Therapy Today October 2015 Volume 26 Issue 8
NB +++ indicates the start of a new section
+++ Contents
Features
Regulars
Publication information
Editorial
Your views
News
Features
News feature The migrant crisis: helping Syrian refugees How prepared are our mental health services to deal with the crisis, asks Catherine Jackson?
We cannot talk if we do not feel free Jude Boyles and interpreters Nathalie Talbot and Bina Pahlevan work with torture survivors seeking asylum.
Adult bullying – are we taking it seriously? Patrick Quinn examines the many facets of adult bullying.
Living with your child’s violence Dave Collins describes how he and his wife remain traumatised by their adopted child’s violent behavior.
IAPT top-up training: lost in translation? Julie Folkes-Skinner explores the potential pitfalls of departing from traditional training methods for NHS psychological therapists.
How I became a therapist Yonca Ozkaya
Dilemmas Letters
Reviews
From the Chair
BACP News
BACP Public affairs
BACP Professional Standards
BACP Research
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Helping refugees
Just as we go to press I’ve received an email from a reader asking us to include less coverage of political, social and international issues and more coverage of what practitioners find useful in their practice. Too late, I’m afraid, because given what is happening in the world we felt it appropriate this month to focus on the migrant crisis. We also received letters from members wanting to know how they, as counsellors and psychotherapists, could help and what we could do as a community. So we put those questions to some of the many voluntary services and organisations in the UK who are experienced in working with these clients.
One of the perhaps predictable answers, from a UN briefing for support staff working with Syrian refugees in refugee camps and in host countries, is that the primary cause of distress for most refugees is likely to be their everyday living conditions, rather than any form of mental illness. This is just as true for refugees living in the UK, who may struggle to attend sessions because they have more essential appointments to do with housing or getting their asylum status. As Sanja Djeric-Kane of Refugee Action Kingston says, the real problem in helping refugees is the lack of any coherent national strategy to deliver the structured support people need if they are to integrate successfully into this society.
The majority of the experience and knowledge in working with refugees sits in the voluntary sector and in many cases, because of recent cuts in funding, much of this work is done by volunteers. Part of the therapeutic work for people who have lost so much is about building new attachments and resilience. Some voluntary sector services are also playing a vital role in providing training and consultancy for NHS and IAPT services, which is hugely valuable. Jude Boyles of Freedom from Torture recommends that people offer more general support by contacting the Red Cross. ‘If you want to volunteer as therapists,’ she says, ‘make sure you get training first.’
Jude also writes about working with interpreters and asylum seekers in a triadic relationship. I had assumed that having an interpreter in the room would be at best a necessary inconvenience; in fact, as the writers describe, the client may initially form a stronger bond with the interpreter who shares their language and also experiences the interpreter as a safe and reassuring presence in an alien situation.
Sarah Browne Editor
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What is the point of therapy?
Pete Sanders is still seeking answers to the question: ‘Can therapy ever be useful and empowering?’
Recently, and notably in the pages of Therapy Today, some counsellors and psychotherapists have been making gestures in the direction of social responsibility. Practitioners have, for example, been expressing alarm at our potential co-option into the Government’s Work Programme, or urging one another to come out of the counselling room and engage with local communities struggling in the backwash of its austerity drive. Many, but not all, fall back to the familiar territory of personal power or agency, suggesting that people-asking-for-help have been enfeebled by the demands of the modern world and its structures and require nothing more than a beefing-up of their personal power; the location of the change process remains inside the person, but it can be awakened only by a trained professional.
In 1993 Hillman and Ventura declared We’ve Had a Hundred Years of Psychotherapy and the World’s Getting Worse (HarperCollins, 1993). James Hillman wrote: ‘Every time we try to deal with our outrage over the freeway, our misery over the office… the crime on the streets, whatever – every time we try to deal with that by going to therapy with our rage and fear, we are depriving the political world of something.’ They were concerned that, when it comes to the relationship between human psychology, fulfilment and the material and economic world, therapy might become part of the problem rather than the cure: ‘… psychotherapy needs desperately to push past the boundaries of its accepted ideas; it needs a new wildness before it’s co-opted entirely as just another device for compressing (shrinking) people into a forced, and false, normality.’
The mountain of evidence of this relationship between human fulfilment and the material world is exhaustively documented in a number of publications, most notably The Spirit Level: why equality is better for everyone by Richard Wilkinson and Kate Pickett (Penguin, 2010). The clue is in the title.
I understand therapy and politics to be intertwined, if not conjoined. From the bottom up, the therapeutic relationship is suffused with, embedded in and created by the social and economic contexts of the helper and the helped.
I suggest that the ‘profession’ or ‘industry’ (terms that used to be vigorously challenged but now go unquestioned as we plough our career furrows) must ask itself if psychotherapy is part of the world or separate from it. Those who disavow the political dimensions of psychotherapy would surely have it not-of- this-world – transformative and transcendent without actually touching down in the gutter. Private practice beckons those who believe that therapy floats above, beyond or in a different realm from real politik. Some sociological commentators claim that therapy is nothing more than a collection of top-down, branded, bourgeois prescriptions for those whose lives are made unliveable by pathologisation and stigmatisation. Even when the client is put at the centre and directs the therapy themselves, therapy has been caricatured as therapist self-serving, monetised kindness. Ouch!
But this understanding, especially when pretty much all therapy is effective to the same degree, leads us to the tricky question ‘What is therapy for?’ Back in 2001 Keith Tudor and I published a manifesto that included the following requirements for a 21st century psychotherapy: psychotherapists’ practice reflects the awareness that the struggle for mental health involves changing society psychotherapists organise and challenge oppressive institutions, especially psychiatric hegemony in the organisation of mental health services, professional monopoly on the control of service provision and direction, and the colonisation of the voluntary sector in mental health psychotherapists support the service user movement in general and, in particular, service user involvement in mental health service development and service user-controlled alternatives to psychiatric services psychotherapists, in their work, account for social inequalities.
So, how are we doing, 22 years after Hillman and Ventura first laid down their challenge? Do we have realistic alternatives to the disease model of mental distress? Can therapy be empowering and useful in addressing people’s difficulties in living? What are the alternatives to today’s obsession with measuring ‘outcomes’ that often do not reflect what people in distress find useful? And how do we redress the imbalance of power inherent in the professionalisation of the helping professions? Counsellors and psychotherapists need to have the courage to ask these questions, and in public, and to find answers and act on them now, not in another 22 years.
Pete Sanders is a retired person-centred counsellor, trainer and supervisor, and a trustee of the Soteria Network. He will be among the speakers at a conference on ‘Positive Action for Change in Mental Health Services’ on 17 November in Nottingham. See www.pccs-books.co.uk
The more you make of it…
Mary O’Sullivan feels that her disability has nothing to do with her work with clients I read Maggie Fisher’s article ‘Working with disability’ in the April issue of Therapy Today, and as I am also a therapist with a disability, felt that I would like to share my experiences. I contracted polio at the age of three months. Both my arms are paralysed, though I have some residual movement in the fingers of my right hand, and I use a powered wheelchair as I have little strength in my legs. I volunteer at a local counselling agency twice weekly and also see clients in my private practice. Over many years I have learned to live a full and rewarding life despite my disability. During my years of training to be a counsellor, it became very clear to me that I need to be at peace with my difference before I can ask anyone else to be. I am now in that ‘place’ and feel that I reflect this in my work with clients and in my everyday life. Prior to meeting my clients, I don’t forewarn them that I have a disability as I feel that my role in working with them has nothing to do with the functioning (or non functioning) of my arms and legs. What they require from me goes much deeper than that, it’s to do with my mind, with ‘me’ and who I am, and of course, who they are. There are the slightly awkward few moments of our first meeting when I go into the waiting room in my wheelchair to welcome my clients, and bring them into my room – awkward for them I might add, not for me. I anticipate the surprise on their face as they realise that the assumption they had made (for that’s all it was) that their counsellor would be able bodied, was wrong. As I greet them and engage with them using good eye contact, warmth and empathy in my voice, I can soon feel the ‘awkwardness’ ebb away as our focus moves to them, and those issues which brought them to me as we begin our work.
What is helpful to me is that they’ve come into my space, and my confidence, in turn, helps theirs. I would only disclose to clients if they also have a disability, in which case it can be a useful process – though not in every case – but other than that I feel it has no bearing on what I’m doing. I have only been asked once by a client why I use a wheelchair. This was at the end of a first session and the questioner was someone who had just told me that she volunteered with disabled children. I wondered if she felt that this gave her the right to ask. I answered her question by saying I was interested as to why she felt she needed to know, and after a pause, she said that she didn’t know why. I told her that I’d had polio, but felt we were both aware that the exchange didn’t feel comfortable.
Thinking about this later, it became very clear to me that it was about personal boundaries; information about me is not something I need to give, it’s not part of my job. However, the client apologised, saying she didn’t know why she’d verbalised her thoughts then, but that it was something she often did that subsequently felt inappropriate and which she frequently regretted. My client was very short, which was something about herself that she didn’t like and interestingly, the matter of personal boundaries arose again much later in our work when she was talking about how people often mention her height, which she felt had nothing to do with her as a person and caused her to feel uncomfortable. She felt these comments from others were unnecessary and not pertinent to her as a person and just after speaking about it she paused and smiled at me, noting that it was exactly what she had done at our first session. This led to us exploring and validating her own feelings when it happens to her and this I felt, would help her in future to change her behaviour patterns, assisting her to hold onto those thoughts and consider how they might affect the recipient. Another client who had come to me with many health issues, burst into tears when she saw that I was disabled, saying she felt guilty. We explored this and I explained to her that from my perspective, there are many things in life worse than using a wheelchair; for me it’s just a tool to get me about. Having said this to her, I felt it was very important in our work to validate her views and feelings around this. We have now worked together for many weeks and she’s able to embrace the fact that her life might be a little easier by using a wheelchair, as and when she needs to, without feeling that she needs permission from society.
I have also found clients to be very thoughtful towards me in ways I didn’t expect. There was the man who came to me with many issues of rejection and drug abuse. Having been referred by his doctor, in our first few sessions he made it very clear that he found the whole idea of therapy and talking about himself to be a waste of time. We had been working together for several weeks and making some progress, when he came to his session holding a large book. As he sat down I was wondering how I was going to deal with this, if he passed me the book, did he realise, that I couldn’t actually hold it. He explained that the book was a photo album of family members he had been telling me about in our work, and asked whether I’d mind looking at the photographs. I said that of course I was happy to look, whereupon he opened the book, turned it round so that I could see it and held it up to me, turning the pages as required. As he spoke about his family I realised that we had reached a relational depth here; my client understood and accepted that I couldn’t hold the book and it made absolutely no difference to him, because what he needed from me as his counsellor, I could give him and my disability wasn’t in the room with us. This incident warmed my heart and clarified my belief that often, the more you make of something, the bigger it becomes.
Mary O’Sullivan is a Registered Member MBACP. Details have been changed to protect identities. +++ News feature
The migrant crisis: helping Syrian refugees
How well prepared are mental health services to help the Syrian refugees we are welcoming to our shores? Catherine Jackson reports
Despite the Government and media hype, the numbers of Syrian refugees who will be coming to the UK under the vulnerable persons relocation scheme are relatively small. At the most recent count (September 2015), 216 Syrian people have already been resettled in the UK under the scheme, which was launched in January 2014. It is aimed specifically at the most vulnerable refugees in the UNHCR camps in Jordan and Lebanon – orphan and disabled children, older people, people with disabilities and victims of sexual violence and torture. From September the Government has committed the UK to accept a quota of 20,000 Syrian refugees, spread over the next five years. But there will be no ‘wave of refugees’ arriving at Heathrow. Indeed, some 4,000 Syrian people have already been granted asylum here since the conflict began, and asylum-seekers from the region, and from other war-torn countries worldwide, continue to be resettled here under other Government schemes.
The Syrian refugees selected through the scheme will have Humanitarian Protection status, however, which means that, unlike asylum-seekers coming to the UK, they will for five years be able to work and claim welfare benefits and will have access to public funds and services. After that, they will presumably have to follow the usual route for all refugees and apply for indefinite leave to remain.
UNHCR recently published a briefing on Culture, Context and the Mental Health and Psychosocial Wellbeing of Syrians, which offers guidance to mental health and psychosocial support staff working with Syrians affected by the conflict, both in the refugee camps and in host countries outside the region (see www.unhcr.org/55f6b90f9.pdf).
The review details the scale of the refugee crisis, its impact on the mental health and wellbeing of the families caught up in it, and the array of emotional, cognitive, physical, and behavioural and social needs that they are likely to have, symptomatic of their exposure to extreme psychological and social distress. But, it says, mental health professionals should not rush to diagnose mental illness; the primary cause is most likely to be the conditions these refugees are encountering daily in their struggles to survive. Non-clinical interventions such as better living conditions could do more to improve their mental health than any psychological or psychiatric intervention. It underlines the importance of treating refugees not as vulnerable victims but as ‘active agents in their lives in the face of adversity’; their care and support should be the business of everyone involved in supporting them in their new homes, not just a few medical specialists. ‘Some of the most important factors in producing psychological morbidity in refugees may be alleviated by planned, integrated rehabilitation programmes and attention to social support and family unity,’ it stresses.
Nothing new
So, how well are services placed in the UK to meet these needs? UK voluntary sector organisations working with refugees and asylum-seekers – and, indeed, other refugees and asylum-seekers themselves – are startled by the unprecedented levels of attention the Syrian refugees are receiving from the media, the general public and the Government. They have been living with these challenges for years. Says Sanja Djeric-Kane, Director of Refugee Action Kingston: ‘We’ve already got around 1,800 on our books, so another 50 isn’t going to make that much difference.’ The real problem, she says, is the lack of any coherent national strategy to deliver the structured, organised, practical support that refugees and asylum-seekers need if they are to integrate successfully into UK society. ‘If we had that structure in place, people would be able to find a place in society much better and would not have so many problems with their mental health,’ she argues. ‘We are lucky here in Kingston in that the local authority supports us – although we don’t know what will happen from April next year, when they review their spending budgets.’
And herein lies the nub: the voluntary sector is largely providing the psychosocial support needed by refugees and asylum-seekers in the UK, wherever they come from. The statutory mental health sector, according to many of those working in the field, is not equipped or resourced to provide the long-term, multi-faceted psychosocial support needed, or even appropriate to do so when many refugees and asylum-seekers are understandably deeply fearful of any state service or official. Yet the voluntary sector has experienced massive cuts in recent years, with many organisations now operating at greatly reduced capacity, if they have survived at all. Says Jude Boyles, Manager of Freedom from Torture’s north-west centre, in Manchester: ‘What is worrying is that the mental health sector has been hugely cut. Many voluntary sector therapy services have had to become IAPT compliant in order to survive and so only offer brief therapies. Third sector services may not be able to work with refugees as they are not able to fund interpretation or their staff haven’t had the training to do this specialist work.’
Richard Garland is Manager of Touchstone IAPT in Leeds, one partner in the consortium of NHS and voluntary sector organisations providing the IAPT service across the city. He is very open about the limitations within which he is working when he tries to reach refugees and asylum-seekers. Touchstone IAPT’s remit is to improve access to talking therapies to black and minority ethnic communities, and he has specifically included refugees and asylum- seekers as one of his primary target groups, but it is hard, he admits, to accommodate their needs and circumstances within the IAPT model. ‘IAPT is what it is. We are working within strict parameters,’ he says. ‘It’s CBT-based and works primarily with anxiety and depression. We are very clear about what we offer and what it helps with, and we do what we can to be as flexible as possible in order to engage with these clients. It’s my job to explore the limits of these parameters to fulfil our remit to widen access to all.’
They deliver services from community venues in the parts of the city where there are large BME populations, their team is trained to work with interpreters, and they try to be more flexible about appointments. ‘Some may struggle to attend sessions because they have much more important appointments to do with issues like housing or their asylum status, so we for instance tend to give them more chances than IAPT usually would before we de-activate their cases,’ Richard says. ‘And we have maintained our own direct referral route so we can manage referrals in the way we see as most effective in fulfilling our remit to improve access.’
Touchstone IAPT has managed to access funding for a mental health assessment worker to conduct assessments at the weekly drop-in run by PAFRAS (Positive Action for Refugees and Asylum-Seekers), an advice and advocacy service for refugees and asylum-seekers in Leeds. A key aspect of the role is to refer people on to appropriate therapy services, including IAPT and the step 4 NHS psychological therapy service. But the waiting time for step 4 psychology is up to a year, and it has within it no specialist trauma service. ‘There is no service in Leeds that can hold trauma clients and work to stabilise them while they are waiting for step 4 treatment,’ Richard says. ‘Touchstone IAPT has tried to fill this gap in the past but our hands are ultimately tied by factors such as the number of people IAPT therapists are expected to see every week and our recovery targets.’ He was able in 2012 for six months to allocate one CBT therapist to work with refugees and asylum-seekers but the resulting drop in the therapist’s outcomes figures and anxiety among her NHS clinical supervisors about supervising this work meant he had to end the arrangement.
Voluntary sector services
Solace is one of the voluntary sector organisations in Leeds to which Touchstone IAPT makes referrals. It is the only agency in the Yorkshire and Humber region dedicated to providing psychotherapy, including specialist pain and trauma therapies, with advocacy support, to refugees and asylum- seekers. Originally set up in 2006, in response to a huge influx of refugees to the area through the Government’s National Asylum Support Service dispersal scheme, Solace has had to downsize in the past two years after two large grants from the Big Lottery Fund and Comic Relief came to an end. It continues to rely on trust funds, including the Big Lottery Fund, as it has received very limited funding from the public sector. It has already been asked to provide therapy to Syrian families who are beginning to arrive in the city.
Solace’s paid staff currently comprise two qualified systemic psychotherapists, who are also trauma specialists, and one full-time pain and trauma therapist, who volunteers half his hours. It also has 12 volunteer therapists and has recently taken on two family therapy trainees. In August it had to close its doors to new referrals for two months, in order to manage its waiting list. Solace also provides training and consultancy for NHS, IAPT and other organisations, and sees this as an increasingly important element of its activity, especially as Syrian refugees are likely to be dispersed to communities with no previous experience of hosting refugees.
That more than half their referrals come from the NHS is not surprising, says Clinical Director Anne Burghgraef: ‘NHS services are not equipped to deal with the complexity of cultural, psychological and social needs that refugees bring.’ She says that what the voluntary sector can uniquely provide is a systemic, multi-modal approach. ‘We start where clients are, rather than making them fit into a particular modality; we tailor a therapy package around their individual situation, initially to stabilise them and then to help them begin to process their experiences.’ Solace offers a wide range of therapies, including systemic family therapy, EMDR, focusing, guided visualisation, bereavement work, stress management and group work. Many clients bring very high levels of stress and bodily pain, and the pain and trauma therapist has proved very helpful for them. The partnership work with other agencies is essential: ‘People who are vulnerable and have had to leave their homes need to form new attachments. They may attach to a therapist in the early stages and we help them to move on to form new networks and new attachments, although it isn’t uncommon to keep a Solace connection for a few years,’ Anne says.
‘We aim to help people build up resilience and their internal resources, while also helping them to develop external, social resources by referring them to other organisations and groups. We signpost and support them to do as much as they can for themselves. For many, their whole world view has been challenged and they may not recognise who they are here. We hope to be a part of their journey to a restored life.’
Counselling – an alien concept
The concept of counselling or therapy is likely to be completely alien to most refugees and asylum-seekers, and especially those from outside Europe, where cultures do not draw a clear separation between mind and body. A lot of pre-therapy work may be needed. Mothertongue, the Reading-based multi- ethnic counselling and listening service, offers informal groups and English classes: ‘We can’t see the point of turning people away because they are not “ready” for counselling,’ says Chief Executive and Clinical Director, Beverley Costa. ‘One of our groups is a knitting group. It provides a place for people – although it has always been women, in fact – to come together with others in a welcoming and lovely space. They can talk and knit, they can knit and not talk, they can talk and not knit. We have even had someone who didn’t knit or talk and still seemed to get something out of it. It’s been really useful in helping people come into the organisation and not feel there is something “mental” about it. It’s also been a way for people to meet other people, to move on from individual therapy and start to form new social networks.’
Another challenge for the NHS is meeting the need for long-term, psychodynamic therapies. The refugees and asylum-seekers most damaged by their experiences are often those who already have a vulnerability relating to their childhood. Dilek Güngör, a migrant herself to the UK from Turkey and now a psychoanalytic psychotherapist, works at the Women’s Therapy Centre in north London and with Nafsiyat, an intercultural therapy centre. ‘At the Women’s Therapy Centre we get a lot of referrals of refugee women from the NHS because the very deep trauma work they need isn’t available. Women come to us because we are a women-only service. They feel safe with us.
‘We work analytically and we can work at depth. We can’t offer more than one year of therapy these days, because of limited resources, although some go on to group therapy after the individual work. To be honest, they all need longer; most of our clients have been tortured or raped or have experienced domestic violence. We are working with very difficult, traumatic experience but in a year we can at least help them understand their problem. We can’t change the past but we can help them see the patterns in their life and develop strong emotional muscles for the future. They use our service well.’
They also get a lot out of the group therapy, she says, although many are initially reluctant to attend. ‘Groupwork works very well for gender-based violence. They find it’s a good way of working because they can identify with one another’s problems and they realise they are not alone.’
Working with young people and children
The Baobab Centre, also in north London, offers long-term psycho-analytically informed psychotherapy to children, adolescents and young adult refugees who have been severely affected by organised violence. Most have come unaccompanied to the UK. All are suffering the effects of overwhelming traumatic experiences and losses, says Sheila Melzak, Baobab’s Clinical Director. ‘Many have seen their parents humiliated, violated, imprisoned or murdered. They will have experienced interpersonal violence themselves. Some have been imprisoned or forcibly recruited to be child soldiers; others have been trafficked for work or sexual purposes.’
Baobab operates as a non-residential therapeutic community, with regular community meetings where all members of the Baobab community, adults and young people, can speak about their experiences in a safe environment and learn that it is possible to express their views openly and disagree without fear of violence. Baobab offers individual and group therapy, discussion groups, and a wide range of group programmes including music workshops, and sports and arts activities. They help the young people access education, health care, benefits and housing, and support them through their asylum claims. Says Sheila: ‘All the research on young people shows they do best if all the services they need are available in one place. We offer holistic, integrated support to address their multiple practical and psychological needs, and we see them for as long as they need. These children have long-term difficulties rooted both in the violence they experienced in their home countries and on their journeys into exile and in the environment in which they are now living, which continually retraumatises them.’ Of the 110 young people receiving their help, just 12 got asylum when they applied, and 69 on appeal, often after many years; the rest are still waiting. ‘They are expected to live with a level of uncertainty about their future that no young person can really cope with,’ Sheila says.
Children have a very different experience of exile to adults, she says. ‘The processes of adjustment are completely different. Very often the children’s lives are significantly normalised by going to school. If they are supported by the school and the school understands the huge transition they are dealing with and has a programme to integrate pupils from different cultures, they adapt much faster than their parents, even if at home they suffer symptoms of trauma and are having to take on adult roles.’
Mentoring in school is very helpful for these children, who may be unable to talk to anyone in their family about their problems because their parents are preoccupied with their own distress. Unaccompanied young people can feel especially lonely, Sheila says. ‘A befriender, who is not a therapist, who can normalise their experience, can play a very useful role. If there were befriending organisations all over the country, staffed by volunteers with support and training, I think that would facilitate integration.’
Volunteering
BACP has been contacted by members in recent weeks asking what counsellors can do, as a profession, to help. Hege Soholt, a child and adolescent psychotherapeutic counsellor based in East Sussex, is one such member who feels BACP could take a lead.
‘I know from those I work with and those I converse with on social media that there are many of us out there wondering what we can do,’ she says. ‘As counsellors and psychotherapists we are in a privileged position to really help but acting alone is not always easy so I contacted BACP as I was wondering what we as a community could do.’
But she also feels that their ethical principles of justice and advocacy challenge counsellors to question the adequacy of the Government’s response to the Syrian crisis. ‘Helping people in need is what we stand for and our ethical principles state that we are there to be advocates for people. With that and the principle of justice, I feel we almost have an obligation to stand up for people who for whatever reasons are not in a position to speak for themselves,’ she says.
The difficulty for voluntary sector organisations delivering support to refugees and asylum-seekers, and often already dependent on volunteer workers, is that they lack the capacity to train and support more volunteers. The levels of trauma presented by clients require specialist skills and supervision. Jude Boyles says Freedom from Torture North West has seen an increase in offers of help from therapists but nationally Freedom from Torture has launched an appeal – its first ever, at www.freedomfromtorture.org/features/8590 – for funds so it can employ, train and provide supervision for additional permanent staff. ‘I think a lot of therapists could adapt their model and transfer their skills very easily to this work but in my experience newly-arrived people need to see someone who is familiar with the range of issues they present. The Syrians we have seen certainly have been subjected to horrific torture.’
If people want to help, Jude suggests they contact the Red Cross or other local refugee organisations that offer more general support. ‘There are many opportunities to volunteer with asylum-seekers and refugees. Do something you can sustain. And if you want to volunteer as therapists, make sure you get training first.’
And there is a huge need for low-level general support within the wider host communities. In Oxford Mina Fazel, a child psychiatrist and research fellow at the university’s Department of Psychiatry, is developing psychological interventions that can be used in schools by any member of staff to support the mental health and wellbeing of refugee and asylum-seeking children. ‘A small number will need specialist treatment for PTSD and that should be provided. But I would say to school counsellors not to underestimate the difference they can make simply by helping these young people settle in school and establish peer groups. A lot can be done at this level to support a whole range of difficulties a young refugee may be experiencing. School is a key venue to embrace these populations in a meaningful way – it’s an important path to inclusion, which is what they want.
‘It’s important not to medicalise their problems,’ she says. ‘We need a multi- tiered approach. Most of the children won’t need the higher level interventions, but they certainly will if we don’t provide the support at this first tier.’
Working with refugees and asylum-seekers
Jude Boyles, Manager of Freedom from Torture’s North West centre in Manchester, talks about trauma work with newly arrived refugees and asylum- seekers
‘The first thing to remember with any newly arrived refugee or asylum- seeker is to pace the information you give them. They are likely to be disorientated, bewildered and traumatised; they won’t always take in all that they are told. So always, in every contact, take time to check their understanding and explain and if necessary repeat it.
‘Their initial priorities will be the basics – where they will live, how to register their children in school, how to register with a GP. They’ll also be desperate to know what has happened to people back home, so they may need to be referred to the Red Cross tracing scheme. Support workers are invaluable at this stage – not necessarily therapists but people who are used to working with interpreters and who can help the family orientate and answer their queries as they settle into a routine. Then you can start to assess what the family and children might need in terms of psychological support. ‘It’s important to be flexible when you’re doing the assessment; be prepared for the process to take longer as the refugee or family is likely to have many questions and concerns. Many will be baffled by therapy; it will seem a very bizarre way of solving their problems. They won’t know how to use the space. So take time to explain what it is and why we know it helps and that you are trained to do this work – you’re not just being kind. ‘ At Freedom from Torture North West we use a holistic assessment process that we’ve developed to assess the range of needs of an individual or family; it’s not just a psychological assessment. Make it clear that you want to understand all the things that are worrying them and that you will try to get them help with any of their problems if you can. Often the appointment with the therapist will be their only chance to speak freely through a qualified interpreter so it’s understandable that they may bring to sessions a number of pressing issues that aren’t strictly related to therapy until their situation settles and stabilises. It is important to link up new arrivals with other organisations so that they have a range of options and sources of support.
Stablising and normalising
‘We use Judith Herman’s trauma model: relationship building and stabilisation, processing and then reconnection or integration. The early sessions will focus on normalising the survivor’s responses to their experiences and giving them a framework for understanding their feelings so they become less frightening and overwhelming, and then tools to manage them. Make sure they understand that it may take time for some of these symptoms to stabilise – they will want to feel better quickly so they can regain some control in their lives.
‘Once they have stabilised you can move on to therapeutic work around past experiences, but it is important to remember that not everyone will want to do that. People tend to disclose at their own pace, but you also have to give them permission to do so. Many will not believe you want to know what has happened to them and will feel ashamed and disgusted about what has been done to them or they have seen or been part of. They may not feel able to find the words to describe some of their experiences. Give them time and pace the work.
‘Try to use a normal voice; don’t drop your voice, as therapists often do: survivors may interpret a quiet voice as an indication of fragility or weakness. Try not to show in your face or body language that you are horrified or even that you are concerned, or they may think they are distressing you and that they should stop there. But you also need to be able to balance this by being congruent and validating how shocking and disturbing their experiences are.
‘Always try to explain things through your client’s frame of reference. Ask what would happen in their home country if someone was mentally unwell. There may be rituals around mental health that will help you understand their behaviours and that you can use in the work you are doing together. They may be doing positive things that they would have done at home that you can reinforce or, if they are not helpful, suggest an alternative.
‘Refugees will need time to adjust to the therapeutic relationship and the vulnerability of sitting with you. Ensure they don’t over expose themselves and that the relationship builds gradually and safely. Some may find the intimacy of the therapeutic relationship embarrassing and may be confused by the strength of their feelings towards their therapist. When we have asked refugees about their experiences of other therapy services, we sometimes find that they have not realised that those weekly sessions were the treatment; they assumed they were just having helpful conversations with a kind and supportive person. So always, always take time to talk things through and explain.’ +++ News
More students seek therapy
Growing numbers of university students are seeking support for mental health problems, a new report shows. The study, conducted by the Higher Education Funding Council for England (HEFCE), found that the number of students with mental health problems increased from 8,000 to 18,000 in the four years up to 2012-13.
The fact that societal attitudes about mental health are changing so that people feel more able to disclose mental health issues, is one possible contributing factor to the increased demand for support identified by the authors. Others include more accurate diagnostic procedures coupled with better treatment allowing people to feel able to embark on university education which they might not have done in the past; there are also increased academic and financial pressures which lead to more mental health issues emerging while at university. Another factor may be that young people are accustomed to accessing counselling having had counselling available at school.
But, according to the report, mental health problems are increasing in complexity as well as in number. Whereas students in the past would typically present with homesickness or relationship problems, more are now presenting with depression, anxiety and self-harm.
BACP member and Head of Brunel University Counselling Service, Ruth Caleb, discussed the issue on BBC Breakfast on 30 September: ‘I think it has become a much more anxiety provoking situation going to university and also going to FE colleges – who are very much the poor sister in terms of resourcing for mental wellbeing,’ she said. http://bit.ly/1MrDzy8
Hiding anxiety
Four in five 18 to 34 year olds put on a brave face when they are anxious, according to a poll by Mind. Despite this, one in five admitted to crying in the past week because of anxiety. Anxiety is one of the most common mental health problems and Mind says crying is actually both a common and useful response to dealing with it. The charity is launching a free guide to help people better understand how to cope with stress and anxiety.
The Mind poll (which interviewed 2,063 adults online) also revealed that a quarter of 18 to 34 year olds feel that showing their emotions is a sign of weakness. This attitude towards emotion and anxiety stands in stark contrast to older adults, with only one in 10 people over the age of 55 believing that showing emotion is a sign of weakness. Older adults appear generally more resilient, with two-fifths of people over 55 saying it has been longer than a year since they cried because of anxiety, or that they have never cried due to anxiety.
Gender also plays a big role: women are three times more likely than men to have cried because of anxiety in the last week, but were also twice as likely to feel better for having cried. Most worryingly, only half of people polled agreed that anxiety could be a mental health problem. In fact, nearly one in 20 people currently experiences anxiety on its own and one in 10 has mixed anxiety and depression. Anxiety has now become level with depression as the most common reason for calls to Mind’s Infoline. http://bit.ly/1QabMQU
Professor Peter Fonagy wins prestigious prize
Professor Peter Fonagy has been awarded the British Academy’s Wiley Prize in Psychology for outstanding lifetime achievement. Professor Fonagy was recognised for ground-breaking research into attachment and mentalization which has had a major impact on early childcare, adoption and fostering.
Professor Fonagy’s research demonstrated that having a secure attachment to a parent or caregiver helps children to develop the ability to understand their own and others’ thoughts and feelings. This capacity, which he termed ‘mentalization’, is uniquely characteristic of humans but individual differences have been shown to influence personality development and mental health in both the short and longer term. He has shown that these abilities are passed from caregiver to child, not genetically but via the quality of childcare.
His research into mentalization has also been extended to psychotherapy for patients with Borderline Personality Disorder (BPD). With Anthony Bateman, Senior Consultant Psychiatrist at St Anne’s Hospital, London, Professor Fonagy developed and evaluated mentalization-based treatment (MBT), which has had a major impact on clinical practice for the treatment of patients with BPD in the UK (NICE CG78) and internationally.
Professor Fonagy said: ‘Naturally, I feel deeply honoured to receive this award which I feel recognises my many collaborators over nearly four decades of research whose contribution I am delighted to join in celebrating.’ +++ We cannot talk if we do not feel free
Interpreters Nathalie Talbot and Bina Pahlevan and therapist Jude Boyles describe the importance of the triadic relationship in work with torture survivors seeking asylum in the UK.
Freedom from Torture is the only UK-based human rights organisation dedicated to the treatment and rehabilitation of torture survivors. Since 1985 we have been offering services throughout England and Scotland to torture survivors, including psychological and physical therapies, forensic documentation of torture, and legal and welfare advice. The majority of our clients are seeking asylum in the UK.
At Freedom from Torture North West our team of therapists works with survivors of torture alongside a group of qualified interpreters in a triadic relationship. We have observed that the presence of the interpreter not only provides a positive contribution to a survivor’s recovery but can also assist in narrative trauma processing work. In our experience the presence of the interpreter seems to add to, rather than detract from, the therapeutic process, and can become one of the most positive aspects of the rehabilitative process for a survivor of torture.
There has been little research on the impact of an interpreter on trauma work with survivors of torture. One study in East London1 into the use of CBT to treat traumatised refugees found that refugees receiving CBT with and without an interpreter did not differ in treatment outcomes. This supports NICE recommendations that CBT should be offered to people presenting with trauma, regardless of language need.
Rachel Tribe, in an article exploring the three-way relationship in therapeutic work with interpreters,2 and in other papers, argues that therapeutic work with interpreters has been viewed more negatively than is warranted: the ‘inherent advantages of this way of engaging with the non-English-speaking client have been minimised or ignored’.
Bearing witness to a survivor’s history of human rights atrocities is an essential feature of our work with clients. But what might be the impact on the survivor of having both the practitioner and interpreter bear witness to their history, or the interpreter bearing witness to the therapeutic relationship/work between the therapist and the client?
Therapists at Freedom from Torture also place emphasis on delivering therapy from a human rights framework but, again, what about the interpreter’s frame of reference? ‘Inevitably the interpreter is called upon to facilitate communication, not as a neutral linguist but as an active participant in the struggle against human rights abuses.’3 Freedom from Torture’s psychological treatment aims not only to address the trauma of past experiences of torture and persecution but also to enable survivors to grieve multiple losses and adjust to life in the UK. Our therapists are trained in a range of models and disciplines. The majority of our trauma work uses a narrative approach, although there are Eye Movement Desensitisation and Reprocessing (EMDR) practitioners in the team who work equally well alongside our interpreters.
Most of our rehabilitative work is also delivered with the assistance of our interpreting team. When they first come to us most clients express concerns about the quality of interpretation or fears about the confidentiality of a new interpreter. This is usually because of their previous experience of poor or unqualified interpreters in other settings, including at their UK Visas and Immigration (UKVI) interviews when they are applying for political asylum.
Introducing a third person into a two-way relationship creates a different dynamic that most therapists experience as a risk. They may feel that they are bringing the unknown and the uncontrollable into a therapy session. Clients are likely to feel a link with an interpreter who shares their language and culture; a study by Miller and colleagues on the role of interpreters in psychological therapy with refugees found that ‘it is quite common for clients to initially form a stronger attachment to the interpreter than the therapist. Several therapists described a pattern in which clients formed a stronger bond with the interpreter, only gradually developing a comfortable relationship with the therapist’.4
At Freedom from Torture, we have heard from therapists new to the work that they can sometimes feel excluded; we have also heard concerns from interpreters about over-attaching or bonding too deeply with clients at the expense of the therapist. As Miller and colleagues observe: ‘This combination of long-term involvement and the interpretation of emotionally intense material sets mental health interpreting with refugees apart from interpreting in other settings.’4
It can feel a risk to the interpreter too. He or she can experience an eerie feeling of solitude: how can you possibly build a bridge between two individuals who would both rather you were not there? The interpreter must gain the trust of two very different people: the practitioner, who might not be used to working with an interpreter, and who may feel reticent or uncomfortable about it, and the client, who may in the past have been let down by a poor quality or inaccurate interpreting service. Inaccurate interpretation may have had a direct impact on their claim for asylum if it occurred in court or in discussions with their legal representative.
We have seen our skilled interpreters work hard to establish relationships with angry and disenfranchised clients. As trust builds, the client’s attention is naturally drawn to the therapist and away from the interpreter, there is less eye contact between the client and interpreter, and the interpreter’s presence diminishes or fades. They are still fully present, but discreetly so, reflecting the tone and manner of the therapist and transferring the feeling and meaning behind the narrative of the client.
The process of interpretation slows the pace of the therapy, and this can be beneficial. The therapist has space, while their interventions and reflections are interpreted, to have eye contact with the client and to carefully think through their responses and interventions. The client too is able to hold this contact while their words are being transmitted, and a flow begins. The process also creates more reflective time for the therapist and more space to gently stop the narrative and explore feelings and sensations.
A survivor may experience the sound of their own language or second language as a trigger for traumatic memories. As Beverley Costa, from Mothertongue, has written: ‘It can be very traumatic for a client to speak or hear their first language, which may take them back to a time when they were not safe.’5 Listening to English being spoken may help make trauma work less overwhelming. For some survivors, hearing their non-native language as well as their own language together may serve as a protective function from over- arousal.
Interpreting silence
Silences are common in therapy. Interpreters are much more used to working in settings where there are time constraints and it is important to process the maximum amount of information as quickly as possible. They may find pauses and silences disconcerting, and even wonder whether the client is resenting them or losing trust in them. They may also lose momentum and may question their own performance. It can be challenging for someone who is used to dealing with words to suddenly find themselves sitting in silence.
So how do you interpret silence, when there are no words to work with? What new meaning will the silence bring into words spoken by the client when they decide to resume the conversation with the therapist? The interpreter does not switch off during these silences; they listen to silence as attentively as they listen to words.
There are of course times, when it is challenging for both. An interpreter may be concerned that the therapist has lost the meaning of something the client has communicated because they do not know the cultural significance of a gesture; a therapist may be concerned that the interpreter’s presence is inhibiting disclosure. If the relationship between the therapist and interpreter is strong, it is possible to explore these dynamics in the room and all learn from them.
There may be times when the interpreter needs to ask for something to be repeated more clearly, and the therapist loses their train of thought and focus. The therapist may feel frustrated and blocked. With a good partnership, it is possible to name these frustrations in the therapy room and it can give permission to the client to voice their irritation at their flow being inhibited or show their anger when the meaning of their words is not captured. Clients may feel humiliated that they cannot express themselves directly to the therapist or feel angry because they are having to disclose shameful events to two individuals, not just one. But exploring such frustrations in the therapy room can bring the triadic relationship closer.
Training and supervision
Our therapists have often observed how the complexity of the interpreter’s work is not always recognised in other services, and our interpreting team talk often of the challenges they have experienced with practitioners elsewhere who have not had any training in working with interpreters.
We have heard about interpreters being left alone in the room with clients, who then ask personal questions or ask an interpreter to translate a letter; about therapists who allow the client to speak in large chunks of narrative that are hard for the interpreter to remember, and about practitioners who instruct the client to ignore the interpreter.
We are privileged to work with such a skilled group of interpreters, and invest in them by providing an induction and training, regular supervision and opportunities for dialogue and learning. Joint training days between the therapy team and the interpreters build on these good working relationships and help us unpick the sometimes sticky dynamics that come up in the work.
Interpreters respect and understand the therapeutic choices and interventions made by practitioners if they have received training in the range of approaches that practitioners are likely to be using. They need to know why practitioners are responding in particular ways and to understand the basic theory behind the various therapeutic models.
Interpreters who have been trained in trauma and suicide risk assessment will be able to understand why the questions are being asked and will aim to reflect the practitioner’s tone and manner. They may also be able to give helpful feedback on the meaning of suicide in particular cultures and other useful insights. We explore these kinds of issues in the 10-minute de-briefing after each session, although we are always mindful that the client is the expert on their particular experience of their country and culture and interpreters are not cultural experts.
Interpreting when a client is dissociating or has a flashback can be frightening for an interpreter, but if interpreters understand what these responses are and are familiar with the grounding techniques that the therapist will use, they will feel safer and confident in the ways they can help.
In narrative trauma work we are aiming to support a survivor in re-visiting traumatic memories in a managed and structured way. The therapist uses the present tense to re-visit a traumatic memory, ensuring the client does not lose connection with the here and now. The past tense is used to separate what was being felt then from what is felt now. It is, of course, vital that the interpreter understands what the therapist is doing and relays their questions and the client’s answers in the correct tense.
Aref appeared fixated on Bina, the interpreter, throughout the therapy sessions, barely noticing the therapist, Robin. This had started to be a concern for Bina and Robin; Bina was gradually beginning to feel unsafe in the room.
We are discovering that the choice of language in therapy is far more complex than a simple ‘First language good, other languages bad’ formula.5 Aref switched to his mother tongue when he was disturbed and distressed, and it became a clue for both Robin and Bina that his levels or arousal were increasing.
In one session, Aref said to Bina: ‘You are my late sister’s portrait. I miss her so much,’ and began to cry, while still staring fixedly at her. This situation was taking Bina into difficult territory and, although she trusted Robin, she felt unprotected and anxious, to the extent that she discussed with him whether she should withdraw from the work.
There are times when it may be useful to explore this kind of transference but both Robin and Bina felt that it would not be helpful here, given Aref’s particular difficulties. Bina was initially worried that Robin would question her decision, or think she was not robust enough to manage the complexities of the work. Their discussion together ensured that she felt valued and was able to withdraw from the work without feeling she had failed the client in some way.
At Freedom from Torture we hold regular supervision groups where our interpreters can talk through any difficulties they are facing and explore the impact of the work in general. These sessions are vital; studies have shown that nearly all interpreters experience some symptoms of vicarious trauma, burn-out, compassion fatigue or increased stress as a result of their repeated exposure to traumatic information and abuse, and much has been written about impact of human rights abuse work on the interpreter.6
When Bina brought the situation to the supervision group many of the group recalled similar experiences when it felt as if a client was talking just to them and reflected on occasions when the interpreter might not be the right fit for the client.
Pierre’s story
Pierre is from Central Africa. Tall and emaciated, he was homeless when he was referred to Freedom from Torture. He seemed distracted when we first started working together, but once the assessment session began he kept his head up and appeared attentive. However, at times his eyes would cloud over and he would become withdrawn, or his face would dramatically change as he remembered traumatic events from the past. He was clearly troubled by intrusive memories and also had frequent flashbacks. Pierre was tense, speaking in a disjointed syntax, and at times clenching his fists. He found it difficult to build grammatical sentences, not because he was illiterate or poorly self-taught but because he was haunted by memories of starvation in the forest and long episodes of detention and torture. The intrusion of these memories made it hard for him to put his thoughts in order and translate them into rational sentences. Nathalie, the interpreter, rendered his broken speech into English as best as she could, including the hesitations, repeated words, back-to-front phrases, distorted grammar and twisted syntax so that the therapist could get a sense of how jumbled up his communication was. She did not edit anything that Pierre said, as this would have obscured the meaning in the way he spoke.
In the third assessment session Pierre began to look at Nathalie with intense suspicion; his eyes narrowed and he leaned towards her to listen to what she was saying. He appeared angry, as though he resented her or felt that her interpretation was inaccurate. Instinctively Nathalie sat back in her chair to create further distance between them. She later said that she wasn’t afraid; she had encountered difficult situations in her work before, but she found the anger and aggression in his face unsettling. She knew too that Jude was fully aware of this shift of mood in the room and she trusted her to manage the situation, so she could continue to focus on every word that was said between them.
Jude spoke calmly to Pierre, asking him to describe what was going through his mind and what he was feeling. She also reminded him that he was in a safe environment, one in which he could get help and support, and that it was fine to voice his frustration. Nathalie mirrored Jude’s calm demeanour and her reassuring and firm tone of voice.
Pierre paused for thought, and then said that he’d had a bad experience with an interpreter at his Home Office interview, which had a negative impact on his claim for protection, and ultimately led to his current destitution. He said that Nathalie had a vague resemblance to the Home Office interpreter, and he couldn’t help but associate them with each other, and so felt upset and insecure.
Jude explained that interpreters working for Freedom from Torture do not work for the UKVI, and that they work to an ethical code of conduct and from a human rights framework. Pierre appeared to relax a little, but he continued to keep a close watch on Nathalie for the rest of the hour.
Pierre was offered another interpreter but he refused this and after a very few sessions he, Nathalie and Jude formed a solid triadic working relationship. Months later, during a review to assess his progress in therapy and define further goals towards rehabilitation, Pierre said that he had discovered an interpreter could ‘work like a mother’. Jude asked him to explore this further and Pierre described how Nathalie was a safe and reassuring presence that reminded him of his early childhood with his family, and he thanked Jude for making this possible. Pierre’s analogy was an unexpected and powerful one that made us even more aware of the importance of the collaborative nature of our work. Pierre went on to work for three years in this three-way dynamic. Then, when he felt his English was good enough, he took the decision himself to say goodbye to the interpreter and continue alone with the therapist.
As is always the case at Freedom from Torture, at the final session the interpreter was able to speak for herself for the first time in their work together. Nathalie described to Pierre what he had meant to her and explained how much she respected him. It was a moving goodbye. Both Pierre and the therapist missed Nathalie’s presence for a while as this triadic relationship had been such an important part of Pierre’s rehabilitation.
Pierre’s attachment to his interpreter was safe and boundaried and he chose when to end it. There were many ways we could have understood Pierre’s choice to continue alone with the therapist. Maybe it was part of his work to forge a new identity in a new country and separate from his past. His choice to speak in English may also have related to the pain of hearing his own language and its reminders of all he had lost when he was trying to re-build and integrate into his new life.
When Pierre ended our three-way dynamic, we realised how profound the impact of his being so poorly served by the Home Office interpreter had been. Pierre’s experience with us of having a skilled and effective interpreter was validating and affirming and enabled him to claim his right for a trained interpreter in other settings.
This is how Pierre himself described his experience of working with Nathalie as his interpreter: ‘ When I met Nathalie for the first time, for me, she changed how I felt about interpreters. She was so good and I learnt to trust her during that time. In the beginning I could see her French was good, but when you meet somebody for the first time you can’t just hand over your body and mind to them. I was not sure I could trust her but the way she interpreted built my trust in her. She gave me what I needed to speak. Week after week, the relationship got better. Because she was from Africa, she understood our French and she spoke like me. If you asked her a question about who I am, she would know me too, like you do. In my country we speak many tribal languages; I speak five languages... but I wanted French, though. For many reasons I wanted Nathalie. My generation is modern and our languages are changing but I wanted French so I could be freer in my talk. Talking was freer in French I think for me.
‘I would always advise people to think about what language is best for them with their counsellor, it is good for most people to have their mother language. But it is different for us all. I wanted to be free and so this was right for me but we should be asked, as it is important. We cannot talk if we do not feel free.’ Aref and Pierre are pseudonyms. Both have given their consent for their stories to be published here.
Nathalie Talbot is a French interpreter and trainer, who has worked as an interpreter for 30 years and at Freedom from Torture North West for the last 11 years. Bina Pahlevan is a Kurdish Sorani and Farsi interpreter who has worked at Freedom from Torture for eight years and as an interpreter for 11 years. Nathalie and Bina interpret across the services Freedom from Torture North West offers: therapy, crisis work, physiotherapy, medical assessments welfare casework. For more information, visit www.freedomfromtorture.org
Jude Boyles is a psychological therapist at Freedom from Torture and has worked with her interpreting team for the last 12 years. Jude co-facilitates the interpreter supervision group.
References
1. D’Ardenne P, Ruaro L, Cestari L, Fakhoury W, Priebe S. Does Interpreter- mediated CBT with traumatised refugee people work? A comparison of patient outcomes in east London. Behavioural and Cognitive Psychotherapy Journal 2007; 35: 1–9. 2. Tribe R, Thompson K. Exploring the three-way relationship in therapeutic work with interpreters. International Journal of Migration, Health and Social Care 2009; 5(2): 13–21. 3. Raval H, Tribe R. Working with interpreters in mental health. London/New York: Routledge; 2002. 4. Miller K, Martell Z, Pazdirek L, Caruth M, Lopez D. The role of interpreters in psychological therapy with refugees: an exploratory study. American Journal of Orthopsychiatry 2005; 75(1): 27–39. 5. Costa B. When three is not a crowd: professional preparation for interpreters working with therapists. ITI Bulletin 2011; January–February: 20– 21. 6. Srependa. Vicarious trauma and the professional interpreter. [Online.] The Trauma and Mental Health Report 2012; 6 January. http://trauma.blog.yorku.ca/2012/01/vicarious-trauma-and-the-professional- interpreter/ +++ Adult bullying – are we taking it seriously?
Patrick Quinn examines the many facets of adult bullying and its influence on our clients and society as a whole.
Have we therapists fully recognised the extent of adult bullying in our clients’ lives and in society? Or have we, like society as a whole, failed to really see what is going on?
We are all increasingly having to face the fact that oppressive behaviour of adults towards other adults is widespread, just as, in earlier decades, we had to face the reality of pervasive and systemic child abuse and neglect, and domestic violence – although denial and collusion continue, as we know from the exposure of the abuses of Jimmy Savile and so many others recently. Now as a society we are being asked to face up to and tackle many different types of adult abuse: the victimisation of vulnerable adults, institutionalised racial and sexual harassment, the street grooming and sexual exploitation of young people, the new phenomenon of cyber-bullying, oppressive and controlling behaviour in non-violent domestic relationships, and bullying at work. (At the extremes we could also include adult enslavement, forced marriage, and people trafficking.)
Much of our counselling business these days comes from workplace referrals. Many of my workplace clients tell me first about what seems to be mistreatment at work (or in other organisations or social groups), then go on to reveal the damage suffered in unsupportive or oppressive close adult relationships. Not long after, if I ask, they may talk about a poor current relationship with their family of origin that is characterised by disinterest, hostility, demands or criticism. How often do you find yourself, as I do, feeling aggrieved about the way other people seem to be treating a client, or failing to support them, while the client feels their suffering is due to their own failure? Just as they may not see how they are being actively abused or oppressed, we may not see beyond the surface presentations of ‘anxiety and depression’, low self-esteem and ‘poor coping skills’.
The research evidence for adult bullying has been building since at least the 1990s. I first encountered the term used to cover both community and workplace bullying in Peter Randall’s work.1 Studies from across the western world in the past two decades tell us more. We know that between three and four per cent of employees experience ‘serious bullying’, and nine to 15 per cent ‘occasional’ bullying.2, 3 We know the extent of domestic violence and abuse in couple and family relationships (an excellent summary of the research is given in the NICE guideline on domestic violence and abuse4). Such abuse can go on unacknowledged and be invisible for years, with the victims often poorly served by the police and criminal justice system and by the other statutory agencies that should protect them.4, 5 We have disturbing and growing evidence of the abuse of vulnerable adults in various settings,4 and about the mistreatment of vulnerable elderly people in our hospitals.6 We know from attachment theory research that people who offend violently against others have a high prevalence of trauma, neglect and abuse in their own backgrounds and that this, if left untreated, will lead to further disturbed and abusive adult relationships.7 We now have unequivocal evidence that childhood and teenage bullying have damaging effects into adult life – the patterns continue, for the bullies and their victims and for those who are both victims and bullies.8, 9
And we know that there is bullying within the therapy and counselling profession – within services, within supervision, and within training bodies.10
Are we doing enough?
So often my clients start a sentence with ‘You’ll think I’m stupid, but...’, ‘I know this must be equally my fault, but...’ Yet this may be someone holding inside themselves the traumatic damage of exploitative control, the crushing of the spirit, the belittling, disempowering and cruelty that leaves the person cowed or terrified, depressed or numbed, indoctrinated and convinced of their own inferiority, stupidity, worthlessness and culpable weakness. When we hear in the therapy room about the misery that results from these experiences, is it enough to do the usual responses our counselling models advocate – active listening, giving unconditional positive regard, empathy and holding?
Sometimes I feel our role should include an element of active believing, ‘taking the side of’ the client and speaking truth to power – at least to the dominant power in the client’s inner world. We may need to model the actively, sometimes even angrily protective parent figure the client may never have had. In Stalking the Soul11 Marie-France Hirigoyen, who comes from a psychoanalytic background, talks eloquently about the destruction of the person’s identity, and about the dreadful processes used to achieve this by those who are skilled and devious enough to practise them. Lundy Bancroft12 is also good on the highly developed skills of victimisation shown by abusive male partners. I feel we as counsellors have a duty to know about these processes, and we need to be able to recognise them when clients are telling us about them, even when they themselves may not be aware of what is going on.
Post-traumatic stress is now widely recognised as a long-term effect of workplace bullying.2 If we hear from our clients about acute anxiety symptoms, panic attacks, sleep disturbances and phobic reactions, it may be important to teach them to recognise post-traumatic symptoms, and to realise that keeping going in abusive situations may only be exposing them to yet more traumatic damage.
I have found Patrick Carnes’ concept of the trauma bond useful,13 which he applies to many situations – marriages, workplaces, religious groups, business partnerships etc. In answer to the frequent question asked about those who put up with exploitation for a long time, ‘Why do they stay?’, he goes beyond the familiar ideas of ‘script’, ‘repetition compulsion’ and ‘disturbed attachment model’ to argue that the very processes of repeat entrapment and betrayal, and the resultant trauma effects, can have an addictive quality all of their own. This can include the ‘misuse of fear, excitement, sexual feelings and sexual physiology to entangle another person’. ‘The unnatural intensity can make all other situations seem superficial,’ he says.
Should we also help those who bully?
How should we as counsellors view those who have bullied and oppressed others? Is it just ignorance, learned behaviour, cultural practices – or defences against their own trauma or insecurity? Does bullying derive from a problem with addictions or impulse control? Should we be offering unconditional positive regard to all involved?
Noreen Tehrani, a respected commentator on workplace bullying and trauma, advocates standing back to view the whole bullying drama and its four protagonists – the four roles of persecutor, victim, rescuer and avenger – and offering unconditional positive regard to all the players.14 In a presentation to the 2014 BACP Practitioner’s Conference,15 she talked of traumatised organisations and teams becoming stuck in a form of traumatic functioning in response to repeat stresses, and so needing intervention at the organisational or systemic level. (In workplace counselling I have heard of situations in which one member of a team was perceived to be the problem, then disciplined or dismissed, but the team remained dysfunctional, so the outcome was as ineffective as casting out a scapegoat.)
However, this approach, I feel, may not be an adequate response to those situations when the bullying is in fact a systematic, skilled, devious, highly- developed process, specifically (and consciously) used by the bully to obtain a sense of power and gratification from the pain inflicted on, and the damage to the lives of, the victims. This may be at the social, group level – gang bullying, favouritism, career-wrecking – or at individual or family level. It can be a form of sadism or perversion, the acting out of destructive envy. Such ideas are explored by Joseph Berke in his extraordinary survey of human evil and malice,16 and Morgan Scott Peck in his description of the type of person he calls ‘the People of the Lie’, who act as if they were decent citizens but destroy the psychological health of those close to them.17 Pat Craven18 and Lundy Bancoft12 both argue that attempts to just understand and offer empathy to violent and controlling men are misguided. They advocate robustly confronting their wrongdoing, because of the evasions they use to deny what they do, and educating their victims, or potential victims, about the hard reality that some perpetrators just want to bully and oppress and, if not prevented by society from doing so, have to be recognised and avoided by the vulnerable.
When clients don’t want to change
I have also encountered with some clients what I would call the ‘enslaved mentality’ – a set of attitudes and behaviours deriving from a profound cognitive schema, or set of script beliefs, that can entrap clients in a place of malign dominance, despite our most caring counselling support. These seem to be mostly learned through traumatic experience in childhood (neglect, rejection and treatment as inferior – the ‘Cinderella syndrome’), and reinforced later in controlling adult relationships characterised by deception and mind games (well-described by Hirigoyen11 and Bancroft12). Such clients commonly tell me how they did all the housework and sibling care as a child and teenager. They may now still be compulsively, tenaciously searching for the approval, love and comfort they were denied then – but, sadly, in exactly the wrong place, with the wrong person/people. They may roll over instantly when offered any reciprocal social transaction by powerful people; they feel compelled to play the part offered, take the blame, accept failure etc – saying no is next to impossible and, if attempted, may leave them terrified and disturbed to the point of compulsive self-punishment. The only exception may be that they will have made courageous efforts to protect their children, if not themselves.
Another rule by which they feel forced to abide is that no one must be left ‘abandoned’, even an abuser who has briefly relented in a moment of remorse or discomfort. Trust and respect must be given back, even to someone who has repeatedly betrayed them. Any lack of love and care from others must be responded to with a redoubling of trying to please. There is no recognition of ‘compassion fatigue’ – self-sacrifice is due to all who appear to need support. With all the world’s suffering, their own is too petty to complain about. Failure to give totally perfect care to another (a dying relative, perhaps, who has never been good to them) is a cause of deep guilt and grief. Any shift towards giving up these behaviours, which we as counsellors might regard as therapeutic progress, may feel instead like a loss, the end, a life’s work failed.
Such a client may be over-compliant in therapy, never telling us when we have got it wrong for them, and allowing us to become over-sure of our skills, and even unwittingly oppressive.
This may go hand-in-hand with what could be called the ‘compulsive empathic tendency’ – trying to deal with another’s bad behaviour by understanding: ‘He/she must be hurt inside, feeling threatened etc. I must forgive and try to help.’ Some children seem to be by nature highly empathic creatures, picking up on the feelings of the adults around them and feeling it is their responsibility to help them. This can be easily exploited by a parent who does not understand appropriate parent–child roles. But empathy can be destructive when it is misplaced. I often feel I want to explain to clients something that may seem obvious to most of us – they do not owe empathy to those who have repeatedly mistreated them – or at least not until they have got away from those people to a place of safety, and recovered their strength and sense of self-worth. (It is, of course, very hard to divorce your parents.)
How could we respond?
Our counselling approaches are powerful tools to counteract the effects of bullying – as long as we fully recognise what has been going on. We can ensure the client feels seen, heard and fully believed, held, valued, comforted, liked, empathised with, and shown the ‘protective parental reaction’. These are the very responses, in fact, that the bullies in their lives will be actively withholding in order to keep them disempowered. They will be deceiving, denying and belittling their pain, to make them feel like a non-person. As one of my clients told me, ‘I am a joke.’ For some such clients, our responses may feel at first unfamiliar and even threatening, and may take a long time to have effect. Some clients seem to need to take our caring responses in small doses, or even leave counselling, to come back at another time.
A note on anger – the counsellor’s righteous anger on behalf of the client may not always be experienced as helpful. Too often I have been mortified to realise that the client has felt it as anger towards them – impatience at their weakness or vulnerability. We know anger is needed to power a robust reaction against mistreatment – but for them, any anger in the air may just mean danger – and their showing it in childhood may have led to humiliation and further punishment. Yet I also believe we should not sit by impassively while we hear stories of dreadful mistreatment. We too then become another bystander who saw but did nothing, who didn’t want to be disturbed.
But for clients who have suffered prolonged adult bullying, and who are caught in a trauma bond – an element of educative, even de-programming work, at the right time, is, I believe helpful. This may involve teaching the client about the signs of PTSD and how to heal from it; encouraging them into better habits of self-care, and to let go of keeping going in abusive situations (such as taking time off sick from work). It may involve telling clients about the standard techniques used by bullies everywhere (and in which we can become experts if we listen to our clients’ descriptions of how they have been treated), so the client realises it’s not something about them causing it. They will not have been the first, and they may need to be told that. It may be useful to show them models of controlling people, such as those described in Pat Craven’s Freedom Programme.18
This ‘educational’ approach may replicate the kind of parental guidance that these clients have never had. There are many self-help books out there too12,19 that we can suggest to clients, alongside our own active interventions to gently challenge their indoctrinated interpretations of bullying behaviour.
If I were inventing another brand of therapy, I might call this ET (emancipation therapy), or DUT (dis-unempowerment therapy). But then, is that not what our therapy is mostly about anyway?
Patrick Quinn has spent a working life as a therapist in mental health services, and continues to co-ordinate a BACP-affiliated staff counselling service in the Hull area. Email [email protected]
References
1. Randall, P. Adult bullying: perpetrators and victims. London: Routledge; 1997. 2. Einarsen S, Hoel H, Zapf D, Cooper C (eds). Bullying and harassment in the workplace: theory, practice and research. London/Atlanta: CRC Press; 2011. 3. Randle J (ed). Workplace bullying in the NHS. Oxford: Radcliffe Publishing; 2006. 4. NICE. Domestic violence and abuse. Public health guidance 50. London: NICE; 2014. 5. Radford L, Hester M. Mothering through domestic violence. London: Jessica Kingsley Publishers; 2006. 6. Francis R (Chair). Report of the Mid Staffordshire NHS Foundation Trust public inquiry. London: the Stationery Office; 2013. 7. Pfafflin F, Adshead G (eds). A matter of security – the application of attachment theory to forensic psychiatry and psychotherapy. London: Jessica Kingsley Publishers; 2004. 8. Takizawa R, Maughan B, Arsenault L. Adult health outcomes of childhood bullying and victimisation: evidence from a five-decade longitudinal British birth cohort. American Journal of Psychiatry 2014; 171(7): 777–784. 9. Wolke D, Copeland WE, Angold A, Costello EJ. Impact of bullying in childhood on adult health, wealth, crime, and social outcomes. Psychological Science 2013; 24(10): 1958–1970. 10. Kierski W, Johns-Green J. When the bully is a fellow therapist. Therapy Today 2014; 25(3): 20–23. 11. Hirigoyen M-F. Stalking the soul: emotional abuse and the erosion of identity. New York: Helen Marx Books; 2004. 12. Bancroft L. Why does he do that?: inside the minds of angry and controlling men. New York: Berkley Books; 2002. 13. Carnes PJ. The betrayal bond: breaking free of exploitative relationships. Deerfield Beach, FL: Health Communications Inc; 1997. 14. Tehrani N. Workplace bullying: the role for counselling. In: Einarsen S, Hoel H, Zapf D, Cooper C (eds). Bullying and harassment in the workplace: developments in theory, research and practice (2nd ed). London/Atlanta: CRC Press; 2011 (pp381–396). 15. Tehrani N. Building trauma-informed organisations. Workshop presentation. BACP Practitioner’s Conference. London, 28 February; 2014. 16. Berke JH. The tyranny of malice: exploring the dark side of character and culture. New York: Simon & Schuster; 1988. 17. Scott Peck M. The People of the lie: hope for healing human evil. London: Arrow Books; 1990. 18. Craven P. Living with the dominator: a book about the Freedom Programme. Knighton: Freedom Publishing; 2008. 19. Horley S. Power and control: why charming men can make dangerous lovers. London: Vermilion; 2002. +++ Living with your child’s violence
Counsellor Dave Collins describes how he and his wife remain traumatised by their adopted child’s violent behaviour yet many care professionals still fail to recognise a situation that is far from rare.
‘Hello. My name is Dave, and I am a traumatised parent.’ I am still coming to terms with those words. It’s taken a while for the penny to drop, even though on one level I’ve known it for some time.
Much has been written about trauma and its many types and effects. Some of the literature talks about vicarious trauma and how parenting a traumatised child can affect you.1 As the adoptive parent of a severely damaged young person, who communicates her internal turmoil and hurt through her behaviours, I have learned that living with this trauma changes life dramatically for everyone in the home.
I am still not sure why I wasn’t fully aware of it before. I had witnessed my wife being slowly dragged down by the terror of it all over many years. I have watched her draw back when she finds herself in a kitchen with children where there are sharp knives lying about, and inexplicably in tears on many occasions. I think I had assumed my personal value of being ‘strong’ was carrying me through unscathed. I was wrong.
Before we adopted her at the age of three, Jennie had experienced more abuses and ordeals than most of us experience in a lifetime. Included in this were five moves through the care system, some of which placed her in circumstances that were equally unsafe and damaging as the ones she had been removed from. The damage to her will be life-long and continues to create ripples that will affect everyone who comes to know her closely.
Having loved and cared for her, and been alongside her in therapy, I too have been strongly affected by the effects of her early childhood experiences, and this has been traumatising. I have also worked as a therapist and supervisor in a team supporting people suffering high levels of distress, many of whom have histories of childhood trauma, and here I have often witnessed and experienced what is also known as vicarious trauma.2
While the same term has traditionally been used to describe both effects, for me the quality of these two is very different and the definition does not fit well with my experience.
I also believe that attributing my trauma simply and completely to Jennie’s trauma and applying the term ‘vicarious’ to it does not elucidate the problem. It diminishes what has happened to me and it certainly does no justice to what has happened to my wife, Anne, who as the mother figure has taken the brunt of Jennie’s anger and aggression over many years. Being strangled, threatened with knives and hot irons and pushed down the stairs are all traumatic events that in isolation could bring a person to therapy. That these events are associated with or consequent on a person who was traumatised themselves in the first place makes no difference. Trauma is trauma.
On many occasions I had to stop Jennie from attacking Anne, sometimes taking a thump or two for my trouble. As she would use knives and any other household implements that came to hand, I became obsessive about putting things away. There were periods when I did not dare leave the two of them alone together and I adapted my work hours to avoid it.
These colourful events increased in ferocity as Jennie grew older. Add to all this a daily barrage of threats, foul language, unreasonable demands and confrontation, which would under most circumstances be described as verbal and emotional abuse, and hopefully you will get a feel for the chaos and danger we lived in.
My neurological, biochemical and psychological response to all these incidents is the same regardless of who created them, and is down to my experience of those events. Giving it the title of vicarious seems to shift the focus onto Jennie’s trauma and away from mine.
‘Part of the problem’
There was also a third facet to our adoption trauma. In the midst of all this mayhem we tried to get help from anyone who would listen. Questions we had addressed during our gruelling adoption assessment process included how we would work with professionals. Unfortunately nothing was said at the time about some of them not wanting to work with us. Not all were competent or empathic and the system was quick to point the finger. A small number of workers were vindictive, and in a couple of instances they were malevolent. The readiness of professionals to rapidly form a view and wield their power has been at times very frightening and traumatic in itself, and some of what was written in reports about us and our parenting skills would put the author in court if the power dynamic were on an equal footing. But clearly it was not; there was a culture operating within which we had little value and few rights, which made me feel powerless and oppressed. Hence social workers were free to dispute Jennie’s diagnosis of attachment disorder, criticise our use of the therapeutic parenting approach we had found worked – and even the therapists involved – and talked about us ‘holding her back’ and being oppressive. We, allegedly, were the cause of the problem and not part of the solution.
In one placement Jennie kept a journal, which we had taught her to do as a useful vent for some of her emotions. We noticed that this was being marked like a schoolbook by the care workers. Whenever she had written Mum or Dad it was crossed through and replaced with Anne or Dave, and had a congratulatory star, a ‘well done’ or smiley face next to it. This is just one minor example of the many attacks that were made on our family life, each one adding to my stress and distress. I consider myself lucky. I had a good upbringing, was loved and protected and developed a good sense of self. Family and parenthood play a key part in who I am today. It’s really important to me, and so all those projections and verbal attacks felt like a direct attack on my core values, on my very existence. Thankfully I realised this, and tried to avoid identifying with the projections, remembering that we did not make Jennie this way, others did. We were just doing our best in trying to repair some of the damage and provide her with some hope.
It was also beguiling to find that in my professional role I could be listened to, valued and appreciated, yet when I put my parent hat on my experience and knowledge suddenly counted for nothing. It was bizarre.
We spent years in the court system, defending our right to be parents and disputing the local authority’s assertion that we were unfit to be so. Even though this eventually backfired on the local authority it was stressful and traumatising, and because of the way the system works we had no real redress. Complaints procedures are like barricades disguised as open doors; one supposedly independent investigating officer warned us that ‘the more you push, the more [the local authority] will push back’. He turned out to have longstanding relationships within the local authority, adding to my trauma symptoms a good dose of cynicism.
I want to stress that we also met many really helpful, empathic and caring individuals who often worked beyond their brief in order to help us. We are still in touch with some of them years later. However, these mixed experiences have left me distrustful of professionals as I now know that competence, integrity and truth are not things I can take for granted. Dozens of professionals of many disciplines have been involved in Jennie’s care in the last few years alone, and with each new team I have felt my anxiety rising.
A cascade of events
Our experience is, regrettably, not an isolated case; it is common and through my personal and professional contacts I know of many adopters with similar stories. The mechanisms that drive this harmful and dysfunctional dynamic are complicated and fuelled by cascading events, situations and interactions. In brief, the cascade may look like this.
When a child is placed it may seem that the adopters and professionals are starting in the same place but they are not; they have very different sets of expectations and needs. All is well when things go well, but when they don’t these differences quickly become apparent. The more difficult it gets, the more people get involved, from increasingly diverse backgrounds.
Adoption, attachment and developmental trauma are extremely complex. Professionals outside of adoption teams have surprisingly little knowledge about adoption, and virtually no understanding of the significance of trauma in the first two years of life. This is critical in how they respond to the situation. They always make the assumption that the reasons for bad behaviour lie outside of the child and, by default, with the carers – what are they doing wrong? This attitude is then mirrored in their safeguarding standpoint, and does not take into account the child’s background and history.
The completely worn down and distressed adopters initially expect services to provide at least some of the answers, and services in turn willingly assume that expert position. When the situation worsens, the lack of both understanding and resources within services creates conflict and working relationships between the professionals and adopters spiral downwards. Challenges to services are taken personally and some professionals allow personal issues to spill over into the professional arena.
Any joined up thinking and co-operative working that might have existed evaporates. Managers protect their budgets and try not to commit to anything. Defensive communication, splitting, pairing and infighting ensue.
By now the adopters are fighting battles on two fronts. They probably fought to get services involved in the first place; now they are at war with some of the service providers and still need help with the child. They gradually lose faith and trust in the system, feel under attack and are traumatised further.
Ultimately, rather than helping the adoptive placement succeed, services unwittingly add to the trauma and level of difficulty the family experiences. Everyone feels helpless and unfulfilled and, not wanting to hold those unpleasant feelings themselves, project them onto the other party in a variety of ways. At this point the group is totally dysfunctional.
My response
My response to all this over several years was to adapt by raising the bar and normalising what to most people was a wildly abnormal home life. There were peaks and troughs, only survived by strong teamwork between Anne and I, and help from the few remaining friends who managed to stay on when so many others had deserted us. This isolation added to my anhedonia; laughter became as rare as dinner invitations. The prospect of a solution from the many ‘experts’ we saw provided some hope but there were days when I could not work: I sat on the stairs and cried when Jennie had left for school. I frequently experienced physical aches and pains; my GP diagnosed depression, which was, tellingly, explained as ‘stress at home’ on the sick notes. Subjectively I felt many things.
At the time there was little recognition of the type of abuse we were subjected to by Jennie, even though it happens in a very significant number of adoptive families. It was almost a taboo subject and where it did happen it was assumed to be the fault of the adopters – that was usually the projection. There certainly was no name given to it. Selwyn, Wijedasa and Meakings,3 in the largest ever study of adoption in the UK, are perhaps the first to give it proper coverage. There is still no significant research on the long-term effects of the trauma on adopters. There is however a new and emerging term now being applied to this type of abuse: child to parent violence (CPV).4 It’s the new big thing in adoption, and even the Government is throwing money at it by making grants to adoption support organisations. New experts who have ‘done the training’ are also emerging. This training, perhaps understandably, is focused on the child and their needs and is in its infancy.
Unfortunately there is still no agreed definition of CPV and it is described in a variety of ways. There is no consensus on how to manage it. To date it has been part of the shadow side of adoption that only those affected fully understand but at least now there is some recognition of the problem by some professional groups.
This new learning will take a long, long time to drip through the system. I recently attended a day’s safeguarding training at which most abuses were covered except CPV. When I asked about this the trainers, who were both on local safeguarding panels, looked blank and then replied with comments that were based on three assumptions – the parent is a mental health service user; the child needs safeguarding from the parents, as it must be the parents’ fault, and there could be no real risk to the parents because if the child is over 10 they can call the police, and if under 10 the child can easily be controlled. Ironically one of the take-home messages of the day was ‘Think the Unthinkable’; it was disappointing that these experts were unable to get their heads around the fact that a child could be a perpetrator.
An abusive relationship
Over time I acquired many of the hallmarks of trauma: anxiety, exhaustion, insomnia, tremors, edginess, feeling unable to cope – and some residual frustration and anger, which hopefully you can detect in this article. Having put up with this situation for years, why has it now hit me between the eyes? Jennie no longer lives with us, although we still support her and we have ‘parented at a distance’ since she left home in her mid-teens. Unfortunately, her not being with us has not stopped the trauma.
We remain in an abusive relationship where past traumas are reinforced and new ones created. Unfortunately she is like a big black hole that can never be filled. We could pour all of ourselves into that hole for the rest of our lives and we would just disappear. Her demands and ambivalent behaviour continue: one week we are the best thing since sliced bread; the next we are the devil incarnate. Her ‘disorganised and ambivalent attachment style’ is one piece of jargon that has been helpful in our understanding but has not lessened her impact on us. As much as we try to stay out of the drama triangle that she is so expert at creating, she has infinite ways to draw us back in. This is often to rescue her, as she is not only dangerous but also extremely vulnerable. Every now and then she will feel the need to reject us in the most violent and extreme manner that she can.
Currently we are back into a cycle of allegations. She has done this since junior school, to varying degrees, both about us and about professionals. Her allegations were initially about physical or verbal abuses but since she became sexually aware they have had a largely sexual content.
There is a sense in which Jennie’s trauma blankets everything, including our attempts to become a family and function as one. It was difficult from day one, mainly due to her aggressive behaviour. Most of the other problems were manageable. As she grew and changed so did our responses to her. Adoption-under-trauma is an evolutionary process where our child lived out her need to dominate, control and coerce us and we evolved to accommodate or counteract that behaviour. Sometimes we were successful, but most often not; always we were the ones who took the hit, physically as well as psychologically.
In their study Selwyn and colleagues show that the figure for adoption breakdown given by adoption managers is very low but when they interviewed adopters it was three times higher. Their findings, based on a large survey of adopters (n=390), were broadly that just over a third of adoptions work out with few problems, about 30 per cent provide significant challenges with highs and lows, and about a third have major difficulties like ours. Of this latter group about 30 per cent of the placements had disrupted, with the child leaving home. We would fall into this category, although our local authority chose not to accept ours as a disruption under their definition of the word, and so we don’t appear on any statistic.
The trauma to this embattled third of adopters is often severe, complex and enduring. It has many facets and is not limited to vicarious trauma as it is commonly understood. It has mostly been ignored and misunderstood, but the impact on adopters includes the full range of trauma-related symptoms. It is often compounded by the very system that encouraged the adopters to adopt in the first place and the issue of hostility towards this group of adopters is an important research topic in its own right.
Adoption is always about the child, and even in writing this article I have found it hard to stay with an exploration of my trauma and not Jennie’s. However, if agencies are truly concerned about addressing the problems of trauma in this group of adoptive families, far more attention needs to be placed on the impact, past and present, on the adopters. Like the children they have cared for, they too have their own trauma timeline and its effects on the future success of their placement should not be overlooked.
As for me, as I attempt to stay a part of Jennie’s life, I need to be acutely aware that, when pulled back into her drama triangle for the umpteenth time, I will not just be dealing with her trauma, I will also have to manage my own.
All the names in this article are pseudonyms, to protect the identities of the people mentioned. ‘Dave Collins’ is a BACP member, a counsellor, supervisor and therapeutic parent whose interests include trauma and particularly the impact of childhood trauma in later life. He can be contacted at [email protected] References
1. Perry BD. The cost of caring: understanding and preventing secondary traumatic stress when working with traumatized and maltreated children. Houston TX: The Child Trauma Academy; 2014. 2. Rothschild B, Rand M. Help for the helper. New York: WW Norton & Co; 2006 3. Selwyn J, Wijedasa D, Meakings S. Beyond the Adoption Order: challenges, interventions and adoption disruption: research report. London: Department for education; 2014. 4. Coogan D. Responding to child-to-parent violence: innovative practices in child and adolescent mental health. Health Social Work 2014; 39(2): e1-e9. doi: 10.1093/hsw/hlu011 +++ How I became a therapist
Yonca Ozkaya
With her own family history of migration, Yonca Ozkaya now works with the children of refugees
I grew up in Turkey, where my great-grandparents had emigrated from Central Asia and the Middle East. I worked as a foreign news reporter there, a career that allowed me to appreciate differences and how the unpredictability of life impacts on people.
In 1993 I arrived in England. I had not run away from war or persecution: my home in Istanbul was intact, my family and friends were still there, and I could return whenever I wished. Still, I faced a variety of challenges, and the need to re-establish myself in a new country.
It was at this time of change and exploration of a new professional direction that I heard about how counsellors use insights about the dynamic within the parent-child relationship to explain why young people behave in a certain way. Curious to learn more, I enrolled on an introduction to counselling course.
A year later my father died of cancer, which was the start of my journey of personal therapy. Alongside therapy, I continued with my part-time counselling training. I found the psychoanalytic interpretations of emotions and emotional challenges helpful, and I began to make sense of my experiences and, later, those of my clients.
I was curious about clients’ reactions to the objects in the counselling room, and this led me do a Postgraduate Diploma in the Therapeutic and Educational Application of the Arts and a Diploma in Parent-Child Therapy. In my counselling training, I became aware of the importance of going at my own pace. I realised I needed to slow down, allow time for feelings to surface, and to process them, and then continue with my learning. In the same way, in my work with children who seem stuck, I stay with them and wait for the process to progress, without rushing it.
As a counsellor, I work with children and young people within educational and voluntary settings, particularly those from unfortunate backgrounds. Some were born in this country and some arrived as small children. Their parents are immigrants or refugees. In the counselling room, their presentation indicates the powerlessness they feel: they were not consulted as to whether they wanted to leave their familiar environment, because their parents were preoccupied with their own, adult, challenges and responsibilities.
As a specialist counsellor/therapist at Ealing Alternative Provision (EAP), I work with the stalled emotional development of these young people. In their early developmental years they may have witnessed domestic violence, disintegration of their family unit, death of a sibling, or drug-addicted or alcoholic parents. A few arrive, unaccompanied, from war-torn countries; others have lived abroad as refugees and then moved with their families to England.
The children arrive at EAP once they are excluded from secondary education. Most are academically bright, but their family circumstances fail them. The main behaviour we see is anger: getting into fights with other children, storming out of classes. All new arrivals are referred to counselling as part of their educational programme. In the counselling room some are very well- behaved, while others are extremely uncontained, yet very creative. Some have never learnt the value of boundaries. When I interpret for them what they might be doing and why, they tend to calm down. Sometimes I respond to them as if they were much younger children, and the aggression in the room turns into a fun activity.
These young people have seen and experienced more than is age- appropriate. Yet, they show me how capable they are, if they are given opportunities. In our counselling room they make creative use of all art forms: they draw, create, perform, sing and play. They talk and recount what hurts them. Their focus is on objects: a ball they can kick when talking, for example, or a children’s version of a boxing kit, which they use to process their anger. They tell each other about their counselling experience – or they hear from the ones who attend counselling, and ask to come.
I tend to think that the faith of one of my great-grandmothers and her sister influenced my enthusiasm to make sense of trauma and loss. They survived a car accident, but their parents did not. As eight year olds, they did not have a chance to process the loss and trauma they experienced. I am now aware of the consequences of unprocessed grief and its impact on the next generations. If one person remains without professional help, there will be others in the next generation who will continue to carry the emotional burden, but needing increased professional and financial provision.
Yonca Ozkaya, Registered Member MBACP (Accred), is a specialist counsellor/therapist at Ealing Alternative Provision in London, and a counsellor/assessor for children, young people and adults at Renew Counselling in Chelmsford. +++ IAPT top-up training: lost in translation
Julie Folkes-Skinner explores the potential pitfalls of top-up training for NHS psychological therapists and the implications for the Government’s plans to increase patient access to non-CBT treatments
The achievements of the Improving Access to Psychological Therapies (IAPT) service are impressive. The Department of Health claims that more than one million people have accessed an IAPT service,1 with half of 680,0001 patients completing treatment and two-thirds deemed to have reliably improved.1 To deliver these treatments IAPT has developed ‘a new, competent workforce … to deliver NICE-recommended treatments’ (p5)1 – which is predicted to reach 6,000 by the end of 2015.2
The updated NICE guidelines for the treatment of depression,3 coupled with recognition that cognitive behavioural therapy (CBT) is not an appropriate treatment for all patients,4 resulted in a commitment to broaden the IAPT workforce to provide a wider range of therapies to better meet patient need. Four new IAPT treatment modalities were approved: Counselling for Depression, Dynamic Interpersonal Therapy, Interpersonal Psychotherapy, and Couple Counselling for Depression.5 Top-up training would be provided ‘to develop existing, qualified therapists in the other four NICE-approved modalities’ (p7).5
The impact of these new IAPT treatments on individual services and in relation to increased patient choice is beginning to emerge. The 2014 Adult IAPT Workforce Census Report2 puts the total number of IAPT therapists at 5,561 with CBT therapists accounting for 42 per cent. Nineteen per cent are described as non-IAPT qualified and 28 per cent are psychological wellbeing practitioners. Only nine per cent (554) of the total workforce are therapists offering one of the four other approved treatment modalities, with Counselling for Depression practitioners representing almost half (47 per cent) of this 554.2
Top-up training
These additional treatment modalities are part of the Government’s programme to extend the range of psychological treatments in primary care, with the intention of improving the lives of more people who present with depression and low mood. The need for these new treatments has resulted in another largely overlooked radical experiment in the training of psychological therapists. Unlike their CBT colleagues these qualified and experienced practitioners will gain new employment or secure their current positions through short, continuing professional development courses that build on their core professional qualifications and clinical experience. These courses lead to a professional accreditation but not the award of an academic qualification. This method of training is attractive to employers because it is much cheaper than the cost of training a cognitive behavioural therapist because practitioners have already acquired the clinical competence upon which these top-up trainings depend.
However, there is a danger that the top-up nature of this training could create serious inequalities between CBT therapists and those offering these other NICE-approved treatments. This is because Agenda for Change6 (the national system used to determine the pay of over one million NHS staff) mostly uses academic qualifications linked specifically to each job role to determine the level of pay. Under this system, top-up training could leave many therapists worse off if their new job title of IPT or DIT therapist is evaluated only on the basis of their top-up training. Undertaking this additional training could result in some experienced practitioners being regarded as less qualified and experienced rather than more specialised.
Personal perspective
I am an unusual dynamic interpersonal therapist in that I was recruited externally and had no previous experience of working in an IAPT service, unlike most other therapists offering non-CBT NICE-approved psychological treatments.2 As an accredited dynamic interpersonal therapist, I am also untypical because I am one of only 65 other DIT therapists currently employed in IAPT services.2 Like most CBT therapists, I am a full-time employee, which makes me unlike the majority of other therapists offering non-CBT treatment modalities who mostly work on a part-time basis.2
I qualified in psychodynamic counselling with a postgraduate degree nearly 20 years ago. I have worked as a therapist in voluntary agencies, education, adult psychotherapy and private practice. I have been a BACP accredited practitioner for over 10 years and a clinical supervisor for 15. I have been involved in the training of counsellors and psychotherapists on BACP accredited programmes and postgraduate research and I have managed a psychodynamic therapy service. I do not believe I am untypical of many of those therapists who are sufficiently qualified and experienced to undertake top-up training.
Qualification
The top-up training for the four new approved treatment modalities follows a very different process from that of CBT therapists. The training does not aim to help practitioners to develop core professional competencies because these competencies have already been achieved through each practitioner’s core professional training qualification and clinical practice. Academic entry requirements are not specified by approved providers of top-up training programmes because their purpose is to build on existing academic qualifications.
Top-up training provides specialised training in evidence-based treatments such as DIT, Counselling for Depression or IPT. It aims to attract practitioners who can comply with complex competency frameworks such as those for psychodynamic/psychoanalytic therapies.7 Around five days of introductory training is usually provided. The heart of the training lies in supervised practice through which therapists develop expertise in the delivery of a particular treatment, and this relies on the individual already possessing the necessary competencies achieved in their core practitioner training and prior clinical experience. There is some variation in how competence is assessed for each treatment modality but all involve supervisor assessment of recordings of client sessions. Some modalities require more or fewer client cases and in the case of DIT, for example, a written case study in addition to supervised practice is required.8
As a system of training it has many merits. Therapists can train on the job and achieve accreditation reasonably quickly. It has also been designed with a view to enabling services to extend the range of treatments available, meaning that counsellors and psychotherapists, like me, get to work in IAPT services where for many years there were few or no opportunities.
However, there is a danger that top-up training could result in NHS employers reaping the benefits of years of professional training, personal therapy, and clinical expertise without offering sufficient reward to this experienced and qualified group of practitioners. This is likely to happen when accreditation is treated as a therapist’s only qualification because in the NHS professional accreditation is something that can only exist alongside an academic qualification. Under Agenda for Change6 accreditation is not regarded as a qualification but only as an adjunct to academic awards.
Lost in translation?
This new way of training has been clearly defined as top-up and that ‘it should be emphasised that this training is NOT suitable for inexperienced therapists or practitioners’ (p6).8 My experience across a number of different IAPT services and teams is that these basic facts are misunderstood. While I was working towards my DIT accreditation I would often be described as a ‘trainee’ and recently I was referred to as ‘newly qualified’. When I was new in post I had some conversations where, to my astonishment, it became clear that some colleagues thought that my only training had been the five-day introductory DIT course. Such comments matter because they deny the professional experience and the qualifications that have been essential for me to train to be a DIT therapist. This seems to stem from a lack of understanding about the nature of top-up training and if this is widespread it could have a negative impact on the terms and conditions of therapists and the professional identity of these ‘new’ practitioners. It could also undermine the Government’s future plans.
In their report ‘Closing the gap: priorities for essential change in mental health’9 the Coalition Government pledged to extend top-up training in order for 300,000 more adults to access psychological therapy. In this report they increase the list of IAPT-approved treatments from five to seven by adding EMDR and CBT family therapy. The current system of top-up training is the only strategy offered in this report as the means of providing the NHS with the therapists it needs. However, no mention is given to the incentives that will be offered to encourage qualified therapists to train and there is no evidence that much thought has been given to the negative impact that being ‘accredited’ rather than having an academic qualification could have on the terms and conditions of these ‘new’ therapists and on their future prospects. For example, therapists with recognised postgraduate qualifications (such as CBT therapists) can be employed in a Band 7 post and usually only staff employed at this level can apply for management positions. Those therapists whose top- up training accreditation is regarded as their only qualification are unlikely meet the criteria for a Band 7 post and the management of IAPT services will continue to be the preserve of CBT trained managers. There is a danger that without ensuring adequate reward for experienced qualified therapists undertaking top-up training, the NHS will fail to recruit and/or retain appropriate staff.
The problem of recruitment of non-CBT therapists is highlighted in the 2014 Adult IAPT Workforce Census Report:2 ‘Counselling provision dominates the non-CBT workforce with a potential underrepresentation of DIT, IPT and couples therapy. The reasons for this distribution of the therapist workforce may need to be explored to inform future local commissioning plans’ (p19).
The report recommends gathering additional data in the 2015 census on ‘specific work force intelligence’ (p21), including details of vacancies for non- CBT posts; interestingly there were no vacancies for non-CBT therapists but 174 for CBT practitioners at the time of the 2014 census. They also propose ‘strategic investment’ (p21) in identifying those qualified staff who could undertake top-up training. This information, they suggest, should be used to assess whether the IAPT workforce ‘is capable of offering an effective choice of therapy’ (p21). What will not be investigated are the experiences of those staff who have completed top-up training and the extent to which such advanced training has impacted positively or negatively on their professional status and working conditions. This information will go some way to evaluating this radical new method of training and could help to inform the development of a national strategy for the recruitment of therapists capable of delivering these non-CBT treatments, upon which the future expansion of IAPT and treatment choice for patients depends.
Conclusion
The absence of an academic level for top-up trainings potentially leaves this new breed of NHS professionals vulnerable. There is a danger that the fact that this training is post qualification and only suitable for experienced practitioners will be lost when translated from policy into practice. Specifically, when policy makers have not considered the potential pitfalls of departing from traditional training methods for the practitioners engaging in top-up training and delivering these new treatments.
With any new system of training there will of course be teething problems but, unless the potential difficulties presented by top-up training for therapists are recognised, this could create serious problems for individual practitioners and for the expansion of this new work force. The absence of an academic award for the top-up training and the omission of an academic level in the entry requirements for these accreditations could result in lower pay and poorer prospects for this group of experienced and often highly qualified therapists when compared to their CBT colleagues. There is a need for a full evaluation of the impact of this radical new method of training and the development of a national strategy for the recruitment of non-CBT practitioners, with a view to realising the vision of treatment choice for patients across all IAPT services.
Recommendations
The problems presented by top-up training could be better understood and remedied by the following:
A national strategy for the recruitment of qualified therapists both internally and externally into top-up training posts which set minimum recruitment targets and inform local commissioning decisions. Training organisations and accrediting bodies of top-up training should specify an academic entry level for all IAPT trainings. Ideally the level should be postgraduate, this would not necessarily require applicants to have a degree or require organisations to make an academic award on completion of their trainings but, as with the UKCP’s argument for psychotherapy, it would credit the prior experience of candidates and recognise the advanced nature of the top-up training. There is a need to raise awareness about this different method of training within IAPT services and to promote the benefits to managers of recruiting experienced therapists internally and externally. Systematic research into the impact of top-up training on practitioners is needed: their practice, their terms and conditions of employment and their professional identity.
Dr Julie Folkes-Skinner is an MBACP (Accred) practitioner and accredited dynamic interpersonal therapist working in the IAPT service for Coventry and Warwickshire NHS Partnership Trust. Please email [email protected]
References
1. Department of Health. IAPT three-year report: the first million patients. 2012. www.iapt.nhs.uk/news/iapt-3-year-report--the-first-million-patients- november-2012-/ 2. IAPT Programme NHS England. The 2014 Adult IAPT Workforce Census Report. 2015. www.iapt.nhs.uk/silo/files/2014-adult-iapt-workforce-census- report.pdf 3. NICE. Depression: the treatment and management of depression in adults (NICE guideline CG90; partial update of NICE guideline 23). October 2009. www.nice.org.uk/guidance/cg90 4. Glover G, Webb M, Evison F. Improving access to psychological therapies: a review of the progress made by sites in the first roll-out year. UK: IAPT; 2010. www.iapt.nhs.uk/silo/files/iapt-a-review-of-the-progress-made-by-sites- in-the-first-roll8208-out-year.pdf 5. Department of Health. Talking therapies: a four-year plan of action. (A supporting document to ‘No health without mental health: a cross-government mental health outcomes strategy for people of all ages’.) 2011. www.iapt.nhs.uk/silo/files/talking-therapies-a-four-year-plan-of-action.pdf 6. Agenda for Change. 2015. www.nhsemployers.org/agendaforchange 7. Lemma A, Roth AD, Pilling S. The competences required to deliver effective psychoanalytic/psychodynamic therapy. 2008. www.ucl.ac.uk/pals/research/cehp/research-groups/core/competence- frameworks/Psychoanalytic-Psychodynamic-Therapy 8. IAPT. Commissioning and curriculum outline: IAPT approved high intensity therapies (additional to CBT). 2011 (version 2). www.iapt.nhs.uk/silo/files/curriculum-and-commissioning-outline-march-2011- update-v0-6-final.pdf 9. Department of Health. Closing the gap: priorities for essential change in mental health. 2014 (version 2). www.gov.uk/government/uploads/system/uploads/attachment_data/file/28125 0/Closing_the_gap_V2_-_17_Feb_2014.pdf +++ Dilemmas
Should you disclose your sexuality in therapy?
This month’s dilemma
Chris volunteers for a charity that provides counselling in schools and is in a placement in a large inner-city secondary school. As an out lesbian she has felt uncomfortable to witness the level of homophobic abuse among the children, which, as far as she can tell, goes largely unchallenged by staff.
Shazia, a 13-year-old child from a Somali family, has been referred to the service because of concerns about her poor attainment. She is shy and withdrawn and has been bullied by other children for being ‘gay’ because she wears trousers and likes to play football. Shazia does not feel able to talk to her parents about how she feels and has disclosed to Chris that she has been cutting herself to manage her emotions. She has also opened up to Chris about being attracted to girls and her fear that her family will reject her if they find out, due to strong cultural and religious convictions that label homosexuality an abomination.
Chris and Shazia have formed a strong alliance and Shazia admires Chris and sees her as a strong, independent woman. Chris feels a desire to protect Shazia and has discussed in supervision the possibility that it might be empowering for Shazia if Chris were to disclose her own sexual orientation in the work. The charity providing the counselling service has clear guidelines against therapist self-disclosure and Chris’s supervisor has cautioned her not to do so.
In session five Shazia asks Chris directly if she’s lesbian. What should Chris do?
Please note that opinions expressed in these responses are those of the writers alone and not necessarily those of the column editor or of BACP. You can read additional responses to this month’s dilemma at TherapyToday.net.
She needs to monitor risk
Dr Gillian Proctor Person-centred therapist, clinical psychologist, assistant professor in counselling at Nottingham University and author of Values and Ethics in Counselling and Psychotherapy (Sage, 2013)
Shazia and Chris are both in difficult positions. Shazia is isolated, negotiating her sexual identity in the face of unchallenged bullying at school and fear of rejection at home. It’s likely her connection with Chris is the only place where she feels accepted and acceptable. Chris is also isolated as a lesbian witnessing homophobic abuse and feeling that both her supervisor and placement guidelines are warning her not to respond to Shazia’s question. It will be important for her to try and understand her supervisor’s position, whether she is being protected from a potential placement response, or whether her supervisor is worried about Chris’s responses, either in terms of identifying with or wanting to protect Shazia.
Chris is aware of the importance of the therapy relationship to Shazia; being the only place she can share her emotional turmoil. While she will be clear that Shazia is using self-injury as a survival strategy to deal with her emotions, she will want to monitor the severity of this, to guard against accidental death and ensure that Shazia has information on harm minimisation. She will be aware of the increased risk of suicide among people who have self-injured and the high risk of suicide amongst young LGBT clients, so will also be concerned to maintain their relationship to monitor this risk and offer hope to Shazia for the future.
Ethically, her client and their therapy relationship need to be Chris’s priority here. If Chris were to do anything other than answer this direct question, the risk of Shazia feeling blamed and unaccepted is high. Even to question why Shazia is asking could be perceived as evasive and runs the risk of Shazia feeling misunderstood and that she has done something wrong. Chris should also think about her own needs in this situation. She feels personally comfortable with disclosing her sexuality to Shazia but is likely to also feel scared that her professional integrity could be questioned and that her supervisory relationship or placement (and therefore therapy relationship with Shazia) could be in jeopardy as a result of not following guidelines. She may feel angry, unsupported and that her sexuality could be seen as an issue for self-disclosure in a way that heterosexuality would not be.
Chris could be honest with Shazia about both these things, saying how she would love to respond to Shazia’s question but she feels scared to given her placement guidelines. She could tell Shazia that she will discuss the situation in supervision and with her placement manager before answering her question and explain that she wants to make sure she is supported to continue working with her. She will need to be alert to Shazia’s responses, and try to ensure that she conveys no feelings of blame. She could then discuss this situation as promised, explaining why she hopes to be supported to answer the question, while being as aware as possible of her own feelings and identification with Shazia. If she can gain this support, she could then also address how to get involved in discussing the homophobic abuse with the school, which will be contributing to many students’ distress.
Rules shouldn’t be broken
Jennie Cummings-Knight www.goldenleafcounselling.com
It’s interesting how often dilemmas involve boundary issues, which shows how difficult it is to negotiate boundaries that we feel comfortable with, even when there are clear rules to help us. In this case, while it is understandable that Chris should feel that a disclosure on her part would be empowering for her client, there are two very clear rules that shouldn’t be transgressed: first, that her organisation has specifically made it a rule that personal disclosures of this sort must not be made and Chris has signed up to work for this organisation; second, her client is a minor and therefore should be treated with special care in respect of her immaturity, vulnerability and the danger of becoming attached to Chris in an inappropriate way since they have already connected very well in the counselling relationship.
The teenage years are a time of discovery for all young people and they need careful guidance as they negotiate their way through forming their own identities. If Chris discloses her orientation, this is likely to result in a premature polarisation of Shazia’s identity, and it would also in this case alienate her further from her family and support networks just when she needs them most.
Chris needs to continue to give support from an appropriate emotional distance, and may need support herself via personal therapy to manage her need to disclose her own orientation to her client. She needs to remember that the client comes first and that her own emotional investment in the issue of being gay may make it difficult for her to be objective in her support of her client. She can answer, ‘I’m not at liberty to disclose my orientation,’ and leave it at that. Or she can ask Shazia why it matters for her to know and talk about that.
Not answering could be detrimental
Dr Cordelia Galgut BPS Chartered Psychologist, HCPC Registered Counselling Psychologist and MBACP (Snr Accred) therapist in private practice
The complexity of this dilemma stems from the fact that Shazia is only 13 and therefore a child. Not that I would question her attraction to girls, more that she’s particularly vulnerable because of her age. As a counsellor on a placement, Chris will put herself in a very difficult position if she goes against the guidelines of the service and her supervisor’s advice. Furthermore, she feels protective of Shazia, which might be clouding her judgment.
However, I’m also clear in my mind that the preferable way forward will be for Chris to answer Shazia’s question and confirm that she is indeed a lesbian. Given the level of homophobic abuse among children in the school and Shazia’s family’s attitude to homosexuality, Chris’s disclosure could well be an emotional lifesaver for Shazia by validating her sexuality in the face of such opposition. Evidence from my DPhil research, plus other researchers’ data, indicates that lesbian clients of all ages need to know whether their therapists are lesbian or not. To avoid divulging this information can be experienced as an abuse of power, even by a young client. Given that Shazia has actually asked Chris, it sounds as though she needs confirmation of what she suspects and to refuse to answer could well have a detrimental effect on Shazia’s emotional state. Furthermore, Chris’s own position will very likely feel compromised if she doesn’t – it could well be the elephant in the room, inhibiting both Chris and Shazia and getting in the way of a successful outcome for Shazia. Yes, Shazia might fall in love with Chris when Chris’s sexuality is confirmed, but my hunch is that she probably already has, so disclosure of her lesbian identity might help Chris handle this situation more easily and sensitively. Chris will need to further explore her desire to protect Shazia in supervision, of course.
The biggest problem for Chris will be justifying what she has done to both the counselling charity and her supervisor and holding on to her placement if she does disclose. I could understand her deciding not to do so, for this reason alone. The issue of whether or not to disclose our sexual orientation unfortunately still seems to be a contentious area in the counselling world in general and among therapists and supervisors alike. When the client is as young as Shazia, there can also be concern about whether her lesbian identity is ‘set’. However, I would ask whether we would question her sexual orientation at 13 if she said she were heterosexual? I suspect not.
Disclose if it’s in her client’s interests
Dominic Davies BACP Fellow, advanced accredited sexual diversities therapist and founder of Pink Therapy
Chris might feel somewhat on the spot being asked about her sexuality, and frustrated by following the advice of the supervisor and the agency, but a very fruitful discussion can be had by asking Shazia: ‘What might it mean for you if I am a lesbian, and what might it mean for you if I’m not?’
The agency policy on self-disclosure needs clarifying. Is it OK for a counsellor who is a mother to state she has children? Or for someone to mention the fact they are married? If that is acceptable then Chris should be able to selectively and appropriately reveal her sexuality when it’s clearly in the interests of the client to do so.
I wonder whether the supervisor has considered the impact on the therapeutic relationship of Chris hiding her sexuality from her clients and colleagues. How effective can she be with one hand tied behind her back? Recent research on therapist disclosure of sexual orientation shows that the cost to both client and therapist outweighs any outdated and spurious notions of therapeutic ‘neutrality’.1, 2 I also wonder if the agency and supervisor are aware of the high rates of self-harm and depression among LGBT teens (20–40%). In light of this it is possible Shazia may present a fairly significant risk to self. This may warrant flexibility in applying agency policies and careful attention to maintaining a strong therapeutic alliance. It’s always flattering when there is a positive transference and Chris may need to be mindful about not over-identifying with Shazia. I wonder if she might be making an assumption that Shazia is lesbian, and while this might well be the case, her gender non-conforming behaviour might also mean she is trans but lacks information to explore this. When working with someone with whom one may have a shared identity, it’s important to be careful not to make assumptions by overlaying one’s own history on to the client’s. If Shazia were questioning her gender, then Gendered Intelligence (http://genderedintelligence.co.uk) would be a good organisation to link her in with.
One very positive and practical thing Chris could do to help not only Shazia but also many other students, is to raise with the senior management of the school that homophobic (and probably transphobic) bullying is taking place and this needs addressing. Schools are sometimes at a loss as to how to address such things and two key resources to support in tackling such bullying are www.schools-out.org.uk and www.educateandcelebrate.org.
References
1. Jeffery MK, Tweed AE. Clinician self-disclosure or clinician self- concealment? Lesbian, gay and bisexual mental health practitioners’ experiences of disclosure in therapeutic relationships. Counselling and Psychotherapy Research 2014. DOI: 10.1080/14733145.2013.871307 2. Harris JL, Dawson DL, Davies D, das Nair R. To disclose or not to disclose? The LGBT therapist’s question. Psychotherapy Research. In press.
Explore why she’s asking
Elaine Leonard Clinical Lead, The Counselling and Family Centre
I would hope any counsellor would feel uncomfortable about witnessing homophobic abuse within a school in which they are working, regardless of their own sexuality. Chris is seeing Shazia as a result of concerns about her poor attainment. The therapeutic value for Shazia of being able to open up about the bullying, self-harming, problems with her parents and feelings about her sexuality will have strengthened the therapeutic alliance and the foundations are set for positive outcomes.
I share the caution of Chris’s supervisor regarding sharing her sexual orientation and would think that unpicking her wish to do so would be time well spent in supervision. As far as the counselling service guidelines about therapist self-disclosure are concerned, again the rationale for such disclosures will be fruitfully explored in supervision. If this were a ‘straight’ child, would a question about the ‘straightness’ of the therapist be raising any dilemmas? I don’t know the answer to that but it’s food for thought.
Should Chris answer Shazia’s direct question about whether she’s lesbian? I’d say it would be worthwhile to allow Shazia to explore why she asks and what it would mean to her either way. I’d be inclined not to answer if I were ever asked. This would model something that may be very useful for Shazia as she matures: that she has the right to share aspects of herself when and if she wishes.
Coming out could empower her client
Peter Bardsley Registered MBACP senior accredited person-centred counsellor and supervisor
Chris is probably right in believing that disclosing her sexual orientation could empower her client. As a gay counsellor I have often observed my gay clients’ increased relaxation and trust when I have come out to them. Conversely, in situations where I have not felt able to disclose my sexual orientation, I have experienced feelings of incongruence that have had a detrimental effect on my work.
As people are usually assumed to be heterosexual (unless there is strong evidence to the contrary), and as most heterosexual people are happy to be identified in this way, I believe that it is discriminatory to prohibit LGBT people from identifying in other ways, if we so wish. This is not disclosure about a personal experience, or about a particular belief system, but a statement about our fundamental identity; and counselling organisations should celebrate diversity among their counsellors if they are to engage with the diversity of their clients.
Chris finds herself in an oppressive environment where there is a culture of homophobia in the school, where her client’s parents are likely to be hostile, and where her counselling service has ‘clear guidance’ which is supported by her supervisor. As her supervisor’s role is to maintain the organisation’s rules, it would be useful for Chris to seek out an independent external supervisor who could support her in processing this situation.
I feel, however, that her options are limited. If she self-discloses to the client and breaches her organisation’s guidelines she would either have to keep this secret from her organisational supervisor, which would seriously damage her professional integrity, or to inform her supervisor and risk a rupture which could be devastating for both her and her client. On the other hand if she says nothing to her client she is colluding with the oppression and could be reinforcing feelings of shame.
Her best way forward is to make as honest and transparent a statement as she can in the circumstances, which it would have been best to prepare in anticipation of the question. It could go something like this: ‘I can hear how important it is for you to know whether I am a lesbian, but I am unable to answer your question, as this would be against the rules of the organisation that I work for. However I want you to know that I really understand the situation you are in and I want to support you to find a way of moving forward that is right for you.’ In this way Chris is following the rules of her organisation, is being totally honest with her client, and is at least accepting the possibility that she could be lesbian. I hope that Chris would also be able to find opportunities to challenge the homophobia in the school and in her counselling service and to argue for the therapeutic benefits of appropriate self-disclosure.
It isn’t her role to protect
Clive Lees School governor and registered MBACP counsellor working with children and young people
The school will have a behaviour policy to deal with bullying, which is what homophobic abuse is, and in addition must comply with the Equality Act 2010, which lists sexuality as a ‘protected characteristic’. If the school isn’t complying with its own policy or the Equality Act, Chris should raise the issue with her manager or directly with the head teacher. Alternatively she might raise it with the Chair of the Board of Governors or, the nuclear option, Ofsted.
Chris might be ‘out’ but that is not the same as inhabiting her sexuality completely and comfortably. Perhaps she is particularly sensitive around the subject? Before raising the issue with the appropriate person, she needs to be certain that there really is unchallenged bullying and that she is not being hypervigilant on account of not being comfortable herself.
Before Chris answers Shazia’s question, she needs to think carefully – hopefully she already has in anticipation of this question. First, why does she feel a desire to protect Shazia? Her role as therapist is not to protect Shazia but to help her understand her feelings and manage and function effectively in her social environment. If she protects her, this removes a degree of autonomy from Shazia and makes her dependent on Chris’s protection. The goal of therapy is for Shazia to be able to protect herself in a safe and constructive way. Why does she feel this desire to protect in the first place? Is she projecting her own vulnerability around her sexuality onto Shazia? Chris needs to explore this in supervision before she answers the question.
Would it help to answer Shazia’s question? Chris can’t say ‘no’ because this would be a lie. If she says ‘yes’, then the conversation becomes about Chris and not Shazia. And what question would come next? ‘How many women have you slept with?’ perhaps, which would obviously be a move in the wrong direction. Chris also needs to be vigilant about the possibility of an erotic transference that might be inadvertently encouraged by answering the question affirmatively. Further, if she answers ‘yes’, there is a risk of developing a collusive ‘us against them’ relationship and giving rise to an inappropriate level of intimacy. Perhaps the better answer would be, ‘What answer are you hoping for?’ This puts the focus back on Shazia and will enable further discussion about what she is hoping for and why.
Her supervisor has also cautioned her not to self-disclose and it is against the guidelines of the charity itself, while a supervisor’s advice is not law, she should discuss in supervision why she is going to disclose, if that is her decision, or why she did if it’s after the fact. She must be prepared and able to argue her case with her supervisor and be open to any learning that arises from it.
Invite a discussion of the subject
Angela Privett MBACP Person-centred counsellor, Southend on Sea, Essex
Chris should explain to Shazia that the charity she works for does not permit her to disclose her sexuality. However, she could ask Shazia what she thinks. If she says she thinks Chris is a lesbian, Chris could explore that further by asking her what it might mean to her if she is, and whether it might influence how she feels about working with her. This would avoid directly answering Shazia’s question but would invite a discussion around the subject.
Clearly Shazia needs to be able to manage her emotions and speak about her feelings. To do so safely in a non-judgmental environment with a therapist she can trust and perceives to be in the same position as her, will be better than cutting herself to manage her emotions.
What’s in a label?
William Johnston Person-centred counsellor in private practice
There is a world of difference between volunteering personal information and responding to a direct question. Chis cannot simply refuse to answer the question, and going into explanations as to why she can’t will alienate her client. She will of course have needed to have some sort of response in reserve before the question was ever asked, since the possibility was always there.
She can certainly ask her client why she has asked the question. She can ask her what it might mean to her if she says ‘no’, or indeed, if she says ‘yes’. It is important here that she does not use this as a means simply to evade the question. Shazia will know that she is doing so and this will likely damage the trust that they hold between them. If this line of mutual enquiry proves unhelpful, she will need to prepare herself for having to answer the question directly. I would equally assert that this is not a question to which the answer can be either yes or no. Sexuality is as complex as the individual concerned. What Chris will have had to consider is what she understands by the term lesbian, and how she relates to her own sexuality. It is hard to believe that it is a label that defines her in total, so she will need to understand the extent to which she identifies with the label and how much that identification matters to her. It seems to me that it is only through a thorough understanding of that question as she directs it to herself that she can both answer Shazia, as well as allowing Shazia to recognise the extent to which she may herself identify with the word.
We are told that ‘lesbian’ is the word that she used: why ‘lesbian’? Why not ‘gay’ or any number of other words that might define sexuality in subtly – or not so subtly – different ways? There is a wealth of themes that can be discussed here and in the end Chris will need to find a way of answering her client’s question – though the discussion, if it is honest, may provide an answer that satisfies her better than any direct response.
Direct questions are best reflected back
Tim Branson MBABCP, MUPCA (Clinical Member), MNCS (Accred), MBACP (Senior Accredited Supervisor of Groups) NHS Psychological Therapist/Specialist Counsellor and counsellor and supervisor in private practice
I immediately felt for Chris when reading that the school children were being subjected to bullying and largely unchallenged homophobic abuse, and wondered what she might do about that dilemma. However, while Shazia has come to therapy to work on her poor attainment, struggling emotionally, not speaking to her parents and developing sexual identity issues have come up. I wonder how her ‘poor attainment’ might be impacted by these wider concerns? A further dilemma then regarding the goals of therapy.
Despite what the school has to say about Chris’s responsibilities toward her client, if Shazia is cutting herself then surely under their contracting around breaking confidentiality in the event of a risk to herself, Shazia’s self-harming might demand Chris contact the GP or CAMHS so the degree of harm can be determined and hopefully treated. It may be that Chris’s contract with her client is time-limited and at session five this could affect her decision to refer.
As a reasonably experienced supervisor, I imagine potential difficulties ahead with Shazia’s presentation of ‘being attracted to girls’ as indeed the cultural and religious implications will surely present her with extreme difficulty, should she actually be questioning her sexual orientation. She may need to be supported through such challenging issues of (cultural/sexual) identity with robust and long-term counselling. Shazia’s transference to Chris seems positive in her assimilation of her as strong and independent – though could this influence Shazia’s views? However it seems that Chris’s countertransference to protect Shazia from others inside and out of her own culture, and possibly her views and beliefs about her own sexual orientation (impacted by a different cultural perspective, perhaps) may be affecting her judgment around how to respond to Shazia’s direct question – as she has already pre-empted in supervision.
Long before I was a counsellor I trained as a Samaritan. It was the best experience any counsellor in waiting could possibly have and I recommend it. It was there that I learned not to arrive on duty dressed in a way that would disclose any particular belief or affiliation, as to do so might affect my efficacy in sitting with a caller ‘on the edge’. And answering a direct question was a no go zone. I recall a quiet middle-aged accountant who also happened to be a trainer, screaming at me in a role-play: ‘How the **** can I talk to you if you’re married?’ Or equally: ‘How the **** can I talk to you if you’re not married?’ (Followed by a theatrical ‘click’ as the phone went down.) I quickly learned that direct questions are best reflected back, as rarely are they proper enquiry, more a way for our clients to explore their thoughts and find ways to engage their own questions. Perhaps simply asking what it would mean for Shazia if Chris were a lesbian … or if she were not? I wonder if that might help Shazia to explore? And perhaps this straightforward dilemma is hiding other more demanding ones in this case.
November’s dilemma
Avril is a recently qualified couple counsellor who works as a volunteer for a Christian counselling service. Six months ago she separated from her husband after discovering he’d been accessing an online dating site that encourages married users to cheat on their spouses. Her supervisor has explored with her whether she might need time away from client work to attend to her own self-care, but Avril is working towards accreditation and doesn’t want to delay accruing the required hours.
Avril has been seeing Zachary and Olivia for couple counselling for the last month. They initially presented because they wanted to work on improving communication in their marriage. A proud and private man, Zachary has hinted at frustrated feelings about a lack of sex in the marriage but not gone into detail. Olivia has not responded to his hints and Avril hasn’t pursued this as a line of enquiry.
Between sessions Avril receives an unexpected email from Zachary in which he confesses to an online porn addiction. He begs Avril not to tell Olivia about it but asks instead if, in addition to continuing to see him and his wife as a couple, she can support him in individual counselling at the same time to help him overcome his addiction. What should Avril do?
Please email your responses (500 words maximum) to John Daniel at [email protected] by 29 October 2015. The editor reserves the right to cut and edit contributions. Readers are welcome to send in suggestions for dilemmas to be considered for publication, but they will not be answered personally. +++ Letters
Research career prospects first
As another counsellor who has recently completed their training, I would like to offer an alternative viewpoint to those presented in recent letters by Jessica Woods (Therapy Today, July 2015) and Max Marnau (September 2015), where the lack of jobs seems to come as a surprise. I too have spent four years training to reach the point of becoming an individual member of BACP and have spent many thousand of pounds achieving it. I too am disheartened by the challenging job market for counsellors. The big difference is that I knew what the future held before I embarked on training.
I am surprised and saddened that people choose to embark on training for a career without first doing some research into that career to understand what the opportunities are and the various career paths available to them. Such a huge amount of time and effort must surely be worth a little due diligence? As Jessica points out, Therapy Today is full of tales of woe about counsellor jobs. I read articles like that when I was researching counselling as a career. My course leader at Manchester University explains to every potential student that the market is tough and that they may find it very hard to get a job, before offering them a place.
I have a career plan, which I update as I learn. I haven’t seriously expected to have a chance at work until I’m accredited. I have a list of CPD that is relevant to the counselling path I have chosen, and am choosing voluntary placements that will give me experience and contacts that will hopefully make a difference when I do look for work. I also know that I may never work as a paid counsellor but, for me, half of the training was about the important personal journey, and I am happy to be a volunteer. All of these I weighed up before starting training, and again when I applied for a loan to pay for it.
I do not mean to criticise as I understand that the situation people are finding themselves in is very hard, but I do think people should remember to hold themselves accountable for their own careers. In this time of austerity our problems are not unique to counselling, and planning our careers, understanding our strengths and working hard to ensure we stand out amongst all job applicants have never been so important.
Alistair Hughes BACP student member
Working for free?
In response to Max Marnau’s letter ‘Still unpaid’ in the September issue of Therapy Today, whilst empathising with his plight in finding work, I find myself coming from a different perspective. Firstly, pursuing a qualification is not a passport or guarantee of landing a job. This is a common complaint and so perhaps before ‘spending thousands’ that one can ill-afford, one needs to explore the viability of work before embarking on a course. At the end of the day, people pursue courses and qualifications for all sorts of reasons. The only thing ‘promised’ is a qualification and this is just the first step towards getting a job.
The second point I wish to make is that while qualified counsellors are working in volunteer roles, they are making a choice and are part of and perpetuating the problem. I took a stance and chose to leave my counselling placement two years ago shortly after qualifying, determined to find paid work and that’s what I did. My second placement was designed purely for students who were expected to leave once they had completed their studies. I have a lot of respect for placements like that one, which prepare you for the next step, ie towards independence.
My third point, which also touches on James Wright’s views in ‘Supply and demand’ in the same issue, is that I don’t think it’s fair to blame BACP and educational establishments if we do not find work months or years later. There are clients out there who are willing to pay and some counsellors are doing very well whilst others flounder. Therapists need to nurture and spend time growing their practices and making constant efforts to generate new clients as well as becoming slicker with their marketing messages. Many therapists believe that they can sign up to a counselling directory and then sit back! In today’s competitive market, that simply isn’t enough. Counsellors would be well advised to review their skill set and fill the gaps. I’m not sure it is the responsibility of BACP or anyone else to provide this skill training, although BACP do host relevant events.
I don’t disagree with Max who is incredulous about counsellors being expected to work for free. I’m not convinced however, that this is the role of BACP. Placement organisers have their own agenda and many operate a service on limited funds; having access to a pool of qualified volunteer counsellors may suit their needs.
Finally, in response to James Wright’s closing comments about ‘areas... saturated with counsellors’ where the demand and ability to pay is simply not there, I have entered a saturated market where I live and that’s not my experience. I have found work at a busy clinic close to where I live and am building my own practice steadily and can see a strong correlation between my marketing efforts and my client numbers. I come from a commercial background, however, and so I know what I need to do and how to do it.
In terms of clients’ ability to pay, I am more inclined to say that this may be part of BACP’s role, ie to challenge the public’s perception who happily fork out for booze, cigarettes, the latest iPhone, holidays, beauty treatments and hairdressers without hesitation. Why not counselling? What price should we put on our emotional wellbeing? This is something I would be keen to see BACP tackle moving forwards. Indira Chima MBACP; MA. www.thecounsellinglivingroom.co.uk
What’s so great about a drum solo?
I read Julian Edge’s assessment of the film Whiplash with some fascination. He is, of course, absolutely correct. Why would we applaud a young man who abandons family and lovers, and an obsessive teacher who drives his pupils to destruction? And all for the sake of a drum solo.
And, oh boy, what a drum solo!
And it is here that Julian Edge reminds me of the health and safety officer who was persuaded by a documentary maker to visit Pamplona during the running of the bulls. ‘It’s fine to enjoy yourself,’ he said, ‘so long as you can do it safely.’ He did, of course, completely miss the point, and it was a point that he was never going to get. Just as, I suspect, Julian Edge cannot get the point of a particular drive for excellence: obsessive, destructive, egotistical, manic; and which those who are witness to the exploits of great musicians, sportsmen and artists of every sort will applaud until their hands bleed, because such individuals inspire us to experience something which otherwise lies beyond our imaginations and all too human limits. Those who are born or trained to such excellence often have no choice in the matter. Obsession is an inherent part of what they do and what drives them in life; even if the same drive may well bring them and those in their immediate orbit complete misery.
And, when all’s said and done, it’s a story, no more or less. And we pin all sorts of labels on stories, whether they be fact or fiction – including our own stories and those of our clients. We call them traumatic, inspiring, humdrum, tragic, depressing, banal, and exciting. By pinning labels on them we judge them according to personal hierarchies. We find one sort of story interesting; others less interesting. Some inspire us, others appal us.
And, yet, if I am to offer my clients (and, I might suggest, myself) the service that they (and I) deserve, I need to understand that stories do not stand or fall according to their content or my own predilections, but according to the manner in which they are told. Jane Austen’s novels are gloriously banal, and she tells them in a way which makes them anything but. So too, it seems to me that what I really need to offer my clients is the gift of becoming interested in their own stories, and learning how to tell them, to others and to themselves, in a way which allows them to value them. Furthermore, to value every aspect of their stories, including the ordinary and the extraordinary. And that includes clients who may have made decisions which have left a wake of destruction behind them, as well as those who have left a legacy of good deeds, as well also as those who have made no obvious mark on the world. I would hope that they can come to value their stories, not because they are right or wrong, important or otherwise, but simply because they are stories, well told, and therefore interesting.
William Johnston Person-centred counsellor in private practice Coverage of cutting edge science wanted
It would be good to see BACP offering scientific horizon scanning in its journal. Even if it is only a snapshot and brief outline signposting readers to the various blogs/websites, etc. Bringing to our attention the cutting edge advancements in science. One example would be the controversial biology- based diagnostics through neuroimaging and monitoring gene expression.1 This is going to radically change the way in which we treat and think about depression and other such mood disorders.
A test that identifies suicide ideation from blood test data and questions designed to identify suicidal feelings is advancing this area of research at the speed of light. We need to be informed.
The phenomenological is our area of expertise and just as Carl Rogers warned if we abandon this area; ‘the working models of reality that would emerge (in the course of theory building) would be increasingly removed from the reality perceived by the senses’.2
As counsellors, when we are in the room with a client, we see the delicate interplay between mind and body – I recently read that the activity of 11 genes seems to change if an individual is thinking about suicide.
I feel we hold a privileged position in seeing first-hand how our thinking and feeling selves can affect our mind and body systems, switching on and off the bio-markers that affect our epi-genetics.3
We owe it to our clients to be well informed and aware of how this new research will impact on our profession. There might even be scope for joint working or at the very least (Rogers’ warning) being a watchful guardian.
Jean Hinsley JH Counselling Services, Counsellor, psychotherapist, mediator and supervisor. Registered Member MBACP (Accred); MA Counselling; Advanced Mediator (Accred)
References: 1. Thomas I. Improving Diagnosis through Precision Medicine. US National Academy of Science & US National Institute of Mental Health (NIMH); 2014. http://www.nimh-gov/about/director/bio (accessed 7 October 2015). 2. Rogers CR. On becoming a person – a therapist’s view point of psychotherapy. London: Constable & Co Ltd; 1969 (p206). 3. Kaminsky Z. Epigenetic factors underlying mood disorders. John Hopkins University, Baltimore; 2013. http://www.hopkinsmedicine.org (accessed 7 October 2015).
Contact us We welcome your letters. Letters may be cut and edited at the Editor’s discretion. Those that are not published in the journal may be published on the Therapy Today website at TherapyToday.net. Please email the Editor, Sarah Browne, at [email protected] +++ Reviews
The critical psychotherapist
Critical psychotherapy, psychoanalysis and counselling: implications for practice Del Loewenthal (ed) Palgrave Macmillan, 2015, 309pp, £25.99, isbn 978- 1137460578
Reviewed by Jane Cooper
When I picked up this book, my first thought was: critical psychotherapy, what’s that? Doesn’t all psychotherapy by definition deconstruct and cause us to reflect? I quickly realised that what was true when I first became acquainted with psychotherapy in the 80s, is no longer true at all. As the talking therapies have become mainstream, our methods have been sanitised. What used to be a unique, confidential encounter has become outcome obsessed, pervasively audited, with confidentiality constantly risk assessed.
This timely book looks at this process in historical context and asks us to reflect on the way the state has come to influence our practice; for example, in promoting methods that take our minds off what is bothering us (p11) or reflecting back that we are the people we would like to be (p295). It is an edited collection with a wide range of valuable contributions from across Europe and North America, from critical psychiatry, neurobiology, queer theory, feminism, Marxism and users of talking therapies.
Surprisingly perhaps, with so many viewpoints, some useful common ground emerges; both the talking therapies and the current obsession with randomised control trials are seen as cultural practices appropriate to a political context, within which Loewenthal and colleagues trace the exercise of power. What has come to be seen in our neoliberal society as ‘common sense’ is, they argue, a smokescreen for the dominant biomedical ideology, which privileges notions of illness and cure and evidence-based treatment.
This book does not set up one modality against another, nor does it set up a new school of counselling, though systemic thinking is flagged up as helpful in redressing the balance of power. Just as a client may be silenced in a family, the critical psychotherapist is currently silenced in professional groupings.
So is there a need for critical psychotherapy? This book provides a convincing argument that if we want to protect the talking therapies from being used as a form of state control, there is. Whatever your modality, if you believe in the resources of the human soul, take a look at this book. You may, like me, be surprised at how the dominant ideology has subtly affected your practice. It is good to stop and reflect on what we are currently being invited to think is ‘common sense’.
Jane Cooper is a counsellor and supervisor The scope of supervision
Getting the most from supervision: a guide for counsellors and psychotherapists Alan Dunnett, Caroline Jesper, Máire O’Donnell and Kate Vallance, Palgrave Macmillan, 2013, 214pp, £22.99, isbn 978-0230348349
Reviewed by Frances Lampert
This book provides a clear, accessible and comprehensive overview of what it means to be a supervisee, taking a different approach to many other texts that focus on the perspective of the supervisor. It covers ethical and legal considerations, roles and responsibilities involved, process and potential content covered within supervision as well as the wider context for this unique relationship. However, the main emphasis of the book is on the centrality of emotional and relational dynamics, differences and challenges within supervision.
The authors go some way to replicating a supervisory relationship by introducing themselves, setting expectations and encouraging reflection throughout. Rather than being a passive recipient, the reader is invited to consider themes raised in relation to their own experiences with the help of prompts, questions, imaginary scenarios and extracts from supervision sessions. This engaging approach also helps to give a strong sense of the autonomy and power of the supervisee to influence the supervisory process.
This book is of primary use for trainees or newly qualified practitioners working in organisations, private practice or with EAPs, giving practical assistance on a wide variety of issues. This guidance ranges from when to ring the doorbell of a supervisor through to techniques to help develop an internal supervisor. It encompasses the managing of complex relational patterns within supervision, such as collusion, competition and unconscious parallel processes. The scope of the material included extends the reach of the book, and as a new supervisor (but more experienced supervisee) I enjoyed reading about the potential impact of different learning styles on the use of supervision as well as suggestions for creative methods in supervision. The chapter on ethics in supervision provides a helpful illustration for supervisees and supervisors alike on applying BACP ethical principles to differing issues.
As someone who uses both individual and peer group supervision, I would have liked to have seen a more extensive examination of the particular features of group supervision and also some examples on the use of group- based creative methods mentioned such as sculpting and fishbowl exercises.
At the end of the book I was left with a clear picture of the scope and complexity of supervision, its role and function; how vital this relationship is for practitioners, their clients and the profession, and how supervisees can take responsibility for getting professional needs met both in supervision and beyond.
Frances Lampert is a counsellor and supervisor
The importance of ‘living experience’
Psychodynamic psychotherapy with transactional analysis: theory and narration of a living experience Anna Emanuela Tangolo, Karnac Books, 2015, 192pp, £21.34, isbn 978- 1782201557
Reviewed by Ian Argent
In this book Italian therapist and trainer Tangolo draws from her wealth of experience of using transactional analysis (TA) in psychotherapy. The title frames things very well – rather than a dry theoretical text, the work and process of therapy are explored in a book where the ‘living experience’ is central.
The introduction and first two chapters provide a grounded and healthy start. Tangolo explores being a therapist; first generally, and then more specifically with TA. Bringing in ideas from philosophy and some creative image- metaphors, she begins to show us something of her style and way-of-being as a therapist.
In the following chapters, the author describes the first steps of therapeutic work; the setting (or therapeutic frame), the assessment, and then the contractual method that is a cornerstone of TA. I thought these aspects were considered in a way that would be particularly useful for a beginning practitioner.
Further on, the process of therapy is explored. Tangolo offers useful examples and case material to illustrate the use of TA concepts such as Decontamination and Script. The work is far from dry and theoretical, written in a gentle, accessible way that brings the ideas to life very easily. What also comes across is the depth or perhaps psychodynamic influence of her work, as she moves from decontamination work to the more analytic or transferential domain of Script Analysis.
Overall, this is a very reader-friendly book, well-rounded in content. Though the chapter on dreams seems to me a little out of place, there are relevant and interesting chapters on group therapy and healing/endings. I especially enjoyed the non-technical ‘living’ style in which material is presented. I think it would be a satisfying read for TA trainees at an intermediate or advanced level, as well as experienced practitioners.
Ian Argent is a transactional analysis psychotherapist in private practice Boarding school syndrome
Boarding school syndrome: the psychological trauma of the ‘privileged’ child Joy Schaverien, Routledge, 2015, 247pp, £27.99, isbn 978-0415690034
Reviewed by Catherine Jackson
Joy Schaverien, a Jungian psychoanalyst with an interest in art psychotherapy, adds to a very small body of literature with this case study of Theo, who was sent to boarding school from the age of eight and emerged aged 17 so well protected from his own and others’ emotions that he is incapable of a loving relationship with anyone. He goes into silent depressions for days on end, is seriously scared he will harm someone and is, not surprisingly, having serious marital problems. According to Schaverien, he is typical of those (mostly) men she describes as having ‘boarding school syndrome’.
Schaverien sets the context: the curiously and uniquely British upper- and middle-class habit of sending their young sons (and to a lesser extent daughters) away to school; the history of Britain’s public (independent charitable) schools – institutions where, for boys certainly, physical and sexual abuse and bullying were rife between masters and pupils and between pupils themselves; the psychological trauma of being suddenly, seemingly brutally rejected and abandoned by their parents, ejected from the family home and denied that sense of being loved and special that is so essential to the developing human psyche and sense of personhood. Shaverien’s use of art therapy techniques to help the adult Theo rescue the small, terrified boy within and bring him to safety is a fascinating process.
Whether ‘boarding school syndrome’ is a unique syndrome, or simply a sub- category of attachment trauma, is debatable. Any child who is deprived of its parents at an early age and subjected to bullying, emotional and physical deprivation and physical and sexual assault is going to suffer from severe trauma and consequent attachment disorders. Perhaps what makes it so distinct is that this abuse is committed under the badge of privilege.
I wish she had given more space to girls’ boarding school experiences. There is some interesting discussion of the effects of a boarding school upbringing on women’s relationships with their bodies and with food. But how does boarding school affect a woman’s own ability to mother? What are women’s emotional scars and how do they manifest in adult relationships? How do mothers themselves feel about handing over their children to the boarding school system? There is much material here for another book.
Catherine Jackson is a writer and editor specialising in mental health issues
Classic text on counselling ethics Standards and ethics for counselling in action (fourth edition) Tim Bond, Sage, 2015, 333pp, £29.99, isbn 978-1473913974
Reviewed by Angela Cooper
This fourth edition of this classic text continues to look at theoretical and practical aspects of counselling, but there are considerable changes. The main one is access to an interactive e-book, with extras such as counselling scenario videos, journal articles and author discussion videos. Other updates include chapters on Working with Social Diversity, Counselling in a Digital Age, and Being Accountable. There is also a very good section on ethical mindfulness.
In order to develop the theme of counsellor reflectiveness, the book opens with a review of counselling and the sources of counselling ethics. The next section explores responsibilities to the client, with issues including negligence, autonomy, competence and confidentiality. This is followed by chapters on responsibility to the counsellor and others (including colleagues and the community), supervision, record-keeping, and being accountable.
As is to be expected of Tim Bond, all the above are excellent, although I particularly like the section on counselling across differences in culture, with the overview on social history and development. Part IV begins with a section on ethical problem solving, providing a six-step process for counsellors to work through when facing an ethical dilemma. But it is the final section, Implications for Practice, which should be compulsory reading for all counsellors and a very sobering read it is too. Discussing the scandals in health and social care over the past 40 or so years (and the table listing these is shocking to read in its own right), Bond writes that the continuation of such scandals reflected a culture so caught up in protecting the reputation of its own service/profession/individual needs that client needs were seriously disregarded. Some of us, he writes, could find ourselves in very similar scandals.
It would be hard to say who this book is not suitable for. Trainees and experienced counsellors, trainers and supervisors will all find it invaluable. But the interactive e-book proved a frustrating disappointment. The contents are great when you can finally get into them but, reader beware, it can take considerably longer to download than the upbeat text suggests, and to date I am still unable to view the video clips. A message to the publishers – sort out the download and those videos!
Angela Cooper is a counsellor and supervisor in private practice
Listen carefully
Listen carefully and other tales from the therapy room Phil Lapworth, Karnac Books, 2014, 200pp, £9.99, isbn 978-1782202172 Reviewed by Nicola Strudley
I started reading Listen Carefully with a mixture of intrigue and trepidation. One of my favourite therapy books is Irvin Yalom’s Love’s Executioner, a collection of short stories about work with fictional clients and I did not want to compare Lapworth’s book with this all-time classic. I need not have worried as Listen Carefully brought something entirely different to the genre, making me consider my own therapeutic approach and ethical boundaries.
The book is made up of 10 short stories from a fictional therapist called Michael Martin. The stories are written in a deliberately provocative way that forces the reader (assuming they are a counsellor or therapist) to consider what they would do in such a situation. There were a couple of occasions that I noticed my stomach flip and churn when faced with an ethical dilemma, wondering how Martin would cope and what I would do.
I enjoyed the chapter about Martin’s supervision where the supervisor asked him to describe the client as an animal, spending the rest of the session unpacking this analogy. Another chapter took the form of a letter to a mature student about to embark on psychotherapeutic training, enabling Martin to rant about aspects of psychological theory and practice. A dream was also used at some stage. Using these different ways of exploring the material kept the book interesting and fresh.
In the introduction it mentioned that the final chapter provided a series of questions for reflection, but I decided to read each of the stories first before taking up this opportunity. This would be an excellent book to generate debate in a peer supervision group and I found the recommended reading list useful.
On a number of occasions I found myself questioning the approach Martin used. However, whilst not necessarily agreeing, I came to better understand why he had chosen to say or do what he did as I read further. The golden thread of this book is that there is no right or wrong way to work therapeutically. ‘Each unique dyad will find its own way to be together for the benefit of the client’ (p149).
Therapy is so individual how can we ensure that we are good enough? How considered are the responses we make? This is a great book to provoke professional self-examination and consideration of ethical issues.
Nicola Strudley is a psychotherapist in private practice
Psychogeography
Walking inside out: contemporary British psychogeography Tina Richardson (ed), Rowman & Littlefield International, 2015, 262pp, £24.99, isbn 978-0230348349
Reviewed by Chris Rose Psychogeography, it seems, is difficult if not impossible to define. The ingredients include: a critical appreciation of the environment and the inherent power structures that shape it; random and chance explorations, mainly walking mindfully; playfulness, spontaneity, creativity; an interest in social, political, cultural histories and memories. Academic and/or non-academic, it sprawls across traditional boundaries of subject matter in a way that I find delightful; I loved this book for its diversity, quirkiness, and thoughtfulness, but how does it relate to psychotherapy?
It is the internal psycho-social landscape that links psychogeography with psychotherapy: we are shaped by our physical and social contexts. Where and how we live, our sense of place and belonging are all bound into our relationships with others, and make us who we are. The environment, as Alexander Bridger points out, is not simply a backdrop; it is woven into us. As one of the contributors to this lively collection edited by Tina Richardson, he promotes a walking based methodology that seeks to grasp the subjective experience of self-in-place. A ‘critical psychologist’, his themes are surveillance, privatisation, social control and consumerism. Psychogeography underlines that our physical environments are shaped by politics.
‘Walking and playing should not be radical, but they can become so in a city designed for commerce and speed’ (p149). So writes Morag Rose, describing the Loiterers Resistance Movement, a group that attracts 800 participants each year to engage spontaneously, playfully but thoughtfully with the environment. Challenging the dominant masculine language and practice of psychogeography, Rose states:
‘Bodies are both materially and socially constructed... constantly (re)configured in relation to their environment. The act of walking lays this bare and emphasises the embodied and gendered nature of experience’ (pp159-60).
Gareth Rees walks through Hastings and describes the memorial benches, constructing fictional anecdotes about those named, and pondering the death of a friend. Free association is never far away from psychogeography, it seems to me.
Andrea Capstick works with and writes about those with dementia, who often retain accurate maps of locations and people from the past. Capstick, in her thought-provoking chapter, links the spatio-temporal destruction of dementia with the destruction of the physical environment – buildings pulled down, roads widened, gentrification, new shopping malls, etc.
‘[T]hinking psychogeographically, dementia can be decentred from its assumed location within the individual brain, out into a shared social environment’ (p223). There is so much more in this collection; historical analyses and contemporary theorising, smell-walks, walking the dog, – it is rich, witty, thought provoking. For any therapist who embraces a social constructionist view of the self, it is a wonderful read!
Chris Rose is a group psychotherapist, writer and Therapy Today Reviews Editor
Witnessing a life story in motion
Set in a car speeding along a motorway, the film Locke (available on DVD) is a stripped-down nocturnal journey into a man’s existential crisis
Ivan Locke (Tom Hardy, pictured) is a married man, a construction engineer who values solidity, dependability and duty above all else. His sense of self is shaped around doing the right thing, being in control of his life.
Professionally, Ivan is responsible for coordinating the pouring of thousands of tons of concrete into the foundations of a multi-million pound new sky- scraper. Tonight, however, life is very different as he drives away from old responsibilities towards a new responsibility. As we accompany Ivan along a seemingly routine motorway journey, cracks are emerging in his existence. Rather than driving home to a football match, required family bonding time with his teenage sons, Ivan explains to his wife that he is driving to the birth of a child, the result of a one-night stand with a woman he met on a work trip.
Concrete is a figurative and literal presence in the film: Ivan’s once solid life crumbles away as he attempts to be an ‘honourable’ man. Locke’s dramatic tension rests on Ivan’s awareness of what is required of him by others while seemingly unaware of what he really wants to do. As a man who can potentially drive wherever he wants, his sense of agency is based upon what he thinks is expected of him by others as well as a reaction against his father’s abandonment earlier in life. In this context, Locke offers a compassionate exploration of male duty without heavy-handed judgment. It is a valuable exploration of traditional male roles of provider and protector bound up by emotional confinement.
Overall Locke is a sophisticated and unusual art film, a character-study rich in atmosphere and strong in plot. Hardy’s performance is adept. He physically and sensitively captures the contradictions of a man with a complex range of feelings he will not permit himself to own. Denial and distortion of feelings serve as back-seat drivers amongst the furious and numerous monologues Ivan directs towards his absent father as he speeds towards his own impending fatherhood.
Stepping into Ivan’s car-world has echoes for me of the therapeutic hour: I felt immersed in witnessing his emotional life in motion. We hear Locke’s voice, and engage with his narrative and emotional expression while never physically meeting other key figures in his life. Watching the film, I could imagine Ivan, the man always in control, walking into a first therapy session meticulously explaining his life story and then calmly saying with tears in his eyes, ‘I don’t know why I’m here.’
Rachael Peacock is a trainee person-centred psychotherapist
Locke (2013, Lionsgate, 85 minutes) is directed by Stephen Knight and stars Tom Hardy, Ruth Wilson and Olivia Colman
If you would like to review a book that has influenced your development as a counsellor or psychotherapist, or a new film, concert, exhibition or event that you think has special resonance for counsellors and psychotherapists, please email Chris Rose at [email protected] +++ From the Chair
BACP is building relationships with other professional bodies, writes Andrew Reeves
The psychological therapies have always attended to the nature and form of the relationship between the ‘helper’ and the person (or group, or community) being helped. That is not to detract from the particular ways in which that relationship has been conceptualised and explained, and the techniques and aspects employed within that relationship to help facilitate change – the different modalities – but they would all fall down without the relationship. I am, of course, very aware that there are some who argue the relationship to be a secondary factor in therapy, and some again that the relationship is entirely irrelevant. Interesting opinions indeed, and ones very different from my own. For me, arguing that the relationship has no significance in the process of counselling is like asserting that the sun has no part to play in the rhythm of life.
Over the years I, like many, have watched professional organisations, including BACP, invest energy into points of disagreement with others rather than commonality. There have been many explanations for this and it is, in all honesty, hard to really pinpoint why this has been the case. However, the core fact remains that, at their heart, all the major professional organisations are entirely committed to the same thing: the safest, most effective evidence- based practice, so that clients can be helped to achieve what they need to achieve; and that clients have choice about how they do that.
It is in that context therefore, that I am beyond delighted to announce a working collaboration between three of those organisations: the United Kingdom Council for Psychotherapy (UKCP), the British Psychoanalytic Council (BPC), and BACP. Each organisation will retain its separateness and individuality, but will also strive to work across common goals and to represent the psychological therapies with a shared, and therefore stronger voice. For example, and as outlined in the recently launched Statement of Intent, areas of potential collaboration include: public protection and regulation; promoting standards of training and research; increasing accessibility to counselling and psychotherapy for all who would benefit from them; developing the evidence-base for what we do; and advocating for adequate funding for mental health.
These are critical areas of practice that I know are important to many of our membership. While the three organisations have independently worked on these initiatives for many years, I believe that by creating this platform from which we can embark on shared undertakings, we might be able to exert greater influence with more concrete outcomes. These outcomes, in turn, have the potential to facilitate change in the profession and, ultimately, for our clients. This feels to be a very exciting time. Such a collaborative initiative has coincided with our own strategic review, which has provided us all with a great opportunity to ask big questions of our Association. Every comment and every email have been read and considered and I am delighted that this is now being nuanced into a new strategic direction: more of that to follow.
In the meantime, however, I hope you will join me in welcoming our new working relationship with UKCP and BPC. Are we out of the woods? No. Is there more to do? Certainly. However, through the good work of many people behind the scenes over a long period of time across all of the organisations, I genuinely hope that we will build on this starting point. Do have a look at our Statement of Intent (ow.ly/SVJ2o) and video (youtu.be/IVJRwk7z9wc), in which I and the Chairs of UKCP and BPC talk about this collaboration. And I would always be delighted to hear your views and thoughts about this and where it might take us in the future.
Officers of the Association
Chair Andrew Reeves
Deputy Chair Elspeth Schwenk
Chief Executive Hadyn Williams
President Michael Shooter
Vice Presidents Sue Bailey John Battle Robert Burgess Bob Grove Kim Hollis Lynne Jones Martin Knapp Juliet Lyon Glenys Parry Julia Samuel Pamela Stephenson Connolly +++ BACP News
UKCP, BPC and BACP: working collaboratively
This month sees the launch of an official collaboration between UKCP, BPC and BACP. Sarah Browne interviewed the Chairs of each organisation on why this has come about and what they hope the benefits will be
Sarah Browne: Andrew, could you explain what it is you are announcing today?
Andrew Reeves (BACP): We are announcing a collaboration between our three organisations. For many years we’ve worked together informally in different areas and I think we are moving to a point where we need to formalise that a little bit; keeping our distinct identities, but identifying the common themes that we really do need to address. It feels like a very exciting step forward for a profession that is really starting to gain maturity.
Julian Lousada (BPC): I think what links our three organisations is the question of how you help a profession emerge and how it plays its part in the provision of services to the mentally distressed. I think one of the things that we are all very aware of is how important it is to have a range of responses to that distress. So we will be looking for ways that we can enter the contemporary discourse around mental health.
Sarah: How will the organisations collaborate and how will they remain distinct?
Julian: This is a profession where there are all these modalities, but we share a discipline. We are all concerned with the quality of what our members deliver. Even though we might do the work slightly differently, we must convince the public and people who make policy that we are credible, disciplined and that we deliver a service that is essential. Mental health policy, let alone practice, is highly contested. I think our collective voice is likely to be more powerful than our individual one.
Janet Weisz (UKCP): I think that our organisations do have distinct identities. They have evolved differently, and therefore the identity of each organisation will remain and I think needs to be nurtured. The robustness of the three organisations and their diversity will be beneficial to the public and to the delivery of services.
Andrew: There is something very important in the distinctiveness of the organisations; because there isn’t a one-size-fits-all. People are individuals with their individual distress and their individual experience. We all have an important contribution to make and I think what we can do is contribute to a culture whereby clients and patients have choice about what it is they access and how they access it. For me that is crucially important.
Sarah: Andrew how do you think that the organisations working together will help potential clients?
Andrew: In a whole range of ways. Whether it’s around professional standards, accountability, ethics, conduct, what we will do is further the work that we’ve done individually to create a robust profession that clients and key stakeholders, such as the NHS or third sector, can trust in. Fundamentally, for our clients or patients it’s about being able to access a therapist absolutely trusting what they do and why they do it.
Julian: I agree that I think clients will benefit by knowing that they will be able to access a therapist from a group of organisations where there is a robustness from the training that they have gone through and in their ongoing professional development. I think that that will be very important for the clients to know.
Sarah: Can we talk about where you all think the profession will be in 10 years’ time? Perhaps I can start with you, Julian?
Julian: Well that’s a very difficult question. I suppose ‘where’ might mean where the profession is located – is it in the private or the public sector. I think all of us would argue that it needs to be in both but it’s increasingly being pushed into the private sector. There are problems with that in terms of access for a whole range of clients. So if you ask where we will be in the future, my view is that, together we can press home that debate and really influence policy, which frankly we’ve not done very well in my judgment. It’s not that we’ve had no successes, but we need to be more robust in being clear about what sorts of policies we think are appropriate and where we can contribute.
Janet: I would like mental health to have absolute parity with physical health. I had a personal example recently where I was unwell and ended up in casualty. Every part of my body was checked, except for my mind. How did the doctors know that this wasn’t something psychological rather than physical? So that’s a small example of where I’d like the profession to be in five years, not 10 years, and I think the collaboration between our three organisations will give us a much stronger voice to go out there and say that mental health is as important as physical health.
Andrew: You can reverse the question and say where might we be in 10 years’ time if we weren’t collaborating? And I think at best we would be in disarray and at worst that we might be pushed more and more into the margins. Picking up on the parity of esteem that Janet raised, I think it is absolutely fundamental that we all recognise that our emotional wellbeing is as crucial as our physical wellbeing. I find that when I ask clients how they take care of their emotional health, they look at me blankly but if I ask about their physical health they’ll reel off a host of things that they either do or don’t do. And that’s a cultural shift that needs to change. Counselling and psychotherapy have an enormous contribution to make, which at the moment, I don’t think we do to best effect.
Julian: I think Janet puts her finger on a strong argument which is about the health economy; if you think about the price to the NHS of medically unexplained symptoms, it is enormous and everybody knows that these patients are presenting to A&E or to hospitals with very serious symptoms that have no physical explanation. There’s clearly a substantial psychological dimension. We know in terms of the number of people presenting at GP surgeries, the cost is enormous. If psychologically minded people could actually work with these patients, all sorts of benefits would accrue.
Sarah: So if there was one major change that could come from this collaboration what would that be?
Janet: I think for me it’s got to be about improving access to and choice of therapy in primary care. I also think that we should be educating people about their emotional health and surely that should be in schools.
Julian: One of the things that I hope will happen is that people trust the integrity of our endeavour. I would hope that all of our members have a look and say gosh, here’s an organisation, with various parts that we would want to get more active in.
Andrew: For me it would be about how treatment guidelines are developed and how evidence is used. I would like to see us develop even more sophistication about evidence, what that evidence means, how it is conceptualised and its relationship with the development of treatment guidelines. I think that we need to be seen to be professionals who are developing practice-based evidence and evidence-based practice informed by client voice and client experience.
Sarah: In a way it’s a moral choice I think, isn’t it, to collaborate and to do the best that you can for the public and for people suffering from mental health problems?
Andrew: It’s a moral and ethical imperative, actually. We can talk about whether we should or shouldn’t, or whether we have a choice to collaborate – for me there is no choice here – this is what we have to do, not for our own gain, but this is about promoting and supporting something that actually saves people’s lives.
Julian: We all keep saying we agree and we do. But I do think we are swimming against the tide. People talk very easily about a relational world and that’s what we all stand for, but actually what makes somebody feel better about themselves is the quality of their relationships. We live in a world which is increasingly fragmented, where the glue of family and social life is much less gluey than it was.
Sarah: So what do you think are some of the specific challenges that the profession is facing at the moment? Janet?
Janet: I think some of the challenges are around the reduction in services both in primary and secondary care – I think alongside that with an increase in awareness of mental health and ill health, to have a reduction in services creates a deep imbalance. We know that people struggle and suffer with mental health issues and I think that there is a long way to go in improving access, waiting times, the choice of therapies and to the different client groups.
Julian: I think one of the big challenges is that we have a reputation for being dominated by middle-class issues and I think we haven’t done enough to change this. We haven’t done enough to show that we understand that there is a mental health consequence to different types of lived experience. So we have a lot of work to do to demonstrate that we are relevant to people from all walks of life with all sorts of issues.
Andrew: The reduction of mental health services in the statutory sector, in the health service, puts greater pressure on the voluntary sector. Organisations delivering really high-quality services, but with even less funding, are being squeezed and closed down. If I want therapy I might not choose to do that through my GP or through a health service, I might want to do that through an organisation that is much more embedded in my community and understands me as an individual. I think this contributes to a culture where our mental health or our emotional health is kind of dispensable so that’s a real challenge and a real problem that we have to grapple with.
Julian: Can I just emphasise that point because we live in a moment where there is a sort of rhetoric about wellbeing and mindfulness and happiness and so on but at precisely the time when all the services that Andrew has just been describing are losing their funding. Now that is a real problem and it’s the sort of problem that breeds cynicism [which] further undermines people’s confidence that politicians mean what they say that they are going to invest in parity of esteem when it’s manifestly clear they are not doing so.
Janet: And just as a slight tangent to that, but not dissimilar, there may be people who will choose to want to access psychotherapy or counselling in the private sector but they’re being offered antidepressants as the ‘treatment of choice’. They may take that instead of thinking about whether some form of counselling or therapy would benefit them, as much, maybe more so. So I think it’s the medicalisation and the antidepressant culture that has grown.
Sarah: Thank you all and I’m sure these debates will continue. Julian Lousada is immediate past Chair of BPC. Helen Morgan is the new Chair of BPC.
To read our Statement of Intent go to ow.ly/SVJ2o and visit youtu.be/IVJRwk7z9wc to watch our short video. This interview is an edited version of a podcast available at youtu.be/-D9iqQaLhR0
BACP AGM on 7 November
We look forward to meeting you at BACP’s 39th Annual General Meeting, which is taking place on Saturday 7 November at 4.30 pm at the Royal Hotel York, YO24 1AA.
With this issue of Therapy Today you will receive eight inserts from BACP: a covering letter, the AGM agenda, a proxy/postal voting form, the minutes of the 2014 meeting, two versions of the Standing Orders (one showing the updates), the financial statements, and an agreement and consent form if you wish to receive an electronic version of these papers in future. Please make sure that you return this freepost consent form to us and also your voting form if you wish to vote by proxy or by post.
New Private Practice Chair
James Rye has stepped down as Chair of BACP Private Practice after a two- year period. James says that he has enjoyed the experience, particularly meeting members and working with a talented Executive Committee.
His successor is Susan Utting-Simon, who has been on the Committee since the end of 2011 and became joint Deputy Chair at the end of 2013.
To learn more about the BACP Private Practice Executive Committee, visit bacppp.org.uk/committee
‘Marketing your service’ event in Southampton
Running a successful private practice can be a rewarding experience for many therapists, offering flexibility and opportunities to develop a portfolio of work. A recent BACP survey found that one of the main challenges faced by private practitioners is effective marketing to attract new clients.
BACP is holding an event called ‘Setting up in private practice: marketing your service’ on Wednesday 18 November at the Holiday Inn Southampton. This event has been designed to help you to identify ways to promote and market your practice in a cost-effective way. It will enable you to plan the implementation of a marketing strategy using a variety of traditional and technology-based tools, and develop marketing messages personalised for your prospective client base.
To register your interest and receive updates on the programme, please email [email protected]
Making Connections
Making Connections are free events giving BACP members an opportunity to network locally, hear about new developments in counselling provision and clinical practice, and meet BACP staff.
In 2016 Making Connections will be in Brighton on 25 February and Middlesbrough on 16 March. Programme details need to be finalised but you can book a place now at www.bacp.co.uk/events
Good practice resources
Four Good Practice in Action resources have now been published in respect of supervision, and also a research overview on ethical decision making. Members can download these new resources from www.bacp.co.uk/ethics/newGPG.php
Further guidance will be available shortly covering online working, legal resources on the subject of safeguarding adults and children, and sector resources regarding private practice and workplace.
If you would like to join one of the focus groups involved in reviewing and giving feedback about new resources, please email [email protected]
Private practice event a success
On 19 September over 1,000 members attended the BACP Private Practice conference, ‘Trauma: the challenge of our age?’, either in person at the Holiday Inn Bloomsbury in London, or by watching online via a live webcast.
The conference looked at trauma from a number of perspectives with the opening keynote by former BBC correspondent, and now transpersonal psychotherapist, Mark Brayne, who explored the implications of modern media on the human psyche.
A selection of workshops followed covering topics such as transgenerational trauma, trauma and dissociative disorder, working with major trauma, and self-care for the therapist in the face of trauma. The conference closed with a keynote by Canon David Wilbraham, Chaplain to Thames Valley Police, who explored the role that faith, belief and spirituality play in the response to traumatic incidents for both individuals and communities. Initial feedback from delegates, at the venue and online, was that the day was a success. Delegates also had the opportunity to watch a recording of the event again via our online on-demand service.
If you would like to learn more about BACP Private Practice, and for details about how to become a divisional member for £20, visit bacppp.org.uk, call 01455 883300 or email [email protected]
Survey prize winners
Membership prizes of a year’s free membership have been awarded to Julia Duffin and the Birmingham Youth Empowerment Project after completing the BACP strategy survey – congratulations. +++ BACP Public Affairs
Around the Parliaments
This period saw the election of two new Labour leaders: Jeremy Corbyn MP was elected Leader of the Labour Party. Mr Corbyn was joined by Tom Watson MP as Deputy Leader.
Forming his first Shadow Cabinet, Jeremy Corbyn appointed Heidi Alexander MP to the post of Shadow Secretary of State for Health and Luciana Berger MP took the role of Shadow Minister for Mental Health (a post dedicated to mental health for the first time). Luciana Berger will also attend the Shadow Cabinet, hopefully an indication of the importance the new Labour leadership places on mental health.
It looks promising too, with Jeremy Corbyn choosing to raise the subject of mental health when he went head-to-head with David Cameron for the first time at Prime Minister’s Questions (PMQs). Challenging the Prime Minister, Mr Corbyn asked: ‘I received over 1,000 questions on the situation facing our mental health services and people who suffer from mental health conditions. This is a very serious situation across the whole country and I want to put to the Prime Minister a question that was put to me very simply from Gail: “Do you think it is acceptable that the mental health services in this country are on their knees at the present time?”’
Labour have a new Leader north of the border too, with Kezia Dugdale MSP elected Leader of the Scottish Labour Party. Ms Dugdale succeeded former MP Jim Murphy, who resigned in June after Labour lost 40 of its 41 Scottish seats at Westminster. Despite the heavy defeat suffered by Labour in the Westminster elections, Ms Dugdale has chosen to stay loyal to her Shadow Cabinet colleagues in the run-up to the Scottish Parliamentary elections next May. She has retained Jenny Marra and Iain Gray in the key roles of health and education however, their remits have been expanded and their job titles rebranded to reflect Labour values – equality and opportunity.
Staying in Scotland, on 1 September the SNP Government set out its Programme for Government outlining the policies, actions and legislation to be taken forward in 2015-16. Within the Programme for Government, the SNP committed to: Further improve child and adolescent mental health services and bring down waiting times. Improve access to services and in particular psychological therapies. Respond better to mental health needs in community and primary care settings.
We are writing as Party Conference season begins, with BACP represented at the Conservative Party, Liberal Democrat and Labour Party conferences. In addition, for the first time, BACP will be represented at the Scottish National Party conference in Aberdeen, where we will be hosting a fringe event on the subject of children’s mental health.
Consultation round up
An integral part of BACP’s lobbying strategy, consultations are an effective way of the Association communicating its views on a wide range of issues with governments, parliaments and non-political organisations.
Since the UK General Election in May, BACP has been busy responding to consultations and has recently submitted a response to the Department for Work and Pensions’ call for evidence into the Impact on Employment Outcomes of Drug or Alcohol Addiction and Obesity.
BACP took the opportunity to emphasise that psychological therapies offered to those with long-term conditions need to be wide ranging, open ended and age appropriate as well as being made available in a range of settings. Additionally, it was stressed that services should be non-stigmatising, financially and physically accessible, flexible, equitable, timely and considerate of a diverse range of needs.
BACP also reiterated that counselling and psychotherapy should not be imposed upon any individual and must remain a choice which is freely entered into. Additionally, all clients should be offered a choice of evidence-based therapies as well as a choice of therapist.
If you wish to get involved in contributing to BACP’s consultation responses, please email the Public Affairs department at [email protected]
Who’s who in Labour’s new health team?
The Labour Party have announced their new Shadow Health team with a position devoted entirely to mental health. The new Shadow Secretary of State for Health, Heidi Alexander MP, will work with Luciana Berger MP in a new role of Shadow Minister for Mental Health.
Heidi Alexander, MP for Lewisham East since 2010, has been brought into the high-profile role having been Deputy Shadow Minister for London from 2013-2015. Before coming into politics the Shadow Minister held positions as Councillor in Lewisham, Deputy Mayor of Lewisham Council before going on to become Vice-President of the Local Government Association.
Her colleague Luciana Berger, holding responsibility for mental health, was previously Shadow Public Health Minister under Ed Miliband’s leadership before being promoted to Jeremy Corbyn’s Shadow Cabinet. Ms Berger, MP for Liverpool Wavertree since 2010, met with BACP during the last Parliament and in December supported a BACP-hosted event in the House of Commons, when we launched a report on parity of esteem and psychological therapies. BACP have written to Ms Alexander and Ms Berger welcoming them to their new roles.
Mental Health Taskforce reports
The Mental Health Taskforce, which brings together health and care leaders, service users and experts in the field, published evidence this month, ahead of its strategy which will be published in autumn 2015.
Formed in March 2015, the Mental Health Taskforce, chaired by Mind CEO Paul Farmer, has been asked to develop a new five-year national strategy for mental health. The strategy will cover care and support for all ages.
This will be the first time there has been a strategic approach to improving mental health outcomes for people of all ages in the health and care system. National bodies will work together until 2021 to help people have good mental health and make sure they can access a range of evidence-based treatment rapidly when they need it.
The evidence published by the taskforce in September was collated through survey responses, written submissions from organisations and individuals, formal meetings and engagement events. It has revealed the top priorities of respondents towards mental health services which include prevention, access and choice of treatment. Furthermore, respondents noted a wish for quicker and timelier access to talking therapies with reduced waiting times.
For further information about the Mental Health Taskforce and how to get involved, please visit www.england.nhs.uk/mentalhealth/taskforce +++ BACP Professional Standards
Newly accredited counsellors/psychotherapists
Carolyn Adair Andrea Andrews Shirley Arnott Nicola Atkins Suzanne Barrett Latoya Boyer Margery Browning Jo Burman Lorna Carroll Ailsa Clark Justin Clark Claire Collins Short Ana Cox Annalaura Dallavalle Jillian Dighton Rebecca Downes Joy Duncan Sara Fairfax Maxine Freshwater Paul Galbally Miriam Gehler Carolyn Gillan Paul Gould Ben Gross Paul Howes Simon Howes Matt Ingrams Ann Jinks Hulya Kusella Ruth Laband Helen Leach Wendy Longstaff Sheena McAuley Loraine McDonald Charlie McKenzie Amber Middlemiss Ashley Millar Perrine Moran Finella Morris Amanda Morton Christopher Moseley Paul Murphy Claire Oakeley Nina O’Shea Geraldine Painter Sally Pendreigh Dominic Quigley Brian Rock Rosemary Rooney Nina Saunders Kelly Scott Michael Sims Chris Smith Christine Sparvell Vivienne Sutton Hedi Threlfall Carolyn Turner Guy Westoby Louise White Nicky Wilson Mandy Wright
Newly senior accredited supervisors of individuals
Sarah Briggs Jayne Ritchie
Newly senior accredited counsellors/psychotherapists
Eva Campos-Formoso Correna Dcaccia Claire Ede Adele Murphy
Organisation with new/renewed service accreditation
WAVE Trauma Centre
For a full list of current accredited services, please visit the service accreditation webpages
Members not renewing accreditation
Geoffrey Ahern Carol Andrews Gillian Arens Maureen Ashley Rosemary Bardelle-Carrier Anita Bartys Valerie Bell Lynn Bergin Judith Brech Virginia Bruno Noel Cahill Laura Cain Sue Canon Marion Casey Hilary Clayton Sue Cottrell Hilary Day Urmila Desai Debra Doggrell Lizzie Dyche Irene Evans Morag Faris Mercedes Fonfria Valerie Garrett Pamela Giles Cheryl Griffith Phoebe Hampton Barbara Hart Kate Hawkins Ann-Michele Hinton Barbara Howell John Jackson-Okolo Judith James Diana Jerman Marlies Kisch Anne Lindsey Meg Logan Claire Martin Wendy Mayle Margaret McKinnon Ian Mogford Cholena Mountain William Murray Tessa Nixon Jean Norris Robert Owen Soledad Poseck Michael Saunders Janet Simmonds Margaret Stevens Gwendoline Warner Penelope Wright
Member whose accreditation has been reinstated Melanie Jo Hopkins-Womble
The above details apply for 1–31 August 2015 and are correct at the time of going to print. +++ BACP Research
Update on PhD research
Unlike psychological services in the NHS, counselling services embedded in further and higher education (FE/HE) face additional challenges of showing effectiveness in a shorter period of time, and with clients whose location is often fleeting. Students only have access to counselling services during their studies and their mental health can have a substantial impact on their academic ability. This is a unique issue which not only requires support from embedded counsellors who are experienced in this context, but also those willing to be responsive to the contemporary student demographic.
This has been recognised by BACP, which is funding a PhD at the University of Sheffield. Doctoral work is being undertaken by Emma Broglia and supervised by Professor Michael Barkham and Dr Abigail Millings. The research aims to inform the design of a randomised controlled trial (RCT) exploring the impact of embedded student counselling on clinical, academic and institutional outcomes. In doing so, Emma’s PhD will produce the initial pilot and feasibility work to prepare for the full RCT.
With the first year nearing completion, the feasibility trial is taking form and is due to commence in February 2016. The design of the trial has been informed by: a scoping review of scientific literature; a survey evaluation of embedded counselling services; telephone interviews with heads of service; a multi-site randomised pilot study of clinical outcome measures; and various engagements with the university and college counselling sector and the newly formed practice research network. The trial will consist of three conditions: 1. counselling as standard practice (control); 2. counselling with technology assisted feedback (intervention); and 3. condition 2 with integrated feedback with clinical measures.
Feasibility work will take place across two university counselling centres for a 12-month period with a qualitative sub-study exploring client and counsellor experience.
Final call for papers
The deadline for abstract submissions to our 2016 Annual Research Conference is Friday 6 November 2015. The conference will be held in the vibrant city of Brighton on 20–21 May 2016, with keynote presentations by Professor Mick Cooper (University of Roehampton) and Professor Kenneth N Levy (Pennsylvania State University, USA).
The event will be co-hosted by the Society for Psychotherapy Research (SPR) UK Chapter and we expect to welcome over 250 delegates over the two days, including international visitors. For more information on how to submit an abstract, please visit www.bacp.co.uk/research/events
Research enquiry of the month: how counselling helps teenagers
This month’s enquiry –‘How can counselling help young people aged 13 to 19?’ – is very timely given the recent report by The Children’s Society about the happiness of children in the UK, and the recommendation of a counsellor in every school becoming a legal requirement.1 We searched our internal abstract database and Google Scholar with the search terms ‘counselling’ AND ‘young people’ OR ‘ages 13-19’, which generated a wealth of resources.
Cooper et al investigated the ‘effectiveness of school-based counselling: using data from controlled trials to ascertain improvement over non- intervention change.’2 Statistical analyses were used to calculate an ‘estimated intervention effect’ (EIE) for the YP CORE scores of individuals in the ‘non-intervention outcome’ group (waiting list control conditions) and ‘actual outcome’ (receiving school-based counselling). A mean EIE was calculated for 256 young people, which showed that counselling was associated with large and significantly greater change than would be expected without the intervention.
In another notable study, how school-based counselling impacts young people’s capacity to study and learn was explored, using a mixed research methods approach.3 Twenty-one young individuals who had previously received school-based counselling were interviewed and completed a brief rating scale. Findings revealed that counselling positively impacted on young people’s academic achievement by improving concentration, behaviour in class, relationships with teachers and motivation to study and attend school.
These findings add to the growing body of literature on the effectiveness of school-based counselling, including young people’s goals and the benefits on young people’s capacity and motivation to study and learn.
If you have a research enquiry, please email the BACP Research department at [email protected]
References
1. The Children’s Society. Children in England among the unhappiest in the world with school. http://www.childrenssociety.org.uk/news-and-blogs/press- releases/children-in-england-among-the-unhappiest-in-the-world-with-school (accessed 18 September 2015). 2. Cooper M, Fugard AJB, Pybis J, McArthur K, Pearce P. Estimating effectiveness of school-based counselling: Using data from controlled trials to predict improvement over non-intervention change. Counselling and Psychotherapy Research. 2015. DOI: 10.1002/capr.12017. 3. Rupani R, Haughey N, Cooper M. The impact of school-based counselling on young people’s capacity to study and learn. British Journal of Guidance & Counselling. 2012; 40(5): 499-514 +++ Behind the pictures
Philip Moran describes what inspired his illustrations in the October issue
Do you consider yourself to have a trademark style? If so, how would you describe it?
I don’t really have one signature style, but I like to think that people could recognise my work. I try to be expressive and dynamic when I draw and paint and I like using different media so I’m quite versatile. Sometimes I use a lot of colour, sometimes black and white, and I can be abstract or more realistic. I think if I kept to one style all the time I would just get bored and the work would go stale. At the moment though I work a lot with ink.
How would you describe the creative process you go through when working on your illustrations? Does it vary?
I would describe my process as involving searching and problem-solving. Every project has different requirements and you have to adapt to each one. I like to think it’s a bit like science: you theorise, research, experiment a bit, discard ideas and refine one until you finally get to your solution. Sometimes I get stuck with conveying an idea and the solution won’t come to me right away, but I try not to get anxious and an idea generally does come after a while. Unlike science, there’s no real right or wrong (unless you’re talking about quantum physics). I also do portraiture and that can be more like a journey of discovery, because I don’t know what the piece will look like until it’s done.
How do you come up with your ideas and what inspires you?
I have quite a vivid imagination, so ideas and imagery come to me straight away. Whether they’re any good or suitable is another thing! I’ll free associate and then start researching. I always try to stay open to new possibilities as I go along. I’m really inspired by experimentation and I also take a lot of inspiration from the art world and powerful artists like Rembrandt, Edvard Munch and Vincent van Gogh.
While working on your Therapy Today illustrations, did the ideas develop gradually or did you know from the outset the direction you were going in?
The ideas did develop gradually from different possibilities. As I read through the articles I wrote down different concepts and images, and then I tried to imagine what could work. For example, with the article on interpreters, one quote that struck me was the idea of building bridges. Can you describe what inspired your Therapy Today illustrations?
I wanted the images to be interesting and powerful, but still understandable. I found the stories very moving and the most important thing to me was to convey the feelings involved.
Can you describe in a nutshell what you were trying to convey with each image?
The cover image about refugees was inspired by the story of a Syrian woman in therapy knitting in silence. I wanted to link the idea of knitting with a refugee family that have no connection with their new home, which is why you can see the knitting next to the family symbolising their bond, but the edges beyond them are frayed.
The adoption illustration was actually inspired by the triangular road sign that shows an adult holding a child’s hand. I thought that people can resemble silhouettes when placed against the sun, so I added a sunset and used their shadows to show an image of the daughter when she was angry. It was a neat way of communicating the different aspects of the relationship. I wanted to show the love and commitment the father had for his daughter in spite of all the difficulties they faced on their journey together.
As I said, the interpreter image was based around the idea of building bridges and I realised that a certain gesture with hands could resemble arches.
The adult bullying image was inspired by electromagnetism. This idea came to me when I read about feeling ‘negative’. I wanted to show that bullying is a kind of distorted relationship between the bully and bullied, and ultimately they’re both linked by their insecurities. I wanted the background to seem like a kind of dark spiral, which just goes round and round.
How do you feel about your finished work? What do you like most about your images and do you have a favourite image?
I'm really happy with them. It was great working with the people at Therapy Today. They trusted me and gave me a lot of freedom. I think I was successful at putting feeling into the work and that’s what I’m happiest with. I’m not sure if I have a favourite, but the adoption image is probably the strongest.
Apart from Therapy Today, where else might we see your work? You can visit my website: philipmoran.ie. This year I had a show featuring portraits of people who promoted and fought for free speech and you can see that there. +++ Noticeboard
Supervisor
Find a supervisor or supervision group in your local area or online
Bosham/Cosham/Fareham Counsellor, Member MBACP (Accred). Qualified supervisor, humanistic/integrative, can work with different models and support with accreditation. Both face-to-face and via Skype. Experienced and trained in adults, couples and children. Contact Angela Hughes 07716 124328
Beckenham, Kent Experienced Member MBACP (Snr Accred) person centred/integrative counsellor and supervisor (Snr Accred); reduced rates for students. Contact: 0208 658 8743; 07900 076732; [email protected]
Hereford/Worcester/Gloucester/Wales Accredited, registered, experienced supervisor of groups and individuals. Reduced rate for students. Contact: 01989 780533; www.janes-counselling.co.uk, [email protected]
London, EC2 Experienced, integrative counsellor offers supervision in the City, face to face or by Skype/phone. Contact Nick 07948 353125; [email protected]; www.counselling-and- hypnotherapy.net
Manchester/Oldham area Supervision with an experienced supervisor and accredited counsellor. Reduced rates for students. Contact: Carmel 07979 551546
Stockport SK4 Qualified supervisor, Registered Member MBACP. Many years of integrative counselling experience, plus hypnotherapy and mindfulness, £45 for 1.5 hours, however, discount for counselling students. Contact: 07963 093250; [email protected] if you would like more information.
Stockport/Manchester Online supervision. Registered Member MBACP, humanistic/integrative therapist. Experienced in NHS, private practice, third sector - individuals, groups and teams. Contact Nigel 07525 374062; www.nigeldawsoncpc.co.uk/supervision
If you are a BACP member, you can place a free entry on the TherapyToday.net noticeboard under one of four headings: supervision, placements, research or networking groups. Please email your wording (approximately 30 words) and BACP membership number to [email protected] Placement
Find a placement in your local area on the placements noticeboard
Bracknell/Wokingham Bracknell and Wokingham College offering a placement for qualified (Diploma level) counsellor: three hours a week. Suits someone wanting to gain experience of working in FE. Help towards supervision costs. Contact: [email protected]; 01344 766227
Crawley/Worthing Counselling placements with Headway West Sussex. Gain experience, free training and supervision supporting people affected by a brain injury acquired since birth – survivors, carers and families. Contact: [email protected]
East and West Kent Volunteer placements for counsellors/psychotherapists. We provide counselling for patients with disordered eating and obesity. Training workshops/cpd, clinical supervision, experience within an NHS framework. Send CV to Manjit Bungar at [email protected]; 01322 220294
Greenwich Volunteer placements for counsellors/psychotherapists. We provide counselling for patients with disordered eating and obesity. Training workshops/cpd, clinical supervision, experience within an NHS framework. Send CV to Manjit Bungar at [email protected]; 01322 220294
Islinghton North London Rape Crisis looking for female honorary counsellors. Daytime and evening roles. Working towards or have a qualification in counselling/psychotherapy and 150 supervised clinical hours. Supervision provided. Please contact: [email protected] Due to the nature of this role this post is exempt from discrimation under The Equality Act 2010, Schedule 9 Part 1.
Lancaster Lancaster University seeks associate counsellor from January 2016 to manage small caseload. Experience of HE and Diploma in Counselling essential. Mentoring provided. Deadline 2/11/15. For details and applications email [email protected]
London, SW4 Placement with The Awareness Centre working short-term with clients within an NHS/IAPT service or HMP Brixton, and long-term with clients within our low-cost service. Supervision included. Must be working towards BACP/UKCP/BPS accreditation, sixty-five supervised adult client hours, in personal therapy, available immediately. Application at www.theawarenesscentre.com, return to [email protected]
Rutland Volunteer qualified counsellors required for counselling in a prison in Rutland. Must have BACP membership and insurance. Contact: Mo Smith 07885 674218; [email protected] Surrey Counselling placements with YMCA Dialogue, three clients per week. We provide short-term interventions for children and young people age eleven to twenty-five. Free CPD/fortnightly group supervision. For information/application pack contact [email protected]
Surrey Royal Holloway, University of London seeks volunteer counsellors qualified to diploma level, working towards accreditation. Free supervision and CPD. Contact: [email protected] by 30 November
West Sussex/Crawley/Worthing Your Space Therapies has counselling, psychotherapy and play therapy placements. Training and supervision provided and trainees are supported on a path to paid work with the service once qualified. For information contact: Laura Creasey, [email protected]
If you are a BACP member, you can place a free entry on the TherapyToday.net noticeboard under one of four headings: supervision, placements, research or networking groups. Please email your wording (approximately 30 words) and BACP membership number to [email protected] Research
Help researchers with their studies by participating in research
Call for participants Happy to Help: How do integrative psychotherapists in private practice experience their need for self-care? A qualitative study on how we can work and live well. Contact: [email protected]
Call for participants Use mindfulness in the counselling relationship or consider yourself to be a relational counsellor? If you would be interested in participating in this research: what is the relational counsellors experience of using mindfulness in the counselling relationship? Contact: [email protected]
Call for participants: Counsellors from a working-class background? I’m interested to hear your experience of the impact of class on counselling training or in practice? Interested? Contact: [email protected]
If you have worked with male clients with eating disorders and are interested in sharing your experiences for my Masters research project, please contact Jason at [email protected] Networking
Find a networking group to join in your local area
North London/Islington/Camden Looking for experienced therapists who might like to join me in starting a new peer/support/networking group. If interested do call me to discuss further. Contact Linda 07967 877732.
If you are a BACP member, you can place a free entry on the TherapyToday.net noticeboard under one of four headings: supervision, placements, research or networking groups. Please email your wording (approximately 30 words) and BACP membership number to [email protected]