his Kurdish client. However, one short sentence leapt out at me: that was the first interpreter (admittedly of the wrong language) leaving with/before the client.

While all clients who need to work with an interpreter should have the opportunity to meet with the therapist without the interpreter from time to time, the interpreter should never leave with the client. In fact, the interpreter should have time with the therapist before and after each therapeutic session – 15 minutes either side is ideal. This is for several reasons. The bonds of language and culture can be a lot stronger than the therapeutic alliance, and you do not need clients and interpreters to go out for coffee together after the session, or for one to put pressure on the other. The interpreter can pick up issues the therapist has missed, or have valuable insight to contribute. And, if the work is very distressing or hard, the interpreter is the one whom everything goes through and who gets the initial impact of whatever is communicated.

Interpreters tend not to be given enough support, but are expected to keep all that they translate confidential; they have all of the words and no voice of their own. Work with an interpreter is triadic: there are three people in the room, with all the attendant dynamics – not two people plus a language machine.

Sushila Dhall Therapeutic Services Manager, Refugee Resource +++ Counselling changes lives

Waiting for the Southsea bus

Finding meaning in our life is no less important just because we are nearing its end, says Helen Kewell

Tom* was one of the first clients I worked with during my training – a 95-year-old man who was referred to me by a nurse in his residential care home because he was struggling to adjust to life alone after the death of his wife. I was terrified. What could I possibly do to alleviate the distress of a man at the very end of his life? As I went to the care home for our first session, I felt inescapably young and impotent before the tidal wave of grief, ill health, powerlessness and distress that I imagined I would meet.

Tom died, suddenly, after we’d had just six sessions together. But, in those six weeks, he turned each of my presuppositions on their head. I learned a lot about myself, what I wanted to do in my counselling career, and what it means to experience love and loss in the therapeutic encounter. Above all, he changed the way I view life, ageing and death, and, crucially, how to work therapeutically with people who are approaching the end of their lives.

I believe that counselling is an emancipatory and political act: by engaging in it, we can liberate ourselves to be all that we can be. I often feel, in my role as a counsellor, that I am mounting a tiny insurgence against a world that celebrates certainty and puts people in social and cultural boxes. Society tends to objectify and isolate the elderly; to regard everyone over a certain age as an amorphous mass, rather than a collection of unique individuals with rich, unique stories.1 Often, older people find themselves excluded from psychotherapy services, unable to access them due to poverty or physical disability, and seek support instead from non-profit organisations.2 Depression affects around 22% of men and 28% of women aged 65 years and over, yet it is estimated that 85% of older people with depression receive no help at all from the NHS.3 Society seems to expect a certain amount of depression in people over 65; it goes with the territory, as it were. Is this OK?

Writing during her own advancing years, Simone de Beauvoir proposed that we experience our old age through other people’s reactions to us, but this often conflicts with how we truly feel inside.4 My wonderful, perpetually cheerful grandmother, on her 90th birthday, giggled as she exclaimed: ‘Ninety! But I don’t feel old! Inside, I still feel like I’m in my 20s!’ This disconnect of personal experience of self with societal perceptions and the physical manifestations of advancing age can be psychologically difficult to bear.

Freud believed that older people were not able to make effective use of therapy.2 Erikson only added the final life stage to his developmental theory as he approached his own old age. He argued that this final stage is about integrating past, present and future to find acceptance of the life that has been lived.1 Rogers, in developing the idea of the human being’s natural tendency to growth, proposed that change can only occur when we are able to fully accept who we are.5 I would argue that, even in very old age, it is still possible, indeed crucial, to challenge long-held life narratives and to dare to write new ones. One excellent way of facilitating this is through counselling.

As counsellors, our role is to recognise, encourage and celebrate the unique individuality of our clients and to explore their reality. When I first came to this work with older people, in the conceit of youth, I believed that self-actualisation was not feasible in the last stage of life and the best I might hope to offer my clients was the alleviation of their distress. The work has profoundly challenged my preconceptions.

Rewriting narratives

We all recognise the stereotype of the elderly person telling and retelling stories of when they were young to anyone who will listen. However, as with any content that is brought to counselling, the stories give clues to a client’s process, how they are in the world and what might be healing and helpful for them; they are not to be overlooked.

Bill was an 80-year-old man I worked with over six months, following the death of his wife. They had been married for 55 years. Glaswegian, talkative and hard of hearing, Bill greeted me at his home each week wearing a flat cap and an ancient pair of silk pyjamas under his clothes to keep out the cold. The story of his life, as it unfolded, was one of poverty, adversity, bloody-mindedness and sheer hard work. He retold it from many angles, week after week, always casting himself as a bad man making poor choices and not deserving love. His grief was held back by his belief that he didn’t deserve the love of his wife in life, and therefore didn’t deserve to grieve for her after her death.

As with any client, a counsellor’s role is to interrupt established patterns of relating and refuse to play along.6 I was struck by how caring and charming Bill was in our sessions and in his actions towards others, and the contrast with his narrative, in which he was a hard, bad man, who had done some awful things in his life. This carried so much authenticity that at first I felt I should be afraid of him, despite feeling the warmth in our sessions. When I brought this disparity to his attention, he brushed me off, unable to entertain the idea that he might be a good person. However, my persistence in challenging his narrative eventually took us on a journey together, back 75 years to early abuse at the hands of a domineering ‘monster’ of a mother and to a realisation, which came dramatically and suddenly in the dusty silence of his sitting room, that he wasn’t to blame.

In Bill’s words, he could never forgive his mother, but he slowly began to forgive himself, to see himself as someone whose trust had been broken, and who had been traumatised by events in his childhood. He found self-compassion and began to rewrite the story of his life from this new perspective – a narrative with greater authenticity than the one that cast him in the role of reluctant patriarch to his large family. Had I taken his story at face value, I might have viewed the development of self as pointless for someone in poor health who himself told me he was ‘not long for this world’. The theory of gerotranscendance is helpful here, as it conceptualises a circular self that uses present reflection on the past to constantly redefine experience and therefore transcend boundaries and limits of age.7 This aligns with the humanistic belief that everyone has potential for growth and that this is enabled through moment-to-moment interrelatedness with others, as with Bill.

Entering their world

It can be confusing and concerning when the elderly or profoundly old who are cognitively impaired don’t recognise loved ones, cannot remember information about their own lives or seem to withdraw into a world that is quite different to our reality. Counselling is all about exploring the client’s worldview, and, for older people who are losing cognition, this can be a powerful antidote in a society that isolates those who don’t conform to the received view of what is ‘real’ and ‘right’. Imagine how frightening it must be to lose your grasp on memory, knowledge and your location, and to have this reinforced by those around you.

A therapeutic encounter, seen through the Buberian paradigm,8 is a point of connection between two domains of existence, not the dominance of one domain over another. Tom, although he was in reasonably good health for his 95 years, had been diagnosed with dementia. I met him weekly, initially in his room, although we subsequently became more flexible about our encounters. Due to his poor hearing and cantankerous nature, many of our sessions had the outward appearance of irritable bickering, despite moments of strong connection and depth. Here was a man who, despite his confusion, was fiercely authentic; he did not hide himself from himself, or from others. His refusal to abide by social niceties and his strong desire to be wandering free dominated our dialogues and his frequent flights of imagination. He corrected me, disputed with me and vehemently rejected any platitudes or my eager trainee suggestions that looking at old photos or listening to the radio might be of comfort. To him, the rest of the world was engaged in inauthentic nonsense and he defiantly wanted his independence and, desperately, the final void of death.

Had someone told me that this, frankly, downright rude man would engender such affection in me, I wouldn’t have believed it. His sense of isolation, now that everyone dear to him had died and he was locked away from his previous life, dominated the narrative of our sessions. Initially I was frustrated. He would repeatedly say to me, ‘Why you are here? What can you do for me?’ I had originally attributed this to a generational critique of counselling, but on reflection it felt more like an attempt to shut everyone and anyone out. This was exacerbated by the fact that, due to his failing memory, it took time each week to re-establish contact and trust. As my regard for him grew, on more than one occasion I responded that he mattered to me, and that I wanted to spend time with him. He found this difficult to hear, but I persisted, and he eventually conceded reluctantly that he liked me coming. The truth is that Tom mattered to me greatly, and I genuinely felt compassion for him. While he emphatically pushed me away, I always asked if I could return, and he always consented. Finding meaning

Our first sessions were quite superficial, as I naively assumed that I should keep things light and avoid anything that might cause him distress. Common sense, as well as research, should tell us surely that this type of approach can cause further distress and isolation for elderly people.9 Indeed, when I braved a more existential standpoint and began challenging his narrative, finding meaning in his life, and addressing his imaginings about dying head on, we were finally able to meet at depth.

These moments sometimes occurred in the corridor of his nursing home, waiting for what he expected to be the bus to Southsea (where he had planned to retire), or as we sat in silence while he held his head or wept, or when he openly discussed his hope for death and explored the different ways he imagined he could bring this about. In these moments, I made no attempt to move him on to cheerier thoughts or to ground him with my version of reality. What happened felt like an important process of validating his own unique reality and lived experience, of joining him there, instead of isolating him further. He began to recognise me, and to wait by the lifts when I was due to visit, instead of sitting, as usual, confused and dozing, in the communal lounge.

Tom’s dementia afforded us, ironically, an opportunity to bring our domains together in a uniquely different place. He often talked as though he were somewhere else. Intuitively, I did not correct him or ground him in my reality; it seemed important to fully be in his world. Once, he announced in a hushed whisper that he was in France, trying to find the nearest port to get home. The following week he talked animatedly about locating some friends in Italy so he could tread grapes. Tom could be lucid and expressive in certain moments, but at other times he was almost pre-expressive, sitting or standing in absorbed silence. Slowly he began to cast me in roles in his imaginings, inviting me into his world. They were compelling and I felt it was important to honour them by reflecting them back to him and staying in his context: ‘You are waiting for a bus to Southsea. If we move to sit here with a clear view of the door, then you won’t miss it if it comes’ (in fact, I wanted us to sit down together in his room, rather than linger in the corridor). At other times, I encouraged deeper exploration through body and sensation, such as asking, ‘What do the grapes feel like when you tread them?’

I was still a trainee when I met Tom; I knew little about theoretical frameworks, but what happened between us felt like pre-therapy. I was trying to offer my humanity and make contact within his reality to minimise the anxiety and isolation he was feeling.10 My hope was that he experienced his true self with me, rather than simply a reflection of a received understanding of what ‘old’ or ‘dementia’ or ‘grieving’ means. In his rambling accounts, I noticed that Tom would begin to recall and reveal more about his life, such as places he’d been or people that were important to him, and that making contact with those memories seemed to bring a noticeable therapeutic release. While his socially constructed, corporeal self was incarcerated in the care home, his real self was wandering wonderfully free, and I felt liberated to be wandering with him. In her novel about Alzheimer’s disease, The Wilderness, Samantha Harvey’s protagonist asks angrily why he can’t say things that aren’t true and asks if ‘there is no freedom in words and thoughts, then where is freedom?’11 The scenes we explored represented Tom as having freedom, authority, experience and power, and felt like an expression of his true self.

Love and loss

Grieving for a client is, of course, much more likely when you are working with profoundly old clients, and this should be actively explored in supervision. But it should never prevent us from having a strong regard for our older clients, or, indeed, from loving them. I believe that, as death approaches, we can experience a reversal of Lacan’s mirror:12 as newborns, we resolve our sense of fragmentation by seeing our wholeness reflected in those who care for us; so too, in profoundly old age, the close attention and regard of another helps to counteract the fragmentation of self and confusion that can be experienced, by validating and integrating the meaning of the life lived with the experiences of the present.

I believe counselling the elderly should be approached without fear of loss, and with hearts that are ready to meet people, even if they are not yet able to meet us. Tom’s death affected me deeply. His gift to me was learning how to be with someone in despair without feeling the need to make it better, how to sit patiently with silences and confusion, and how to talk about death frankly.

I was unable in the end to attend his funeral but I later found a way to make contact with my own loss, by sitting on the beach at Southsea and saying goodbye to him there.

*Details of the elderly people described here have been changed so that none are identifiable.

Helen Kewell gained her PG diploma in humanistic counselling from the University of Brighton. She works in private practice in Sussex and has a particular interest in working with the elderly, chronic illness and grief. She also volunteers with Cruse Bereavement Care (www.crusebereavementcare.org.uk).www.helenkewell.co.uk

References

1. Erikson JM, Erikson EH. The life cycle completed: a review. New York: WW Norton & Company; 1977. 2. Pilgrim D. Psychotherapy and society. London: Sage Publications; 1997. 3. Health and Social Care Information Centre. Health survey for England, 2005: health of older people. [Online.] Leeds: HSCIC; 2007. www.hscic.gov.uk/pubs/hse05olderpeople (accessed 14 September 2015). 4. De Beauvoir S. Old age. (Trans Patrick O’Brian.) Penguin Modern Classics. London: Penguin; 1977. 5. Rogers CR. On becoming a person. London: Constable; 1961. 6. Bott D, Howard P. The therapeutic encounter: a cross-modality approach. London: Sage Publications; 2012. 7. Tornstam L. Gerotranscendence: the contemplative dimension of aging. Journal of Aging Studies 1997; 11(2): 143–154. 8. Morgan-Williams S. All real living is meeting. Journal of the Society for Existential Practice 1996; 6(2): 76–96. 9. Dodds P. Pre-therapy and dementia: an action research project. Post-doctoral thesis. Brighton: University of Brighton; 2008. 10. Prouty GF, Portner M, Van Werde D. Pre-therapy: reaching contact impaired clients. Ross-on-Wye: PCCS Books; 2002. 11. Harvey S. The wilderness: a novel. New York: Anchor Books; 2010. 12. Lacan J. Ecrits: a selection. (Trans Alan Sheridan.) London: Tavistock Publications; 1977. +++ Presenting issues

Women at the edge

Sophie Livingstone describes the intensity of relational work with women confronting their sexually compulsive behaviours

Lauren came to see me last year, describing sexually compulsive behaviour that had begun seven years previously, when she was 17 and became aware she was attractive to men. She had a long-term boyfriend, but she was not faithful. Her drinking and drug-taking were excessive. Three to four times a week, she picked up young men in pubs and clubs and had sex with them, in alleyways, cars, toilets, and in her bedroom at home. There was nothing in the experience of sex itself that was pleasurable for her; there was simply a powerful compulsion to get a man into bed. She would awake hungover the next day, filled with feelings of repulsion and contamination, and distressed that she had done it again. She could make no sense of these behaviours; she desperately wanted to stop, but could not.

Lauren is a composite portrait, typical of many of the clients I have seen with similar problems.

Controversy surrounds the idea of sex ‘addiction’. The influential American Association of Sex Educators, Counsellors and Therapists (AASECT) does not recognise sex addiction or porn addiction as a disorder. It states that ‘linking problems related to sexual urges, thoughts or behaviors to a porn/sexual addiction process cannot be advanced… as a standard of practice for sexuality education delivery, counseling or therapy.’1 I have taken to using the words ‘addiction’ and ‘compulsion’ interchangeably, although I favour the latter term. There is no doubt for me that some men and women struggle with compulsive sexual behaviours. These behaviours are, in my view, distinct from consensual, informed, consciously undertaken sexual activities, or infidelity, or having a high sex drive. The sexually compulsive person feels driven to have sex, or look at porn, or seduce someone (anyone), usually in response to difficult feeling states. They are preoccupied with sex, or seduction, and can experience states of intense sexual arousal in anticipation. The sex itself, however, does not make them feel good about themselves. It does not meet their needs in the way their anticipation and fantasies suggest it might. Over time, these behaviours can become hugely destructive to emotional wellbeing and, in the case of the women I have worked with, physically dangerous too. Contrary to what people may believe, sex addiction really is not that sexy.

While there is plenty of literature addressing the presentation in men (see, for example, Patrick Carnes and Rob Weiss in the US; and Thaddeus Birchard and Paula Hall in the UK), there is far less focus on sexually compulsive women. In the US, Alex Katehakis and Marnee Ferree have written specifically about women. Here in the UK, Paula Hall has called for more home-grown exploration of sexual compulsivity and addiction. I have found that the research of Manpreet Dhuffar2 and Fiona McKinney3 offers a sensitive and cogent insight into women struggling with these behaviours, and the issues that can arise in the work with them.

Women and sexual compulsivity

Women’s stories of problematic sexual behaviours are hidden, obscured by dominant narratives about female sexuality that conceptualise them in derogative ways: a mess, ‘fucked up’, damaged and dangerous. When a woman appears out of control in a social situation, uses alcohol and drugs, and/or disappears to have unsafe sex with strangers, the idea that there is a sexually compulsive behaviour going on is probably not considered.

I feel a fierce resonance with women who struggle with compulsive, out-of-control sexual behaviours, in part because I recognise something of myself in them, but also because I believe their conflicts reflect the profound difficulties women can face in trying to ‘realise’ themselves in a complex, contradictory, patriarchal social system. Dominance and submission play out in sexuality in myriad ways, both positively and negatively, and are often a theme in the sexual encounters craved by the women I see. As Michael Bader writes:4 ‘The answer to the question of how patriarchal gender roles create adults who derive intense sexual gratification from acting out [dominance and submission] in bed lies in the complicated ways our minds internalise social expectations and make them our own.’

Compulsive behaviour is the consequence of impulsive attempts to deal with uncomfortable and painful feelings. If a ‘sex addict’ is feeling sad, or lonely, or bored, or in emotional pain and despair, planning – often in a very ritualised way – and then carrying out the preferred sexual behaviour will temporarily alleviate it. The planning is often the most pleasurable part of the process. The sex itself is often mechanical, functional and disappointing; if euphoria is present, it is short-lived. Self-loathing and shame resurface as the arousal chemicals subside in the brain. Mark Lewis, a cognitive neuroscientist in recovery from substance addiction, argues that this is because dopamine, thought to be a major protagonist in the drama of addiction, is the neurochemical of desire, not pleasure. It creates the feeling of wanting; the thought of not therefore having is unbearable.5 This drives us to seek an intense experience, but it does not deliver the euphoria of a job well done. Over time this process cements itself into the neural pathways of the dorsal striatum, which is responsible for compulsive activities – activities requiring no thought or reflection, just compulsion. It is powerful, and it is not pleasurable. ‘Addicts’ are enslaved by this neurological process. There is a ‘deadness’ to compulsion, a lack of vitality.

Psychoanalytic theory can illuminate the self-harm apparent in acting-out behaviours. Marcus West describes a primitive ‘collapse and submit response’, in which the individual ‘becomes in thrall to the experience of death, which they cannot bear, yet from which they find it extremely difficult to escape’.6 In submitting, a woman hands herself over to the other ‘as a capitulation, as a surrender to their fate’, no longer able to struggle against the other’s overwhelming power. West suggests this pattern can become incorporated into the personality as ‘submission in the hope for protection and care’, which leads to a disavowal of ego-functioning, reinforcing the exposure or vulnerability, and leaving the woman powerless and trapped. This torment is nonetheless preferable to the dangers of abandonment.

Betty Joseph describes such ‘patients’ as having suffered early relational trauma – a lack of ‘warm contact and real understanding’, or a violent parent, emotionally or physically.7 ‘In the transference one gets the feeling of being driven up to the edge of things… potentially depressive experiences have been felt by them in infancy as terrible pain that goes over into torment [and] they have tried to obviate this by taking over the torment, the inflicting of mental pain onto themselves, and building it into a world of perverse excitement, and this necessarily militates against any real progress towards the depressive position… It is very hard for our patients to find it possible to abandon such terrible delights for the uncertain pleasures of real relationships.’

Lauren’s story

The women I have worked with have all had an immense impact on me. They stay with me outside of sessions. They make me feel about them. They are powerful and vivid, but also intensely vulnerable. Each has described a need to ‘push’ something when they have engaged in risky sexual encounters, and this often takes the form of violent, submissive sex with strangers or with partners they know are harmful to their wellbeing. This is not the negotiated, consensual power exchange of BDSM,* but exposing themselves to coercion and danger. It is as if they can only ‘find’ themselves through turbulent states of mind. Often there is identifiable trauma – childhood chaos and relational trauma, unnamed abuse or sexual assault – and significant problems with emotional regulation. Powerful feelings escalate fast and the only option appears to be an equally intense acting-out behaviour. I perceive in this a need to be embraced, to come alive, to find their shape. As Jessica Benjamin writes:8 ‘The desire to inflict or receive pain, even as it seeks to break through boundaries, is also an effort to find them.’

Lauren’s family history was chaotic and fractured by addiction and multiple, open parental infidelities. Her relationship with her mother was fraught, volatile, sometimes violent, and enmeshed. Her father watched pornography with her and brought women home for sex on a regular basis, with no discretion or sensitivity to how Lauren might feel. Her parents separated when she was nine. Lauren reported feeling unbearable emotional pain throughout this period, but, on the instruction of her mother, she told no one what was going on. This created a sense of deep shame about ‘having feelings’.

At the age of 14, at a party, she felt unable to say no when a man of 25 demanded oral sex. Afterwards, he offered her money, which she refused. She felt ‘indescribable’ revulsion and showered obsessively for days. At the age of 19, she charged a man for sex for the first time. She felt she had sunk to a new low and tried to get her act together. She found herself a job in an office, but would show up late, wretched and hungover, or drink too much and behave badly at work social events. Her boss, a man 20 years older than her, appeared to be taking her under his wing, but was in effect grooming her. She developed a powerful infatuation with him, during which she experienced episodes of arousal so strong it felt unbearable. She began an abusive relationship with him. He was overbearing and controlling, and would hurt her when they had sex. Lauren experienced this as annihilating to her spirit and soul, but it also felt in some way ‘right’. She told me she knew he would ‘destroy’ her, but that there was an inexorable sense of destiny to this relationship.

McKinney argues that sexual compulsivity in women shares ‘features of addiction, deliberate self-harm, borderline personality disorder and trauma’.3 It is a potent combination and, clinically speaking, working with these clients is not for the faint of heart. I found it very hard indeed to listen to Lauren’s story.

She described being triggered into overpowering arousal by obsessive attachments to dysfunctional men, and experienced violent sexual nightmares if she could not act on her sexual compulsions. She was bright, funny, attractive and had so much going for her. However, she could not hold onto any sense of self-worth. She was lost and vulnerable. She made bold statements that she only had sex with men she hated. Sex was about hatred – of herself, of the men she could seduce so easily, of the sexual double standards to which women are subject. Being sexually predatory and objectifying men made her feel powerful, for a time. This complex combination of feelings perhaps reflects the complexity of factors influencing this particular form of self-destructive behaviour: the cultural construction of ‘male’ and ‘female’ sexuality and gender power relations (the sociopolitical context); relational trauma in her family, and the impact of that on her ability to regulate her feelings and connect with others, and the shame produced by both.

Working relationally

My core training is in integrative psychotherapy. I tend to work ‘relationally’: that is, I subscribe to ideas around the co-regulation inherent in the therapeutic relationship – that we are mutually influencing and co-create the relational space, and that my material interacts with the client’s. I tend to be very attuned and empathic. I have undertaken training and personal work that enables me to connect therapeutically with others.

McKinney comes from a background in addiction treatment and found in her research that ‘treatment’ in the addiction field was often ‘limited to formulaic, task- focused cognitive and behavioural interventions, a top-down, directive approach’.3 The relational aspect of the work is less elaborated in the more behavioural models. I feel I can see why. There is an intensity to relational work that demands an ability to stay with the strong affect and sometimes disturbing and distressing material – a sense of volatility and unpredictability. ‘These are not difficult clients, but difficult treatment dyads,’ McKinney writes.3 Working from a more relational, integrative or humanistic stance, it can feel very hard to contain the volatile and potent affect triggered by close interpersonal contact. I also noticed that attempts to ground the affect by working with the body can also be derailed by what feels like the client’s hypervigilant sensitivity to having her body ‘controlled’ by an empathic other (as opposed to an abusive other).

Lauren could feel invaded by these interventions and become shy and reticent, or uncomfortable and snappy. She feared her body would betray her, and she would become overwhelmingly aroused. It was difficult for her to bear intimacy. She was accustomed to intensity, which is, as we know, not the same thing.

We may be eroticised or sexualised by the client, or find ourselves becoming aroused. Almost all my clients have described being seductive without realising it. It’s a procedural memory, suggesting sexualisation of the attachment system. I try, with varying degrees of success, to stay vigilant to enactments and collusions. The erotic transference that may enliven therapeutic alliances with clients who are not sexually compulsive becomes complicated in the relationship with a sexually compulsive woman – and, in my experience, more so than with a sexually compulsive man.

Conscious collaboration

I found with Lauren that it was empowering to work collaboratively to help her ‘think’ more about what was going on internally when she was triggered. At the clinic where I work, we use a containing framework for understanding behaviours and establishing bottom lines early in the therapy process, such as Hall’s ‘Cycle of Addiction’.9 Hall’s work is clear and instructive, and is enormously useful in terms of psychoeducation. I think working this way mediates the affect so it is more tolerable. When I have asked my female clients what they found most useful in helping them to stop on previous occasions, the answer has been ‘strict boundaries’. They do not want tenderness and empathy; they want something ‘strict’, something to ‘come up against’. This, in a way, echoes the ‘pushing’ of compulsive sex – Benjamin’s ‘effort to find their boundaries’,8 but it also, perhaps, expresses a disavowed longing to be held emotionally. They perhaps also feel their ‘locus of accountability and responsibility’ must be outside themselves, at least to start with. There is a need for the therapist to function almost as an auxiliary ego for a while, and fulfil a robust containing function. Arguably, the task of therapy is to help the client internalise this locus, so they can look after and regulate themselves, for themselves.

Early recovery is often fragile. With Lauren, over time, we began noticing that the energy and charge of her sexual activities was lessening. The behaviour patterns became ego-dystonic, and her increasing awareness of her emotional process made ‘acting out’ a far less attractive option. She began to empathise with others’ experiences of her when she was at her most florid, and to deal more directly with her shame. She began to grieve the loss of the bright hyper-reality of compulsive sexuality, but also to grieve more deeply for the confused and lonely child and adolescent she had been. Her relationship with herself began to change.

Escape from the ordinary

She also began to see how much she ran away from ‘ordinariness’ and the ‘everyday’. She was having to tolerate some boredom, without trying to ‘enliven’ herself with destructive or dramatic behaviours. Slowly, as the behaviours lost their grip, more of life became available to her – a moment of noticing sunlight sparkling on water, a feeling of hopefulness as she walked down the street, the pleasure of hanging out with new female friends. According to Lewis,5 new neural pathways associated with reward are building, while the pathways associated with compulsive sex are beginning to lose their power.10 In relational terms, she also learned that she defensively objectified herself and men when her pain got too great, and that she could call on the help of a growing circle of friends, or find other ways to soothe herself. Sometimes this worked and sometimes not, but we were moving in the right direction.

Esther Perel writes that ‘loving another without losing ourselves is the central dilemma of intimacy’.11 To truly engage sexually, we need to have a stable sense of self, so that we can let go of it for a while, and have enough trust in the relationship to be able to tolerate our partner letting go of us – so we do not need to ‘mask our ravenous appetites and conceal our fleeting need to objectify the one we love’.

I think the activity of therapy can be akin to the activity of having sex. We pay attention to all those signals that our clients hide or that escape their awareness, note what we feel in our bodies or observe in theirs, and sense whether they will allow us in or surrender to intimacy, or if they surrender too easily, or resist, or try to penetrate us instead. We notice the rhythms of interaction, where there is tension and where there is flow. Therapy, like sex, is profoundly exposing and profoundly intimate, and sometimes a bit messy (if you’re doing it right). Where there is mutual trust and respect, and the capacity for recognition, both activities can be vital and restorative. The bedrock of a positive, rewarding sexuality is a good-enough relationship with a partner but, more cogently, also with one’s self, and I believe there is much we can do to help ourselves, and our clients, achieve this.

*The term BDSM includes bondage and discipline, dominance and submission, and sadism and masochism.

Sophie Livingstone is a psychotherapist and supervisor in private practice, and a psychosexual and relationship therapist at Innisfree Therapy, a sex-addiction treatment centre in central London.

References

1. AASECT. AASECT position on sex addiction. [Online.] Washington DC: AASECT; 2016. www.aasect.org/position-sex-addiction (accessed 16 February 2017). 2. Dhuffar M, Griffiths MD. Understanding conceptualisations of female sex addiction and recovery using interpretative phenomenological analysis. Psychology Review 2015; 5(10): 585–603. 3. McKinney F. A relational model of therapists’ experience of affect regulation in psychological therapy with female sex addiction. Doctoral dissertation. [Online.] London: Middlesex University; 2014. Eprints.mdx.ac.uk/14413/1/FMcKinneyThesis.pdf (accessed 15 February 2017). 4. Bader M. Arousal. New York: Thomas Dunne Books; 2002. 5. Lewis M. The biology of desire. Melbourne: Scribe Publication; 2016. 6. West M. Into the darkest places: early relational trauma and borderline states of mind. London: Karnac Books; 2016. 7. Joseph B. Addiction to near-death. International Journal of Psychoanalysis 1982; 63: 449–456. 8. Benjamin J. The bonds of love: psychoanalysis, feminism, and the problems of domination. New York: Pantheon Books; 1988. 9. Hall P. Understanding and treating sex addiction. London: Routledge; 2013. 10. Naked Truth. Road to Brighton. [Video.] Manchester: Visible Ministries (undated). http://visibleministries.com/road-to-brighton (accessed 15 February 2017). 11. Perel E. Mating in captivity. London: Hodder & Staunton; 2007. +++ Mental health

Rethinking human suffering

Stephen Joseph argues that person-centred theory provides a robust framework for understanding and working with severe mental distress

Over recent decades, the person-centred approach has become a major force in the world of counselling and psychotherapy. Yet the person-centred approach to understanding distress and dysfunction has commonly been overlooked in mainstream mental health services. This is, perhaps, due to the mistaken belief among many psychologists and psychiatrists that person-centred therapy is a good idea for the ‘worried well’, but that serious mental health problems should be left to the ‘proper professionals’. This becomes, of course, a self-fulfilling prophecy. As the person-centred approach becomes marginalised in the NHS because of these beliefs, training courses find it hard to provide placements and supervision for trainees to work with clients with more severe forms of mental distress, and so person-centred practitioners emerge from their training ill-equipped to work with anyone but the worried well, at least in the eyes of these other professionals.

Clash of paradigms

But a deeper look at the theory that underlies person-centred practice shows it does have great potential for helping people who would otherwise be considered to have serious mental health problems. The main problem is communication, as we are essentially dealing with a clash of paradigms: the potentiality model of the person- centred approach on the one hand, and the medical model on the other.

The person-centred approach to helping is based on the assumption that human beings have an inherent tendency towards growth and development: movement towards becoming fully functioning will happen automatically when people encounter an empathic, genuine and unconditional relationship in which they feel valued and understood. However, it is recognised that such relationships are rare; the inherent tendency towards becoming fully functioning is more frequently thwarted and usurped, leading instead to psychological distress and dysfunction.1 For the person- centred therapist, the power and direction for change comes from within the client; their task is solely to provide the new relationship that allows the person to flourish.

The medical model is based on the assumption that there exist specific disorders requiring specific treatments – an assumption embodied in the Diagnostic and Statistical Manual of Mental Disorders (DSM), now in its fifth edition.2 DSM-5 is a voluminous work, running to many hundreds of pages, which describes the range of psychiatric disorders and the detailed procedure for the diagnosis of each.

Whether or not they adhere strictly to the DSM, many mental health professionals take for granted that there is a need for specific treatments for specific conditions; alternative ways of thinking are rarely acknowledged. The person-centred approach emphasises developmental processes and the actualising tendency of the individual; there is no need for diagnosis, because problems in living all have the same essential cause and the approach to therapy is always the same. Person-centred therapy is a relationship in which the client is able to grow and self-right in such a way that they move away from façade, from pleasing others, and towards self- direction, openness to experience, acceptance of others, and trust of their self.3 As a consequence, the person-centred approach uses different terminology to describe mental health.

Explaining disorder

Rogers wrote that, in his experience, whatever their problem, whether it was to do with distressing feelings or troubling interpersonal relations, all clients are struggling with the same existential question: how to be themselves. But to what extent can person-centred personality theory account for the range of psychopathology that is described in the DSM?

There are three defining features of the medical model:

1. the focus is on the individual – the origins of distress and dysfunction are seen as within the person 2. the practitioner is seen as the expert on what the patient needs, who knows what is best for the patient 3. the emphasis is on distress and dysfunction, and what is weak and defective about people.

Ultimately, the challenge posed by the person-centred approach is to rethink the nature of human suffering. Rogers’ person-centred theory offers a meta-theoretical perspective on human nature founded on the assumption that human beings have an inherent tendency toward growth, development and optimal functioning.1,3,4 Unpacking the implications of this for practice, the person-centred approach is in direct opposition to these three features of the medical model:

1. person-centred therapists are concerned with the social systems of family and community and how external forces act on the person, leading to the development of conditions of worth, which in turn affect their processing style 2. person-centred therapists see the client as the expert on what is best for them and seek to form collaborative relationships in which the client directs the therapeutic process. The therapist is non-directive because the direction comes from the client, hence the term ‘client-centred’ 3. person-centred therapists are interested in the constructive and healthy potential of people and their movement towards becoming fully functioning, consistent with the aims of positive psychology.

Various individuals and professional groups may seize on one of these three points of opposition to define themselves, but still hold fast to the other features of the medical model. They may perceive themselves as standing against the medical model but, in fact, continue to promote others of its features. Only the person- centred approach offers an alternative to the medical model in all three ways – by looking to health and wellness, seeking to understand the social processes, and taking the stance that people are the best experts on themselves.

At least, that is the theoretical stance of the person-centred approach. In reality, these ideas may not always have been put into practice so well.

The approach has been most successful at promoting the idea that people are their own best experts, but less so in the promotion of health and wellness. In my view, many person-centred therapists have themselves forgotten their theoretical roots, so immersed and besotted have they become with the medical model and its notions of deficit and dysfunction. Person-centred therapists have become so accustomed to using the language and terminology of psychiatry that they have forgotten that theirs is a potentiality model. In looking to the future, we need to ensure that all three aspects of person-centred theory are now given equal attention.

Evidencing the argument

It will seem self-evident to many that the person-centred approach offers a more ethical and effective way of helping, but that is not enough. It must be shown to be so. There is already substantial evidence for the therapeutic role of relationships,5 but there is a long way to go yet if the person-centred approach is to gain credibility in the current mental health system. If that is ever to happen, we need to take research more seriously and get new evidence that shows the person-centred approach really is an alternative that makes a difference in our understanding of how problems arise and how people can be helped.

Furthermore, we need to do more than convince ourselves. The person-centred approach is not widely represented in our universities, where such research often takes place. Awareness of it among other professionals is minimal. If we want the approach to be taken more seriously, we also need to communicate the research beyond the person-centred community. As I see it, future research developments are needed in a number of areas.

First, we need to see new research that accommodates the ideas of evidence-based practice as they are framed through the lens of the medical model. Such research would develop person-centred conceptualisations of the various diagnostic categories and test the effectiveness of person-centred therapy for specific conditions – not to provide a justification for the medical model, but to show that there are other, more humane ways of thinking about and working with people who have a diagnosis. We need research that meets the standards of professional psychology and psychiatry journals and speaks directly to these audiences in ways that they understand, so that the person-centred approach gets taken more seriously within the wider mental health arena. However, in doing this research, we must be open to testing and discovering the strengths and the limitations of person-centred therapy. Our research may not always show us what we expect or want to find. There may be conditions that really are not well-suited to person-centred therapy, but I think we can safely assume that the majority of conditions for which people currently seek help can be addressed through the person-centred approach. In terms of therapy for specific conditions, the most significant development of recent years has been the Counselling for Depression (CfD) programme.6 Some may see this as compromising the principles of the person-centred approach, insofar as it adopts the language of the medical model. For example, CfD by definition involves the diagnosis of depression. On the other hand, those involved in CfD may see this as a necessary compromise that has meant the person-centred approach is taken seriously in the NHS and by funding bodies.

Second, for those whose stance is to reject any involvement with the medical model, other research and scholarship is needed. Our own understandings of the person- centred approach from its own frame of reference cannot stand still. We need to continue to define our assessment procedures. We need to describe our own use of models of dysfunction. We need an understanding of social and cultural forces. Research that develops person-centred theory in its own right, not as a compromise to other positions, is vital if the approach is to maintain and develop its own distinct stance to mental health. Such research can continue to build in the specialist humanistic and person-centred journals.

Third, rather than remain isolated, person-centred practitioners should also align themselves with other professionals who hold similar views on some of the same theoretical aspects. Such research need not compromise the principles of the person-centred approach, but simply take it to new and influential audiences that will be receptive to its ideas and values. In promoting social justice, we would do well to look to the profession of social work, which shares our concern about the societal causes of distress and dysfunction and their prevention. In terms of health and wellness, recent years have seen much interest in positive psychology.

Towards full potential

It seems self-evident to me that the person-centred approach is a positive psychology.7 Positive psychologists are concerned with understanding what makes life worth living, which ought to sound familiar to the person-centred psychologist, counsellor or psychotherapist.8 After all, it was Rogers who introduced the idea of the fully functioning person. But this is not to say that all positive psychology is person-centred. What makes the person-centred approach a unique form of positive psychology is its underlying meta-theoretical stance that human beings are organismically motivated towards developing to their full potential. Research will benefit from a broader positive psychological conceptualisation of measurement that embraces a theoretically consistent approach. We need new research that can show that mental health problems are better understood as expressions of thwarted potential, and that person-centred therapy leads to increases in people becoming more fully functioning, not simply to reductions in distress and dysfunction. Imagine that, instead of diagnostic assessment, we had a new system that was based on these ideas, and that therapists no longer thought about symptom reduction, but about the promotion of a person’s potential.

In these three ways – first, by researching person-centred therapy in medical model contexts and using person-centred theory to understand psychiatric concepts; second, by building strong theory and scholarship within the person-centred approach, and, third, by aligning the person-centred approach with contemporary developments such as positive psychology – we can begin to advance new evidence for the person-centred approach to mental health. Ultimately, the challenge posed by the person-centred approach is to rethink the nature of human suffering.

Stephen Joseph PhD is Professor of Psychology, Health and Social Care at the University of Nottingham, where he is convenor of the counselling and psychotherapy teaching cluster. He will be a keynote speaker at the BACP Research Conference on 19–20 May.

This is an extract from his latest book, The Handbook of Person-Centred Therapy and Mental Health: theory, research and practice, edited by Stephen and published by PCCS Books.

References

1. Rogers CR. A theory of therapy, personality, and interpersonal relationships as developed in the client-centred framework. In: S Koch (ed). Psychology: a study of a science. Vol 3: Formulations of the person and the social context. New York: McGraw-Hill; 1959 (pp184–256). 2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed). Washington, DC: American Psychiatric Press; 2013. 3. Rogers CR. On becoming a person. Boston, MA: Houghton Mifflin; 1961. 4. Rogers CR. Freedom to learn. Columbus, OH: Merrill; 1969. 5. Cooper M, Joseph S. Psychological foundations for humanistic psychotherapeutic practice. In: Cain DJ, Keenan K, Rubin S (eds). Humanistic psychotherapies: handbook of research and practice (2nd ed). Washington, DC: American Psychological Association; 2016 (pp11–46). 6. Sanders P, Hill A. Counselling for depression. London: Sage; 2014. 7. Joseph S. Positive therapy: building bridges between positive psychology and person-centred psychotherapy. London: Routledge; 2015. 8. Maddux JE, Lopez SJ. Toward a positive clinical psychology: deconstructing the illness ideology and constructing an ideology of human strengths and potential in clinical psychology. In: Joseph S (ed). Positive psychology in practice: promoting human flourishing in work, health, education, and everyday life (2nd ed). New York: John Wiley; 2015 (pp411–427). +++ Writing

I write, therefore I think

Executive coach Liz Cox explains how reflective writing can boost our personal and professional development

Many of us can relate to the Socratic saying: ‘The unexamined life is not worth living.’ As coaches and counsellors, we believe our lives are enriched by self- examination. We learn from our mistakes, challenge our behaviours and grow in our personal and professional endeavours by exploring our assumptions about the world. In the words of coach, supervisor, transactional analyst and author of Reflective Practice and Supervision for Coaches, Julie Hay, ‘The point of reflection is to enhance capability.’1

Although some readers may groan at the thought of any sort of writing activity, it can be an invaluable tool for reflective thinking. For many of us, writing has become a formulaic process of capturing data and facts in the form of notes, reports, emails, client correspondence and so on. Some of us may remember childhood as a time when we enjoyed the creative process of storytelling; others may only remember – with dread – schoolwork returned with endless spelling and grammar corrections.

But here is a new thought: rather than being tethered to the rules and restrictions of the writing discipline, what if we could use this medium to free up our thinking? What if it could become a creative platform for new insights and take us on exciting journeys of self-discovery? This becomes possible when we see the process of writing as thinking. As Kaufman says, ‘One cannot engage in the process of writing without simultaneously engaging in thinking… scribo ergo cogito.’2

From a neuroscientific perspective, this is the process that Kaufman describes as ‘reduced activation of the Executive Attention Network and increased activation of the Imagination and Salience Networks’.3 Unpacked, this means allowing the brain to access the more creative and emotional territories contained within the limbic system, while reducing the interplay of the prefrontal cortex, with its rule-bound executive function – the part of our brain that wants us to write in complete sentences, preferably with correct spelling and punctuation.

Still sceptical? I was, too – but then I found myself undertaking a creative writing task as part of my MSc in coaching and behavioural change at Henley Business School. After a six-minute ‘free-writing’ exercise, we were asked to spend a further 30 minutes writing about a subject of our choice. The pieces that people wrote and shared with the rest of the group were extraordinary glimpses into personal histories and emotional territories that were often as illuminating to the writer as they were to others in the group. Rich detail of life-changing events, personal relationships and domestic detail poured forth, carried in the authentic voice of their authors. Freedom from the restrictions of ‘proper writing’ had tapped a vein of creativity and emotional authenticity. This was a light-bulb moment for me. Through writing, we had been pushed into revealing previously hidden levels of thought and depths of emotion. By producing a piece of written work, rich material was now at our disposal for further exploration and reflection. The writing exercise had brought to the surface our stories, and had enabled us to shine a new light on our internal narrative. As one fellow student said to me: ‘It’s like finding the key to a secret doorway.’

Note-taking

This more liberated writing technique doesn’t just apply to the personal, creative territories. Our professional writing tasks – for example, note-taking – can also benefit from a more freestyle approach. Rather than imposing a logical, structured format on your client notes, Hay recommends that you write a ‘stream of consciousness’ directly after the client session.1 She suggests you divide your paper into three columns. In the first column, you note what was said by the client. In column two, you record your responses to what the client said, alongside or below any client interaction. In the third column, you write down any questions or insights that occurred to you at the time. In this way, you create a set of thoughts and observations that can provide fertile material for further analysis and reflection.

Stream-of-consciousness notes

I have found this more free-flowing approach to note-taking extremely helpful in allowing me to capture the thoughts and feelings that emerge at the time, which I can then go back to with a more analytical focus at a later date. For coaching assignments of any length, the series of notes you make along the way lend themselves to a meta-analysis of themes and issues that can help progress the conversation further. Just recently, I found that an emotionally charged coaching session, which was especially challenging at the time, became much clearer to me once I had gone through this note-taking process. My stream-of-consciousness notes revealed to me new areas of language, tone of voice and use of metaphor, as well as the shape and flow of the conversation, which brought new insights.

Of course, some may say that recording the conversation would serve the same purpose. But I wonder if this is true? A recording is a helpful way to go back over a coaching conversation and a great tool for learning and development. But I think that the notes you make afterwards play an invaluable role in highlighting the key aspects that resonated with you, at some level, during the session, which you can then reflect on further. It also allows for that element of creative thinking and additional insight that comes from the process of writing as thinking.

Keeping a journal

In Oscar Wilde’s play, The Importance of Being Earnest, Gwendolen exclaims, ‘I never travel without my diary. One should always have something sensational to read on a train.’4 I couldn’t agree with her more. A learning journal is where the more free-flow approach to writing adds another dimension of insight and depth to the learning experience, allowing you to ask, not just what you did, but also how you felt about it at the time and how you feel it impacted on the coachee. Treating this as a subjective arena and a piece of written material for your eyes only gives you permission to really interrogate the learning issues and reflect deeply on how you can develop and take things forward. As Holly describes it, this is an invaluable writing forum for reflective practice, as it is one where ‘you are both the learner and the one who teaches’.5

In my case, I also keep a personal diary. I find it invaluable for keeping track of where I am professionally as well as personally. I now regret not writing a diary earlier in my life, as I realise what a powerful medium it is for capturing thoughts and feelings as life unfolds, be they minor domestic moments or life-changing events. While my diary may not be a ‘sensational’ read, I genuinely find it fascinating to look back and see my internal processing on a day-to-day basis. It is another valuable means of self-reflection.

The liberating force of writing as thinking has played a big part in encouraging me to keep up a diary. In the past, a major deterrent would have been self-criticism about the quality of my output. But this is not about producing a literary work to rival Jane Austen or Virginia Woolf; it’s about using the writing medium to unearth my inner thoughts. Viewing it as such liberates you from the unhelpful inner critic. To use Gallwey’s phrase, it allows us to win the ‘inner game’ against self-doubt.6 Another factor for me is technology. Being able to type up my diary – and other forms of writing – on my laptop, security-protected in electronic files, makes me feel much more inclined to commit my thoughts and ideas to ‘paper’. It is easier and safer, and keeps them well away from prying eyes.

However, a word of warning. There are several issues to consider in relation to storing any original material on a laptop, especially sensitive client data: the risk both of losing data (not backing it up, theft, laptop malfunction etc) and of others gaining access to it. For example, client notes can be required by a court of law in a legal case where they are considered relevant. It is important to consider ways of protecting the anonymity and confidentiality of your clients when storing any notes.

Narrative for self-reflection

An important role of the coaching process is to build the self-awareness of our clients. Equipping them with the means for self-reflection helps to create a pathway to that goal. As Kets de Vries says, ‘To coach people successfully, it is essential for both the coach and coachee to understand what is going on underneath the surface.’7 I have found narrative, in the form of personal stories and diaries, to be a powerful way for clients to access hitherto unconscious patterns of behaviour and belief systems, and introducing them to the concept of writing as thinking can be helpful in overcoming any initial scepticism and resistance to undertaking these writing tasks.

Jean-Paul Sartre wrote: ‘A man is always a teller of tales, he lives surrounded by his stories and the stories of others, he sees everything that happens to him through them.’8 In this sense, coaching could be described as helping people to make sense of their stories. And reflective writing can play a key role in accessing those stories.

A final thought

Here’s an ancient Buddhist story. A man comes galloping into town on his horse. A passer-by calls out to him, ‘Where are you going?’ The man replies, ‘I don’t know – ask the horse.’

Reflective writing invites you to go on a journey of exploration, to let go of your inhibitions and to allow the process to take you to new places. It can be a thrilling ride of self-discovery. For coaches, it is one of the most powerful tools at our disposal for enabling our own personal and professional development, and for helping our clients to make significant shifts. According to van Nieuwerburgh, reflective writing is one of the most helpful ways of developing a coaching ‘way of being’.9 It simply requires a different mindset that sees writing not as requiring thinking, but as thinking itself.

Boxout 1: Unable to say no

James wanted to improve his time-management skills. I suggested he keep a diary of his working week – both a factual record of dates and activities, and an emotional narrative describing how he felt about these events. This was highly revealing. A key theme emerged around James’s inability to refuse work demands, no matter how unreasonable. This opened up new territory around self-esteem and personal development, and ultimately enabled him to make meaningful change in how he managed his time and the demands placed on him.

Boxout 2: Resistance to writing

Susan was referred to me by her company with a very specific work challenge. She was regarded as extremely able in face-to-face contexts, but her written presentations were felt to lack coherence, depth and supporting evidence. Given that this was a writing issue, we agreed to try a creative-writing exercise. Susan wrote a story about her childhood. Her relationship with her mother was crucial to the story, and a strong theme was her mother saying, ‘It’s easier to do it yourself.’ We talked this through, and Susan suddenly saw the connection with her business reports, and an underlying resistance to ‘explaining’ the issues clearly on paper. This insight helped her identify more helpful strategies to improve her writing. It also opened up new awareness of some of the unconscious drivers informing her relationships with her more ‘needy’ clients.

Boxout 3: The six-minute write

Think of this as a ‘warm-up’ to the main event, like stretching before a gym session. It helps to loosen up the writing muscles and opens the creative floodgates. Write whatever is in your head, making sure that you are not censoring yourself.

Write without stopping for six minutes.

Don’t stop to think or be critical, even if you doubt its ‘quality’.

Allow it to flow without worrying about spelling, grammar or proper form.

Give yourself permission to write anything. You do not even need to reread it.

Whatever you write is right; it is yours, and no one else need read it.

Following the six-minute write, plunge into your writing task. You will be amazed at how much easier it has become, and how fluently the words flow onto the paper.

(This exercise is adapted from Bolton G. Reflective Practice. London: Sage; 2014.)

Liz Cox is an executive coach and consultant, previously ran a market research company, Directions, and is also a non-executive director on the board of The Big Picture, a global design research agency. [email protected]

This article was first published in the January 2017 issue of Coaching Today. bacpcoaching.co.uk/coaching-today

References

1. Hay J. Reflective practice and supervision for coaches. Maidenhead: Open University Press; 2007. 2. Kaufman P. Scribo ergo cogito: reflexivity through writing. Teaching Sociology 2013; 41(1): 70–81. 3. Kaufman SB. Beautiful minds: the real neuroscience of creativity. Scientific American 2013; 19 August. [Online.] https://blogs.scientificamerican.com/beautiful- minds/the-real-neuroscience-of-creativity (accessed 28 March, 2017). 4. Wilde O. The importance of being earnest and other plays. Oxford: Oxford University Press; 2008. 5. Holly M. Writing to grow: keeping a personal/professional journal. Portsmouth, NH: Heinemann; 1989. 6. Gallwey T. The inner game of tennis. London: Pan Macmillan; 1986. 7. Kets de Vries M. Mindful leadership coaching. Basingstoke: Palgrave Macmillan; 2014. 8. Sartre J-P. Nausea. London: Penguin; 2000. 9. Van Nieuwerburgh C. Introduction to coaching skills: a practical guide. London: Sage; 2014. +++ Research into practice

From visual to verbal disclosure

Liddy Carver delves into a paper on use of creative activities to help people with severe depression put their feelings and experiences into words

This month, Research into Practice asks whether visual arts can help counsellors work with clients with severe depression.

A paper by Lee, Mustaffa and Tan reports how counselling approaches can be enhanced by visual art-making activities. It explains how they produce valuable observational data that throws light on what is going on for the client when they might otherwise struggle to articulate experiences and feelings.

Three case studies show the use of visual art-based activities alongside person- centred counselling in a psychiatric outpatient setting. Amy, 44 and married with a teenage daughter, was diagnosed with major depression five years ago. Shawn, 47, divorced with two teenage daughters, was diagnosed with major depression eight years ago. Potter, a 34-year-old man, was diagnosed with dysthymic disorder six years ago.

According to the study, for each of these emotionally imprisoned clients, revisiting painful events via creative methods, such as painting and collages, enabled them to crystallise negative emotions, which could then be worked out.

Reference: Lee KL, Mustaffa MS, Tan SY. Visual arts in counselling adults with depressive disorders. British Journal of Guidance and Counselling 2017; 45(1): 56-71. doi: 10.1080/03069885.2015.1130797

At first glance, it is difficult to see the relevance of this research to UK-based, person-centred, experiential counsellors and cognitive behavioural therapists with extensive experience of working with severely depressed clients. However, when a problem keeps manifesting in relationships, you need to resolve it, and that begins by putting it into words.

Visual arts – traditionally used with children – may, as the researchers claim, help clients who struggle to verbally communicate existential crises. The study was conducted as part of Lee’s doctoral dissertation, and used qualitative and quantitative research methods to explore the benefits of visual arts activities for three clients attending the counselling unit at a Malaysian psychiatric hospital. The data collection and analysis included observations of six counselling sessions with each client and of their artwork, evaluation questionnaires from each session, interviews with the clients, visual diaries and a research journal. The study focused on four questions: How do adult clients feel when they are creating and talking about their artwork in the counselling process?

Do they think that their artwork has helped them to express their feelings about their problem?

In what ways has their artwork helped them to face or manage their problem?

What do they believe is the best way to use visual arts in the counselling process?

In this way, the clients were invited to become co-researchers into their own malaise and how best to approach it.

Setting aside disagreements about the most appropriate psychological intervention for depression, visual arts-based therapy applied in this way can sit comfortably alongside most established models devised to address its emotional toll. So, while at first sight this paper might seem to offer little to a sophisticated audience, its insights may benefit therapists’ practice with adults diagnosed with major depressive disorders who find it difficult to articulate, or even be aware of, their affective response to past experiences.

The three participants were each asked to complete four art-making activities. The first was to choose art materials and colours, and do some simple, freeline drawing. They were then introduced to the notion of using art as a communication tool, and encouraged to try out different kinds of materials to find those they liked best. In the second activity, they were asked to draw a picture of their current self-image and make a collage of everything they had and what they felt they needed, and through this to explore their feelings, thoughts and behaviour. In the third stage, they were asked to create a future self-image. Finally, they were asked to draw and write down their feelings in a visual diary at home, which they could share with the counsellor.

The counsellor concentrated on empathic listening while observing clients’ responses and artwork. The participants were guided towards the research questions, and each activity was carefully introduced in a stepped-up process, with the aim of helping them value their efforts and achievements.

Findings

The researchers have collected a striking amount of data under six themes: ‘feelings of unfamiliarity’, ‘feelings of satisfaction’, ‘expressing emotions’, ‘facing problems’, ‘facilitating deeper self-understanding’ and ‘making progress in counselling’.

For instance, Potter struggles to express his feelings, and explains: ‘When I drew, I went back to my childhood drawing style, which is the part I don’t want to face…’ Drawing helped him feel ‘… a bit cheerful when I went home’. However, ambivalence persists about confronting previously well-hidden issues: ‘I don’t have the courage to face myself. When I drew, I could face my problems, but I was a bit avoiding.’ But, ultimately: ‘Through my artwork, I discovered things that I’ve not thought of before… I could go into my inner self at a deeper level through drawing. Yes, I feel it did help. For example, I dared not face facts, face my own self, but I could understand myself more clearly through drawing.’

Likewise, although Amy initially finds the process ‘a bit embarrassing because I am a perfectionist that cannot draw very well’, she engages in the art-making activities and her counselling: ‘I followed the guideline to draw what I wanted to express, and I felt that would be realistic… So my wondering became engaging, focused and free, like following my mind. Then I felt very comfortable, and was interested in knowing the outcome or purpose of the counselling process.’ For Amy, the two are complementary. First: ‘Maybe previously, I never faced and thought about my negative emotions deeply… Through the thinking processes, I can understand better about my weaknesses.’ Second: ‘I can understand better the meaningfulness behind the drawings, and then I know what my problems are, since all the issues have been brought to the surface.’ This gives confidence: ‘I can visualise what I want and hope for my future.’

Less articulate, Shawn finds drawing: ‘… is not so tensed, like the ordinary counselling session… I feel that when the person is more relaxed, and is given the freedom to draw, a lot of expression will come out.’ Although Shawn is not entirely clear about the objectives, he says: ‘The times when I shared it was a relief… From the art activities, I discover… the reality of problems I am facing and what steps I can take to overcome them.’ Despite his initial hesitancy, the emphasis on expressing emotions in the making and sharing of his artwork helps Shawn share his feelings of helplessness.

By the end of the study, all three participants are showing clear changes in their mood and their ability to engage with counselling. According to the study, these changes demonstrate how art enabled them to move ‘from the personal visual disclosure to verbal disclosure… express their real feelings, focus on exploring those issues they were concerned with, face their problems more directly, and understand themselves at a deeper level’.

Indeed, one of the participants, Amy, reportedly told the researcher that ‘research studies such as this could develop more helpful therapeutic methods than merely taking medication in helping the patients with depressive disorders’.

What can we learn?

Creative arts can be applied in counselling alongside more orthodox talking therapies.

Counsellors can assimilate the material to address clients’ practical problems and help them unscramble how depression affects them and their relationships.

This approach can also: safely contain clients’ ambivalence about disclosure of feelings, without relying on verbal language to share narratives. In conjunction with traditional counselling approaches, creative arts can give voice to clients’ powerful emotions, thoughts and memories when words are difficult or seem insufficient alleviate fear by using imagination to convey visual representations of clients’ experiences, providing a first step towards a therapeutic alliance build resilience in terms of clients’ coping mechanisms and ability to recover from stress support clients to make choices, problem- solve, make meaning and safely express complex reactions offer clients new ways of seeing ‘self’ and actively engaging in their path to recovery.

For clients who find social interactions difficult, creative-arts activities may initially be more acceptable than other forms of psychosocial support. If counsellors do choose to go down this route, it would be a good idea to explain to their clients the aims, procedures and benefits of this approach.

Liddy Carver is a BACP-accredited counsellor currently completing her doctoral research on counselling training. She worked as a counselling trainer for several years, volunteers at a student counselling service, and is Managing Editor of Counselling and Psychotherapy Research.

Get in touch. Is there a recent research paper you’d like Liddy to report? Email [email protected] +++ Dilemmas

This month’s dilemma

Must I show my client what I’ve written in my notes?

Matias, an accredited counsellor in private practice, keeps handwritten notes of the main issues discussed in client sessions. He anonymises them by filing them under the client’s initials and stores clients’ contact details in his smartphone.

His notes also include a full case history, his hypothesis about clients’ psychopathology, if relevant, and his strategy for working with them. He also uses his notes to process his own countertransference responses, and finds this particularly helpful if he is experiencing a strong negative response to a client. He has heard about the Data Protection Act, and is aware that some therapists in private practice register with the Information Commissioner’s Office. But, because he doesn’t keep identifiable client records electronically, he doesn’t think this is relevant to him.

Matias has been working with a client whom he experiences as critical of him and of therapy in general. The client also voices his anger towards work colleagues – who he thinks talk about him behind his back – and his difficulty trusting people.

Following a particularly challenging session, after which Matias has written about how hard he finds it to empathise with, or find anything to like about this client, the client asks him if he keeps notes of the sessions and, if so, whether he can see them.

What would you do in Matias’s position?

Please note that the opinions expressed in these responses are those of the writers alone and not necessarily those of the column editor, Therapy Today or BACP.

Serious breaches

Peter Jenkins Author of Professional Practice in Counselling and Psychotherapy: ethics and the law (Sage, 2017)

Unfortunately, Matias’s private practice has serious failings at a number of different levels. In legal terms, he may be in breach of the Data Protection Act (DPA) 1998, by failing to register with the Information Commissioner’s Office (ICO).1 In professional and ethical terms, he may also be in breach of the BACP Ethical Framework, section 14(f), which requires him to keep up to date with the law and regulations. In therapeutic terms, Matias may well feel the need to process his countertransference towards the client. However, it may be that the very detailed kind of narrative process records he keeps is ‘excessive’ in DPA terms. He could, for example, still process his own emotional responses to the client without writing in such detail. At the very least, he could make brief Post-it notes, to be destroyed after use in supervision, rather than retained, potentially as part of the permanent client record.

Matias seems ill-informed about his obligations under the DPA 1998. In all probability, his storing of client personal data in electronic format on his phone means that he should register with the ICO, whether or not he also keeps manual records of therapy and manual process notes. If he’s in any doubt, there is a very simple checklist available on the ICO website, which should quickly resolve any uncertainty on this issue (ico.org.uk/for-organisations/register).

Assuming Matias does need to register with the ICO, the client has a general right of ‘data subject access’ to his or her own files. Another, more technical issue here is whether the client can access Matias’s handwritten client and process notes. This depends on whether these are filed in a highly systematic way, consistent with what is defined as a ‘relevant filing system’ (see ico.org.uk/for-organisations/guide-to-data- protection/key-definitions for the criteria). By not keeping up to date with standard data protection requirements, Matias risks a fine from the ICO of several hundred pounds, a professional complaint by his client to BACP, and the need to respond to the aggrieved client under the ‘duty of candour’, as required by the BACP Ethical Framework.

How will it help?

Mark Redwood Humanistic gestalt counsellor in private practice

First, Matias is wrong in his belief that he doesn’t have to register with the ICO. He is keeping information about his clients on his smartphone, which most definitely means he should register. In addition to registration, Matias also needs to consider whether keeping his clients’ contact details on his smartphone is secure enough.

Second, the client seems not to know whether Matias keeps notes on their sessions. I feel this is an important part of the contract between therapist and client: the client needs to know how their information will be used, and who will see it. For example, Matias’s notes might be subpoenaed.

In dealing with this request, there is a very big unanswered question: what does the client hope to get from reading the notes? In this dilemma, this seems to be the most important question to attend to, rather than whether Matias should release the notes. Exploring this question with the client would help Matias and his client decide what to release and how.

In my own practice, I have read out my notes while my client took their own notes, because they wanted to capture the important turning points. Knowing this enabled me to pick what to read and how. For me, a decision about releasing notes is always about therapy. The question I am really trying to answer is: how will this help my client?

Address issues of betrayal

Sue Lyons BACP-accredited psychodynamic counsellor in private practice

It appears that this client has pursued therapy because he has difficulty trusting people. He believes that people are not straightforward with him, and that they discuss his undesirable qualities behind his back. He is clearly angry and hurt, and his apparent criticism of therapy is an indication that he is already experiencing his therapist as yet another person who may be concealing negative feelings about him.

As part of our commitment to ethical practice, we are encouraged to do everything we can to develop and protect our clients’ trust, and to maintain high standards of honesty in our work. I believe Matias has no option but to disclose the fact that he keeps notes. However, this request to produce his notes on their sessions would provide Matias with an opportunity to confront his client’s fears about what he thinks people conceal from him and why they do so. If Matias is able to contain his client’s anxiety and address head-on the issues of trust and betrayal that his non-disclosure raises, he may well be able to repair any damage caused to the therapeutic relationship.

Countertransference reactions are an important part of understanding the unconscious worlds of our clients, but, if our countertransference is overwhelmingly negative, we have to ensure that we work it through in supervision. Ongoing negative countertransference can have a cumulatively damaging impact on a client’s unconscious experience of the therapist and, if not addressed and worked through, will almost certainly undermine the therapeutic experience for the client.

The development of trust and a relationship of integrity and respect are fundamental parts of our work with clients. If Matias continues to struggle with his countertransference with this particular client, even after taking it to his supervisor, he may want to consider whether he can continue ethically to work with him; it might be advisable for him to refer the client to another therapist.

Finally, this incident should prompt Matias to change the content of the notes he keeps on his client sessions. Countertransference musings can be kept elsewhere, separate from client notes, and ideally should be destroyed once they have been thought about in supervision. Matias should also inform his clients during the contracting process that he keeps brief, limited notes of sessions, as it is important that clients are fully aware of the information that is being kept about them.

Finally, Matias would be wise not to keep clients’ contact details on his smartphone. Smartphones are particularly vulnerable to theft or loss, but a desktop computer may also be hacked or stolen. Therapists need to be highly vigilant about data security, whether data is stored manually or electronically. Registration with the ICO is a complex topic that Peter Jenkins covers in detail in his article on ‘Data protection in private practice’ in the Winter 2012 issue of Private Practice journal.1

Reference: 1. Jenkins P. Data protection in private practice. Private Practice 2012; Winter: 24– 27. tinyurl.com/lg2cmqc (accessed 10 April 2017).

September’s dilemma

Lee is 32 and comes to Portia for therapy following a relationship breakdown. Brought up in foster care from the age of eight, he is desperately unhappy, terrified of being rejected and has developed a strong need to please, which masks deep feelings of worthlessness.

Portia is in her early 40s and in an unfulfilling marriage. She has felt deep compassion for Lee since the first session and, as their therapeutic relationship has deepened, has found herself looking forward to their weekly meetings and often thinking about him between sessions.

In one session, Lee shares a dream he has had recently in which they are lying together and Portia is cradling him. He tells her he wishes she could hold him in that way for real. In a rush of excitement and fear, Portia says, ‘If I weren’t your therapist, I probably would.’

She feels guilty after the session, and wishes she could take back what she said, although she also thinks it is therapeutic for Lee to know that he is lovable and desirable. She finally decides she needs to come clean in supervision about what’s happened.

If you were Portia’s supervisor, how would you respond?

Please email your responses (300 words max) to [email protected] by 18 July. The editor reserves the right to edit contributions. Readers’ suggestions for dilemmas are welcome but will not be answered personally. +++ Talking point

Screen-to-screen

Picking up on the theme in this month’s news feature, we asked counsellors for their views about working online and by phone or email

Jo Lucas Integrative psychotherapist in private practice, Cambridge

I use Skype, but only when people ask for it, and to date only with people with whom I already have a therapeutic relationship. When I started using it, I was surprised at how effective it was. I expected the screen to be a real barrier to the relationship, and to experience much more performance anxiety. It helped that I knew the clients well already. But my screen is reasonably big, so the client’s face is almost life-size and I can see when expressions flow across their face, and respond.

What I do find limiting is that I can’t reach out physically in the same way as I do when the client is in the room – the element of presence is different. I also find I have to work harder to stay in contact with the person on the screen, especially if I’m using my iPad. It’s like the difference between a television and a cinema screen – I feel somehow less connected, which makes me realise I need to always use the larger screen, especially if other things are getting in the way.

I’m surprised that I don’t find physical presence essential. If a client said they only wanted to work online, I’d give it a go. It’s certainly a real boon to people for whom travel is an issue – in that respect, new technology does open up a realm that would otherwise be closed to some people.

Adrian Francis Person-centred counsellor, based in Bridport

I’m profoundly deaf and work primarily with people who have hearing loss. Online therapy doesn’t work so well with signing clients, because it’s a very physical language: you have to see the whole body to get the whole picture. When you’re both in the same room, you can pick up on everything, pass a box of tissues, engage in creative therapy, or show clients books and resources. It’s especially difficult if clients want to use their mobile phone, as you can only see them from the neck up. Online therapy isn’t an option for clients with Usher syndrome, because they have restricted vision. I also think it’s important for a client to go outside their home for counselling, so they can leave their issues in that safe space and walk away. With Skype, the session is terminated by the press of a button, which may leave clients feeling alone at home with their problems.

Karl Pegg Person-centred counsellor in Colwyn Bay

I worked for many years with Samaritans and did a lot of email counselling then. I think it can help people to make the transition from never having spoken to anyone about their problems to being able to trust and engage with face-to-face therapy. However, there are important elements you can’t access through the written word, like tone of voice and expression.

Telephone is probably for me the best non-face-to-face option: I can get a feel for the person and there’s a lot more to work with in terms of all those signals you can pick up from the spoken word, even if you can’t see the face.

I don’t much like Skype. I find it takes more time to get into the counselling session, just because there is that physical detachment. I don’t feel I can tune into my clients’ feelings so well, in the way that you can feel in your own body something that comes from a client who is physically present. I feel I have to work harder for less of a connection.

That said, I’d sooner offer Skype if it meant someone could have counselling. But I worry that the therapy world is having to bend itself to new technology and we are losing something important in the process.

Soha Daru Integrative counsellor, based in Leeds

I’ve used online therapy ever since I qualified, even though a lot of the tutors on my course were not in favour of it. I just thought about the benefits it offers. If you look at the primary components of person-centred therapy – empathy, unconditional positive regard, creating a warm, safe, accepting environment, congruence, honesty and openness – you don’t have to be in the same room to create that environment. People say there are things you can miss online, but you can see the person quite clearly. If you’re not picking up so readily on non-verbal clues, it can make you more acutely alert to other forms of expression.

There are important differences – I have clients all over the globe, and that can be quite challenging with regard to the different terms and conditions for providing therapy, such as confidentiality issues. Clients need to know the risks; if a client is feeling suicidal, it may not be so easy to locate someone to contact in an emergency. The contract is slightly different, too – clients are in their own homes, so we need to contract for that to ensure they find a place where they are on their own, with no distractions. I find it helpful to use headphones and I encourage clients to do the same. There can be problems with connectivity, so you have to be prepared for that.

But, if all the above is in place, we can reach out to so many people who might not otherwise access our support.

Niki Reeves Attachment-based psychoanalytic psychotherapist and supervisor, based in Southampton

Practitioners often say that online work is not as good as face-to-face, but that’s because they often come to online work thinking it’s just the same, or approach it like Skyping a friend. You need to learn the skills to do this properly, and you need to prepare clients for it. I use VSee, which gives a bigger picture, and I insist the client uses a desktop computer with a big screen and sits back so we can both see each other from head to waist, as though we are sitting in front of each other.

Relational depth depends very much on the client. I have been in the room with a client and never got the emotional connection and closeness that I have with others online. Some people would never come to face-to-face therapy because it’s too close and too intimate. I have clients with agoraphobia and clients who are carers who would not be able to have therapy if they couldn’t do it online. In eight years, I’ve only had two clients who said it wasn’t working for them.

Chloe Langan Humanistic counsellor and supervisor, based in Inverness

When I moved up to Scotland from Kent, a number of my clients suggested we continue on Skype, which is how I started to use it. I now use it a lot, partly because it’s not easy to find a counsellor in the Highlands and islands. Some of my clients would have to travel miles to see me – for some, it would be a boat trip or flight to the mainland.

For me, the primary difference is in the contracting. Before the first session, I have a conversation with the client about things like making sure that their iPad is fully charged, that I have a telephone number in case the connection goes down, and that they are in a private space, with no interruptions. Online, you are working in someone else’s home, and you need to state those baseline boundaries very clearly at the start.

I use headphones, even if I’m the only person in the house. I’ve noticed I lose focus more easily online, and wearing the headphones seems to help. Once, I wouldn’t have considered changing how I worked, but moving here has opened up a space to consider different possibilities. If it means I can provide a service to someone who would not otherwise be able to access counselling, then I am very glad to be able to do so.

If you’d like to join our Talking Point panel, email [email protected] +++ Self-care

How do you take care of yourself?

Forced by ill health to cut her counselling hours, Figen Murray pours her therapeutic skills and energy into handicrafts

It all came about because I suddenly lost much of my hearing and got tinnitus in my left ear. I had to reduce my counselling workload, as listening is more effort when you’ve got poor hearing. I was quite down, but then I remembered the advice I often give to clients – that tapping into their creativity is good for the soul – and so I started making craft gifts, such as patchwork hearts, knitted monster mitts and teddy bears. I made so many that my daughter set up an online shop for me and, thanks to my son tweeting about it, it went viral.

The knitted bears are for adults, because they often forget how to play. I took to writing a little story about each of them to go on the website with their photos and, as I’m a counsellor, I gave them personal problems – Claudia who struggles with her work/life balance, Collette who has weight issues, Owen who can’t manage his anger, Trevor who self-harms…

Whenever someone bought a bear, I’d put a short update to their story in the package. In response, my customers started sending me their own stories, and telling me how they could identify with the characters I’d created. I’ve sold the bears worldwide, and donated a lot of the proceeds to charity. There’s a long-distance truck driver somewhere in America with one of my bears for company.

Just recently I decided to turn the stories into a book, which I wrote in about six weeks and self-published. The words just poured onto the paper. I’ve been a counsellor, coach and supervisor for 20 years, and have a head full of people’s stories, as well as my own trials and tribulations as a mother raising a family of five children. For me, it was an emotional and headspace-cleansing process. I feel playfulness has come back into my life now it’s done.

You can find Figen’s bears at www.depop.com/imperfecthearts

Her book, Bears Have Issues Too, is available from Amazon.

How do you take care of yourself? Email [email protected] +++ From the Chair

BACP President David Weaver and I have had the pleasure in recent weeks of meeting our vice presidents (VPs). Not everyone in the membership will realise that we have VPs, or why. It is quite simple: they bring an immense depth of experience and influence to the association and they support our work to lobby and challenge at a national policy level.

I am writing this on my way to meet Professor Dame Sue Bailey, formerly President of the Royal College of Psychiatrists, a specialist in child mental health and a powerful presence in advocating for the highest standards of mental health practice.

Recently, we met Julia Samuel, psychotherapist, founder of Child Bereavement UK and author – as readers will know from her article in last month’s issue, her first book, Grief Works, is an outstanding read. Julia is also very skilled in communicating about therapy in the media, and her ability to speak about the experience of bereavement in a way that touches many is an example of public engagement at its most inspiring.

We were also delighted to meet Luciana Berger MP, former Shadow Minister for Mental Health, who has agreed to become a VP. Luciana has long been a strong advocate for change in the way mental health services are funded and organised. She is notable for her commitment to speak with and learn from people who are themselves receiving mental health support and delivering care on the frontline.

We also receive support from Kim Hollis QC, a former winner of the Society of Asian Lawyers’ award for Most Successful Lawyer, and Juliet Lyon, whose outstanding work over many years with the Prison Reform Trust has contributed to significant change in the penal system.

I am often contacted by members asking, rightly, what steps BACP is taking to influence policy, inform stakeholders and commissioners about the value of counselling, and raise the profile of the counselling professions in the public realm. Our VPs, alongside our President, are essential to that work. They can reach audiences in a way that we could not otherwise. Our strategy is based on principles of social justice – our VPs are all outstanding women with the influence to bring about real change, and I am delighted they are willing to work with BACP for counselling and psychotherapy.

Email: [email protected]

Twitter: @Reeves_Therapy and @BACP

BACP board and officers

Chair Andrew Reeves

President David Weaver

Governors Natalie Bailey, Eddie Carden, Sophie-Grace Chappell, Myira Khan, Andrew Kinder, Caryl Sibbett, Vanessa Stirum, Mhairi Thurston

Chief Executive Hadyn Williams

Deputy Chief Executives Cris Holmes, Nancy Rowland +++ BACP round-up

Our monthly digest of BACP news, updates and events

New look for BACP

Our association exists for one simple reason: counselling changes lives. This core principle is so fundamental to us that we’re incorporating it into our new logo, placing the message that counselling changes lives at the very heart of our identity. You will start seeing this logo in the summer, on the letters, emails and documents we send you, as well as on our new website. As the year progresses, our new look will gradually replace the current one, and will continue to evolve as we develop over time and incorporate your feedback.

The new logo will also be available from the summer to Registered Members, Accredited Members, Senior Accredited Members, Accredited Services and Accredited Courses to use to promote your own work to the public.

To see how the BACP brand has evolved over our 40-year history, and to find out more about our refreshed visual identity and what it means for you, visit www.bacp.co.uk/about_bacp/newlook.php

We’ll be introducing you to other elements of our refreshed visual identity over the next few months. We’ll update you via the BACP round-up pages, your monthly news e-bulletin, our Twitter feed and our website.

Membership survey – thank you

We had almost 8,000 responses to the Membership Engagement Survey in February. Thank you – we really appreciate your feedback and support. The results will help us focus on what’s most important to you as we shape the services and benefits we offer.

We would also like to send our congratulations to the five winners of the one-year free BACP memberships: Carole Leech, Caroline Nottage, Linda Baxter, Marilyn Finch and Wendy Padley. Well done – we hope you enjoy your prizes!

We’ll be reporting the results of the survey back to you later this year.

Commission on loneliness

BACP is among the organisations supporting the Jo Cox Commission on Loneliness. The cross-party campaign, launched in January in memory of murdered MP Jo Cox, encourages communities to tackle loneliness. Older people are a key strategic priority for BACP’s work, and we have supported the commission’s campaign through a series of dedicated tweets aimed at increasing public awareness of the issues and encouraging people to take time out to talk to each other.

Loneliness is often called the silent killer. Research shows that it can increase the risk of premature death by up to 25%. It also affects self-esteem and recovery after illness, and is linked with depression and suicide.

Counselling for women prisoners

The Independent Advisory Panel (IAP) on Deaths in Custody has backed BACP’s call for counselling to be available to all women prisoners. IAP has published a working paper on ‘Preventing the Deaths of Women in Prison’, with interim findings and recommendations from a rapid information-gathering consultation at the beginning of the year. This was launched after 12 women took their own lives in prison in 2016, the highest recorded number since 2004. BACP responded to the consultation, as did IAP stakeholders and members of the Ministerial Council on Deaths in Custody and the Advisory Board on Female Offenders.

Several of BACP’s other recommendations have also been highlighted in the report, such as mandatory mental health awareness training for prison staff.

Nancy Rowland, BACP Deputy Chief Executive, said: ‘We hope that the information in the report will lead to significant practice change in policing, prisons, health and housing services, leading to real policy change for this vulnerable group.’

Other recommendations include focusing the whole prison environment on promoting the mental and physical health of all prisoners, and providing a greater range of mental health and substance misuse treatments in the community, including counselling services and talking therapies.

For more information, please visit bit.ly/2ouuNFi

BACP PhD bursary

Congratulations to BACP member Dr Michael Minn, who has recently completed his PhD. Dr Minn was a recipient of the BACP PhD membership-fee-waiver scheme for two years of his study, which he found very helpful.

BACP makes funds available for members who are studying for a doctorate in counselling or psychotherapy. There are 12 bursaries available. They cover the full cost of a year’s BACP membership (excluding accreditation fees). The bursary is for one year’s membership only, but members can apply for and receive it up to three times.

Applicants must be current members of BACP and must already be registered on their PhD/doctoral course. The deadline for applications is 5pm on 23 June 2017. Successful applicants will be informed by 30 June 2017, and the bursary will take effect from their next membership renewal date.

For details, visit www.bacp.co.uk/research/resources/Membership%20fee%20waiver %20scheme.php

Public engagement roundtable

In March, BACP held a roundtable discussion with a range of external stakeholders to look at the feasibility of developing a client panel or focus group, and the best ways of engaging with hard-to-reach communities.

The meeting was chaired by BACP’s new president, David Weaver. Guest participants included people with experience of service-user research and service- user involvement in mainstream organisations, and representatives from the BMA Patient Liaison Group and Mind’s engagement team.

A number of themes emerged from the discussion. Part of BACP’s engagement with hard-to-reach communities was seen to be about looking at how counselling training has become an exclusively middle-class activity, as there is no subsidised training. It was also felt that BACP needed to collaborate with a broader range of organisations and networks than it currently does.

The twin aims of public engagement were identified as working to change the misinformation the public has about what counselling is and what it isn’t, and developing some kind of structure to enable clients or prospective clients to feed their views back to BACP so that the client voice influences the development of the profession.

BACP accreditation

Newly accredited members, services and courses

We would like to congratulate the following on achieving their BACP accredited status.

Counsellor/psychotherapist: Krupali Adathiruthi Samantha Airey Sophie Amoni Alison Baily Lorraine Baines Lorraine Balaam Yvonne Barham Steve Barker Phillip Birch Ben Bourne Julie Bowen Annabelle Boyes Dianne Breakwell Jean Burden David Buswell John Carter Lara Chitty Julie Chivers Tamsin Cullen Supriya Dharmadhikari Alison Doherty Lucinda Drayton Crissy Duff Patsy Edmonds Karen Elliott Lesley Foulkes Joanna Gibbons Deborah Hamer Samantha Handley Alison Harris Natalie Hawkins Andrea Heaton Sybille Henry Emma Kingswood Louise Lightfoot Sue Lunn Anne-Marie Lynn Emma MacDonald Juliet May Margaret McCarthy Teresa McFall Sheena McKean Kate Megase Jo Anne Miller Susan Morris Josephine Myddelton Ann Parker Heather Pashley Angela Plant Shakeera Price Christine Robinson Janet Russell Helen Rutherford Chhaya Shah Sameena Shakil Anat Siani-Walker Julie Smart Maria Spyrou Cheryl Stainer Emma Stimson Lesley Strabel Rebecca Stremes Alison Sutcliffe Barbara Taccioli Joanne Tan Paola Tartaglia Victoria Todd Melanie Tucker Charley Venables-Bland Christina Waterhouse Nicola Woods Maria Yetman Melanie Youngman Cristina Zorat

Senior accredited counsellor/psychotherapist: Rebecca Aharon

Senior accredited counsellor/psychotherapist for children and young people: Celine Arnold John Bradley Debra McDonald-Webb

Senior accredited counsellor/psychotherapist for healthcare: Peter Leitch

Senior accredited supervisor of individuals: Juliet Layton

For a full list of current accredited services and courses, please visit the accreditation webpages at www.bacp.co.uk/accreditation

Members not renewing accreditation (counsellor/psychotherapist): Allison Armstrong Michelle Attias Joan Bagnall Mina Blair Jeanette Brazier Wendy Burrows Frances Coad Florence Copley Dominic Davies Oriana Davies Elizabeth Day Angela Dickinson Jack Doherty Tara Evans Janette Fawkes Lorna Godwin Anna Goff-Kai Helen Greenall Celia Hacking Anna Hamilton Edwina Hicks Alison Hopkins Anna Janmaat Ruth Jordan Melanie Lamb Karen Langridge Pauline Lessem Elizabeth Lewis Christine McGowan May Morgan Lois Mummery Christopher Murray Teresa Nicholls Sandra Nyakupinda Robin Page Josna Pankhania Susan Rice Sandra Rose Lesley Rosen Linda Sensicle Josephine Sexton Richard Simpson Ella Soakell Haines Maureen Staines Nicola Sternhell Jonathan Stoker Kathryn Taktak Caroline Tamman Ian Taylor Anne Thompson Anne Towers Julia Tye Fiona Wagstaffe Sarah Warhol Rhona Webb Isobel Webster

Accreditation reinstated: Christina Morris Poilin Quinn

All of the details listed are correct at time of going to print.

Disclaimer: please be aware that BACP may have more than one member with the same name. To check whether someone is a registered accredited member, please visit the BACP Register at www.bacpregister.org.uk/check_register CfD Practice Research Network

The BACP Counselling for Depression Practice Research Network (CfD PRN) is a network of practitioners, trainees, supervisors, trainers and researchers. The CfD PRN aims to develop practice-based evidence for CfD, support the commissioning of CfD, and secure the position of counsellors working in the Improving Access to Psychological Therapies (IAPT) programme in England.

The network provides members with the opportunity to communicate, share information and resources, and discuss topics of interest.

For more information or to join the network, please visit www.bacp.co.uk/research

CYP Practice Research Network

The BACP Children and Young People Practice Research Network (CYP PRN) is a network of over 1,000 people who work with children and young people as counsellors, trainers, supervisors or researchers.

The network is a great resource for sharing information and best practice, and for raising issues for discussion. Topics that have recently generated a lot of discussion among members include how many young people it is appropriate for a secondary school-based counsellor to see each week, and school-based counselling contracts.

For more information and to join the network, please visit www.bacp.co.uk/research

Learning from Scottish members

BACP was invited to lead a two-hour seminar with members of the Glasgow BACP Private Practice Network to introduce our new Four Nations approach, share details of our work to influence policy and practice in Scotland, and discuss the challenges Scottish members are facing on the ground. This is one of a series of visits we are making to each of the four UK countries to inform our Four Nations approach.

Steve Mulligan, BACP Policy and Engagement Lead, Four Nations, said: ‘It was a fantastic opportunity to talk through the work we are doing to strengthen relationships with decision-makers from across the political spectrum in Scotland, and to listen to our members so we can adapt our approach to best serve their needs, as well as find opportunities where we can work together to secure positive change.’

Susan Knox, a private practitioner from the Isle of Arran, who is a member of the Glasgow BACP Private Practice Network, said: ‘Given the distinct social and political environment in Scotland, a “one size fits all” approach was not working, and I was pleased to hear more about BACP’s Four Nations approach. After Steve’s visit, I felt reconnected to BACP and reassured, and I left the meeting feeling very positive.’ Scotland’s 10-year vision

BACP has warmly welcomed the new Mental Health Strategy 2017–2027 published by the Scottish Government late last month, following negative responses to the draft plan last September.

The strategy includes a pledge to review access to counselling and guidance services in Scotland’s secondary schools. BACP has campaigned for this for several years. There is explicit recognition of the importance of counselling and psychotherapy throughout the strategy. Dr Andrew Reeves, Chair of BACP, said: ‘We hope that this is the catalyst for Scotland’s children to be given the same emotional support enjoyed by their peers in other parts of the UK. Talking therapies have a critical role to play in health and wellbeing, and we hope that the strategy’s commitment to increasing the mental health workforce will include vital investment into the provision of evidence-based psychological therapies. BACP is keen to work with the Scottish Government to ensure its implementation delivers the transformative impact Scotland needs.’

School-based counselling in Wales

The Welsh Government’s latest statistics on the performance of its independent school counselling services show its important benefits for schoolchildren.

YP Core scores for psychological distress among young people before and after they received counselling fell from 19.2 to 11.6. In addition, 88% of children and young people who had counselling did not need onward referral.

Welcoming the data, BACP Chair Dr Andrew Reeves said: ‘The cost of five sessions of counselling is equivalent to just one contact with child and adolescent mental health services [CAMHS]. Investing a fraction of the mental health budget on school- based counselling services helps to keep children in school and avoid unnecessary and often stigmatising mental health diagnoses, as well as reducing the burden on the already stretched and costly CAMHS services.

‘Currently, only Wales and Northern Ireland have statutory school-based counselling. We will continue to campaign to ensure all children and young people across the UK have equal access to help and support.’

Meet the BACP Board of Governors

Andrew Reeves:

Who? Senior Counsellor at the University of Liverpool, Senior Lecturer at the University of Chester, Project Director with the Charlie Waller Memorial Trust, independent practitioner and author. Why join the Board? For me, BACP should be an organisation that is about relationships first, not business first. I wanted to play a part in bringing the philosophy of counselling and psychotherapy back to the heart of the association.

Your vision? Short term, for BACP to continue to work collaboratively to create a culture in which we can create a stronger voice for the profession. Mid-term, for clearer training standards and points of entry into the profession, clearer career structures, more paid employment opportunities for counsellors, and for counsellors to be paid a proper wage for their skills. Ultimately, for clients to be able to access a choice of counselling services when they need to and how they decide to do so, and for services to be freely accessible for all.

Wisest advice you’ve ever been given? ‘Give it time.’ Quick change is not always sustainable, even though it can look good in the short term.

Sophie-Grace Chappell:

Who? Professor of Philosophy at the Open University.

Why join the Board? Because counselling has been enormously helpful to me, and because I believe I have something to contribute to BACP as a professional ethicist.

Your vision? Untackled, individual unhappiness and psychological malaise is not only a profoundly bad thing in itself; it is also a significant drag on economic and social efficiency. Counselling and psychotherapy are key tools for freeing people from their inner traumas and dysfunctions, and unsatisfactory relationships, and letting them live in a way that realises their real potential. I would like to see a government and a counselling profession that are united in their understanding of this, and in their aspiration to make it happen.

Wisest advice you’ve ever been given? ‘The greatest thing you’ll ever learn is just to love and be loved in return.’

Mhairi Thurston:

Who? Lecturer in counselling at Abertay University in Dundee and Programme Leader for the MSc counselling course.

Why join the Board? I’m nearing the end of my second term of office and I’ll be standing again this year. BACP and its Board have never been in better shape. It feels so important to keep continuity and stability so that key strategic intentions can be developed and progressed.

Your vision? Employability is high on my wish list. I would love to see a proper career structure developed for the counselling professions, where employees are valued and paid a decent wage.

Wisest advice you’ve ever been given? ‘You can’t change the cards you’re dealt, but you can change how you play the hand.’ Natalie Bailey:

Who? A counsellor/psychotherapist/supervisor working with 16- to 19-year-old students on the apprenticeship scheme at a further education college in east London. I also work in private practice in London’s Canary Wharf, and supervise trainee and newly qualified counsellors.

Why join the Board? I wanted to make a contribution to change in areas I am passionate about – access to counselling for young people, parents and carers of children with special educational needs and disabilities, and for hard-to-reach communities.

Your vision? In five years: that there are trained counsellors in all school settings, and the necessary funding to pay them for their work; and more support for parents/carers of children with disabilities. In 10 years: that the public can have confidence in the quality of counselling; we have cracked the issue of stigma; and that there is universal recognition of the relevance of counselling in our everyday lives.

Wisest advice you’ve ever been given? ‘Never eat burnt toast.’ It reminds me of the importance of self-care, both personally and professionally.

Andrew Kinder:

Who? Chartered counselling and chartered occupational psychologist, registered coach, Associate Fellow of the British Psychological Society, registered practitioner psychologist, and senior accredited BACP counsellor.

Why join the Board? To make a difference within the counselling professions and, in particular, to highlight the issues of employability of counsellors.

Your vision? The counselling professions need to be flexible, innovative and forward- looking. BACP’s strategy highlights the importance of positioning our services to commissioners and employers so that many more people can benefit from the counselling professions. But we need to avoid being purist and at the same time ensure we highlight best practice. In essence, BACP has a crucial role to meet the needs of its members better, especially around employability.

Wisest advice you’ve ever been given? ‘The purpose of life is not to be happy. It is to be useful, to be honourable, to be compassionate, to have it make some difference that you have lived and lived well.’ (Ralph Waldo Emerson, poet.)

Vanessa Stirum:

Who? A divorce mediator.

Why join the Board? Because, as a non-member, I wanted to make a contribution at board level to the future of the organisation. Your vision? For BACP to be a leader in the delivery of counselling and psychotherapy, and to be recognised as a key influencer in defining the future of talking therapies.

Wisest advice you’ve ever been given? ‘Take responsibility for yourself and your actions.’

Caryl Sibbett:

Who? A senior accredited counsellor/psychotherapist, art psychotherapist, supervisor, lecturer and researcher. I offer these services through my own consultancy business.

Why join the Board? Because I believe in the values and work of BACP. I also want to promote the work of the counselling professions in the UK, and particularly in Northern Ireland.

Your vision? That BACP will extend access to counselling for more clients. I am passionately committed to developing more paid work for practitioners, with appropriate working conditions and pay rates that are professional, fair and constructive. In the longer term, to continue to develop and champion the value of counselling and the counselling professions.

Wisest advice you’ve ever been given? ‘Don’t let the sun go down on your wrath.’

Eddie Carden:

Who? Chief Executive of Renew Counselling, a BACP-accredited charitable counselling agency in Essex.

Why join the Board? I felt that, as an organisational and individual member of BACP, I have experience and insights that would enable BACP to better understand and meet members’ needs and champion our profession.

Your vision? More collaboration between the professional bodies in our field, to give a strong, united voice on the significance of our work. Personally, I would like to see statutory regulation for our profession, as I consider that voluntary regulation leaves us in a no-man’s land.

Wisest advice you’ve ever been given? ‘If a job’s worth doing, it’s worth doing properly.’

Myira Khan:

Who? Accredited counsellor and qualified supervisor in full-time private practice, Associate Tutor at the University of Leicester, and founder of the Muslim Counsellor and Psychotherapist Network (MCAPN).

Why join the Board? I believe I can represent and reflect the diversity within the counselling profession and networks, as well as promote counselling to black and minority ethnic and Muslim communities. I wanted to be able to contribute to and pay back the organisation that has been so supportive to my work and to MCAPN.

Your vision? I would like to see the profession genuinely represent the vast diversity of the clients and client groups we work with. We need to encourage and support people from a greater diversity of ethnicities, cultures and religions to train as counsellors or psychotherapists, take up clinical and teaching/training roles, and work in our professional bodies. Short term, I would like to see the BACP Register become the industry standard for counselling training and qualifications, and eligibility to apply for jobs.

Wisest advice you’ve ever been given? The best thing is to be kind – to treat everyone, including myself, from a place of love and care. My dad told me that. He taught me about self-care before I even heard the term.

Professional conduct notices

Hearing findings, decision and sanction Laura Elizabeth Francis Reference No: 541348 Swansea SA3

The complaint against the above individual member/registrant was heard under BACP’s Professional Conduct Procedure, and the Professional Conduct Panel considered the alleged breaches of the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy.

The Panel made a number of findings and was unanimous in its decision that these findings amounted to professional malpractice on the grounds of incompetence and the provision of inadequate professional services, in that the service for which Ms Francis was responsible fell below the standards that would reasonably be expected of a practitioner exercising reasonable care and skill. The Panel found no evidence of mitigation and imposed a sanction.

For full details of this decision, visit www.bacp.co.uk/prof_conduct/notices/hearings.php

Hearing findings, decision and sanction Frances Karen Taylor Reference No: 754006 Kent BR8

The complaint against the above individual member/registrant was heard under BACP’s Professional Conduct Procedure, and the Professional Conduct Panel considered the alleged breaches of the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy. The Panel made a number of findings and was unanimous in its decision that these findings amounted to professional misconduct in that Ms Taylor’s behaviour contravened the ethical and behavioural standards that should reasonably be expected of a member/registrant of this profession.

The Panel found some evidence of mitigation and imposed a sanction.

For full details of this decision, visit www.bacp.co.uk/prof_conduct/notices/hearings.php

Withdrawal of membership Susan Atkin Reference No: 562259 Dumfries and Galloway DG13

A sanction was imposed on Ms Atkin following a professional conduct hearing.

Ms Atkin failed to comply with the sanction and her membership of BACP was withdrawn. Any future application for membership of BACP will be considered under Article 12.3 of the Articles of the Association.

Full details of all professional conduct decisions can be found at www.bacp.co.uk/prof_conduct/notices/termination.php

CPD opportunities

The BACP professional development day (PDD) programme comprises a number of titles delivered across the UK.

The days have been designed to deliver CPD opportunities with clearly defined learning outcomes that will develop practitioner skills in the specified areas.

The days are interactive to enable every delegate to get the maximum individual benefit from attending. To achieve this, expert tutors have been selected to deliver the programmes and delegate places at each event are limited to a maximum of 25.

For a full list of PDD titles, please see the events listing on these pages. For a full list and to book, go to www.bacp.co.uk/events/conferences.php or email [email protected]

Events calendar

7 July Professional development day Working with erotic transference and countertransference, with Sally Openshaw London 8 July Professional development day Bridging the gap: working with unprepared clients, with Trish Blundell Norwich

4 September Professional development day Supervision: relationship, authority and ethics, with Steve Page Edinburgh

28 September Professional development day Working safely and therapeutically with domestic abuse, with Gary Williams Bristol

11 October Professional development day Integrating artwork into your counselling practice, with Pauline Andrew Newcastle upon Tyne

21 October Professional development day Bridging the gap: working with unprepared clients, with Trish Blundell Manchester

27 October Professional development day Suicide and suicidal ideation, with Kirsten Amis Cardiff +++ Analyse me

Where I work

Cluttered, cosy, calm or clinical? What do our therapy rooms say about us and how we work? Elaine Davies describes her workspace

I work from a converted garage. It’s an integral part of the house, and it wasn’t getting much use as a garage, so I turned it into my counselling room. I put in the biggest window possible, and I thought a lot about the décor. I’ve chosen some very nice artificial lighting – uplighters and a standard lamp – and the colour scheme is lilac and cream.

Lilac rug

I have a lilac rug, to go with the lilac theme, and wood flooring. I chose that because I didn’t want clients to be worried about walking mud all over the carpet. I want them just to be able to stomp in as they are, in their work boots if need be.

Snuggle chair

It’s a dedicated counselling room – I like that it’s the clients’ space and that I can pull the door closed on it when I finish work for the day. There’s a two-seater settee and a square snuggle armchair, both in lilac. I let the client choose which they want to sit in. They tend to stick with the seat they first choose, which can be an opener for interesting conversations about looking at things from different perspectives.

Something green

There’s a big plant – I think it’s a castor oil plant – but I’m not green-fingered at all; I just thought it would be nice to have something green in the room, a bit of screening. I do look after it – it’s not dead yet. I’ll sometimes bring in a vase of fresh flowers, but I’m always mindful that scents and smells can be a trigger for some clients, particularly in trauma work.

Winter warmth

I’ve got an electric fire, fixed on the wall. It’s one of those fires with artificial flames. You need the heat in the winter months, but I feel the flames also give out a sense of warmth. If people feel safe and cared for, they’re going to feel more able to talk about difficult stuff. Certificate

On the wall above the bookcase is a big print of an iris. I keep my framed BACP registration certificate on the bookshelf below it. That was a conscious decision I made a few years ago when I joined the Register. I feel it’s all part of helping clients feel safe. On the shelf there’s a selection of self-help books on topics like coping with panic and anxiety – books that I might recommend to clients. I’ve also got a portable wipe board for my CBT work. I haven’t got around to putting one on the wall.

Treadmill

The only other thing in the room is my treadmill. My sons got it for me a couple of years ago, because my work is so sedentary and I need to lose a bit of weight. It’s very heavy, and there just wasn’t anywhere else to put it. I do use it a couple of times a week. It’s also given me more empathy with clients who find it hard to motivate themselves. But it’s been a good topic of conversation, particularly with clients who want to get more active, to lose weight or to help manage depression. I’m actually discussing with my supervisor how I could use it in sessions with clients.

About Elaine

Now: a CBT therapist, counsellor and supervisor, based in South Wales.

Also: Clinical Lead Manager for an IAPT service in Hereford.

Was: and still is, occasionally, a CBT lecturer.

First paid job: GP receptionist, which was where she first realised the link between physical and mental health.

What does your counselling room say about you and how you work? If you’d like to describe your workspace here, email [email protected]