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Therapy Today November 2015 Volume 26 Issue 9

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+++ Contents

Features

Regulars

Publication information

Editorial

Your views

News

Features

News feature Working on the edge: supporting aid workers Fiona Dunkley reports on how InterHealth Worldwide supports aid workers who respond to international crises.

‘ You don’t talk your business to people’ Helen George explores the barriers that prevent African Caribbean older women from seeking counseling.

The NHS in 2015 Gillian Proctor reflects on how the NHS has changed since 2002.

Retirement – a tale of attachment and loss Anne Power outlines the dilemmas for therapists considering retirement

When supervision goes wrong Els van Ooijen considers what can go wrong if supervisors are not adequately prepared for the role

How I became a therapist Susan Utting-Simon

Dilemmas Letters

Reviews

From the Chair

BACP Public affairs

BACP Professional Standards

BACP News

BACP Research

BACP Professional Conduct

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Visit www.therapytoday.net to read our archive of articles published since September 2005, some of which are free and others can be purchased online. You can also read our online content, including:

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Behind the pictures Daniel Haskett describes the inspirations behind his illustrations for this issue.

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Cultural barriers to counselling

The issue of hard-to-reach groups is an ongoing challenge for mental health services. Research shows that black, Asian, minority ethnic and older people are among the groups least likely to access counselling services. Helen George carried out research looking at what prevents older African Caribbean women from seeking help with mental health problems. Her findings make interesting reading. Culturally, opening up and talking about personal problems is not the norm amongst African Caribbean women. Their coping mechanisms are more likely to be their faith and drawing strength from being part of their community.

One thing that particularly struck me was that participants felt the tough lives they had led – coming over to the UK, bringing children from the West Indies, finding work, often doing several menial jobs, enduring racism – had created resilience: ‘That was a real test in life…’ said one interviewee. ‘Now they gonna look in your face and tell you that they don’t want no counselling because they have gone through all that without any help.’ Another interviewee cited racism as a reason for not being offered support. Helen works for an IAPT service, which she says has made great efforts to reach out to this group, but this sort of awareness building, she argues, needs to happen throughout the profession.

In 2002 Gillian Proctor wrote an article for the BACP Healthcare journal in which she imagined the history of the NHS from 1985 to 2015. In this issue she considers the extent to which her predictions – for what is essentially the ongoing privatisation of the NHS – have come true and forecasts further developments for the future. In 2002 Gillian described the ‘efficiency’ and ‘accountability’ discourses which have led to the reduction of resources – so that cheapest is usually best – and the ‘industry of regulating bodies’ that we recognise in the NHS today. The effect of all this on mental healthcare has of course been profound. Her hope is that, despite now having to operate in a ‘value-free technological-based healthcare’, the values of counsellors and psychotherapists will continue to have an impact on individual clients.

Sarah Browne Editor

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A new therapy for politics?

Time to listen to messages from the world of feelings and images argues Andrew Samuels

Politics in many Western countries has broken down. Despite the arrival of Jeremy Corbyn on the scene, no one would deny that we urgently need new ideas and approaches that go beyond the traditional ways we think about political activity. A worldwide move to revitalise politics has emerged. Political theorists, ecologists, economists, sociologists and Russell Brand have all had their say. Perhaps it is now time to consider how psychotherapy and counselling might make a contribution to the transformation of politics for which so many people yearn. Some will find this notion provocative or even outrageous – until they recall where our politicians’ conventional thinking has led us.

Therapy is not only a means of easing or understanding personal distress. There are links between the internal life and political and social issues which, if explored, add to our understanding of and capacity to move freely in both of these realms. As citizens, we need to balance the politics of the internal world of emotional, personal and family experiences with the psychology of pressing outer world matters such as the economy and class system, leadership, environmentalism and nationalism. Therapy can also help to remodel politics by generating a sense of meaning, not only in private but also in public life.

But before this balance can be achieved, we need to revise our present notions of citizenship, to recognise that today’s citizen requires a conscious familiarity with both the internal and external dimensions of experience. This political self-awareness means understanding how our political attitudes have been affected psychologically by family, gender, sexual orientation, ethnicity, nationality and socio-economic status – and how our personalities have been irradiated by the political times in which we live.

Just as an exercise, I invite readers to think of their first ‘political memory’, the first time you can recall becoming aware of power issues in society, the existence of a famous politician, a world event, or simply of living in one country as opposed to another. Isn’t the ability to retrieve and evaluate our political memories handicapped by the lack of an appropriate language for it? Historically, citizenship has always expressed itself in changing linguistic forms and today’s citizens might begin to speak a new hybrid language of therapy and politics – though not the kind the media use, which mostly just involves pseudo-psychological analyses of our leaders’ ‘character’.

I have seen something like this hybrid language emerge in my clinical work. One of my clients, an Italian banker of 35, had a dream in which there was a powerful image of a beautiful mountain lake with deep, clear, crystalline water. The client’s first association was that the lake was a symbol of his soul, or at least his potential to develop a deep, clear, soulful attitude to life. His next – and unexpected – association was to the pollution on the Adriatic coast of Italy which had clogged up the coastal waters with algae and weeds. He began to explore the connections between ‘soul’ and ‘pollution’. Can one’s soul remain pure whilst there is pollution in one’s home waters? How could the lake, mysterious and isolated, relate to the mass tourism economy being damaged by algae on the Adriatic?

He began to wonder: who owns this lake? Who should control access to such a scarce resource? Who is responsible for protecting the lake’s beauty from pollution? From psychological issues, such as how his problems interfered with – polluted – his development, he moved to political issues such as environmental despoliation and the degradations – as well as the opportunities – presented by mass tourism. And then he moved back again from the political level to the internal one, and then again to politics. (It does not have to be one or the other.) The dream played a part in the client’s life choice to give up banking and return to Italy to get involved in Green politics.

Another example: at a ‘political clinic’ in London shortly after the Tottenham riots, I asked the participants (who came from diverse political backgrounds, not all of them therapists) to recall and record their emotional, fantasy and even physical responses to the riots – just as therapists try to observe and understand such responses in themselves to what their clients tell them. People said that they had often reacted in a bodily or other highly subjective way to political events. They remembered experiencing strange pains in specific parts of their bodies, suffering from general symptoms such as nausea or giddiness, finding themselves mysteriously falling asleep, or noticing odd images arising within them. But they feared that these distressing responses to political issues would not be taken seriously in everyday political discourse, which tends not to regard such phenomena as significant.

In terms of economics, therapists can contribute a view of human nature that speaks with authority about benevolence, altruism and the desire to become more connected to others, but without denying the shadow of selfishness, greed and competitiveness. Alongside examples of economic benevolence (such as willingness to pay higher taxes for approved causes), there is also a good deal of economic sadism in people. At workshops on the ‘economic psyche’, I prompt participants to fantasise about winning the lottery. People who would not consider themselves materialistic and are committed to social justice come up with images that are quite shocking to them – images of cruelty and exploitation. For example, one philosophy professor fantasised about fencing off the ski slopes at Gstaad for his own personal use. This didn’t seem so awful until he suddenly blurted out that he would hire the SAS to kill anyone who came within a mile. Then he collapsed in tears, appalled at what he had just said.

Andrew Samuels is a psychotherapist and Professor of Analytical Psychology at Essex and former Chair of UKCP. He is the founder (with Judy Ryde) of Psychotherapists and Counsellors for Social Responsibility. His book, A New Therapy for Politics?, was published on 19 October by Karnac Books. www.andrewsamuels.com

Schools need mental health education

Given the prevalence of mental health problems among young people, therapists should be teaching PSHE lessons in schools argues Mike Ellen

I work with a team of two other therapists from Mind in West Essex delivering CBT in schools. We work with groups or one-to-one with secondary school pupils experiencing stress, anxiety, anger management and confidence issues.

Schools can be difficult environments. You’ve got exam pressure, peer pressure and parental pressure, or sometimes lack of family support, all affecting young people. Teaching is also becoming an increasingly stressful job due to the exam targets and huge amounts of admin. Perhaps it’s no surprise that increasing numbers of teachers in Britain are accessing counselling.

What is more surprising, given the increase and prevalence of young people with mental health difficulties, is the lack of mental health education in schools. Research indicates that one in 10 young people, of school age, suffer from a mental health problem.1 Mental health problems in children and young people can be long-lasting. It is known that 50 per cent of mental illness in adult life (excluding dementia) starts before age 15 and 75 per cent by age 18.2 Research also shows that one in 15 young people in Britain have harmed themselves.3

PSHE (Personal, Social and Health Education) is part of the national curriculum. But it includes very little on spotting mental distress, what you can do to mitigate it, and where you can seek professional help. Some schools have employed counsellors, and I have seen how this really helps to embed a therapeutic culture within a school. Young people feel freer to talk about what is troubling them.

But in some schools, discussing mental health is off the agenda. This often creates an atmosphere in which young people are afraid to discuss any mental distress. They fear it will be taken as a sign of weakness and exploited or held against them.

It is a step in the right direction for local authorities to commission therapists, like my colleagues and I, to go into schools and provide a safe environment for young people to talk to us about what distresses them. There is clear evidence that embedding a counsellor or counselling service in a school more permanently produces good outcomes. Both actions usually benefit those most in need of therapeutic interventions. However, the existing research on mental health interventions in schools, points to a need to embed general awareness in the national curriculum. The ‘DataPrev’ study,4 funded by the European Commission from 2007–2009 was a meta-analysis of research from schools across Europe, Australia and the USA. It concluded that more targeted and specialised interventions for the few individuals at the more acute end of the spectrum were greatly helped by generalised education for the school population at large.

Moreover, it seems sensible to argue that a generalised education in positive mental health can help reduce the numbers of young people at the more acute end of the spectrum who remain undiagnosed and untreated. If schools use therapists in a more joined up way, by allowing them to teach some PSHE lessons, it could go a long way to embedding greater mental resilience, and increasing awareness and understanding.

The Centre for Mental Health estimated that the cost of poor mental health to social services and the economy in England during 2009–2010 was £105 billion. When one considers the huge emotional and human cost of enduring mental distress, in addition to the economic argument, the imperative to embed positive mental health training in the national curriculum becomes pressing.

Mike Ellen is a Psychological Wellbeing Practitioner. You can contact him at [email protected]; visit www.mindinwestessex.org.uk

References

1. The Office of National Statistics. Green H, McGinnity A, Meltzer H, et al. Mental health of children and young people in Great Britain 2004. London: Palgrave; 2005. http://www.hscic.gov.uk/catalogue/PUB06116/ment-heal-chil- youn-peop-gb-2004-rep1.pdf (accessed 5 November 2015). 2. Dunedin Multidisciplinary Health & Development Research Unit. Welcome to the Dunedin Multidisciplinary Health and Development Research Unit (DMHDRU). http://dunedinstudy.otago.ac.nz (accessed 5 November 2015). 3. Mental Health Foundation, and The Camelot Foundation. The truth about self-harm... for young people and their friends and families. 2006. http://www.mentalhealth.org.uk/content/assets/pdf/publications/truth_about_s elf_harm.pdf (accessed 5 November 2015). 4. PSSRU LSE. DataPrev: evidence-based programmes for promotion and prevention in mental health. A database, guidelines and training for policy and practice outline of a research project funded by the European Commission. http://www.pssru.ac.uk/pdf/p077.pdf (accessed 5 November 2015). +++ News

Widening gap left by CAMHS

School counsellors are under increased pressure to fill a widening void in therapeutic help available for youngsters because of restrictions in their local child and adolescent mental health services (CAMHS).

Research by the NSPCC covering 35 mental health trusts in England found that of 186,453 cases referred by family doctors and oather professionals, 39,652 did not receive help from CAMHS. In six trusts just one in six were seen. The NSPCC found that strict criteria with a ‘high clinical threshold’ is denying children treatment.

Deborah Spraggon, Clinical Manager for school counselling provider Entrust Associates has found increased demand for school counsellors as a result of the restricted access to CAMHS. ‘Our model is intended to step into the widening gap in the provision of therapeutic intervention for young people,’ she said.

Place2Be Chief Executive Catherine Roche said that it was vital that where school counsellors identified higher levels of need where specialist skills were needed, that may not be available within schools, that dialogue was maintained with local CAMHS. ‘There has to be joined up professional contact. CAMHS might not be able to take up a case but two professionals can be aware of the situation,’ she said.

In January the Government announced a £1.25bn cash injection for mental health for children and adolescents. Of this, £143m is to be used this year plus £30m on improving services for those with eating disorders. According to a report in online magazine Community Care, benefits of this funding could take up to 18 months to filter through.

Mums-to-be at higher risk of depression

Pregnant women are at a far higher risk of depression than official data suggest, but few seek help because of feelings of guilt and shame, according to a new poll.

A survey of 1,000 women conducted by website BabyNet, revealed that almost a third of mothers-to-be experienced depression and anxiety. Figures from the National Institute for Health and Care Excellence (NICE) suggest less than half of this amount (12%) have depression.

Stigma around mental health issues prevented women seeking professional help, with guilt and embarrassment being the biggest factors cited in the survey. Just under half of women polled (44%) admitted fear of being labelled mentally ill.

Charities are working to break down the barriers that prevent women seeking help. PANDAS, a charity for mothers and families is urging women to request talking therapies and help from support groups, as well as using its helpline.

‘We are working hard to let people know that, “It’s OK not to be OK.” I urge anyone suffering to speak about how they are feeling,’ said Rachael Jones, co-founder of PANDAS.

A new initiative in London’s Greenwich from MumsAid is providing free weekly counselling sessions for new mothers aged 19 or under, funded by a grant from BBC Children in Need.

Mental health anti-stigma campaign launches

Parents and teenagers are the target of a national campaign that launches this month to reduce mental health stigma in England.

Time to Change, the mental health anti-stigma programme run by Mind and Rethink Mental Illness charities is to roll out a programme of national advertising and visits to schools backed by £660,000 funding by the Department of Health.

The full details of its campaign are yet to be revealed but it is understood that the project will be inviting its ‘young champions’ volunteers to promote open conversations to youngsters and their parents. Young champions are volunteers with the project who have experienced a range of issues from post- traumatic stress disorder (PTSD) to depression and anxiety.

Time to Change has run a series of anti-stigma campaigns since it began in 2007. It claims that its campaigns have made a positive impact on public attitudes towards people with mental health problems.

Said Sue Baker, Director of Time to Change: ‘Young people have told us that stigma is life-limiting – it affects friendships and school life and for a quarter it even makes them want to give up on life.’

Scotland’s antidepressant use

A huge hike in the number of people using antidepressants in Scotland over the last decade has prompted a call for greater investment in talking therapies.

The Scottish Conservatives and the Scottish Liberal Democrats have highlighted increased use of medication and called for better access to counselling. This follows data from ISD Scotland that show antidepressants prescribed for depression, anxiety, obsessive compulsive disorder and neuropathic pain have soared by 66 per cent over the last 10 years.

The report indicates a link with the number of dispensed antidepressants and areas of the highest deprivation. Greater Glasgow & Clyde prescribed the highest number of antidepressants while NHS Lanarkshire had the second highest rate. NHS Western Isles showed the lowest rate. The peak use was in the age range of 50-54 years with the majority, around two thirds, being women.

In September the SNP Government set out its policies, actions and legislation for 2015-2016 which included improved access to services, in particular psychological therapies. It also promised better response to mental health needs in community and primary care settings.

The full report, Medicines Used in Mental Health, can be found at http://ow.ly/Uem7o

In brief

Music for mood

Those who listen to sad or aggressive music may experience higher anxiety or neuroticism, according to a new study. Researchers at the Centre for Interdisciplinary Music Research at the University of Jyväskylä, Aalto University in Finland and Aarhus University in Denmark found that the style of music has a direct impact on mood. The authors of the report suggested that certain listening styles could have long-term effects on the brain.

Urge surfing for addiction

The Centre for Addiction Treatment Studies has released the first in a series of free training resources. It explains how cravings can be overcome by ‘Urge Surfing’, a process using a mindfulness-based relapse prevention programme. The video, posted on YouTube, is aimed at professionals and addicts. Visit www.youtube.com/watch?v=9wdsJayLhnM

CBT could help ME

Sufferers of Chronic Fatigue Syndrome (CFS), also known as ME, may be helped by Cognitive Behavioural Therapy (CBT) and graded exercise therapy (GET), says a new study. The research followed hundreds of sufferers for two years and found significant improvement in their symptoms of persistent physical and mental exhaustion. Other symptoms can include poor concentration, depression and panic attacks. The research carried out by Oxford University was published in The Lancet. MPs promote mindfulness training

The Government is being urged to train hundreds of therapists in Mindfulness Based Cognitive Therapy (MBCT) in a bid to lower the chances of depression relapse.

A year-long inquiry by a group of MPs concluded that initial funding of £10m should be made available through the Improving Access to Psychological Therapies (IAPT) training programme, to train 100 MBCT teachers a year for the next five years to provide courses to adults at risk of recurrent depression.

It also recommends mindfulness is taught in schools to tackle behaviour issues and raise educational standards as well as help young people to develop life-long skills for their wellbeing. The group also wants prisons and probation services to trial courses.

The parliamentary group examined scientific evidence provided by The Mindfulness Initiative, a coalition from Oxford, Exeter and Bangor Universities.

Professor Mark Williams, Wellcome Principal Research Fellow at the University of Oxford and Professor of Clinical Psychology said that the report emphasises evidence-based policy development.

‘The first step is always to look at what works but the vital next step is then to implement the results of the scientific discoveries so all can benefit,’ he said.

MBCT already has approval by the National Institute of Health and Care Excellence (NICE) but the report highlights that while 72 per cent of GPs want to refer patients to MBCT only 20 per cent have access to courses.

To read the full report, visit http://ow.ly/TZDhT +++ News feature

Working on the edge: supporting aid workers

Fiona Dunkley outlines the work of InterHealth Worldwide in psychologically preparing, supporting and sustaining humanitarian and aid workers responding to crises around the world, such as the Ebola epidemic

Ebola in West Africa is no longer in the headlines, but on the morning of 25 April 2015, many workers who were still in or not long returned from Sierra Leone, Liberia or Guinea, were woken by phone calls asking them to pack a bag and head to Nepal. A natural disaster, causing large numbers of casualties and fatalities, had struck. As the earthquake ripped families, homes and communities apart, people cried out for food, water, shelter and medical assistance. Teams landed from all corners of the earth and set to work building a response, but before long the humanitarian effort was questioned.

A headline in The Guardian read, ‘Nepal earthquake: tensions rise over slow pace of aid’.1 It is easy to criticise, but the logistics and planning that go into a major international crisis response are immense. The death toll in Nepal climbed to over 6,000 and many more people were displaced. ‘At least 200,000 houses have been destroyed and another 190,000 badly damaged. An estimated 2.8 million people are living in the open in need of assistance and protection.’2

The welfare of humanitarian and aid workers will never capture the public imagination in the way that their beneficiaries do. But consider their stress profiles. How often are they at home? Do they even have a secure base? How do they build and sustain intimate relationships? How much suffering, brutality and scarcity have they witnessed? How does their own safety measure up to the needs of, for example, the people of the Central African Republic where life expectancy is 51 years?

InterHealth Worldwide is an agency that specialises in supporting just such workers. It was founded in 1986 by two former missionaries, Marjory Foyle, a psychiatrist, and Veronica Moss, a medical doctor. They experienced first hand the physical and psychological impact of working in what is rather euphemistically called ‘the field’. InterHealth started from humble beginnings in a small back room at the Mildmay Hospital, a former cholera facility, in Bethnal Green.

In 1988 Ted Lankester joined as Director. The team has now grown into a registered charity supporting around 300 organisations and 10,000 individuals. InterHealth offers holistic care covering travel, medicine, nursing care, occupational health and psychological services. Its aim is to prepare, sustain and support individuals serving around the world from offices in London and Nairobi. There is more demand than ever before. Individuals are more at risk of being wounded, killed or kidnapped. The UK-based UN Humanitarian Outcomes research, 2013, shows there has been a 66 per cent increase of risk from the previous year. They suggest that the reasons for this include the increasing number of workers being deployed and the increasingly unstable environments in which they serve. The research further reveals that travelling by road is the most dangerous activity. In 2013, 155 aid workers were killed, 171 seriously wounded and 134 were kidnapped.3

World Humanitarian Day is held on 19 August each year. In 2003 this was the date that the UN headquarters in Baghdad was bombed, killing 22 people. Anthony Lake (Executive Director of the UN Children’s Fund – UNICEF) highlights the risk: ‘Humanitarian workers were killed in South Sudan by armed fighters while supporting the mission to reach malnourished children… In Gaza aid workers have lost their lives in shelling attacks while providing critical care to the sick, the wounded, and the dying, and comforting families of the dead.’4

A range of responses

InterHealth’s clients include the Department for International Development (also known as UK Aid), Save the Children, Médecins Sans Frontières (MSF), Mission Aviation Fellowship (MAF), World Vision, Plan International and the British Red Cross. I have recently reviewed and developed InterHealth’s responding in a crisis (RIC) plan. The model has three tiers, incorporating low- level, mid-level and high-level responses. A low-level response includes incidents that impact individuals, such as suicidal ideation, psychosis and sexual assault. These crises can generally be managed by one member of the Psychological Health Services (PHS) team. InterHealth has developed a suite of appointments to meet the needs of our unique client base. Low-level interventions include trauma assessment consultations (TACs) and the longer personal impact review (PIR) appointments. Mid-level responses are designed to address incidents that impact several individuals, such as road traffic accidents, suicide bombings, hostage-taking or kidnapping. These would generally need to be managed by the wider PHS team. In some circumstances we offer TACs and PIRs alongside trauma briefings or debriefings for groups.

High-level incidents that InterHealth has responded to include the case of the Arctic 30 – when Greenpeace environmental protesters were held in a Russian prison in 2014, the impact of Typhoon Haiyan in the Philippines, and the public health crisis surrounding the Ebola epidemic. In addition, we train agencies in family liaison in crisis and psychological first-aid programmes.

The fact that the Nepal earthquake came right on the heels of the Ebola crisis defines the world we live in; lurching from one disaster to another. It’s significant that we have managed as many RIC cases so far in 2015 as in the whole of last year. At an individual level, humanitarian and aid workers present with post-traumatic stress disorder (PTSD), traumatic stress response (TSR) and burnout. Agencies involved in the Ebola response demanded urgent support from InterHealth when the World Health Organisation declared Ebola an international epidemic on 7 August 2014. InterHealth rapidly designed a bespoke psychological support programme for aid workers being deployed. The package enabled candidates to think seriously about their self-care and resilience levels.

‘I realised that the psychological support before and after my deployment was really helpful in keeping me going: I recognised this had been missing previously. I will definitely use these services again’ (doctor, Liberia, January 2015).

Working with Ebola

The PHS practitioners are skilled at predicting outcomes in the field, preparing individuals to be as resilient as they can be in highly demanding roles and supporting and enabling a quick recovery on their return… As individuals returned home from Ebola-affected areas we began to hear stories of just how tough these assignments were: ‘In 35 years of emergency response experience, working with Ebola in the early stage was the hardest thing I have ever done’ (senior leader from INGO).

Most assignments that involved direct contact with patients were kept to a maximum of four weeks due to the intensity of the work. The average amount of time wearing the personal protective equipment (PPE) was one hour and it took 20 minutes to remove the kit after each shift. Many clinicians were frustrated in what they could achieve in such a limited amount of time. The ‘no touch rule’ and obsessive thoughts of catching Ebola became challenging:

‘I was fine until I started working there. The slightest ache or pain made me think I had a death sentence’ (lab technician, Sierra Leone, November 2014).

‘As a doctor I was doing very basic care rather than using my skills to the full’ (doctor, Sierra Leone, December 2014).

The work was intensive, distressing and exhausting. All these factors made the individual more vulnerable to mental health concerns. During the psychological reviews (end of assignment) we noted high levels of anxiety and burnout. Due to the high demand for personnel needed in such a crisis, less experienced staff were sent out. This created a risk for the patient and colleagues. Some staff were sent for longer periods of time, and these individuals showed greater signs of suffering from vicarious trauma, as well as individuals whose assignments were extended. Staff often overworked, which can be a sign of vicarious trauma; not knowing when to stop or listen to one’s body for signs of exhaustion. ‘One patient ran out of the confined area as she was delirious; we had to contain her quickly. Everyone was at risk’ (lab technician, Sierra Leone, January 2015).

Many aid workers found Christmas 2014 a particularly difficult time; the desire to reconnect with their family and friends, especially not having been able to experience touch from anyone, became challenging, due to the 21-day rule. Some individuals chose not to see their family and spent Christmas alone, especially if family members had young children. The fear factor surrounding Ebola led some individuals to believe that they could catch Ebola from anyone who returned from the Ebola-affected area and therefore, at times, this caused aid workers to be isolated and left out of work or family situations. Aware of this, once a member of staff had gone through the medical screening process, we made a significant point of shaking the hand of an aid worker returning from an Ebola-affected area.

‘The no-touch policy was really hard and it was made worse by those who avoided me when I returned home’ (HR manager, Sierra Leone, November 2014).

While listening to these moving stories from aid workers on their return, one image stayed with me: the tree of hands. Children who were leaving the clinic after having been given the all clear (many having lost family members to Ebola), painted their hands and left their print on the survivors’ tree.

Some of the material worked through in the counselling sessions involved guilt (placing someone in the wrong area or not being able to do enough), powerlessness (the enormity of the disease), and/or difficulties re-integrating into ‘normal life’. Some aid workers struggle to find purpose or meaning when returning from the field, or experience difficulty joining in socially (conversations feel ‘meaningless’) or even giving themselves permission to have ‘fun’ again. I often hear, ‘how can I enjoy myself, when all these terrible things are going on?’

However, generally humanitarian aid workers are highly resilient individuals and, with the right specialist support, recover well. Reflecting on her experience accompanying aid workers to West Africa to respond to the Ebola crisis, Ruth Dormandy, PHS team leader at InterHealth, commented in May 2015:

‘While it has been one of the most challenging ongoing pieces of work we have encountered, it has also been a privilege to accompany humanitarian staff on their journey to West Africa and back. They are a dedicated group who often feel isolated as a result of the work they do, so InterHealth’s contact and specialist understanding really make a difference to their resilience. We are full of gratitude for what they do on behalf of all of us and are ready to be of assistance by focusing on an individual’s psychological wellbeing before, during and after their assignments.’ Learning from crisis

On 24 March 2015, InterHealth held an Ebola Forum in Southwark Cathedral, focusing on learning points. Among the organisations that attended were: Public Health England, The Salvation Army, VSO, CHASE OT, Medair, Save the Children, The British Red Cross and Doctors of the World. It was exciting to see these organisations work collaboratively, many stating that through the Ebola crisis new working relationships had been formed. We facilitated groupwork and the following themes emerged from this (collated by Dr Simon Clift, InterHealth Worldwide, Director of Health Services, March 2015): 1. The inherent challenge of mounting such a large-scale emergency response. It was identified that there will be some chaos in the beginning phase. Organisations must have their policies and procedures up to date. 2. Specialist training. Specialist training was essential pre-deployment as well as in the country. 3. Psychological health services. There was a general recognition that this was an extremely important component of the healthcare provision for staff and volunteers. 4. National staff care and support. Equal support needs to be offered to national and international staff. 5. Provision of healthcare and psychosocial support in the country during deployment. Psychosocial support for staff and volunteers in the field was a key component of safeguarding the health and welfare of those deployed. It was suggested that key managers could be trained in psychological first aid (PFA) so that those experiencing stress-related symptoms could be identified at an earlier stage and appropriate support given in a timely fashion. 6. Post-deployment. More than one group felt that the post-deployment processes and support were underdeveloped when compared to the rigorous pre-deployment process. 7. Interagency collaboration. There were calls for greater interagency co- operation eg standardising HR policies and benefits packages, agreeing a system of accreditation of prior learning (diplomatic passport) and a sharing of good practice. 8. InterHealth’s Ebola-related services. There was a general consensus that InterHealth’s partnership with organisations had been very much appreciated. In particular having a named contact person at InterHealth has been valuable.

Closing thoughts

InterHealth Worldwide is committed to the health and wellbeing of those making the world a better, fairer and healthier place. I can only admire the stories I hear every day from international workers willing to take on these challenging roles to make the world a safer place. Their passion and drive are inspiring. As an NHS nurse stated during her psychological review appointment on her return from Sierra Leone earlier this year: ‘I am so excited to tell you how wonderful it was to serve and make a difference. I would go back in a heartbeat.’ Fiona Dunkley is a senior accredited BACP psychotherapist, supervisor and trainer. Fiona worked in the NHS within forensic sexual assault and was the lead counsellor at Transport for London. She is an associate working with the Police and The London Fire Brigade, and also works for InterHealth Worldwide and in private practice in Walton-on-Thames. Email [email protected]; visit www.fionadunkley.com

The author would like to thank Lynn Keane, psychotherapist at InterHealth, for her help in editing this article.

This article first appeared in the summer 2015 issue of Counselling at Work, the quarterly journal of BACP Workplace. To join BACP Workplace or subscribe to its journal, email [email protected] or for more details visit www.bacpworkplace.org.uk

References

1. Davey M, Weaver M. Nepal earthquake 2015. [Online.] 29 April 2015. www.theguardian.com (accessed 5 June 2015). 2. Burke J, Rauniyar I. [Online.] 1 May 2015. www.theguardian.com. 3. World Humanitarian Day: UN honours sacrifices, celebrates spirit of aid workers. [Online.] 19 August 2014. www.UN.org (accessed 17 June 2015). 4. Executive Director Anthony Lake. Protect those who work to protect children and families. NY: UNICEF; 19 August 2014. www.UNICEF.org. +++ ‘You don’t talk your business to people’

Helen George explores the barriers that prevent African Caribbean older women from seeking counselling Illustration by Daniel Haskett

Repeated surveys have shown that black, Asian and minority ethnic people use counselling and psychological therapy services far less than white indigenous people in the UK. Research also shows that fewer older people make use of these therapies in comparison with other age groups. In both cases there is no evidence that their needs for, or likely benefits from, therapy are any different.

This article reports the headline findings from my own research, conducted for my master’s degree in counselling and psychotherapy, to find out what prevents African Caribbean older women from seeking support for their mental health needs. My interest in the issue has grown considerably over the last few years for a number of reasons. Firstly, in the last six years of working as a counsellor in the primary healthcare sector, I can only ever recall working with two older adults over the age of 65 and both were white British. I have worked in two inner-city London boroughs with high numbers of African Caribbean older people and have become increasingly aware that they are not being referred or even self-referring for psychological help.

The second reason is my cultural connection with this group. My parents, who are African Caribbean, migrated to the UK in the early 60s. They are retired now and in good mental and physical health. Unfortunately this is not the case for some of our family members and friends of similar age to my parents. In the last few years I have witnessed a number of them suffering from clear symptoms of depression, but to my knowledge they have never sought any help from mental health services.

My wish in this research is that it may help us find ways to increase this age group’s willingness to seek help and, more significantly, tell us what we as a profession can do to overcome any barriers to accessing our help and make what we offer more engaging and appealing.

Common mental health problems such as depression are reported to affect one in five older adults over the age of 65 and this figure increases for those over 85 and those living in residential care and nursing homes.1 If you add ethnicity into the mix, then the figures rise significantly: for black and minority ethnic (BME) groups prevalence of depression is reported to be up to 60 per cent higher.2,3 The paradox is that, despite these alarmingly high rates, older adults in general do not seek support for their mental health needs and are under-represented in the caseloads of psychological therapy services.4-7

To the best of my knowledge no empirical research has ever been conducted within the counselling and psychotherapy profession on the attitudes and views of African Caribbean older women in the UK specifically in relation to accessing therapy. However, researchers in the US have made a significant contribution to the body of literature, not only by examining the barriers but also by trying to unpack the processes whereby older adults decide whether or not to seek help when experiencing mental health issues.8-12

The findings from one particular qualitative study of 37 African American older adults13 suggest that the chief barriers were the participants’ own experiences of growing up African American in black communities, and the influence of those experiences on their attitudes to and views about depression and other mental health problems. For example, most of the participants spoke about their community not showing compassion for people suffering from depression. Because of the stigma attached to it, sufferers tended to either not disclose that they were seeking help or to adopt a self- reliant attitude: that they should be strong enough to deal with it on their own. Most of the participants also spoke about turning their problems over to God: that reading the Bible and praying would help them to overcome their difficulties. Another significant finding was the link between the participants’ experiences of racial discrimination and its impact on their sense of self. They felt that because they were able to survive years of racism and prejudice, they were more than able to deal with their own mental health problems. It was also suggested by some that they wouldn’t even recognise the symptoms of depression because of the many struggles they had experienced, or know when they might need to seek help.

Connor and colleagues examined the barrier of stigma in relation to race and seeking help and found that older African Americans are more likely than their white peers to internalise the stigma of mental illness and hold negative attitudes towards seeking mental health treatment.14

In one UK qualitative research study that explored and compared the views about depression of 40 white British and African Caribbean older people,15 the main finding was that, irrespective of ethnicity, all the participants recognised depressive symptoms as a problem. However, most of the African Caribbean participants did not think it was a mental illness. They believed that the causes of depression were the person not believing in or having enough faith in God and a lack of contact with their community. As such, they didn’t think it was appropriate to seek help from a GP. The study also found a high level of perceived stigma attached to mental illness but this was not exclusive to the African Caribbean participants.

My own study was qualitative, and I used thematic analysis to draw out my findings. Recruiting participants was not easy. I made contact with African Caribbean voluntary organisations and churches, met key contacts to outline the aims of my research and gave talks in several African Caribbean day centres. But I frequently encountered reluctance among these older women to discuss the issue of mental health with me.

In total, four participants agreed to take part in the study: Audrey, aged 73, who came to the UK from Grenada in 1967; Bernice, 85, who arrived here from Antigua in 1962; Carol, 71, who immigrated here from Jamaica in 1961, and Dawn, 71 and from Antigua, who also came to the UK in 1961. This article summarises the three over-arching themes that emerged from my interviews with them.

What stops them

Towards the beginning of her interview, asked about what prevents African Caribbean women of her age group talking about their mental health problems, Carol told me: ‘… It’s a cultural background thing. Deep! Deep rooted …’ This is a particularly profound statement in that it captures the essence of the many sub-themes that emerged in my interviews and was shared by all the other interviewees. Resistance to opening up and talking about problems is a powerful cultural norm that’s entrenched in African Caribbean women.

The participants described how their upbringings played a crucial part in their current attitudes towards opening up to others and talking about their problems. As Bernice told me: ‘… I think it’s something we raise up to be like from our parents to say keep your business to yourself and not telling everybody about.’

Dawn too, talking about her childhood, described growing up in a ‘no questions asked’ atmosphere: ‘No one would talk about this or that. They would say, “What you want to know for?”… I didn’t even know the name of my great grandmother because it’s not something you would ask like.’

Carol talked about the way these attitudes were passed down from mother to daughter and the powerful taboo on ‘talking out’: ‘Black women bought it on and they also pass it on to their daughters who you know… just the thing “You don’t talk your business to people… it’s none of their business”… And if you’re in the family and you’re talking out, you know… you’re called a few [nervous laugh] undignified names. You’re seen as you know… the person who talks too much, don’t trust her, don’t trust him!’

Fear was a consistent thread that ran through all of their accounts, both in relation to developing a mental illness and to being labelled as mentally ill. Audrey, now retired, still worked part-time in health and shared an account of her professional experience: ‘At work we have psychologists and it is very difficult to get older women to attend with the psychologist. The black women say things like, “I don’t want to see no psychologist – I’m not mad!”’

She offered the following explanation: ‘… mental health in the Caribbean is different and the intervention is different… People would be running up and down the road you know, doing awful things before somebody would try and help them. So people don’t want to be associated with that and I think this is it. It’s the same as having to put an elderly relative in a care home or something. The stigma.’

But there was also a strong sense of pride in their own resilience; they hadn’t been offered any help when they first came to the UK and they didn’t need outside help now. Audrey described how she ‘had to cope through all the hard times when I first came over to England and all the way. I had to go to work… to two and sometimes three jobs a day to get by. I had to look after the kids and put a meal on the table – perform my day-to-day things’.

Carol had a similar view: ‘… when black people came here, they took what jobs they could, did a lot of menial jobs. Life was not easy – full stop... That was a real test in life – trying to survive and cope and they came through all that and they, the majority of them, managed to get a roof over their heads, probably to bring children over from the West Indies… now they gonna look in your face and tell you that they don’t want no counselling because they have gone through all that without any help.’

Negative experiences when they had sought help from doctors also emerged as a significant barrier for two of the women. Carol spoke quite passionately about GPs being unhelpful or uninterested in older people: ‘… you hear this right across the structure… right across the structure you hear people say that the doctor didn’t take any notice, or they write a couple pills and send you off on your way to keep you quiet.’

Race discrimination was also considered a reason for not being able to get the help and support they needed. Bernice told me bluntly: ‘… because I’m black they don’t want to know’.

What they do instead

I also explored with them the coping strategies they used to help them when they experienced personal troubles. Interestingly, despite the strong taboo on talking outside the family, two of the women did describe talking to friends, although both stressed that what helped was just the talking, not talking about their problems. Audrey recalled: ‘… when I had my kids young or had problems… I have somebody… I would call my friend and say look… so and so and so... and that’s the way of us, and we talk about it… and before we finish we end up talking about something else you know. So most people have that network, they have somebody they can call on.’

Dawn described how: ‘… I would make a phone call… because I feel down, but once that person says hello and start talking to me, that would make me feel good, and that prevents me from saying to her… well you know, my husband and me are not happy you know… I don’t have to go through all that… just how we are talking… it lifts me up.’

It might be that, once they had immigrated to the UK, leaving their extended family circle behind, they felt able to bend the rules that were implanted in them as children and create new circles of insiders within the much wider circle of outsiders, whom they could trust. In Bernice’s case, this also included her minister: ‘The thing with me is that I talk to the minister you see. I know he’s confidential. If things are on me mind and so forth …’ Religion and belief in God were central to three of the interviewees in helping them overcome their difficulties. They described their faith as an important source of comfort and support in alleviating their suffering. Bernice described how her parents taught her to keep her problems to herself and ‘talk to Almighty God about it’ instead. She talked about the early days when she first came to the UK: ‘I used to cry when I came here first. I used to cry a lot as I left my children behind. One day – that time I could get on my knees and I prayed to Almighty God. I say Father God I am so tired of crying. I keep crying all the time and I would really like to stop crying you know.’ She told me: ‘I do have the belief that God has an acting part in your life. God or Jesus… I always think that if you pray and ask him to help, you kind of feel relieved… and this is the truth. Because if it wasn’t for that – where would I be?’

What needs to happen

An important aim of my research was to try to identify what needs to happen to make it possible for older African Caribbean women to access counselling. At the beginning of the interviews all the participants were asked if they understood what is meant by depression and anxiety. Two, Carol and Audrey, were familiar with the concepts because they had worked in the health sector. The other two, Bernice and Dawn, said they had heard of the term ‘depression’ but did not have a clear understanding of what it was. Neither had heard of anxiety as a mental health problem.

I read them the symptoms listed in both the PHQ-9 depression and GAD-7 general anxiety disorder questionnaires, and it was interesting to see how Bernice related her own experiences to some of the symptoms of depression. For example, she immediately seized on the symptom of poor appetite: ‘At one stage I wasn’t eating at all and the minister came here and said that I’m losing weight and “Look at your face, your face gone all the way – right down – you not eating”. And the following Friday he came and said “Look at me, look at me – you got to eat, you got to eat.”’

This example indicates a strong possibility that at some stage, or perhaps at several stages in her life, she had suffered from depression without being aware of it. Audrey, who was familiar with the concept of depression, felt very strongly about the need for African Caribbean women to be educated about it: ‘… I think that for things like depression that there is not the awareness, there is not the support and people need to be aware of it. Need to be aware that it happens, that it’s not their fault that it happened. That it’s normal for people to become depressed.’

In a sense Audrey’s plea highlights the task for the counselling and mental health sectors to raise awareness of common mental health problems, such as depression among African Caribbean older women. This would then, hopefully, have a knock-on effect in reducing the stigma attached to mental illness and enabling them to know when and where to seek help.

Two of the participants – Bernice and Dawn – did not know about counselling and psychotherapy, what it entails or how they could access it. Once I had explained what it was, Bernice certainly showed an interest: ‘… I wouldn’t mind having someone to talk to me about bereavement or sickness or anything like that. I don’t know some part of it, but I know some people cannot believe their father died or their sister died.’

Dawn too (after considering the definition) felt that counselling could help African Caribbean older women and they should move with the times: ‘… that shy way of thinking that you can’t tell people this and you can’t tell people that… it’s out!’

However, Carol, who did know about counselling and psychotherapy, was more sceptical about the benefits: ‘I would think that if a counsellor had to meet somebody who is probably carrying 30 or 40 years of baggage they would probably wish that the person disappears.’

Awareness raising

The findings in this study indicate a clear need, at both practice and research levels, to increase awareness and understanding of mental health issues among older African Caribbean women. From a research perspective, more and larger studies are definitely needed to explore in greater depth the barriers and coping mechanisms that African Caribbean older women use to cope with depression and anxiety. This would inform the design of training programmes for psychological therapists and services so they are able to adapt and develop what they are offering so that it is more acceptable and accessible to this group of women.

I would argue that practitioners and psychological therapy services need to think outside the box if they are to find more effective ways of engaging this group. Not only is there an urgent need to improve their understanding of the help available and how to access it; they need also, at the very least, a basic understanding of common mental health problems. The IAPT service where I work has made great strides to reach out to different communities and groups but I feel that, as a profession, we need to go a few steps further, cross the bridge and visit places where African Caribbean older women go, such as churches, community centres and social clubs, and talk with them about mental health. Hopefully this would help to reduce the high levels of stigma and help at least some of them to feel more comfortable about asking for help.

With those women who still do not feel able to seek help, we need, perhaps, to respect their privacy and cultural traditions of ‘not talking their business’ and consider other ways that they can be supported so that they don’t have to continue to suffer in silence. I don’t have all the answers, but I hope this article lays down some of the groundwork for the emergence of creative ways to reach out to this small but significant population.

Names have been changed to protect identities. Helen George completed her MA in counselling and psychotherapy at the University of East London in January 2014. She is happy to share her research. Email [email protected]

References

1. Age Concern. Undiagnosed, untreated, at risk: the experiences of older people with depression. London: Age Concern; 2008. 2. Williams ED, Tillin T, Richards M, Tuson C, Chaturvedi N, Hughes AD, Stewart R. Depressive symptoms are doubled in older British South Asian and Black Caribbean people compared with Europeans: associations with excess co-morbidity and socioeconomic. Psychological Medicine 2015; 45: 1861– 1871. 3. Mental Health Foundation. The fundamental facts: the latest facts and figures on mental health. London: Mental Health Foundation; 2007. 4. Age Concern. Improving Services and Support for Older People with Mental Health Problems. London: Age Concern; 2007. 5. Department of Health. Older People: Positive Practice Guide. London: Department of Health; 2009. 6. Department of Health. Talking therapies: a four-year plan of action. London: Department of Health; 2011. 7. Price G. Age-equality of access: why aren’t IAPT services doing more about it? PSIGE Newsletter 2011; 113: 15–18. 8. Robb C, Haley WE, Becker MA, Polivka LA, Chwa HJ. Attitudes towards mental health care in younger and older adults: similarities and differences. Aging & Mental Health 2003; 7(2): 142–152. 9. Yang JA, Jackson CL. Overcoming obstacles in providing mental health treatment to older adults: getting in the door. Psychotherapy 1998; 35(4): 498–505. 10. Mackenzie CS, Gekoski WL, Knox VJ. Age, gender, and the underutilization of mental health services: the influence of help seeking attitudes. Aging & Mental Health 2006; 10(6): 574–582. 12. Currin JB, Hayslip B, Schneider LJ, Kooken RA. Cohort differences in attitudes towards mental health services among older persons. Psychotherapy 1998; 35(4): 506–518. 13. Segal DL, Coolidge FL, Mincic MS, O’Riley A. Beliefs about mental illness and willingness to seek help: a cross-sectional study. Aging and Mental Health 2005; 9(4): 363–167. 14. Connor KO, Copeland VC, Grote NK, Koeske G, Rosen D, Albert S, McMurray ML, Reynolds CF, Brown C. Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults. Aging & Mental Health 2010; 14(8): 971–983. 15. Marwaha S, Livingston G. Stigma, racism or choice: why do depressed ethnic elders avoid psychiatrists? Journal of Affective Disorders 2002; 72: 257–265. +++ How I became a therapist

Susan Utting-Simon

After a painful start in life, Susan Utting-Simon came across Carl Rogers whose words rang clear and true

Like many therapists, my decision to train came out of personal experiences of difficulty and encountering the benefits of therapy for myself. Being a young person was, mostly, a very painful experience – I seemed to have different values from many people around me. I was often described as ‘too sensitive’, and for many years I internalised that evaluation as a criticism: something was ‘wrong with me’ and needed to be addressed. My struggle to find a self- identity that was acceptable to my family led to long-term depression. Despite this, I was never offered therapy.

Somehow I muddled through my late teens, got a reasonable education and, when I was 20, took a lucky opportunity to work in the fashion industry, which sustained me for a long time, feeding my need to explore the world and different attitudes. However, I lacked the confidence to be truly congruent and continued trying to fit in, resulting in further decisions that were not good for my mental health. Eventually, after the loss of my first child, I experienced a major breakdown, but also a breakthrough, because in seeking therapeutic help, I felt truly understood for the first time. I found the courage to end my disastrous relationship and relocated back to London. I was 30 years old and I felt my life was finally my own.

The decision to retrain as a therapist started as a ‘thinking aloud’ with a colleague, who acknowledged, on my return to work after the loss of my son, that I was different. Despite its undoubted glamour, I no longer had a passion for the industry that had been my lifeline during challenging times. I told him that if I could help anyone to get on with their life after things had been so unbearably bleak, as they had been for me, that was a worthwhile thing to do. I began my training in 1997 and knew straight away that I’d made the right decision.

I’d read about various different models of therapy and the person-centred approach seemed to fit quite naturally with my personal values. During my adolescence I had tried several times to tell someone how much I was struggling, but I’d never been taken seriously. The notion that I knew I needed to feel heard, understood and have some autonomy in my life was ridiculous to my family and the various professionals I had encountered. Suddenly, here I was, reading about Carl Rogers, and his words, ‘It is the client who knows what hurts, what directions to go, what problems are crucial’ (On Becoming a Person, p11), rang clear and true for me.

I completed a diploma in person-centred counselling, following it up with a postgraduate course in working with children and young people. During my diploma I had begun counselling young people at a voluntary sector project in Leeds city centre and found myself in awe of their resilience and capacity for change. I have always felt that if I had been offered such a service in my teens, my life would certainly have taken a different path, and I have continued my involvement with the project for over 15 years in various roles. I currently run a supervision group there for trainee counsellors on placement.

As I completed my diploma I also took on paid work as Assistant Project Manager at The Survivor-Led Crisis Service, also in Leeds. Working in a user- led project at this point in my life was very healing for me. My personal experiences of mental ill health were seen as desirable criteria for the post, not something to be ashamed of. I met some amazing people there who remain trusted friends today. When you work ‘out of hours’, at night time over the weekends, when pretty much all other services are shut, you need to be able to rely on your colleagues and also have a clear sense of your own robustness. This was excellent training for my later decision to set up in private practice, where so much of the time we have to rely on our own instincts and manage/assess our capacity for the work.

After several years I built my small private practice into my primary source of income. I have developed a ‘niche’ in working with children and younger adults and also supervising other therapists who do such work. It is crucial to have a supervisor who understands the specific needs of this client group and I really enjoy supporting therapists who work in the field.

Taking on the role recently of Chair of BACP Private Practice is, I feel, the next stage in my journey: the chance to share with others the lessons I have learned from setting up in private practice and meet with other colleagues who are as passionate about the work as I am.

Susan Utting-Simon is an MBACP (Snr Accred) counsellor/psychotherapist, supervisor and trainer working in private practice in Leeds. She has an interest in working with children and young people and transcultural issues. www.susan.counselling.co.uk. Email [email protected] +++ The NHS in 2015

Gillian Proctor reflects on the accuracy of her 2002 predictions about the future of the health service Illustration by Daniel Haskett

In 2002 I wrote an article for Healthcare Counselling & Psychotherapy Journal1 as though it was 2015 and I was tracing the (at that point) fictional history of the NHS from 1985 to 2015. This was based on my experiences in 2002 with the healthcare system in the US; the discourses that were current in the UK at the time seemed to prefigure a move to an insurance-based healthcare system provided by the private sector. In this article I reflect on the extent to which my predictions from 2002 were accurate and predict again the possible changes to come.

In 2002 I described the ‘efficiency’ and ‘accountability’ discourses, which were becoming increasingly prominent at the time. The ‘efficiency’ discourse was used to argue that better management of existing resources would improve healthcare, rather than increasing resources. This justified the split between ‘purchasers’ and ‘providers’, which led to the ‘commissioners’ and ‘providers’ division of today. The ‘accountability’ discourse was used to scare the public about ‘rogue practitioners’ doing their own thing and justified the transfer of power from healthcare professionals to managers, with professionals needing to prove that their practice was ‘evidence based’. This approach supported an industry of regulating bodies, such as NICE, in deciding what would count as evidence, and in increasing the power of approaches within mental health that fitted nicely within a technological, scientific model (such as CBT), moving mental healthcare further away from the idea of relationships, and professionals further away from the idea that who and how we are as people matters. These discourses perpetuate the myth of standardising mental healthcare, as though any human relating can be done in a uniform way.

As part of this approach, the notion of performance-related pay was already being mooted in 2002, which I predicted would be introduced across the board, with individuals being judged by their ‘efficiency’ and adherence to ‘evidence-based practice’. These discourses have since been described by Rizq2-4 as characterising the New Public Management (NPM) policy changes in public sector services (health, education and social services) since the 1980s. She explains that these organisational structures are ‘increasingly characterised by managerialism, surveillance and bureaucracy and privilege efficiency, performance and transparency, over professional accountability and collegiality’.3

I also described the effect of the purchaser-provider split, which was to establish the split between public and private healthcare, and predicted that employers paying for private healthcare for their employees would become more common. As a result, funding for public healthcare would be reduced and the necessity for private healthcare increased, with public healthcare remaining just for emergency healthcare procedures. I predicted that purchasers would become insurance companies, which would be unregulated and they could decide themselves which treatments would be deemed ‘essential’ and ‘effective’, agreeing to evidence-based interventions for particular diagnoses. This would lead to service provision being completely based around diagnosis and limiting services to those that were financially viable or financially subsidised by interested parties, such as pharmaceutical companies, who would also have stakes in the insurance companies, thus ensuring profits all round, rather than any focus on patient care. In this insurance-based system, patients with ‘pre-existing conditions’ would be refused treatment, which would lead to many people refraining from visiting medical professionals in case a diagnosis was made which would then become a ‘pre-existing condition’ and limit future care.

So how far are we now from this financially based American system? Thankfully, as yet, the healthcare system in the UK has managed to resist completely following this profit-based trajectory, although I would argue that, in many ways, we are not far away, while still being able to maintain a discourse of an NHS which is ‘free at the point of access for all’. Clearly, it is politically important to maintain the illusion of protecting the key philosophy of free healthcare for all. In the lead up to this year’s general election, the NHS became the issue of greatest salience for the British electorate for the first time since 2006,5 being mentioned by 45 per cent of people as among the most important issues facing Britain. However, the issue was much more likely to be seen as important by those aged over 55 (51%) compared with those aged between 18 and 24 (24%). Clearly, the future of the NHS is an issue that no political party can afford to ignore currently, with all parties offering reassurances about its future and increased resources.

NPM policies have continued to strengthen since 2002. The discourses of ‘efficiency’ and ‘evidence-based practice’ have proliferated, with cuts to NHS and all public sector funding having been renamed ‘efficiency savings’. Purchasers have become Clinical Commissioning Groups (CCGs) most recently, and providers can be from the NHS, voluntary sector, social enterprises or private sector. Services are tendered for, with bids from each competing provider, with the least costly often being judged the most ‘efficient’ and best value. In an attempt to submit the lowest cost bids, service provision is limited to small numbers of sessions and the practitioners who provide the service are either the cheapest possible counsellors (ideally working voluntarily and often highly experienced and qualified), or the most compliant and usually the least qualified and experienced ‘low-intensity’ workers.

The domination of IAPT

Mental health services are now dominated by IAPT, which focuses exclusively on ‘evidence-based’ and short-term interventions for clients with particular diagnoses (mainly anxiety disorders and depression). The vast majority of workers in IAPT services offer CBT, often by minimally trained psychological wellbeing practitioners (PWPs) offering ‘low-intensity’ interventions for a small number of sessions (usually six). More recently, IAPT committed to extending the ‘choice’ for patients to other modalities of therapy which are mandated by the NICE guidelines for depression, which include counselling for depression (CfD), interpersonal psychotherapy (IPT), dynamic interpersonal therapy (DIT) and couple therapy for depression (CTD), each of which have had to go through the process of providing enough evidence through randomised controlled trials (RCTs) to prove their effectiveness with clients diagnosed with depression. Yet evidence from a survey by UKCP and BPC6 suggests that, overall in mental health services, there has been a reduction in choice for patients, with a decrease in the length, intensity and type of psychotherapy provided, the number of clients accessing longer-term psychotherapy and an increase in waiting times. At the same time, the clinical experience and qualifications of those providing the psychotherapy have decreased.

Of course, in reality most clients entering IAPT services could not be diagnosed with simple depression or anxiety, with a mixture being much more common,7 but the inadequacies of applying the medical model and RCT research conditions to a clinical population are ignored. Some consequences of these limited therapy options are to create a new industry in training already trained and experienced clinicians in an evidence-based therapy and further demoralising and devaluing the existing workforce.

The idea of diagnoses being used to decide which evidence-based interventions clinicians can offer has indeed been introduced across mental health services, with mental health diagnoses being renamed as ‘clusters’, focusing mainly on severity and level of need as opposed to type of difficulties. This is a handy idea, meaning all mental health professionals are able to ‘cluster’, thus not limiting the process of diagnosis to psychiatrists. Clusters now form the basis of the national tariff payment system whereby provider services are allocated a certain amount of money to treat each patient (tariff), depending on their cluster. Using a Mental Health Clustering Tool (MHCT) to evaluate outcomes has now been recommended in England.8 Fugard9 discusses one of the problems here of recommending an unreliable measure with very poor internal consistency.

Rizq4 points out how these mental health policies take for granted the uncritical acceptance of diagnoses on which the whole system is based, and yet the system is still haunted by the previous historical view of madness as signalling unreason and being scary – the dehumanisation of madness. This fear of the ‘other’ leads to constant anxieties about the shared human experiences of vulnerability, fragmentation and death among those who work in the system and in the organisations themselves. At the same time, the policy and language shift from ‘mental illness/health’ to ‘wellbeing’ emphasises the needs to be ubiquitous and human and, at the same time, disavow the messiness (unpredictability and ‘unmeasurability’) of distress.

Focus on measurement

The emphasis on evidence and standardisation leads to an overwhelming focus on measurement in IAPT settings. Each client is required to complete the Minimum Data Set (MDS) of outcome questionnaires at each appointment, and clients are deemed to have ‘reached recovery’ if their scores have reduced from above to below a certain threshold. This use of outcome measures to mimic evidence-based practice is extremely suspect, with the questionnaires used having little validity (having been devised to measure the effects of medication by pharmaceutical companies, as opposed to other measures that have some validity to measure change in psychological therapy, such as CORE outcome measures)10 and used because they are free. Results are reported without any explanation of contexts or differing starting populations in different areas. Services have the constant pressure of being able to successfully report good recovery rates, which are used to compare across services and these pressures are often transferred to psychological therapists. This pressure to produce good figures cannot but affect the work of the counsellor in therapy, with the consequence of a service focus on ‘symptoms’ that are measured by the MDS at the expense of the factors that are important to the client in distress. The pressure on clinicians to see large numbers of clients leaves little room for other clinical activities, such as supervision and support, or any opportunities for reflection about our work, leading to high levels of stress. Often IAPT service managers are not counsellors or psychotherapists, have little understanding of the importance of relationships, and focus exclusively on the political targets of waiting times and recovery rates.

Wainwright11 critiques the implementation of systems for quality improvement on their lack of evidence base and suggests that organisational ethics need to be considered, with respect to how much the way an organisation functions encourages or discourages ethical thinking and behaviour. He suggests that the push towards standardisation in healthcare is not only impractical due to complexity but can also lead to the demoralisation of the workforce. Similarly, he critiques the target-driven culture of the NHS, not denying that usually targets are achieved, but that, at the same time, ‘they may also have serious consequences that may be concealed’, and that these consequences may work against the purpose of the original target. It is not difficult to apply his analysis to the IAPT culture of attempting to standardise mental healthcare, setting targets for recovery and, at the same time, discouraging ethical behaviour in practitioners by the constant focus on numbers as opposed to people and relationships, and drastically decreasing the morale of the workforce, due to high workload, stress, and little support. At the same time, the focus on recovery rates conceals the consequences for many clients, such as those who are refused a service because they are measured as not needing one (they don’t meet ‘caseness’), those clients whose service finishes because their measures demonstrate they have ‘recovered’ but their personal goals are far from being met, or those clients who do not have the choice of the kind of therapy they would like, as they have already dropped out of a service after one experience with a worker who didn’t seem to understand their personal difficulties. Similarly obscured is the reduction in longer-term psychotherapy options for clients who need much more than the IAPT symptom-focused short-term model on offer (see UKCP/BPC, 2013).6

Rizq4 further identifies the IAPT programme as exemplifying the NPM ideals of transparency, accountability and governance, and describes how the ‘virtual reality’ of the activity data is part of the wider discourse of ‘evidence- based practice’. She draws on the Lacanian notion of a ‘fetish’ to describe how these measuring practices are an ‘attractive fabrication’ which conceal the lack of ability of the service to respond to distress with care. Thus the fetishisation of bureaucracy disavows our anxieties about vulnerability, illness and death. Hence IAPT represents a case par excellence of ‘one in which the dependency and psychological suffering of patients, as well as the anxieties and limitations of those tasked for caring for them, are simultaneously disavowed and concealed beneath overwhelming bureaucratic and governance systems’.

I would argue that it is not just our anxiety about vulnerability, illness and death which is being concealed by this insistence on measuring ‘symptoms’ of ‘illnesses’. This preoccupation also conceals a huge amount of evidence about the causes of distress not being physiological or biological (as in a medical model), but being social and political. The evidence that is most convincing relates causes of distress to environmental factors, such as abuse, deprivation, violence, discrimination, powerlessness and unemployment (see Proctor).12,13 IAPT services, particularly in areas of deprivation, will be caught between service requirements and trying to respond to the real social and material needs of their clients, with the separation of experiences of anxiety and depression from these needs (as mandated by IAPT) being completely impossible. This leaves both clients and clinicians stuck between their reality and service discourses that make no sense at all; a true recipe for madness! Further, it leaves psychological therapies yet more open to the accusation of being responsible for further perpetuating the inequalities that cause the problems that they are supposed to be addressing (see Proctor).13

IAPT also plans to adopt a system of Payment by Results (PbR), but rather than this being based on activity or needs (as in the clustering model), it is proposed to base this on outcomes as measured by the MDS. As Fugart9 points out, this will exacerbate further the difficulties in the MDS being a good measure of outcome, as once a measure becomes a target, it ceases to be a good measure,14 being vulnerable to obvious manipulation by service providers and users who want to ensure the survival of their service. As Fugart9 summarises: ‘It is difficult to see how any data gathered that have been subject to these difficulties could tell clinicians or service providers anything helpful about their services or the wellbeing of those who use them.’ Fugart9 points out an additional problem with publishing recovery rates on league tables, without any information on uncertainty or without any context of interpretation. The effect of this on psychological therapists working in IAPT services is that there is a continual battle with recovery measures, with constant ethical dilemmas about what to do with clients who don’t recover, or with scores which don’t reach above ‘caseness’ at the start and, therefore, can never demonstrate recovery, and a constant challenge to try to respond to individual need rather than focus on the service demands of bringing about change as quickly as possible, as demonstrated by an outcome measure.

At the same time, many IAPT services are now not provided by NHS providers, with counsellors often working on zero hours contracts, not being paid if clients do not attend, and sometimes only being paid if clients ‘reach recovery’, with the counsellor thus evidencing their effectiveness. This is, of course, performance-related pay with reduced terms and conditions way beyond what I had envisaged in 2002.

Whereas the US insurance-based system does indeed reduce rewards and increase administrative pressures for clinicians, this NPM bureaucratic system in the UK at least equals the resultant change of emphasis from clinical to administrative skills on healthcare workers, with consequent increases in stress and decreases in morale. Both systems also equally shift the focus from collaborative relationships between experienced clinicians and unique clients to measurable and standardised outcomes of treatment.

Rizq3 suggests that the preoccupation with measuring also serves the function of trying to define the borders of its culture and keeping out the parts that she describes as ‘abject’ (disavowed and pushed away in disgust) following Kristeva.15 In mental health services, the experience of distress and vulnerability is abjected, to be replaced by ‘wellbeing’ and financial and economic productivity. However, the abject in fact can never be entirely discarded, but always remains just out of reach, in the shadows of subjectivity. Mental health services remain in the precarious position of being mandated to provide care for mental distress, yet operate within bureaucratic systems that serve to regulate, disavow and abject the very care that they are mandated to provide. She warns that psychotherapists who engage with emotions and attempt to relate with care are in danger of containing all the abject within the service and are thus at risk of burnout.2

There is a real question of how the other new approaches can fit into the IAPT system, which has a clear focus on the ‘symptoms, thoughts and behaviour’ of consumers who have the agency to choose the approach which suits them. The focus in CfD (the only humanistically based approach offered within IAPT – see Sanders and Hill)16 on emotions does not fit the wellbeing agenda, where emotions are abjected, and threatens the defence.

The focus in CfD on the unique person rather than any diagnosis also struggles to fit with the diagnostic foundations of the service. IAPT is not set up to offer care to the vulnerable but to offer ‘choices’ for people who want to ‘deal with’ or ‘address’ their deficits in wellbeing, or their symptoms of mental ill-health. There is no space for emotions, attachments or feelings in counsellors for the clients they have relationships with, topics which used to be legitimate subjects in supervision for psychological therapists. Although counsellors should still have supervision from a supervisor using the approach that they work with (such as CfD), the priority for management is often now ‘case management’, focusing on changes in the MDS and how quickly clients can be discharged; this says it all – clients have become ‘cases’ to be managed, not people to be related to, worried or concerned about.

Continuing privatisation

In the meantime the privatisation of the NHS continues surreptitiously. The Translantic Trade and Investment Partnership (TTIP) is a proposed deal between the EU and the US, which would enable US companies to become much more involved in the provision of many former public services such as education, water, rail and healthcare services, in the UK (providing health, medical and dental services). The TTIP deal includes an ISDS (investor-state dispute settlement) clause, enabling our Government to be sued by private corporations in secret courts for passing laws that threaten the profits of these companies. This deal would effectively make a reversing of the privatisation of our healthcare services financially impossible.

The role of non-NHS providers in delivering NHS-funded care in England increased markedly from 2006 to 2012, reflecting explicit policy decisions.17 In 2006 the NHS spent £5.6 billion (in 2011/12 prices) on care provided by non-NHS providers; by 2011-2012, this had increased to £8.7 billion.17 Care by private providers grew more quickly than by voluntary sector or local authority providers. Paying for private healthcare insurance or treatment fell during the same period, with private providers gaining more of their income from the NHS. Currently self-pay is the area that is growing the most in the NHS, with individuals choosing to pay privately for specific services, mainly elective operations, although it is likely this will spread to other areas, such as mental health.

The Nuffield report17 warns about competitive distortions between NHS and non-NHS providers, recognising the strategies used to ‘be competitive’ in private industry. It is certainly possible that private companies can submit a very competitive tender to provide a service and then use patients who access this service, which will inevitably make a loss, to ensure profits in other services. Within all of this, it is never clear to me how private healthcare organisations can possibly represent better value for money than organisations who do not aim to make a profit, but aim to deliver the best care possible within the financial constraints. The only possible way for private companies to deliver better care to patients, at a lower cost than NHS providers, is by reducing the pay or terms and conditions offered to its employees.

The saturation of the discourse of evidence-based practice now means that this is a rarely contested given, with outcome measures and clustering being used without any consideration for their validity or effects on client care. It seems that the move from values-based healthcare18 to the illusion of value- free technological-based healthcare is nearly complete. Despite exposure to the inadequacies and even tricks involved in producing evidence and clear values and dynamics of power involved in what questions are asked and how they are answered in research, and the lack of applicability of experimental research to real life, the idea of the gold standard of ‘evidence’ being the RCT remains.

Rizq4 refers to the NPM restructuring of the NHS since the 1980s, including the introduction of quasi-markets, quality management, competitive tendering and other market-related reforms. She suggests that these neo-liberal regulatory and performance management systems are a perverse organisational solution to the difficulties of dealing with distressed patients; perverse in that these systems pretend to deal with this distress (by measuring it) and, at the same time, disavow the distress. Ultimately, the consequent ‘tick box culture’ created undermines the chances of staff really responding to distress by undermining care and human relating. The Francis report19 holds this culture responsible for deaths, saying ‘statistics, benchmarks and action plans are tools not ends in themselves. They should not come before patients and their experiences.’

Yet most people working in the NHS chose to do the jobs they do because of their values and their wish to help people in an ethical and meaningful way. There is a long tradition of other approaches to ethics in healthcare that offer meaningful alternatives to the quasi-legal technological approaches. Values- based ethics of care and relational ethics prioritise the importance of people and relationships, as opposed to techniques and interventions and, of course, these ideas are at the heart of counselling and therapy, where there is little disputing the evidence that the relationship matters.20 As long as we continue not to question the politics and values behind the taken-for granted mandates of ‘evidence’ (as though such a thing was an undisputed fact, as opposed to a highly political funded justification), it will get harder and harder for those of us who like to live and work in accordance with our most cherished ethics and values to remain within the NHS.

So the current political climate mandates any changes to the NHS to maintain the illusion of a continuation of the cherished British tradition of publicly- funded healthcare, thus limiting the move towards an insurance-based system. However, through the saturated discourse of ‘efficiency savings’ and ‘austerity measures’, which are barely contested, the increase of competitive tendering for all provider services is set to reduce stability and equity of service, and decimate terms and conditions for employees. The public service might still seem to be public for the patients, but the good terms and conditions, which came with the low pay attached to most public sector jobs, have already reduced substantially in the last five years and are set to continue to reduce much further across the board. At the same time, the days of autonomy, opportunities for innovative practice, valuing relationships, and being trusted as a clinician are long gone, with the discourse of ‘evidence- based practice’ successfully leaving many clinical decisions to NICE and CCG funding decisions. Consequently, morale and goodwill among the workforce have plummeted.

Startlingly, since 1997 the percentage of members of BACP who are also members of the BACP Healthcare division has fallen from nearly 12 per cent in 1997 to seven per cent in 2002, to 2.8 per cent currently. Although this figure does not capture all members who work in healthcare, the decrease is likely to chart the reduction of counsellors who work in healthcare settings during this era of increased regulatory and performance management systems. More and more NHS practitioners are moving away from what was an ethical choice to work for a free at the point of access service, to try and work independently, perhaps offering services privately or becoming AQPs (Any Qualified Providers) to independently provide services for commissioners. Both these options offer much less stable forms of income than previous NHS contracts did for counsellors and psychotherapists, and leave patients vulnerable to inequities of funding decisions and constantly changing services.

Lines of resistance?

Are there still lines of resistance for counsellors and psychotherapists in the NHS who value humanity, relationships, and want to work with distress and powerlessness, as opposed to the denial of inequalities and the messy emotional work which is mental healthcare? Is there hope where unusual IAPT managers can still focus on these values in addition to the political priorities of recovery rates? Can we resist and still survive without our values being compromised beyond a level where we can still recognise and live with ourselves? Can we work collaboratively to help each other survive in solidarity and, for the sake of our clients and the future of an NHS, where the values of human care and relationships still matter?

I remain hopeful that despite the ongoing privatisation of our cherished NHS (while maintaining the illusion of a public service), our values as counsellors and psychotherapists can have an impact on individual clients. Perhaps, in areas where there is a critical mass and support among counsellors and managers with such values, these values can influence services for the benefit of client care. But we are fighting against an extremely powerful tide of bureaucracy and free market economics, and the stakes and ongoing costs of this fight for survival of alternative perspectives are high.

Dr Gillian Proctor worked in the NHS as a clinical psychologist and psychological therapist for 22 years until she took redundancy in 2013. She now works as an independent clinical psychologist, psychotherapist, and clinical and research supervisor (www.gillianproctor.co.uk) and as an Assistant Professor in Counselling at the University of Nottingham, delivering courses on counselling for depression (CfD). She is also an Associate Lecturer at the University of Huddersfield. Gillian welcomes responses from anyone who wants to form a network for discussion of, and support for, how to survive as a counsellor in the NHS – please [email protected]

This article was first published in the October 2015 issue of Healthcare Counselling & Psychotherapy Journal (HCPJ), the quarterly journal of the BACP Healthcare division. To join BACP Healthcare or subscribe to its journal, email [email protected] or for more details visit www.bacphealthcare.org.uk

References

1. Proctor G. The NHS in 2015: science fiction or a scary possibility? Healthcare Counselling and Psychotherapy Journal 2002; 2(3): 2–6. 2. Rizq R. IAPT, anxiety and envy: a psychoanalytic view of NHS primary care mental health services today. British Journal of Psychotherapy 2011; 27(1): 37–55. 3. Rizq R. States of abjection. Organization Studies 2013: 35(9): 1277–1297. 4. Rizq R. Perverting the course of therapy: the fetishisation of governance in public sector mental health services. [Online.] doi: 10.1080/02668734.2014.933034 (accessed 27 July 2015). 5. Economist/Ipsos MORI Issues Index February 2015. The NHS remains the most important issue facing Britain. [Online.] (www.ipsos- mori.com/researchpublications/researcharchive/3535/The-NHS-remains-the- mostimportant-issue-facing-Britain.aspx (accessed 27 July 2015). 6. UKCP/BPC. Quality psychotherapy services in the NHS: summary findings from the UKCP and BPC members’ survey. [Online.] www.bpc.org.uk/sites/psychoanalytic-council.org/files/Summary%20findings %20from%20NHS%20survey.pdf (accessed 27 July 2015). 7. Office for National Statistics. Psychiatric morbidity among adults living in private households, 2007. London: HMSO; 2009. 8. Department of Health. Mental health payment by results guidance. Leeds: Department of Health; 2013. 9. Fugart A. The ethics of national routine outcome monitoring policies; a case for taking action. Clinical Psychology Forum 2015; 267 (March): 11–15. 10. CORE IMS. [Online.] www.coreims.co.uk/About_CORE_IMS.html 11. Wainwright T. Ethics and quality improvement systems. Clinical Psychology Forum 2015; 271: 9–12. 12. Proctor G. The dynamics of power in counselling and psychotherapy: ethics, politics and practice. Ross-on-Wye: PCCS Books; 2002. 13. Proctor G. Therapy: opium for the masses or help for those who least need it. In Proctor G, Cooper, M, Sanders P, Malcolm B (eds). Politicising the person-centred approach: an agenda for social change. Ross-on-Wye: PCCS Books; 2006. 14. Strathern M. ‘Improving ratings’: audit in the British university system. [Online.] doi: 10.1002/(SICI) 1234-981X (199707)5:3<305::AIDEURO184>3.0.CO;2-4 (accessed 27 July 2015). 15. Kristeva J. Powers of horror: an essay on abjection. New York: Columbia University Press; 1982. 16. Sanders P, Hill A. Counselling for depression: a person-centred and experiential approach to practice. London: Sage; 2014. 17. Nuffield Trust. Understanding competition and choice in the NHS. [Online.] www.nuffieldtrust.org.uk/our-work/projects/understandingcompetition-choice- nhs (accessed 27 July 2015). 18. Fulford KWM, Dickenson DL, Murray TH. Healthcare ethics and human values. Oxford: Blackwell; 2002. 19. Francis R. The Mid Staffordshire NHS Foundation Trust Inquiry. Independent inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005–March 2009. London: House of Commons; 2010. 20. Cooper M. Essential research findings in counselling and psychotherapy. London: Sage; 2008. +++ Retirement – a tale of attachment and loss

Anne Power reflects on the dilemmas for therapists considering retirement Illustration by Daniel Haskett

To think about retirement is to think about ambivalence. It raises as profound dilemmas for the individual practitioner as it does for the profession. From time to time letters and articles in Therapy Today have indicated the challenges faced by counsellors and therapists who set about closing a private practice.1,2 In recent years BACP and other regulating bodies have been introducing new categories of membership which recognise the complexity of retirement. What is not yet in place is policy about retirement and thus the responsibility for assessing when to end and how to do it, lies with each practitioner.

In this article I will address questions about ‘when to retire’ and ‘how long to take’ as well using attachment theory to understand the experience of clients whose therapist shuts up shop.3 I will draw on my interviews with 13 therapists who were either fully retired or in the process of closing their practice.4 The focus of my study was on therapists and counsellors whose clients are long term – clients who began the work with the implicit understanding they could attend sessions until they were ready to end. When practitioners work on short-term contracts or within an organisation, the counsellor’s retirement will raise important issues but may not intrude as severely into the client’s space. The different but related challenge of making a temporary break for maternity or sabbatical leave is addressed in my book.

Few retired counsellors or therapists have written about their journey into retirement but one who kept a journal and then shared her experience is Boyd-Carpenter.5 Like most therapists she was motivated to retire by a mixture of push and pull factors. On the push side the most pressing factor may be a sense of reduced capacity for the work. Some changes, such as reduced stamina, can be well managed through reducing our clinical hours, or even simply adjusting the times at which we work. Staleness with the work might be tackled through finding a more challenging supervisor who works from a slightly different modality or it might really signal that we are ready to retire. As one of my interviewees put it: ‘Gradually I began to find it too difficult to be constantly putting my centre of gravity into somebody else – that exquisite self-control’ (p32).4

For other changes, such as reduced memory, there may be no remedy and thus when older therapists experience increasing difficulty in retaining details of clients’ lives this may be a sign that it is time to stop. Even more difficult to assess than memory is the kind of cognitive decline which makes it hard for us to make links – and yet this is the heart of our work. Clients rely on us to be able to see a connection between the way they are speaking about their partner and what they once told us about their parents’ relationship. Equally we would not want to miss an association between a dream from last night and one the client had six months ago, yet how can we know when we are missing such connections? Supervisors may be able to pick up decline in our mental agility but probably only once it is quite progressed, as most of us can put on a good show for an hour in the presence of a respected mentor. If a therapist were beginning to make mistakes with the diary or with names, a supervisor could only challenge this if he or she were given the facts.

In some cases physical illness makes retirement the wise course – whether because the counsellor feels too ill to work, needs too frequent time off for medical appointments, or is living under too much uncertainty about a diagnosis. The decision is occasionally a clear one and brings relief, more often the case is ambiguous and the decision itself can feel tortuous. One of the contributors to my study made the very reluctant decision to retire when she noticed her memory failing her: ‘I didn’t have a dilemma I just didn’t want to do it, but I also knew that there was really no choice. You can’t take the risk of thinking, “What the hell is she talking about, who is this Philip?”’ (p37).4

The decision to retire

Pull factors for retirement could be happy life events, such as the arrival of grandchildren or perhaps the retirement of a partner. Some retirees pursue a longstanding dream to study new subjects, to take up a neglected hobby or to travel. Other counsellors face more daunting pull factors, such as caring for a partner or sometimes their own parents or sick children. Some may be obliged to close their practice because of a house move and be unsure if they can face starting over. In all these cases personal finances have a guiding role in decisions. Clearly retirement is more enjoyable for those who have enough resources for a comfortable life. Occasionally therapists say, ‘I can’t afford to retire.’ Fortunately this is generally said as a figure of speech meaning, ‘I’d love to be a bit better off so I could have a care-free existence.’ Most of us would agree that if a therapist were becoming unfit to practise, whether through age or any other circumstance, she would need to stop working regardless of the size of her pension pot. To carry ‘boldly’ on is to put clients at risk of being abandoned through sudden retirement or held hostage through their loyalty to a crumbling therapist. In my research I heard many stories of such damaging outcomes, even though this was never the focus of my enquiry.

In my small sample I found some inverse correlation between age and the length of time allowed for the process. The shortest period of notice was six months and the longest retirement was arranged as an organic process with each client being let go in their own time so that the process for the therapist took close to eight years. To make sense of how different therapists were navigating this transition I identified four sub-groups amongst those I had interviewed.

The younger retirees I spoke to were in their 60s. They were more motivated by pull factors and it was notable that their ambivalence about taking this step was very high; this seemed to be partly because there was less pressure on them to make this choice and so the capacity for self-doubt was not balanced by any clarity about the need to retire. These younger therapists tended to allow the least time for the process and some of them felt that too drawn-out an ending would be unhelpful to clients. I think this intensive time scale needs to carry a health warning for the therapist, since closing a busy practice in six months does involve a very concentrated experience for the practitioner.

The classic group was the name I gave to those in their 70s who were motivated by a mixture of push and pull factors. These therapists were particularly attached to their work yet very realistic about their increasing risk of illness or loss of capacity as they aged. They conveyed the strongest sense of grief about the loss of the work. This group allowed themselves plenty of time for the decision and then allowed their clients 18 months to two years’ notice.

Another sub-group comprises those who were forced into retirement. Three therapists in my sample felt obliged to retire due to their own ill health or cognitive decline. Ending a career in this way tends to involve acute grief and requires mourning and courage in order to reach a place of acceptance. For this group, experience of retirement may hinge chiefly on their health. If they are well enough to enjoy leisure or new learning then there can be fruitful years once the imposed loss has been grieved.

Two of my contributors were older therapists still practising in their late 80s; these two participants were interesting for their very different stories. Where one was still demonstrating impressive intellectual strength as she went through the process, the other recently retired was facing a steep physical and cognitive decline. If I ever had much faith in the idea of a mandatory retirement age, hearing these two divergent stories made that option less convincing. Yet the profession has to find some way to protect clients. The evidence is clear6,7 that we cannot rely on clients to challenge a failing therapist and a deep sense of loyalty means that many patients will stay with a practitioner who has become quite unfit for work. In my view registering bodies need to provide additional structure to support supervisors in the task of challenging supervisees. Anecdotal evidence tells that supervisors may allow, or encourage, supervisees to move on when they have doubts about practice. This is not so surprising when we consider the challenge the supervisor faces. One of my interviewees had worked with a supervisee who had declining cognitive ability; she described what it took to sustain a challenge with someone who repeatedly forgot what had been agreed.

These four groups were based on tangible differences between retirees and they cannot tell us about the impact of our internal world on how we manage loss. Most of us who do this work are aware of being wounded healers and it is often our challenging early environments that have motivated us to better understand ourselves and others. If becoming a therapist has been an aspect of our own healing process, how hard might it be to let it go? If we are fulfilled and affirmed by our daily interactions with clients, we may doubt what we could possibly find to replace this intense, boundaried engagement with another.

One of my interviewees reflected on this: ‘It’s about saying goodbye to a huge part of one’s life... and I think that’s been really hard…. Loss of identity, loss of feeling worthwhile, that you’re contributing and offering… all those things that would make one feel quite good… I used to feel quite good about myself after seeing a client… I found being a therapist really creative’ (pp156-157).4

How clients respond to being left

Being reliably available and sensitively attuned at a set time week after week is a key part of the containment we offer and thus when the therapist says she will be withdrawing there can be dismay in clients. Fortunately this experience of rejection can be worked with and, in some cases, the working through can lead to a deepening of self-understanding and a fuller resolution of old patterns. Because attachment theory speaks directly to issues of separation and loss, it can be particularly helpful in understanding and containing the varied responses of clients.

Clients with a more avoidant pattern will be more likely to understate their distress both to the therapist and crucially to themselves. I heard of a number who swiftly announced that they really had wanted to stop anyway. Only one or two actually ended in order to avoid being left, whilst some others continued to attend sessions but became more defended against the meaning of the relationship. An example of this virtual departure was described to me by someone whose therapist had imposed an ending for relocation. This former patient said that in their mind the therapy had ended at the moment their therapist shared the news. In this sad case we have no information from the other side of the room – did the therapist notice that the client had ‘departed’ and what did she do to invite the client to re-engage?

Clients who have ambivalent/preoccupied traits may show more overt protest and distress about the ending, even if their message is disguised as anger or disappointment about other aspects of the work. For these clients, whose early family life led them to develop strategies for getting and keeping a parent’s attention, there may be feelings of desperation as they see their attachment figure retreating from them. Where early attachments were particularly interrupted – such as clients who were adopted or who lost a parent in childhood – there may be a disorganised attachment and the news of their counsellor’s retirement will be particularly significant.

Whatever the client’s attachment style we will want to think about the stage they have reached in the work and the way they are currently experiencing the transference. It would be easy to assume that clients who have nearly ended or who have just started in therapy will be less affected by the news but this will depend on other factors. When a client enters an open-ended therapy they have the right to assume that, barring calamities, the therapist will be available as long as they are needed. For a new client who has just made the huge step of exposing themselves to therapy, the news that her therapist will be retiring could feel like a sharp betrayal. Clients who are in the middle of their therapy journey will vary. Some may feel real benefit from transferring to a new therapist – perhaps a chance to work with someone of a different gender or modality. For some the intrusion of the therapist’s own agenda could be very damaging. If a client has recently reached a deeper stage of trust, allowing the therapist to become profoundly important in their inner world, the abandonment would be very hard. For such a client we might expect that parts of the self are being temporarily carried by the therapist and consequently the loss of connection to this other who knows me, perhaps better than anyone ever has, will feel deeply threatening.

How therapists cope with closing a practice

The experience of retirement is interwoven with that of aging and this makes it impossible and perhaps unnecessary to separate them fully. For most people retirement is a major transition which points towards the end of life and which signifies, to the young, that we are old. This alone makes it daunting because our society is known for low respect for elders and for devaluing those who are not participating in the economy. In addition this life stage may bring multiple losses – of health, capacities, family members and friends. There is a risk that defences, which could relax a little during our most productive and fulfilling years, may resume a sharper hold on us as we face uncertainty, anxiety about death and the prospect of losing independence.

There are many facets to the losses which retirement brings – one which was grieved by several in my study was the loss of colleagues. As well as loss, those in the process of closing a practice will face increased intensity in the work. Given this need to be available to our clients, who all have a fresh reason for distress and anger, how can the counsellor support him/herself and remain robust enough to work with this protest? Some retirees find it very helpful to return to personal therapy for a period. Others are able to get sufficient support from supervision and to use that space to acknowledge and process feelings thrown up, not just in response to particular clients, but also around the loss as a whole.8 We need a supervisor who is sufficiently comfortable with her own aging process that she is open to thinking about how the supervisee’s retirement may be impacting on the supervisory relationship. If we have established a tradition of annual reviews in supervision, this may provide a context for supervisor and supervisee to think together about aging and perhaps to evolve a plan of how we would eventually want to wind down our work.

Once the decision is taken it will be important to track the process of telling each patient; almost every member of my study reported a particular difficulty about telling a certain patient – the time never seemed right: either the client arrived with a crisis of their own, or it was too close to a break, or the therapist had to take a dental appointment. In such cases we need time to ponder what is going on in our counter-transference. Then there will be decisions to make about referral on – clients may have a view but the therapist will want to take time to ponder what they feel is best and perhaps to come up with the name of a colleague for those clients who want to be referred on. Again our own feelings and anxieties about our work could impact and we need supervision to help with discernment. Are we over-protective towards clients, wanting them all to go on to more work, because we cannot bear that they will be fine without us? Or are we over-cautious about referring on because we dread our work being scrutinised by a younger colleague? Conclusion

We are used to the repetition of patterns, and retirement is no different – we are likely to approach it in the spirit we have brought to previous endings. The more avoidant of us will struggle to allow the full meaning, and the more ambivalent may find ways to hold on longer. Some envy towards younger colleagues and some regret about what we have not achieved are likely to be part of the package for most of us.

All of us will eventually reach our final session. When we close the therapy room door there may be a honeymoon period before settling into a new life stage in which we all hope for fulfilment but are fearful of loneliness and loss of meaning. Vaillant9 suggests four predictors of satisfaction in retirement (forming a new social network, playing, creativity and life-long learning) and he offers a delightful distinction between playing and creativity:

‘Picasso worked tirelessly to be sure that the whole world was watching. In contrast, a kitten performs acrobatics never exactly performed before’ (p230).9

Those of us in peri-retirement may want to think carefully about how we might include Vaillant’s four criteria in our life after work. If we work with long-term clients it is particularly vital that we plan ahead: we will want to select what type of clients we take on and to avoid working with those whose early attachments were fractured. Whatever our modality, our theories will help us understand the impact of an imposed ending, and through this reflection we aim to minimise harm to patients from this unusual intrusion of the therapist’s own agenda.

Anne Power is a member of BACP and UKCP and has trained as an attachment-based psychoanalytic psychotherapist, as a couple counsellor with Relate and as a supervisor with WPF. She is a Visiting Lecturer at Regents University, London, and has a private practice in London. She is the author of Forced endings in psychotherapy and psychoanalysis: attachment and loss in retirement, published by Routledge in 2015. Please email [email protected]

References

1. Sugg S. Retirement: when is it time to stop? Therapy Today 2011; 22(7): 19. 2. Russell M, Simanowitz V. Retirement or renaissance? Therapy Today 2013; 24(2): 14–18. 3. Bowlby J. The making and breaking of affectional bonds. London: Tavistock Publications; 1979. 4. Power A. Forced endings in psychotherapy and psychoanalysis: attachment and loss in retirement. Hove: Routledge; 2015. 5. Boyd-Carpenter MJ. Reflections on retirement. Psychodynamic Practice 2010a; 16(1): 89–94. 6. Carlisle E. Life-long analysis? In: Junkers G (ed). The empty couch. London and New York: Routledge; 2013 (pp67–78). 7. Sorensen B. And when the therapist or supervisor dies… In: Barnett L (ed). When death enters the therapeutic space: existential perspectives in psychotherapy and counselling. Hove: Routledge; 2008 (pp193–206). 8. Power A. When a supervisee retires. Psychodynamic Practice 2012; 18(4): 441–455. 9. Vaillant GE. Aging well: surprising guideposts to a happier life from the Landmark Harvard Study of Adult Development. Boston: Little, Brown and Company; 2002. +++ When supervision goes wrong

Els van Ooijen considers what can go wrong if supervisors are not adequately prepared for the role

The number of supervision training courses is ever increasing, yet it is not uncommon for practitioners to receive supervision from untrained supervisors. During my 15 years’ experience as a supervision trainer I have heard many stories about the kind of supervision people receive, ranging from excellent and supportive to unhelpful and traumatic, with many shades in between. Ideally, supervision should be a place where we offload, regroup, reflect, learn and develop. Proctor1 identified supervision’s three functions as supportive or restorative, educative and normative. These three functions are intricately intertwined and all three are totally dependent on the quality of the supervisory relationship. Without a good relationship with our supervisor we are unlikely to feel safe enough to bring to supervision difficult issues or possible mistakes, in which case we will neither get the support we need, nor the opportunity to learn or feel assured that we are working well and ethically. In this article I give an example of what can go wrong if supervisors are not adequately prepared for the role.

Vignette

Sarah had been supervised by James for many years, so when he retired she felt this as a real loss because theirs had been a warm and mutually respectful relationship. Sarah was a very experienced counsellor and indeed had a number of supervisees herself; for her new supervisor she therefore chose Ann, who had been working as a counsellor for a long time. Sarah had not met Ann before, but during their first meeting, when they discussed their respective backgrounds, she felt sufficiently comfortable to start supervision with her.

I happened to meet Sarah six months later, and asked how she was getting on. Immediately her eyes filled with tears. ‘Not good,’ she said, ‘in fact I’m very upset.’ Ann had seemed OK, Sarah said, but she had come to the conclusion that she has no idea about how to supervise. ‘Ann doesn’t seem to give me any credit for possibly knowing what I’m doing! Instead she seems hell-bent on trying to catch me out.’ Sarah explained that she had tried talking to Ann about this and things had seemed to improve but then had started to slide again. ‘It got to the point where I was dreading supervision, as I didn’t want to bring anything I might be criticised about. One session was particularly bad and left me feeling really upset.

‘I had spent quite a bit of time going through my client notes in order to find something fairly straightforward to talk about. In the end I decided to bring a client who I really enjoy working with and had not talked much about before. But I didn’t get very far at all. ‘I wanted to first give a brief synopsis of my work with the client before going on to talk about something that happened in the last session, but Ann soon stopped me and said, “Could you please get to the point?” I felt annoyed and told her that as this was a client I hadn’t talked about much I wanted to give her a bit of context. Ann then said, “Why? I am not the one working with the client.” This made me feel criticised and I became defensive. I told her that as a supervisor I tend to find it helpful to have a bit of context before spending time reflecting on what is going on in the therapeutic relationship. She then lectured me that supervision is all about making sure that I work effectively and ethically, and that she’s not therefore interested in knowing that much about the client. I felt rubbished and confused by Ann and wondered, “What on earth is going on between us right now?” but was too angry to say anything and just sat there glaring at her.’

Sarah decided to start looking for a new supervisor straight away. She didn’t feel safe enough to try to work things out with Ann. ‘I’m sure she means well,’ said Sarah, ‘and is trying to do the same thing as I do in supervision, it’s just that she seems to have no idea how to do it! For example, she never asks, “What was that like for you?” or “What are you left with?” or “What do you feel in your body when you’re in the room with this client?” or “What is going on for you right now as you are talking about this?” or anything else to encourage my reflection. I wonder whether she has had any training in supervision and may just be repeating what she has experienced.’ Ultimately Sarah recognised that this supervision made her feel the same way she had felt in the past when she was bullied in an organisation and had to take time off work.

Need for a secure base

Supervision is quite tricky – a lot of people assume that experience as a therapist is all you need, but that’s not true; it is actually quite a different activity. Sarah’s experience shows that things can sometimes go badly wrong in supervision. Supervision is not counselling or therapy, but for each activity to be effective a secure relationship is crucial. Omand refers to supervision as a ‘joint enterprise, a rich experience, often enjoyable and stimulating, (but) sometimes problematic’.2 That supervision can sometimes be problematic is shown by research carried out by Ramos-Sanchez et al.3 This showed that negative supervisory experiences can in turn have a negative effect on the supervisee-client relationship: ‘It is hard to imagine that effective supervision can occur without a solid supervisory relationship.’3

It is therefore helpful to ‘take the time to get to know each other a bit before embarking on a supervision agreement and to listen to your own feelings about the other person’.4 It is also essential for both supervisor and supervisee to be respectful and to take care of each other. No one should leave a supervision session feeling as if they’ve been bullied, as happened in the above example. When we go to supervision we put ourselves in a potentially vulnerable position, so it is essential that we feel able to talk about how we work, without feeling judged or criticised. However, anxious supervisors may become overly prescriptive and rule driven, which can result in conflicted relationships with their supervisees.5 It seems likely that this is what happened between Ann and Sarah. Despite her considerable counselling experience, Ann may have felt intimidated by Sarah and overcompensated by being needlessly authoritarian. Sarah for her part was probably still mourning the loss of her previous supervisor and might have needed more time to adjust to working with a different person.

When we discussed what had happened further Sarah told me that not only did there appear to be a personality clash between Ann and herself, she also felt that they had different views on the supervisory relationship. Sarah said that whereas her view of the supervisory relationship between experienced practitioners is one of equality, this did not appear to be the case for Ann. Sarah’s experience appears to be in line with research carried out by McCarthy Veach et al who identified individual differences and power differentials as possible causes of conflict in supervision.6

As counsellors or psychotherapists we aim to provide a ‘secure base’, an environment where clients can process difficult experiences, so that those experiences do not get repeated in other relationships.7 Similarly, it is part of a supervisor’s function to provide a secure base for supervisees and thus respectfully hold them, so that they in turn can hold their clients. As McCluskey and Gunn point out, practitioners need empathy and a ‘containing environment where they can make sense of the turbulence of the often unprocessed feelings that they may be dealing with, both in themselves and others’.8 Bowlby himself appears to have been a good example of how to be containing in supervision and is described by at least one supervisee as ‘warm, caring, and reflective all the way through’ which helped the supervision to become a ‘secure base’.9

In counselling and psychotherapy we use ourselves as a tool, which has been described as a ‘therapeutic use of self’.10 If therapy goes well, we connect with clients in a deep way; Mearns and Cooper call this ‘working at relational depth’.11 As a supervisor, I need to be respectful of that and attempt to meet my supervisees at a similar level. It can feel anxiety provoking to be in supervision, which is why I endeavour to make the supervisory relationship one of equality, safety and warmth. Too often, though, I hear stories of supervisors who are seen as authority figures or ‘experts’ who do not facilitate their supervisees to reflect, but tell them what they think is going on and what the supervisee should be doing about it! Although such supervisors may be held in awe by some of their supervisees, a failure to help practitioners reflect on their practice can result in the creation of overly dependent supervisees. This is because without reflection therapists cannot learn, as ‘what goes unnoticed is not consciously experienced, so cannot be turned into learning’.12 Gilbert and Evans refer to this supervisory style as ‘disciple hunting’ and see it as an abuse of power.13

It is the task of the supervisor to help the supervisee reflect on her practice, come to new insights and thus achieve a ‘super’vision.4 In doing so, both learn from the experience, which is in line with the educative function of supervision. As far as the normative function is concerned, it is preferable to adopt a ‘hermeneutic of faith’ rather than one of ‘suspicion’.14,15 This means that instead of adopting a critical or fault-finding attitude, it is good to start from the assumption that each practitioner wants to work ethically and to the best of their ability. If, however, the supervisor senses that there is a problem with someone’s work, it would be good to help that person become aware of this by, for example, asking them to reflect on all the possible consequences of a course of action.

In view of the importance of supervision it would seem imperative that supervisors are adequately trained for the role,5 but in reality there appears to be considerable variation in the length as well as the quality of such training. It is encouraging therefore that BACP has recently developed a Training Curriculum,16 that provides a framework for the training of supervisors and is based on supervision competencies as identified by a comprehensive review of existing research.17

This is an important development that should help bring clarity regarding what is involved in supervision and how practitioners can best be prepared for this important role.

All identifying details have been changed and persons concerned have given their permission.

Dr Els van Ooijen is a relational-integrative psychotherapist, supervisor and author.

References

1. Proctor B. Group supervision: a guide to creative practice. London: Sage; 2008. 2. Omand L. What makes for good supervision and whose responsibility is it anyway? Psychodynamic Practice: Individuals, Groups and Organisations 2010; 16(4): 377–392. 3. Ramos-Sanchez L, Esnil E, Riggs S, Wright LK, Goodwin A, Osachy Touster L, Ratanasiripong P, Rodolfa E. Negative supervisory events: effects on supervision satisfaction and supervisory alliance. Professional Psychology: Research and Practice 2002; 33(2): 197–202. 4. Van Ooijen E. 2013 Clinical supervision made easy (2nd ed). Ross-on-Wye: PCCS Books (p16; p32). 5. McCarthy Veach P. Conflict and counter-productivity in supervision – when relationships are less than ideal: comments on Nelson and Friedlander (2001) and Gray et al (2001). Journal of Counseling psychology 2001; 48: 396–400. 6. McCarthy Veach P, Yoon E, MacFarlane IM, Ergun D, Tuicomepee A. Clinical supervisor value conflicts: low frequency, but high impact events. The Clinical Supervisor 2012; 31(2): 203–227. 7. Bowlby J. A secure base: clinical applications of attachment theory. London: Routledge; 1988. 8. McCluskey U, Gunn J. The dynamics of caregiving: why are professional caregivers vulnerable to anxiety and burnout, and how do we support their well-being? Attachment: New Directions in Psychotherapy and Relational Psychoanalysis 2015; 9(July): 188–200. 9. Ezquerro A. John Bowlby: The timeless supervisor. Attachment: New Directions in Psychotherapy and Relational Psychoanalysis 2015; 9(July): 165–175. 10. Wosket V. The therapeutic use of self: counselling practice, research, and supervision. London: Routledge; 1999 (p4). 11. Mearns D, Cooper M. Working at relational depth in counselling and psychotherapy. London: Sage; 2005. 12. North GJ. Recording supervision: educational, therapeutic, and enhances the supervisory working alliance? Counselling and Psychotherapy Research 2013; 13(1): 61–70. 13. Gilbert MC, Evans K. Psychotherapy supervision: an integrative relational approach to psychotherapy supervision. Buckingham: Open University Press; 2000 (pp109–110). 14. Orange D. The suffering stranger: hermeneutics for everyday clinical practice. London: Routledge; 2011. 15. Josselson P. The hermeneutics of faith and the hermeneutics of suspicion. Narrative Inquiry 2004; 14(1): 1–28. 16. Counselling supervision training curriculum: a curriculum framework for counselling supervision training. BACP; 2014. http://www.bacp.co.uk/research/resources/supervision-curriculum.php 17. Roth AD, Pilling S. A competence framework for the supervision of psychological therapies. Research Department of Clinical, Educational and Health Psychology, University College London. 2008. http://www.ucl.ac.uk/pals/research/cehp/research-groups/core/competence- frameworks/Supervision_of_Psychological_Therapies +++ Dilemmas

Maintaining boundaries in couple work

This month’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 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 online on the TherapyToday.net website.

She can’t agree to his request

Julia Greer MBACP (Snr Accred) psychoanalytic psychotherapist, couples counsellor and supervisor in private practice

Avril has limited experience as a couple counsellor. Since her own relationship has recently ended traumatically it may be difficult for her to separate her personal issues from that of her client’s. It’s very concerning that when this was addressed in supervision her need for accreditation hours was prioritised over her possible current fitness to practise. Was the organisation informed about the supervisor’s concerns and Avril’s apparent refusal to attend to this issue? And who is holding accountability for Avril’s work? Avril appears to have aligned herself at one stage with Olivia by not pursuing Zachary’s valiant attempt to communicate his concerns about their sexual relationship. Might this be connected to unresolved issues in her own past relationship, or discomfort in addressing the sexual aspect of couple work? Contracting with clients in advance of a discovery or disclosure helps the choice a therapist makes about secrets. We also need to be mindful of our legal and ethical responsibilities, and know how to respond when the boundaries we have set are breached.

Avril cannot agree to Zachary’s request because she would be colluding with him in another layer of deception and betrayal. Additionally she may have no expertise in assessing or working with Zachary’s own diagnosis of online porn addiction. We don’t know if this means looking at online porn on a frequent basis or compulsive and escalating sexual activity online, which may include illegal images or meetings with online contacts, including sex workers for sexual activity in the real world. Avril’s options are to hold the secret, help the secret to emerge, or to constructively end her work with the couple.

If Avril has contracted that contact outside of the sessions will be disclosed then Zachary may have found a way of beginning to disclose a secret and should not be surprised if Avril reminds them both of this part of the contract at the start of the next session, and tells Olivia that she has had an email from Zachary. Her best option may be to reply to Zachary telling him she will not work with him separately and she will not hold this secret and will end couple work if he chooses not to disclose. She can ask him to make an initial disclosure in or out of the session to his wife and then work with the couple to deal with the impact of the initial disclosure.

They may both need individual and couple work, possibly with counsellors with specialised knowledge of sexually compulsive behaviours and the impact of disclosure work on partners. In the event of Zachary deciding not to disclose, she can end the work with the couple, perhaps by taking a break from couple work on the basis of her own need for self-care.

She can’t hold a secret

Clare Ireland Individual and couple counsellor in private practice and one of six founder members of Coupleworks

This dilemma poses difficult boundary issues. These seem to have contributed towards Avril’s present predicament with regard to Zachary’s request. It seems possible that her supervisor’s and her decision that she did not need time away from work has exacerbated the situation and made the next step harder. Avril’s personal story and the reasons we are given for her recent separation present the possibility that she may not be able to remain objective. While her husband’s online dating activities and Zachary’s confessed porn addiction are not entirely the same, it would seem hard for Avril to detach and remain balanced if she agrees to Zachary’s request. The best solution may be to explain to Zachary in her email reply that she cannot hold a secret that is unknown to Olivia. That would be true even without the online part of the problem. This would mean that she could no longer work with them as a couple. If he feels able to tell Olivia what has happened then they could return to the sessions and together with Avril look at what has happened and try to find a way to understand the root of their situation. There may be things that feel too hard to address together but with Avril’s help they may find some areas where the communication between them can be improved.

If, however, Zachary feels unable to tell Olivia, Avril can suggest referring them to another couple counsellor and Zachary can find a personal therapist who works with addictions and the way to surmount them. Avril might be helped personally by finding a therapist who can help her to process what has happened in her marriage, and the secrets therein. There may be help for her in her Christian counselling service or if she felt this might not be safe, she could find an independent therapist. They could look at issues of rejection, lack of trust, anger and betrayal. This would help Avril in her work towards accreditation.

Don’t engage with the email

Clive Lees MBACP counsellor working with children and young people

The first issue is whether Avril’s personal experience with her husband is undermining her resilience, a personal moral quality in the Ethical Framework, and whether her apparent reluctance to acknowledge this means she is not demonstrating humility, another personal moral quality. The supervisor should clarify that her need to accrue the hours necessary for accreditation is not a relevant consideration in determining the best course of action for the professional care of her clients. The only issues are: firstly, whether her personal experiences have impaired her resilience and if so what should be done about it, and secondly whether she has the humility to acknowledge her weaknesses. Failure to address these issues would mean that, firstly, the ethical principle of beneficence would be undermined since she would be acting in her own interests and not those of the client, and secondly she would not be abiding by the ethical principle of self-respect, which requires practitioners to care for themselves.

But what of the clients? Acceding to Zachary’s request for concurrent individual counselling would fatally undermine Olivia’s trust in the process and would act out the non-communication between Zachary and Olivia. Avril should decline to engage with the email and avoid establishing any individual relationship separate from the relationship with the pair of them. Hopefully her contract with them will make this clear. She might simply respond to the email by saying that she would be happy to discuss the subject if he would care to bring it up in their next conjoint session. I believe it would be best if, in that session, Avril did not herself reveal the existence of the email, partly because this would mean she would then be bringing new material into the room and partly because it would undermine Zachary’s trust in Avril. If Olivia learns of it, Avril can confirm the existence and say she did not engage with it.

Why did Avril not pick up on the hints? She should explore this in supervision to see whether her own personal circumstances make Zachary’s sexual frustration an uncomfortable topic for her. Another issue to explore is whether the hints really were about his sexual frustration and not simply her interpretation. However, a possible intervention might have been, ‘That sounds like a hint,’ and see if either of them responded. In this way, a conversation could have been started about the lack of communication between them, which was, after all, the presenting problem.

And what of the alleged online porn addiction? It may not really exist, it may or may not be serious or indeed illegal, and it may or may not point to deeper relationship issues. Avril will have to wait until Zachary reveals it in a conjoint session. Could Avril refer Zachary to another counsellor for individual counselling? It is an option but on the available information I would not do so as it could represent Zachary acting out and perpetuating the non- communication with his partner.

Offer each of them solo sessions

Nick Turner MBACP, UKCP, COSRT; relationship and sex therapist and course director of the diploma in sex addiction counselling at the Institute for Sex Addiction Training

One principle of couple therapy is that confidentiality is owed to an individual, not to the couple. Avril should, unless there are exceptional circumstances, uphold Zachary’s confidentiality. In couple therapy this can sometimes carry the consequence that the therapist is left holding a secret. The judgments that Avril must make with the assistance of her supervisor are whether: 1) the secret is a challenge to the physical safety of one or other of the couple; 2) the secret she now holds threatens the viability of her continuing to work with this couple; and 3) she believes she is competent to work with this particular secret. So far, the only judgment considered with her supervisor is her fitness to practise.

The use of porn is widespread: children as well as adults are likely to have been exposed to internet porn. Addiction to internet porn is also widespread but may not be well understood by those who seek help for it nor by therapists. The fact that Zachary has confessed to ‘an online porn addiction’ in an email to Avril merits an assessment which she may not be competent to conduct, even if she were in a position to do so, which she is not. Though the use of porn by one of the couple might challenge the viability of the relationship, it is much less likely to pose a threat to physical health – masturbation is a good example of safe sex.

It can be very challenging for a counsellor to hold a secret. The fact that one member of a couple is using porn, however, need hardly be a big surprise to a counsellor. A competent couple therapist provides an opportunity for each of the couple to discuss their thoughts and feelings about their sexual relationship in a safe and supportive environment. The couple may be disinclined to take up this opportunity early in counselling but the counsellor should nevertheless make it clear that this is a discussion that can be had later and follow up any cues swiftly and sensitively. Avril seems not to have picked up on cues from either Zachary or Olivia, possibly reinforcing embarrassment (or perhaps guilt or shame?) about sex for this couple.

One way forward for Avril is, at her next appointment and without replying to Zachary’s email, to make a standard offer of a solo session with each member of the couple, to help them explore in private relationship issues they may not yet feel ready to discuss together. Obviously, a clear confidentiality contract needs to be agreed with the couple in advance. In the solo sessions Avril will be able to clarify the boundaries of her work with the couple and to signpost Zachary to the support he needs to address his concerns about online porn. This will help Avril establish a clearer agenda with the couple for further subsequent couple therapy. Finally, Avril needs to examine her views, values and attitudes about sex and to undertake further training in sex addiction.

She must make an onward referral

Christina Fraser, MBACP, relationship counsellor

When working with couples it is paramount that allegiances are not formed between the therapist and either one of the couple. The couple is the client rather than either of the two individuals. Couple counsellors will often be contacted by one or other of the couple in therapy and it’s vital not to feel seduced by this. In every therapist there is a struggle against being omnipotent: becoming the helpful listener who can sort out the mess.

Avril has only just qualified and may not yet have met this situation, but one helpful focus in couple counselling is working with the understanding that the therapist does not hold a secret that only two people in the room know. If she holds this knowledge then she and Zachary have an alliance about which Olivia is oblivious. Avril should take this to supervision, preferably before the next session, and inform Zachary that reluctantly she cannot continue to work with them both unless he opens up to Olivia. She might also discuss with her supervisor how her own recent situation may lead her to want to try and get more involved with their case. It might be tough for her to absorb all this parallel drama so soon after the circumstances of her own separation.

This new piece of knowledge is part of the fabric of Zachary and Olivia’s relationship and it sounds as if perhaps something in their sessions together may have propelled him into wanting to change this behaviour. It’s a brave step to confront an addiction, and he needs to see an addiction specialist or psychosexual therapist. Working with one of a couple at the same time as seeing both of them is not ethical or helpful. Secrets and loyalties will prejudice the relationships. When connected to the couples we are working with, it’s often hard to pass one of them on to another therapist, but Avril has no choice.

She’s not skilled to work with porn addiction

Gina Crowley, Teacher, lecturer in education (SEN), coach and trainee couple counsellor

I understand the need for trainee and recently qualified practitioners to build up their hours but this therapist may need to be reminded that the basis for any therapeutic relationship cannot be the therapist’s need for accrued hours. When the therapist’s main focus is on his or her own need then something is amiss. Regardless of Avril’s recent personal history and her own attitudes to internet sex and the ethics of working with Zachary privately, it is unlikely that she will be qualified to counsel someone with a porn addiction.

This year I attended two BACP CPD days with Paula Hall on porn addiction. I learned a great deal and now perhaps have the tools to identify someone with a porn addiction. But I do not know enough to counsel or work effectively with such a person. This is specialised work and to work effectively with the growing number of porn addicts requires specialist training.

She should address the email in the next session

Sarah Briggs, MBACP (Accred), Director of The Grove Practice Limited

Although Avril is unsettled by Zachary’s disclosure, she can rely on important ethical resources: her training, the organisation’s therapy contract and her supervision. The dilemma is how to support Zachary and respect Olivia following his secret disclosure and request for individual therapy hidden from Olivia. However, both parties in this marriage instructed Avril jointly. Her training provides a duty of care to each client in a framework where the relational dynamics are the focus of attention. Her verbal and paper contract should ideally state that any communication with the agency or therapist from either couple client would be made transparent to both parties. Hopefully Avril also stated in the first session that she would not keep any secrets.

Drawing upon this contract and referring to organisational guidelines, without responding to Zachary’s email, she can begin the next couple session by stating that she has received an email from Zachary that would compromise their couple therapy unless it is addressed. Zachary then has a choice about how to proceed without Avril necessarily being required to make any further revelation – she can hold printed copies of his email in her folder in case she needs to present evidence of the situation in the session. She can unilaterally withdraw from working with this couple if Zachary is unwilling to talk further, saying she may not be the best therapist for them, while referring them or him to another therapist in the agency – one who has superior psychosexual training and experience in tackling porn addiction. Avril cannot un-know the knowledge she gained from Zachary. If she replies to the email without Olivia’s knowledge, or if she continues the couple therapy while Olivia is in ignorance of this, or even if Avril undertook individual therapy with Zachary while intending to uphold the couple therapy, she would be colluding with Zachary’s secrecy and undermining Olivia’s autonomy.

Although it may be destabilising or explosive when Avril brings this into awareness, arguably she cannot continue relationship therapy with this couple without attending to the input from Zachary. This situation is a stark reminder that overtly discussing sex in couple therapy early in the process can avoid subversive tactics from clients to address the topic (Zachary had raised sexual frustration, which was not pursued by Avril or Olivia). Avril may interpret that Zachary has found a way to prompt discussion of material that he could not voice directly.

Parallel process is presumably on Avril’s mind: this couple’s presentation, alongside her own recent marital separation following the discovery of her husband’s secret online activity. There is also a parallel process for supervisory attention: Zachary’s porn addiction was secret, as was his request for secret therapy. Avril can reflect in this scenario upon the applicability of these particular personal moral qualities listed in the BACP Ethical Framework: integrity, fairness, competence, courage – adjacent to the Christian values of the organisational context and the provisions of the Data Protection Act 1998.

Maintain authenticity and professionalism

Colin Wels, MBACP (Accred) counsellor in private practice

I realise that there are two schools of thought on couple counselling: one that says one should see the individuals for sessions as well as the couple together; another that says that the couple is the client and that there should not be contact with the individuals on their own, except for making practical arrangements.

As a counsellor that works in the second way, I think there are compelling reasons for doing so. If I have information about the couple that has come from outside of the session, and I was not to share this with both parties, I am holding a secret. Thus I am being inauthentic and incongruent, with the danger that I might accidentally divulge the secret, or I might be asked a question by one of the couple that either shows I have been withholding this information or alternatively that would require me to lie. At that point there would be a complete loss of trust in me as a counsellor and a challenge to my professionalism.

In this particular case I would have made clear in the contract that I will not talk to either individual on their own, and if one leaves the room (for instance to go to the toilet), I will leave the room as well. In that way the person who left the room would be in no doubt that nothing else was said and being kept from them. I would explain that I do not want to be responsible for keeping the secrets they might have from each other.

I would suggest to Avril that she now says to Olivia and Zachary that she can no longer see them as a couple because Zachary has spoken to her as an individual and therefore has broken the contract. She should then refer them to another couple counsellor. Avril could say to Zachary that she could carry on with him on his own to work on his issues, but would not be able to work with Olivia because of the individual contact Zachary has had with Avril.

Her impartiality has been compromised

Leon McCarthy, Level 4 diploma student, West Herts College

This is obviously a delicate situation for Avril, but I can’t help wondering if she made her boundaries clear at her first meeting with Zachary and Olivia. A counsellor wouldn’t normally have to tell clients that divulging personal details outside the room is inadvisable but this surely has to be inferred. Did something in Avril’s demeanour give Zachary license to feel he could contact her outside the confines of their sessions? Although it is very difficult to completely keep one’s email address secret, should Avril not have made it clear that contact should only be made through the agency she is representing?

Before she even thinks about replying to Zachary, Avril needs to contact her supervisor for help and advice in managing this tricky scenario. However, I imagine that it would be impossible for the same counsellor to see a client both individually and as part of a couple. That said, Zachary has asked for her help and I would certainly hope Avril would at least be encouraged to signpost him to other agencies better suited to help his addiction. It seems a shame that Zachary’s need to talk about sex (or the lack of it) wasn’t explored further in the sessions. It seems his need to discuss this was unfortunately suppressed and he has now chosen to blurt it out in an unsolicited manner.

As for her future counselling with Zachary and Olivia as a couple, I wonder how this can proceed. I cannot see how Avril can carry on seeing them with the new information that only she and Zachary are party to. Avril cannot unknow what she now knows and the impartiality needed for her role has been severely compromised. Having experienced a not completely dissimilar situation in her own marriage, Avril’s ability to fully empathise with Zachary’s situation could be in doubt. It seems that her need to amass hours may have clouded her judgment and perhaps six months was just not long enough before offering counselling to couples.

Ignore things at your peril

William Johnston, Person-centred counsellor in private practice I do not see any circumstances under which Avril can agree to seeing Zachary on his own. So far as I can see, the only way that the sessions can be saved are if Zachary can become willing to talk about his use of pornography in the next session. If he won’t, then this particular elephant is going to be far too big to be sidestepped. Even without such an arrangement, Avril has been placed in the impossible position of carrying a secret on his behalf. This is not a confidence, since he revealed it to her in a form – a private email – which, if the boundaries of the sessions have been reasonably well defined, should sit quite outside the norms of this counselling relationship. My suspicion is that despite Zachary’s plea that Avril not tell Olivia, he might want the secret to be blown open. It is difficult to think that he would not understand that Avril couldn’t do as he asks. On the other hand, it is Zachary who is going to have to broach the discussion.

If Zachary will not bring the discussion to the sessions, then the greater difficulty for Avril is going to be how to terminate the sessions. Inventing a reason is out of the question, and simply terminating them without explanation is likely to create a lot of distress for Olivia. I can’t see that there is a good or painless way of doing this.

I do note that Zachary felt the need to tell Avril about his pornography addiction. I also particularly note that he hinted in sessions (or a session) that he was frustrated with his sexual relations with Olivia, and that Avril did not pursue this. I am really puzzled as to why she didn’t. It almost feels as though Zachary’s email to Avril is a desperate shout for help where his hints were ignored. I would urge Avril to reflect on her own relationship with sex and sexuality. Does she find this a difficult subject to engage with? Or does she somehow see it as secondary to other concerns?

December’s dilemma

Pat, an experienced counsellor in private practice, has been in regular monthly supervision with Sylvie for over a decade. He has greatly valued her supervisory input over that time, and their relationship, though strictly professional in the early years, has grown increasingly personal and he is very fond of her. In his mid-60s, Pat considers himself to be in the latter stage of his career; some 10 years older than him, Sylvie gives no indication she’s thinking about retirement.

Over the last year when something urgent relating to his work with clients has arisen and he has needed to contact Sylvie between supervision sessions, Pat has found it increasingly hard to receive a timely response from her to his phone messages and emails. He has also noticed that she’s been forgetting details about his clients at an increasing rate over the months. Because he knows well enough how it feels to be getting older, he has tried gently to talk to her about these issues but feels his efforts have landed on deaf ears. Furthermore, he knows Sylvie has had some extremely difficult issues to deal with in her private life and he has a lot of compassion for her. He also intends to wind down his own practice within the next couple of years and would rather try to improve the situation than find another supervisor.

What should Pat do?

Please email your responses (500 words maximum) to John Daniel at [email protected] by 25 November 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

The trauma of adoption

Thanks for a heartbreaking and informative description from Dave Collins on some of the traumas of being an adoptive parent. As an adoptive mother and ex-Adoption Medical Advisor and Designated Doctor for Children in Care, I learnt that social workers are generally over-optimistic about adoption as a solution for children who need new parents. All adopted children have been traumatised even when adopted soon after birth. I was particularly worried when first-time adoptive parents were expected to take on two or three very traumatised children with enormous emotional needs, and have seen a lot of these adoptions break down very painfully. The literature suggests that children who are adopted should start therapy early to address the inevitable (and universal) attachment trauma and the trauma of abuse, and if this doesn’t happen the outcomes may be very poor even when adoptive parents have been devoted and steadfast in their love.

Prospective adopters need to be warned that this choice is likely to challenge even the most securely attached adopters and it is not for the fainthearted. In addition the challenges may only start in adolescence or when adoptees reach adulthood. Therapists need to understand that all adoptees were traumatised even though they cannot articulate the trauma, which is held in their bodies as pre-verbal implicit memory, and too many therapists collude with adult adoptees when they report that for them adoption is not an issue.

Jan Topley Counsellor, supervisor and EMDR practitioner, Bristol

Who wants the psychiatric model?

James Agar suggests (Letters, Therapy Today, September 2015), that there is a marked difference between the training of counsellors and psychotherapists, and he cites especially the issue of understanding psychiatric labelling. His assertion that the difference is ‘five years and £50,000’ makes me want to weep.

Ironically in the same issue David Cadman (p38) echoes other calls for the internecine warfare between counsellors and CBT to stop. Now we have another war – albeit one which has simmered away for years. At its heart is the issue of trying to be accepted as ‘professional’ by other professionals, so involving the dreaded ‘status’. The psychotherapist wants to be seen by the psychiatrist as a worthy peer.

However, let us look at what exactly is being signed up to – the pathologising of clients by labels assigned to them through the DSM-V or ICD-10. At a recent conference the inspiring Eleanor Longden suggested that we ask individuals not ‘What is wrong with you, but what has happened to you?’ How far we stray from that acknowledgement of distress when we believe our worth is coming from an acceptance and apprenticeship into the psychiatric model. I understand diagnosis and labels, but in the end what matters is the person in front of us, their story and the sense we can make of it between us, in order to alleviate that distress to some degree. That is not to rubbish all medication, and yes some individuals want and appreciate a label. Surely what we offer is an additional/alternative way of describing and understanding personal experience.

So yes, those who train in psychoanalytic and psychodynamic traditions may spend time studying the medical model, but it doesn’t mean that those who do not are less worthy or less effective. We can all read and assimilate information, and our clients have often been receivers of medical wisdom – some to good effect, some not. There are many within psychiatry who find the system of categorising and labelling unhelpful (Joanna Moncrieff, Sami Timimi etc), so why would we want to become acolytes of that system, which is itself subject to criticism (see Dr Ben Goldacre on Serotonin and depression, or Sami Timimi on ADHD and Ritalin). My plea is for less ego, more focus on what good any of us can do, and especially on alleviating distress in the best way we can, whilst recognising that no one has a monopoly on virtue and truth.

Diane Collingwood

Let us see beyond the title

In James Agar’s letter (Therapy Today, September 2015), he argues that the distinction between psychotherapy and counselling should be maintained on the basis that psychotherapists are more highly trained than counsellors due to their course requirements.

Whilst I agree with the need for effective practitioner training and working competence, what appears to be missed by both this letter and the original article (‘What’s in a label?’, Therapy Today, June 2015) is the existing breadth and depth of experience many counsellors bring with them into training. I have studied and worked alongside counsellors from all walks of life, including those from social work and psychiatric/psychological backgrounds, as well as individuals with lived experience of mental distress. I am not alone in having worked in a variety of mental health settings pre, during and post training. I have worked within mental health for nearly 10 years, incorporating several roles at the ‘sharp end’, including survivor-led crisis support and advocating for individuals detained under the Mental Health Act on both locked and forensic wards.

Let us not make sweeping generalisations; just as I hope we would all aim to see beyond a client’s label, let us see beyond the ‘counsellor’ or ‘psychotherapist’ title to the person, skills and experience underneath. Zoe Gilbert MBACP

Personal therapy is important

I trained both as a counsellor and as a psychotherapist and value both trainings whilst also acknowledging the differences.

James Agar (Letters, Therapy Today, September 2015) refers to the anxiety that medical labels can cause to counsellors because of the lack of training in mental health in counsellor training (in contrast to psychotherapy training). I agree this is a deficit and that counsellors need to be better prepared for working in medical settings and alongside our medical colleagues.

However, for me the biggest difference between counsellor and psychotherapy training, and what in my view sets them apart, is the requirement for personal therapy. As a psychotherapist I was required to have my own therapy for the five-year duration of the training which included two years of twice weekly therapy.

In my view having had personal therapy is as important as ongoing supervision for working in depth and for working with complex need.

Frances Bernstein MBACP (Accred), UKCP Registered Psychoanalytic Psychotherapist, Cert Sup

Vulnerable to bullies

I have always been vulnerable to bullies. At school I came in for fairly subtle bullying – the sort of teasing to which you are meant to reply: ‘Sticks and stones etc.’ It doesn’t work, of course, because humiliation does not have to be physical to hurt to the core. Vestiges of that vulnerability remain to this day.

I also recognise that there are two facets to my situation when faced with bullies. There is the energetic movement of the bully and my own internalised helplessness. I can’t control the bully, but I can learn better to confront that energy and to hold on to my own power. I don’t always manage to do so – though it gets better.

Reading Dave Collins’ account of living with his adoptive child’s violence, I was struck more than anything else by the sheer honesty of his account. Above all, I heard no attempt to apportion blame – either to himself, his wife, or to the child; and this despite the concerted efforts of the professionals he encountered to do precisely that. In fact, though he expresses considerable frustration around the responses from those professionals, even there I did not hear him blaming them. Just anger for their failure to listen.

Accordingly, when Patrick Quinn, in his article on adult bullying, implies that there might be bullies who are simply evil, and therefore beyond redemption, I cannot accept that notion. In my own experience of being bullied, I recognise that people have done and said things to me that are simply wrong, and they needed to be confronted – and possibly, in extreme cases – locked up, simply because it was not possible to get through to them. But I also recognise that, however little I might care about it in the moment, there are always reasons behind every action. There is also a form of knowing which is not knowing. There have been aspects of my own life where I know that I am doing something wrong; I am secretive and manipulative around doing it; and I am somehow also disconnected from my actions, so that, in this other life that I lead, what I did never happened, or can in some magical way be explained. It is only when I am confronted in the moment, such that I find myself running into cold reality as though it were a brick wall, that I am able to acknowledge the true nature of my actions.

Every tale, as in Dave Collins’ account, has a backstory. The backstory can never fully explain what is happening today, and certainly cannot provide excuses for abusive behaviour. It is there, however, as part of the overall narrative, and cannot be ignored, as though it were possible to draw a beginning and pretend that there is no history before that beginning.

My own vulnerability dates back to the circumstances of my birth, parenting and family, and my bullies all have their own backstory. Part of my own story includes my helpless loathing for individuals who are as worthy of compassion as anyone else, and whom I cannot pity. I accept my own hatred as part of my continuing story, just as I also value the days when I do manage to stand up for myself; and those truly glorious days when I can see straight through to someone else’s pain, without either adding to it, or being overwhelmed by it.

William Johnston Person-centred counsellor in private practice

Relate branch closed

I completely agree with the email from the reader asking to have less coverage of political, social and international issues and more articles dealing with practical matters relating to practising as a counsellor. In September it was China and last month you featured refugees. While it is interesting to think about these subjects maybe Therapy Today is not the best platform. There are other pressing issues which might have more relevance to readers.

Relate in Lincolnshire ‘ceased trading’ last month with the closure of eight offices and the loss of 30 counsellors. There is no mention of this in Therapy Today yet the immediate need of couples and individuals is left unmet. The implication for counsellors in private practice and the other sectors is huge; and the worry is that this is a trend for the future. Lack of funding is the reason given by the Lincolnshire Echo. Is Lincolnshire the first county to be felled?

That such a well-established organisation could close as the country prepares for an influx of refugees who may, in time, be among the couples seeking an accessible form of help seems strange. Denise Pickup

Unpaid work

I completely agree with Max Marnau’s letter (Therapy Today, September 2015)and feel very strongly about the injustice of counsellors working unpaid. I also think that BACP could play an instrumental part in promoting pay for counsellors/psychotherapists.

During my placements, of course I understood that I would not be paid but, as soon as I qualified, searched for paid work. I did manage to get paid work in a charity but at a very low rate. However, there were many advantages from working there and I received a good enough wage to live on (in conjunction with my other part-time job). I eventually managed to set up a private practice, leave the charity and, in the space of about two years, also leave my job in the legal field to do counselling in private practice full-time taking direct referrals, referrals through other organisations and EAPs. However, I still find that pay for counsellors and psychotherapists falls way below that of coaches, psychiatrists and psychologists.

I do not agree with James Wright, in his letter in the same issue, that the market is saturated as this applies to many other professions but they still get paid. I also believe that organisations do have the ability to pay at least something but take advantage of counsellors and psychotherapists’ need for client hours and also their passion for the work.

I believe that there are historical reasons for counsellors/psychotherapists not getting paid but also because counselling and psychotherapy does not fall into the medical model of ‘treatment’. Max is spot on with his examples of other professions who get paid and the injustice that exists in the counselling field. What actually makes me laugh (defensively of course) is how organisations advertise work using the word ‘honorary’ counsellors – as if it’s a highly valued position but actually means unpaid! Maybe, if enough counsellors and psychotherapists say no to unpaid work, things will start to change.

Anna Keen MBACP Accred Counsellor; Integrative Counselling, Maidstone and Tunbridge Wells in Kent

Natalie Rogers

I have just heard of the death of Natalie Rogers – Carl Rogers’ daughter – my friend, mentor and teacher of person-centred expressive arts who died 17 October aged 87. I feel her loss more deeply than I would have imagined; remembering Natalie and reflecting on her significance to me, I am aware of my commitment to the person-centred approach as a creative practice. Here in the UK I hear mixed views of Natalie’s work – some loved her, were inspired by her integration of creative expression into a person-centred approach. Others criticise her work – too directive, more an art therapy than a person-centred approach. She was committed to making a stand against oppression and to using person-centred expressive arts for mediation and peace work. She was a strong feminist and helped me to integrate my politics with my therapeutic practice.

Natalie was wise and shared her passion and creativity. She was loving and was moved by the love and caring of others. At times I also found her impatient. I loved her kindness and generosity, her willingness to be real and honest about her feelings.

The most significant thing that Natalie taught me is something about how the PC Approach is a way of being. A creative process in itself, it is the art of being an artist in relationship. I don’t mean the use of creative forms of expression in therapy – something I both love and continue to struggle with. I mean that she showed me and reminded me, in every aspect of her way of being, that the person-centred approach is not just a model of therapeutic work that I can learn, that can be manualised, researched, ‘evidenced’. Rather it is a way of living and loving fully and creatively in relationship with others.

I have been practising person-centredness for many years now, as a counsellor and in the rest of my life. I have learnt a huge amount from training, from studying theory and research. But I have learnt most, and facilitate best, through experiencing, practising and playing with what it means to be those six conditions in each moment of connection and interaction with another.

Lisa Anthony

Heather Beattie

It is with sadness that I write of the passing of Heather Beattie who died in hospital on 8 October after a short illness, with her family present. Heather was a BACP senior accredited counsellor with over 25 years’ experience, in both the NHS and private practice. She was well known for her work with adults, children and young people, and couples, and also for her work as a supervisor.

I first met Heather over 30 years ago when we were volunteers with Belfast Samaritans, and was struck by her combination of calm and energy and her personal warmth. She was always passionate about the profession and very dedicated to maintaining high standards, and providing the best service she could, whether to clients or supervisees. Despite having to manage health conditions in recent years, which meant she carefully monitored the number of hours she worked, she was always striving to find ways to learn and develop as a practitioner. Only recently she had been developing a service to help people with eating disorders access counselling, as she had specialised in this field. She had also been thinking about writing and publishing, and I believe she still had a great deal to offer our profession.

She will also be remembered for her kindness and humour, and I believe, a gentle faith and compassion. Our thoughts are with her family, and those who have lost a dedicated therapist and supervisor.

Christine Christie Psychoanalytic psychotherapist, Belfast

Contact us

We welcome your letters. Letters may be cut and edited at the Editor’s discretion and those not published in the journal may be published on TherapyToday.net. Please email the Editor, Sarah Browne, at [email protected] +++ Reviews

Pluralism and existential therapy

Existential psychotherapy and counselling: contributions to a pluralistic practice Mick Cooper, Sage, 2015, 264pp, £22.99, isbn 978-1446201312 Companion website: https://study.sagepub.com/cooper

Reviewed by Helen Hayes

In this new book Cooper describes his own version of existential therapy, whilst adopting a stance of pluralism viewing multiple perspectives and practices as helpful to different people at different times. This is reflected in the structure of each chapter which starts with an overview of theoretical ideas, describes their practical application including client case vignettes followed by a critical discussion often referring to empirical evidence, and concludes with a summary of the client issues for which the material might be most relevant.

Cooper’s model of existential therapy closely resembles Ernesto Spinelli’s, emphasising the relational, phenomenological, and experiential aspects. He discusses the primacy of relatedness in human existence, starting from Buber’s I-thou relationship, moving on to person-centred work on relational depth, and then his own formulation of I-I relating as an extension of Buber’s concept to intrapsychic relations. The following chapter on working phenomenologically contains much that would be familiar to person-centred, humanistic, Gestalt and experiential practitioners, as well as existential therapists, with the emphasis on staying close to the client’s experience, clarifying feelings, sensations and meanings within their frame of reference, and using creative methods to enhance the exploration.

However, I felt that this inclusiveness risked losing the particular flavour of existential work. Only in chapter four, ‘Freedom and Choice’, did the specific contribution of an existential perspective become apparent, followed by chapter five on ‘Limitations’ and chapter six on ‘Purpose and Meaning’. For me, these three chapters represent the core of existential work, and Cooper offers a sophisticated yet accessible discussion of these themes in psychotherapeutic practice. Complex philosophical ideas are clearly summarised, client material and invitations to the reader to participate in self- reflective exercises bring the ideas to life, and the inclusion of contemporary research findings enriches the discussion.

This is a practical and pragmatic text offering a version of existential therapy that is flexible, integrative and inclusive. Students and trainers would appreciate the down-to-earth way in which the book illustrates the practical application of theoretical ideas to counselling practice, supported by the accompanying website resources. The book ends on a lighter note, with lists of the top 10 existential films to watch, books to read, and songs to sing along to, a nice way of reminding the reader that existential concerns are indeed everyday experiences.

Helen Hayes is an existential psychotherapist & counsellor

Risk in counselling

Working with risk in counselling and psychotherapy Andrew Reeves, Sage, 2015, 169pp, £20.99, isbn 978-1446272916

Reviewed by Julia Denington

Working with Risk is one in a series of books entitled ‘Essential Issues in Counselling and Psychotherapy’. It covers the key essential issues around risk and I would strongly recommend it as essential reading, particularly for students in training, recently qualified counsellors and psychotherapists as well as those who are more experienced.

The book has a simple layout and reads easily. Each chapter has an outline, introduction and ends with a summary. In the first two chapters Reeves begins by identifying what is meant by risk, and explores risk assessment. He discusses the advantages and disadvantages of questionnaires, as well as professional and ethical accountability.

Subsequent chapters cover the various dimensions of risk. There are chapters on suicide, self-injury and self-harm, of which much has previously been written. However, Reeves also includes chapters on violence and harm to others, safeguarding and child protection as well as various mental health presentations, namely depression, psychosis and eating disorders. There is a chapter devoted to supervision and managing risk in the therapeutic process, which includes the importance of self-care for the therapist. There is also a brief section on working with risk online, which I found useful.

In exploring risk, Reeves addresses five contexts within the different chapters: situational, relational, contextual, professional and personal. There are clinical vignettes throughout the book and the reader is encouraged to ‘pause for reflection’, in order to consider their own practice and how they may respond in certain situations.

The importance of an honest and collaborative approach is emphasised throughout, as well as the need for clear contracting in order to maintain safe and professional boundaries. Research data are included, plus essential references to the law; for example, the importance of considering the client’s mental capacity within the context of risk.

The book is aimed at counsellors and psychotherapists of all modalities. However, Reeves does not explore how different theoretical orientations might influence or work differently around issues of risk. I thought this could have added an interesting dimension and debate, for example, considering an existential as opposed to a psychoanalytic understanding of risk. Perhaps this is for a follow up.

Overall, I found this a straight-forward and useful guide. This book should be mandatory reading for all those undertaking counselling and psychotherapy training.

Julia Denington is a lecturer, integrative psychotherapist and supervisor

Gender and power in the workplace

Gender, power and organisation: a psychological perspective on life at work (second edition) Paula Nicolson, Routledge, 2015, 180pp, £29.99, isbn 978-1848723238

Reviewed by Linda Watkinson

This book is written primarily for managers within organisations, organisational consultants, and students of business studies and social and behavioural sciences. However, it explores much that will be of relevance to therapeutic work. First published in 1996, it asks the question, ‘Have things changed for women in the twenty first century?’ It presents a realistic, if somewhat dispiriting, account of the complex issues around gender and power in organisations and importantly, it provides a balance to the post- feminist, motivational literature which argues that the battle has been won; that women can have it all.

That women are attaining more powerful roles in organisations is acknowledged by Nicolson, albeit that they remain in the minority. She explores extensively the psychological cost for women as they balance the demands of family and work, and negotiate ‘inbuilt’ traditions and male privilege within organisations. Her research is wide ranging and examines the social, the psychological, the biological and the interpersonal. Consideration is also given to the intrapsychic, the conscious and unconscious influences, along with the dominant discourses in society that shape an individual and their experience of the world. She explores too, the challenges for men, as the gender balance changes within organisations.

There is much of interest to the practitioner in this book, although it is more likely to be useful to counselling and psychotherapy students, particularly if they do not have a grounding in the social sciences and business studies. It could also provide a useful resource to recommend to clients, both female and male who are experiencing challenges around gender and power in the organisations in which they work. Although written in an academic style it is a very readable slim volume.

Nicolson concludes that whilst there are now more women in senior roles compared to 20 years ago, the apparent improvement has disguised the continuing problems of gender-power relationships and in particular, the lack of good mentoring schemes and networking opportunities. Women, particularly those in senior roles, often remain isolated, and she suggests that the burden falls upon women to make sense of organisational culture, its constraints, and to develop suitable coping strategies. The ubiquitous presence of these power relationships ensures that it will appear in the therapy room with regularity.

Linda Watkinson is a counsellor

Experiencing CBT as a therapist

Experiencing CBT from the inside out James Bennett-Levy, Richard Thwaites, Beverly Haarhoff, Helen Perry, Guilford Press, 2015, 278pp, £19.99, isbn 978-1462518890

Reviewed by Caz Binstead

As therapists we ask a lot of clients: we ask them to explore themselves, encourage them to be open and curious, and undertake honest and brave reflection, appraisal and discovery. Here is a book that asks therapists to do just that.

The aim of this book is to explain and then guide therapists through the practice known as Self-Practice/Self-Reflection (SP/SR). Presented in 12 modules, SP/SR is a training that leads the reader through a series of common-place CBT exercises. We are invited to immerse ourselves experientially in a structured programme of self-reflection and discovery – to engage in an honest, direct and personal journey with maximum commitment and reflection. Chapter three lends expert guidance to support you throughout. Readers are encouraged to dig deep in their best reflective capacities, but also to think about their own boundaries and create a gentle balance between challenge and compassion.

The early chapters get bogged down in showing SP/SR as an evidence-based model and are at times wordy and reference heavy. This seems out of place in an otherwise practical and concise book that appeals to therapists using CBT at varying levels.

Experientially, this book is of great value, with well-crafted exercises, good visual diagrams and comprehensive guidance throughout. I enjoyed the invitation through the case study examples to address generic ‘problems’, as well as specific ones that occurred in my work as a therapist.

I also found the ‘Module notes’ a useful added bonus, providing short accompanying comments, and references on each chapter, thereby giving the reader more food for thought, including the option (if wanted) to look up and read more on certain aspects. This book encourages therapists who use any form of CBT to have the courage to know themselves better. And the invitation is the beautiful opportunity to sit with our clients with a mutual understanding of the limitations and strengths we all have as humans. As the CBT pioneer Christine Padesky says in the book’s foreword:

‘Your credibility, the therapeutic alliance, and client adherence are enhanced when you have “walked the walk”’ (Padesky foreword ix, Bennett- Levy et al).

For me, anybody can learn CBT techniques. A true relational CBT approach is one that is infused with empathy and compassion, with a therapist who embodies authenticity and ‘human-ness’. This book will invite you to walk that edge. So, if this is your goal... get reading!

Caz Binstead is a therapist, mindfulness-based practitioner, supervisor and writer

Counselling ethics

Standards and ethics for counselling in action (fourth edition) – interactive eBook Tim Bond, Sage, 2015, 333pp, £29.99, isbn 978-1473913974

Reviewed by Angela Cooper

An increasing number of books are published with interactive online supplements and we asked our reviewer to add to her previous review of this book (October issue) by looking at the benefits or otherwise of this addition.

This is my first experience using interactive eBooks for work, and after some initial trepidation and a few hiccups accessing it, I was impressed.

To download the book, the reader follows some pretty straightforward instructions. Reading through the online text they can then use icons to link to five different resources. These are videos of counselling scenarios (each followed by some reflections from Tim Bond), YouTube videos, further reading on relevant subjects, web links on codes and frameworks, and multiple choice questionnaires. I read the book first then went online to work through and pick up links. Alternatively the book could be read online and links followed through as you go. There is a high degree of flexibility and choice.

There are a few minor gripes. One or two of the video clips seem the wrong way round, some of the questionnaires could be phrased more clearly and a few of the web link articles seem aimed more at an American audience. However, these are minor concerns when viewed against the overall standard. Having spent some time perusing a variety of clips and articles and completing the questionnaires, I felt very satisfied. This was firstly due to successfully accessing the various resources, and secondly because the learning element of this approach exceeded my expectations. As with the book itself, the interactive eBook is ideal for therapists at all levels of training and experience. The biggest challenge for some may be apprehension about working online in this way, but take a deep breath and go for it. It really will be worth it!

Angela Cooper is a counsellor and supervisor

The therapeutic relationship

The therapeutic relationship in counselling and psychotherapy Rosanne Knox and Mick Cooper, Sage, 2015, 156pp, £20.99 isbn 978-1446282908

Reviewed by Sharon Breen

This invaluable little book punches above its 156-page weight, delivering common-sense advice and insights into that most revered aspect of the therapeutic encounter: the relationship between a counsellor and client. Packed full of answers to commonly asked questions – and those you may not have thought to ask – suggestions, tips and clinical examples, it is an easy and enriching read.

We begin, appropriately enough, at the beginning of the counselling relationship with a look at the therapeutic framework: boundaries, confidentiality, the counselling environment and contracting. The authors follow this up with chapters on empathic understanding and listening; being real; relating at depth; therapeutic relationships with children and young people; and telephone and online counselling.

The book’s strength lies in its ability to make a complex subject understandable, without dumbing down. I particularly liked each chapter’s ‘personal reflection’, which invites the reader to think more deeply about some of the ideas raised. There are also suggestions for further reading and ideas for research – a bonus feature for those thinking about dissertation topics.

A downside to the book’s size is that answers to complex questions are brief. Nevertheless, this is a good introduction to a subject that is at the heart of what it means to be an effective counsellor.

Aimed at trainee and newly-qualified counsellors, it is a must-read for those starting out. As a relatively new therapist, I devoured it in one sitting and was left wanting more. For practitioners with more experience, it is an aide- mémoire on how to deepen the connection with our clients. However it is framed, the quality of the counselling relationship is often the key to helping clients explore, change and grow. This is a book that can accompany that journey, providing a warm, knowledgeable voice to allay our fears, correct our misperceptions and encourage us to believe in ourselves. I have no doubt it will find its way onto many reading lists.

Sharon Breen is a counsellor, group facilitator and writer

Working with pain

Transforming emotional pain in psychotherapy: an emotion-focused approach Ladislav Timulak, Routledge, 2015, 181pp, £24.99, isbn 978-1138790186

Reviewed by Bernadette Lynch

A sense of hope in the face of human suffering is the strongest theme of this book. Building on the work of Greenberg, Pascual-Leone et al, it provides a conceptual formulation and a practical mode of therapy for addressing profound emotional pain and, crucially, for transforming it in ways that last and liberate.

Timulak suggests that the main beneficiaries of his book will have some background in emotion-focused therapy (EFT). He underestimates the clarity and accessibility of his exposition. As a relative novice in this field, I had no difficulty following his formulations. He clearly defines the key building blocks of the EFT approach: primary emotions (core pain), secondary emotions (global distress), unmet needs, triggers, and maladaptive self treatments. These are then used to construct the central proposition of the book: primary painful emotions, based on fear, shame and loneliness, are a response to ‘a – typically interpersonal – injury, which prevented or violated the fulfilment of the individual’s basic human needs’ (p29) of safety, validation and connection, and these can be transformed.

Particularly useful are the clearly headed sections throughout, the flow charts that elucidate the transformation process, and the case examples that illustrate the techniques of imaginary dialogue (empty-chair and two-chair) in action. Less helpful was the frequent repetition of the building block definitions and key stages although this may have embedded the process more deeply. A nod to other work around emotion and/or needs, such as the tenets of Human Givens Therapy, Somatic Experiencing work with trauma, or even Maslow, would have been welcome.

However, I particularly enjoyed the second section of the book that offers a refreshing therapeutic framework for this transformation of pain: that within an authentic and healing therapist/client relationship, core pain can be accessed and named, unmet needs articulated and addressed, losses grieved and a place of relief and empowerment reached by the client from which to move forward. Bernadette Lynch is a trainer in mental health

Reflecting on consciousness

The sower and the seed: reflections on the development of consciousness Alan Mulhern, Karnac, 2015, pp239, £30.69, isbn 978-1782202462

Reviewed by Els van Ooijen

This unusual book morphed from its original conception of a ‘slim volume’ on psychotherapy and self-awareness into a sumptuously presented poetic and artistic reflection on consciousness. The author explains how he allowed the text to emerge ‘into being’ and condensed the material until its meaning felt congruent with his inner experience (xiv). The result is a very readable book in six parts that spans the totality of the development of human consciousness, from its beginning to the present day. According to its central philosophy, evolution expresses its imminent intelligence through a continuous cycle of creation and destruction. Each subsequent level reaches a higher level of complexity and consciousness before it is, inevitably, destroyed.

The book’s six sections concern different aspects of this process. Parts I and II reflect on the origin of consciousness as expressed in creation myths. Early man’s oneness with nature ended with the emergence of ego consciousness and the repression of instincts and emotions. In the West the cult of the Great Mother was replaced by patriarchal civilisations (portrayed as the hero slaying the dragon) and influenced by the ‘Abrahamic’ religions (p52). Part III discusses how the emerging individualised consciousness contained an implicit misogyny, viewing matters of sexuality and reproduction (and therefore Nature) as ‘evil’ (p89). The patriarchal psyche, however, became aware of a great loss as ‘the fall’; our expulsion from the Garden of Eden caused a deep rupture in our consciousness, estranging us from ourselves. In Parts IV and V the author reflects on the consequences of the Enlightenment and capitalism, emphasising that although we are capable of wisdom, spirituality and love, we should not underestimate ‘the darkness’ of our species (p129). Part VI expresses through Mulhern’s own poems the individual quest of individuation.

Mulhern’s influences include art, poetry (Blake, Dante), Hindu philosophy, and thinkers such as Capra, de Chardin, Bohm and Jung. I thoroughly enjoyed reading this rich and wonderful book and would recommend it to anyone interested in the human condition.

Dr Els van Ooijen is a relational-integrative psychotherapist, supervisor and author

The happiness illusion: how the media sold us a fairy tale Luke Hockley and Nadi Fadina (eds), Routledge, 2015, 212pp, £29.99. ISBN 978-0415728706

Reviewed by Colin Feltham

The title of this book implies that one will be reading another critical analysis of the fashionable and over-hyped concept of happiness as promoted by the media. This is accurate to some extent but largely misleading. This 10-chapter book is in the main a series of Jungian meditations on selective aspects of film and media. The authors include academics in media analysis and gender studies and some clinicians. An underlying indisputable principle here is that television, film and other media have conditioned us to expect certain kinds of routes to happiness, especially the ‘happy ever after’ kind, that seldom if ever materialise. The depth psychology line that happiness is not an entitlement but part of our acceptance of life as a journey is broadly adhered to.

Television series and films are interlaced with fairy tales, archetypes and contemporary gender identity preoccupations. Among the films discussed are Her, Wings of Desire, Ordinary People, Basic Instinct and Snow White and the Huntsman. Some romcoms and reality TV programmes are examined. Princes and princesses, golden eggs, androgyny, the ageing beauty myth, advertising, makeovers, and consumer capitalism all appear in these pages. Happy marriage receives due critique, and as might be expected the ‘tyranny of the male gaze’ is used to remind us that cinema is still dominated by men. The ‘myth of authentic self-actualisation’ is one of the most interesting chapters, focusing on TV makeover programmes. Saving Mr Banks, the film about the ‘actual’ Mary Poppins, gets a passing mention but much more could have been made of this highly relevant, thought-provoking film.

The book will appeal to postgraduate students of film and media studies and Jungian psychotherapy. Unfortunately it has less to offer most practising counsellors and therapists or scholars of sociology, psychology and critical theory who wish to investigate the current over-selling of the happiness concept. Few or no links are made to Layard, Seligman, Csikszentmihalyi, Fredrickson or other prominent pushers of the happiness illusion, or to specific iconoclasts like Barbara Ehrenreich and David Smail. The narrowly Jungian focus impoverishes, in my view, what could have been a significant addition to the analysis of spurious strains of positive psychology and exaggerated self-help claims. However, the book adds weight to mounting awareness of the limits of capitalist hedonism, as also seen for example in Banksy’s biting Dismaland art project.

Colin Feltham is Emeritus Professor of Critical Counselling Studies, Sheffield Hallam University

Trauma, fear and love: how the constellation of the intention supports healthy autonomy Franz Ruppert, Green Balloon Publishing, 2015, 344pp, £19.95. ISBN 978- 0955968365

Reviewed by Anne Gilbert

In recent years Ruppert has been recognised for his pioneering work on multi- generational traumatology. In this, his fourth book, he further develops his approach. His ideas originated from the Family Constellations methodology of Bert Hellinger, a therapeutic method in post -war Germany working systemically with individuals, couples and organisations, that used representatives to stand in for members of the client’s family. Ruppert has refined the approach to concentrate on working with traumatisation, naming it the Constellation of the Intention.

The opening chapters explore Ruppert’s views on the nature and functioning of the psyche, and what constitutes good mental health. This links in Chapter 4 to his claim that traumatisation from multiple causation is the major cause of psychological distress includes an analysis of how victim/perpetrator dynamics result in splits in the psyche, and how symbiotic trauma can be carried across multiple generations in families. In Chapter 6 he presents his model of psychotherapy using the constellations methodology, including how his work differs from the original practice of Family Constellations.

Chapter 7 brings theory to life, comprising 50 case studies from individual and group constellations to demonstrate Ruppert’s holistic approach. These cluster around themes of, for example, sexual violence, birth trauma, adoption, and physical illness. I found the sections on wars, the opportunities in times of peace and the affects of war through four generations particularly thought provoking. I appreciated the author’s honesty in admitting we do not yet fully understand how the constellation process works. The book concludes with a summary of the process for moving from traumatisation to healthy autonomy

I felt something was lost for me in the translation of the text from German, with the phraseology jarring at times. Also, although I imagine it was not the author’s intention, there was a lot of gender stereotyping particularly in relation to claiming mothers are responsible for the transmission of trauma to their children.

Ruppert’s ideas, however, are both challenging of traditional orthodoxy and pioneering. The book makes an important contribution to raising awareness of the still under-researched area of trans-generational trauma and will be of interest to many professionals in the field of mental health, counselling and psychotherapy.

Anne Gilbert is a Gestalt psychotherapist and supervisor

Film: Amy DVD release: 1 December 2015 Reviewed by Lorna Swain

Where do you put love when it has nowhere to go? The film Amy (Asif Kapadia, 2015) ponders this question. An honest and sensitive account of the life of Amy Winehouse is told through a montage of private videos shot by friends and family, chat-shows, awards' ceremonies and footage of live events. It reflects a life that does not show progression: Amy, the person, seems trapped somewhere between the age of 9 and 15. In this period when her father left the family and she started to feel strange and did not know why. Her stunning jazz voice emerged and a familiar story unfolds.

We watch Amy, in her desperation for love, following the familiar path of mistaking comfort for love and then clinging on with all her might. The nature of her relationship with her boyfriend-cum-husband leads her in to drug addiction and despair. The relationship with her father who left her life and then re-appeared, feeds her bewilderment. All the while, the love of old friends who are longing to help her is put in second place. The most encouraging aspect of the film was just this – the voices of those few friends who did not forsake her and did their best in this confusing world to save her.

Someone in her music company said when Amy sang they heard an old jazz soul in a young woman's body. As an audience we are captivated by her incredible voice and soulful lyrics; as the artist, Amy is trapped in their embrace. What chance does an 18 year old have to survive a talent of such magnitude? And what help can a therapist be in such circumstances? It was moving to watch how the 'child' straining to become an adult did her best in a world designed to exploit her. When the music stopped, a terrible emptiness entered.

As so often, addiction masks the true problem of where love is. Amy famously refused rehabilitation and professional help. Perhaps then, the only real possibility is the solidarity of friendship – the modelling of true love. Does the therapist have anything to offer here? I believe there is a role in helping to build, strengthen and preserve a strong and secure support network of friends. One person alone cannot do it, but a group together with this support might just be able to.

Just a few mornings before she died, we see Amy on the phone to an old girl friend. 'Bye, I love you', she says in a sing-song voice. She still did not know what that word meant. Tragically, she did not live long enough to find out.

Lorna Swain is a counsellor in private practice +++ From the Chair

When it comes to mental health the obvious is missed time and time again, writes Andrew Reeves

Some things in life are simply baffling. Really, some things are so obvious, and yet the obvious is missed time and time again. For example, we want our children to have the best possible education and then tie teachers up with procedures, paperwork, red tape, statistics and league tables so they are left exhausted, demoralised and leave the profession in droves.

If we look a little closer to home and consider mental health, then things are no different. It is important to say at this juncture that by mental health I mean the broadest span of emotional experience, as well as the specific times of distress and crisis. Some call this ‘wellbeing’; I have to confess to not liking this term very much as it is increasingly hijacked by politicians to mean something that gets more and more diluted over time. A bit like mental health- lite. It’s not that I’m against the concept of wellbeing per se, but rather that it seems to me to become a readily available euphemism to avoid saying what we really mean: that there are times when any one of us can experience mental health distress or crisis, where we feel out of our depth and in need of help.

Having worked for many years as a social worker in a mental health crisis team I learned first hand, and from my own personal experiences, that the safety and predictability of our worlds can be changed in a heartbeat; that we never can, or should, take our own mental health for granted for it can shift from strength to fragility so quickly and often without us even noticing it is happening. Of course, this is not a message that needs pushing home around our physical health: we are told daily what is good for us, what is not good for us, and what we could be doing to improve our physical health. But mental health remains hushed and hidden and, despite the best efforts of many people, heavily stigmatised.

A year ago BACP launched a report ‘Psychological Therapies and Parity of Esteem: from commitment to reality’ (http://bit.ly/12oWm7J) at Westminster, and have been arguing this cause at every opportunity since. As I write this column we see in the news the initiatives by Normal Lamb MP and Andrew Mitchell MP, who have joined forces with a number of celebrities, to further argue for parity of mental and physical health. I welcome these and many other initiatives to try to put mental health on the map. Yet progress remains so slow and, as I said in my opening remarks, what is so seemingly obvious remains so clearly overlooked.

It is in this context that I believe counsellors have a crucial voice in this debate and can continue to shout about the importance of our work and the value of counselling for our clients. I have believed for many years, and indeed it was one of the reasons why I trained as a counsellor, that advocacy is an inherently important part of the role as therapist. That when appropriate and with consent we should advocate for our clients, but that we should also shout loudly about the bigger issues that contribute to the distress we see on a day- to-day basis.

It really is quite ridiculous that mental health should continue to be the poor relation to physical health. It is quite obvious that good mental health contributes greatly to good physical health, and vice versa. It is quite simple that the more we can pay attention to our own emotional wellbeing, the greater the likelihood that we will experience personal benefits, and that those benefits then translate out into the communities and societies in which we live. But, it seems, that some things are so obvious they simply continue to pass people by.

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 Public Affairs

Party conference round-up

Last month was Party Conference season and BACP was represented at the Conservative Party, Labour Party, Liberal Democrats and Scottish National Party Conferences. Here’s a round-up of some of the major mental health talking points.

At the Liberal Democrat Conference Norman Lamb MP, the party’s health spokesperson and former coalition Government Minister with responsibility for mental health, spoke at length on mental health. He said that he would make it his ‘personal mission to keep fighting until every person suffering mental ill health has a right to get treatment on time’. He ended with a rallying call, telling the Liberal Democrat delegates, ‘Our mission must be very simple: equality. Nothing more, nothing less. We must end the historic injustice suffered by those with mental ill health.’

At the Labour Party Conference Luciana Berger MP, the first ever Shadow Minister for Mental Health, told us that ‘The Labour Party is putting mental health centre stage’. She went on to say that the role is not just confined to the NHS: ‘We know that mental health is a cross-cutting issue. It needs a cross- cutting response in our communities, in our schools and our workplaces. For the young girl with an eating disorder. For the pensioner suffering from loneliness. For the veteran affected from post-traumatic stress.

‘I’m keen to work with patients, health professionals, campaigners, councillors, and trade unionists to do two things,’ Berger said. ‘One: to hold this Tory Government to account for their broken promises on mental health. Two: to develop a world-class mental health programme to be implemented by the next Labour Government.’

In a speech at the Conservative Party Conference, the Secretary of State for Health, Jeremy Hunt MP, mentioned the successes of the last five years, pointing to the maximum waiting times introduced. He went on to say: ‘From next May we will go further with assessments on MyNHS about the overall quality of mental health… area by area.’ For SNP see below.

SNP fringe event on children’s mental health

BACP hosted a fringe event for the first time at the Scottish National Party (SNP) Conference on ‘Children’s mental health – can Scotland do more?’ The event proved extremely popular and was full to capacity with a strong panel line-up including Jamie Hepburn, SNP Minister for Mental Health, Mark McDonald MSP convener for both the Mental Health and Children and Young People cross-party groups in the Scottish Parliament and BBC Scotland’s Health Correspondent Eleanor Bradford acting as Chair. Minister Jamie Hepburn said that families were beginning to feel more confident in seeking mental health assessments, and more children and adolescents were receiving treatment. He stressed that the SNP intended to do more following on from the £100m investment in mental health services earlier this year. Mark McDonald pointed out that social media bullying should be a priority and that schools need to be educated to ensure they were able to give the right support to children and young people.

BACP’s Lead Advisor for Children and Young People, Karen Cromarty, was on the panel discussing the benefits of school-based counselling in Scotland, currently the only one of the four nations in the UK not to have a national- strategy around school-based counselling.

Karen said: ‘Counselling for children and young people has a vital role in preventing mental ill-health.’ She added that ‘Northern Ireland and Wales have counsellors in all of their secondary schools… The situation is not the same in Scotland, which has no national strategy and no ring-fenced funding provided.’

Also on the panel was the Chief Executive of the Scottish Association for Mental Health, Billy Watson, who said: ‘Early intervention is vital. The sooner we help children to talk, the faster they will get the help they need. Alongside ensuring children have quick access to counselling, schools should bring in a “whole school approach” to mental health.’

Mental health in Wales

The Welsh Government celebrated World Mental Health Day on 10 October by marking the third anniversary of the Welsh 10-year mental health strategy ‘Together for Mental Health’. Mark Drakeford, Minister for Health and Social Services announced a new 28-day target for treatment from this month, saying: ‘Wales introduced waiting times for assessment and treatment by local primary mental health support services in 2012. From April 2013 to March 2015 the all-Wales performance against our 56-day target for referral to assessment has improved from 50 to more than 80 per cent... From this month we will change the 56-day target to a 28-day target.’

The Minister announced that the Government will also continue to ringfence the mental health budget, provide an extra recurrent funding of £15.6m for mental health services in Wales focusing on children and adolescent services and dementia care, while investing a further £1.9m to support adult talking therapies.

The Welsh Liberal Democrats also initiated a debate in the Welsh Assembly calling on the Government to introduce a 28-day waiting time for access to mental health treatment, improving mental health training for teachers, health professionals and employers while also ensuring the proportion of funding for mental health within the overall NHS Wales budget reflects the relative size of the disease burden in relation to physical health.

Consultation on pregnancy and parenthood in young people

An integral part of BACP’s lobbying strategy, consultations are an effective way for the Association to communicate 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.

We recently submitted a response to the Scottish Government’s consultation on Pregnancy and Parenthood in Young People. We took the opportunity to stress that any services offered to support young people, including counselling and psychotherapy services, should be non-stigmatising, financially and physically accessible, flexible to the needs of those accessing them, equitable, offered in a timely manner and considerate of the diverse range of needs individuals may have.

BACP is currently preparing a response to the Northern Ireland Public Health Agency’s consultation on the future of the Lifeline Crisis Intervention Service. If you wish to contribute to this consultation response, please email the Public Affairs Team via [email protected] +++ BACP Professional Standards

Newly accredited counsellors/psychotherapists

Jason Adams Simon Arthur-Smith Jane Barker Elizabeth Barr Sara Bevins Tom Brown Sally Bunce Kikis Cacoullis Philip Cahill Donald Charnock Jenny Charters Paula Chuter-Baker Susan Clare Christine Cooper Christine Cornick Virginia Cornwell Susan Cottrell Catherine Cour-Palais Adam Cox Stephanie Cross Steven Curic Daniel Da’Bell Ruth Durham Nicola Engel-Khan Michelle Finnegan Amanda France Andrew Gange Katy Grange Catherine Gray Jacqueline Hale Jake Halls Julie Hanson Jan Harper Tracy Haynes Sara Hitchens Lindsay Horsley Jennifer Jones Linda Jones Wendy Jones Avraam Karagiannis Mohammed Abbas Khan Mandy Leaver Mandy Lee Julita Levinson Shaun Lewis Hope Marshall Dermot Martin Louanne Martin Veronica Martin Sue Matheson Des McEnaney Angela McMillan Francis McQueen Emilia Mihali Tonia Mihill Guy Millon Catherine Mulcaster Emily Newman Carol O’Doherty Ian Orr-Campbell Kalpana Patel Patrick Pescollderungg Heather Peters Alexis Powell-Howard Christina Poynts Elizabeth Quester Philippa Rashbrook Caroline Redmond Sheila Robinson Susan Rock Arabella Russell Anne Ryan-Thomas Sharon Sheppard Claudia Smith Ella Soakell Haines Fiona Spring John Stanness Naomi Stewart Karen Sturch Elaine Symington Carole Thomson Marett Troostwyk Gillian Tunstall Martine Vanwyck Elizabeth Venn Adele Watiez Paula Watts Andrew Webb Alison White Ann Whitwham Moriam Yarwood

Newly senior accredited counsellors/psychotherapists Sharon Dodd Lee Partis

Newly senior accredited counsellor/psychotherapist for children & young people

Caroline Caffyn

Newly senior accredited supervisors of individuals

Louise Andrews Sally Scott

Members not renewing accreditation

Vera Andrew Brenda Balls Sandra Blakeborough Peta Bowker Nicola Brown Anita Canter Trevor Castleton Jane Coggins Dawn Devereux Frances Eaton Kareen Feyrer Paula Fitzsimon Barbara Hardwick Richard Hill Myra Hutchings Terri Jacks Deborah James Hazel Johnson Claire Kelley Nicola Legge Christine Leighton Claudia Millar Lesley Montgomery Elizabeth Morris Vivienne Morris Charlotte Naismith Gillian O’Rourke Stefania Piazzalunga Dorothy Ramsay Stephen Raybould Kaye Redman Maura Richards Elizabeth Robertson Margaret Russo Shirley Sandiford Elizabeth Schofield Kathryn Seymour Paman Steer Alison Suggett Judith Thompson Thomas Thorpe Amanda Todd Bridget Townsend Jane Walters Marie Wanty Debra Whalley Alexandra Whittall Judith Worrell

Member whose accreditation has been reinstated

John Davies

Please note that the above accreditation details apply for 1–30 September 2015 and are correct at the time of going to print. +++ BACP News

BACP Private Practice news

New Executive Committee

BACP Private Practice has a new Chair. Susan Utting-Simon is a counsellor/psychotherapist, supervisor and trainer of individuals and groups in Leeds, with 15 years’ experience of working in private practice. She has been self-employed for the last six years and has a special interest in working with children and young people and transcultural issues.

Susan says: ‘I hope that, along with my very experienced colleagues on the Executive, I can use my knowledge and experience to good advantage. Feedback is essential and I welcome your thoughts on how the Committee can best serve its members. I promise to do my best to continue the excellent work done by my predecessors.’ (Susan is featured in this month’s ‘How I became a therapist’ on p17.)

Alongside former Chair James Rye, Wendy Halsall, John Crew and Meg Logan have also stepped down from the Committee this autumn after dedicated service over a number of years.

Wendy joined the Committee in 2008, acting as Chair from 2010 until 2013. John joined soon after and was Finance Officer from 2010 until 2013. At that time there were just three members on the Committee so it was hard work keeping it going. Meg Logan joined in 2012 and was on the sub-committee planning the division’s very successful conferences.

BACP Private Practice has two new Committee members: Lesley Ludlow and Rachel Vint, who have established regional networking groups in South London and Edinburgh respectively.

If you would like to contact the Executive Committee with any feedback, please email [email protected]

2016 conference

For the second year running the BACP Private Practice annual conference, this year on the theme of trauma, sold out with a long waiting list for places. This was the first BACP conference to be broadcast live online to an additional audience of 850 people, bringing the total number of delegates to 1,100.

Plans are already underway for the 2016 conference, which will be held next September on the theme of relationships. Further information will be available in the next issue of the Private Practice journal and forthcoming e-bulletins. To be sure of a place, please sign up as soon as possible when booking opens around March 2016.

For more information about BACP Private Practice and details about how to join or subscribe to its journal, please visit bacppp.org.uk

New BACP Spirituality Chair Elect

Maureen Slattery-Marsh has stepped into the position of Chair Elect of the BACP Spirituality division and will work closely with the current Chair, Melody Cranbourne-Rosser, and the Executive Committee (Valda Swinton, Gillie Jenkinson, Kathryn Kinmond, Keith Hackwood and Manda Ncube) in their work for the division. Maureen’s current role is Clinical Manager of ICAP West Midlands, a charity delivering counselling and psychotherapy to Irish and other immigrant groups who have been affected by trauma, abuse, loss and migration. She also works as a trainer, lecturer and counselling supervisor.

For further information about Committee members, divisional projects, spirituality-related resources, and joining information, visit bacpspirituality.org.uk

Event for NHS counsellors

The next ‘Counsellors working in the NHS’ network meeting will take place on 2 December 2015 at the University of Central Lancashire (UCLAN), Preston, starting from 1.30pm. Any NHS counsellors (or counsellors working in the voluntary sector commissioned by the NHS) can attend this event by registering with PPN North West at http://ow.ly/U8iSy. Email [email protected] for further information.

Update from BACP Universities & Colleges

Help to support student counselling services

This summer has been a turbulent time for some student counselling services, with some being closed and rearranged, in particular sixth form and FE colleges.

The BACP Universities & Colleges (BACP UC) division has come together through its close JISCMail community and a strategy is emerging for services where the value of counselling is being questioned. We are producing downloadable briefing sheets for services to be able to use as support. Email the BACP UC Chair, Jeremy Christey, at [email protected] if you think that your service is being rearranged or threatened, so we can keep track of this. BACP UC survey

The BACP UC annual survey has just closed, with many services contributing a second time, after our record number of participants last year. The survey results are available on the research section of the BACP UC website at bacpuc.org.uk

BACP UC JISCMail

JISCMail is a forum that many BACP UC members have found supportive and is used daily by a significant number of members. The Executive now has a planning group that keeps track of the themes on JISCMail and sends a feed of these to the Executive, so we can implement a strategy to put into action the ideas that come from both the Executive and JISCMail forums.

For more information about BACP UC and details on how to join, visit bacpuc.org.uk +++ BACP Research

Research enquiry of the month

This month’s research enquiry asked ‘Which psychological therapies are effective for autism?’ A brief search was conducted on Google Scholar and also our internal abstract database using the terms ‘psychological therapies’ AND ‘autism’ OR ‘ASD’; this search generated a wealth of literature on various psychological therapies for individuals diagnosed with autism.

Carrick and McKenzie1 trained non-counselling specialists working with clients at the severe end of the autistic spectrum in person-centred counselling and pre-therapy skills. A powerful dyadic change process was observed as well as trainees reporting a significant change in the lives of clients, which suggests a more successful approach to working with this client group. Scarpa and Reyes2 conducted a pilot study to explore the efficacy of a developmentally modified cognitive behaviour therapy (CBT) programme for young children with autism. Eleven children aged 5-7 were randomly assigned to an experimental or delayed treatment control group. From pre- to post-treatment, all children had less parent reported negativity/lability, better parent-reported emotion regulation, and shorter outbursts, and also generated more coping strategies in response to vignettes. Although further research is required to conclude about its efficacy, this study suggests that young children with high functioning autism may benefit from CBT to improve their regulation of anger and anxiety.

It is also important to note that many alternative therapies have been found to be effective in individuals with autism. The effectiveness of five one-hour weekly sessions of narrative therapy with young people with autism was investigated by Cashin and colleagues.3 Findings revealed significant improvements on the Kessler-10 Scale of Psychological Distress and also on the Emotional Symptoms Scale of the Strengths and Difficulties Questionnaire. Narrative therapy is therefore shown to have a significant impact on psychological distress and emotional regulation in autism. The research noted here all contributes to a wider body of research and despite limitations of small sample sizes, it suggests that a range of psychological therapies could be considered effective for individuals with autism.

References

1. Carrick L, McKenzie S. A heuristic examination of the application of pre- therapy skills and the person-centered approach in the field of autism. Person-Centered & Experiential Psychotherapies 2011; 10(2): 73-88. 2. Scarpa A, Reyes NM. Improving emotion regulation with CBT in young children with high functioning autism spectrum disorders: a pilot study. Behavioural and Cognitive Psychotherapy 2011; 39(4): 495-500. 3. Cashin A, Browne G, Bradbury J, Mulder A. The effectiveness of narrative therapy with young people with autism. Journal of Child and Adolescent Psychiatric Nursing 2013; 26(1): 32-41.

Publication bias may overestimate the effectiveness of therapies

A recent systematic review and meta-analysis has suggested that publication bias may overestimate the effectiveness of psychological therapies for the treatment of depression. Publication bias has been defined as ‘the tendency on the parts of investigators, reviewers, and editors to submit or accept manuscripts for publication based on the direction or strength of the study findings’ (p1385).1

Driessen and colleagues2 identified US National Institutes of Health (NIH) grants that had been used to fund randomised clinical trials, which compared psychological treatment to a control condition or other active treatment, in adults diagnosed with major depressive disorder (MDD). Fifty-five clinical trials which took place between 1972 and 2008 were identified, of which 42 (76.4%) led to publications. Results from the remaining 13 (23.6%) trials were defined as being ‘unpublished’; however, researchers were able to obtain the original data for 11 of these studies. In trials that compared psychological treatment to a control condition of any type (eg no treatment, treatment-as- usual, pill-placebo and non-specific psychological placebo), adding unpublished studies to published studies reduced the effect size (the size of the difference between conditions) estimate by 25 per cent. However, the researchers noted that psychological treatments for depression were still significantly more efficacious than the control conditions, even when data from unpublished trials were added to data from published trials.

Reasons for not publishing findings from clinical trials included: not being accepted for publication (n=2, 15.4%) or not being submitted for publication (n=6, 46.2%). In the remaining five trials (38.5%) it was unclear whether or not researchers had tried to publish their findings.

The authors concluded that publication bias is present in clinical trials funded by NIH, which overestimates the effectiveness of psychological treatments for depression in adults. Guideline developers, practitioners and commissioners should be aware of these overestimated effects when recommending treatments for depression.

References

1. Dickersin K. The existence of publication bias and risk factors for its occurrence. Jama 1990; 263(10): 1385-1389. 2. Driessen E, Hollon SD, Bockting CL, Cuijpers P, Turner EH. Does publication bias inflate the apparent efficacy of psychological treatment for major depressive disorder? A systematic review and meta-analysis of US national institutes of health-funded trials. PLOS ONE 2015; 10(9): e0137864. CPR New Research Award

Submissions are being invited for the CPR New Researcher Award, sponsored by Wiley. The winning entry will receive £100 worth of Wiley book tokens. To be eligible to apply you must currently be a full-time or part-time student or have graduated within the last 24 months, and have completed a research project in the counselling and psychotherapy field.

Submissions are in the form of a manuscript and the applicant must be the first author and not have published in any journal previously. Submissions for the award can also be made by having your first article accepted for publication in the Counselling & Psychotherapy Research (CPR) journal.

The deadline for submissions is Friday 29 January 2016. For details of how to apply, please visit www.bacp.co.uk/research/resources/awards.php or email Angela Couchman at [email protected]

BACP Outstanding Research Award

If you have completed or written up a piece of counselling and psychotherapy research in the past three years then you are eligible to apply for the BACP Outstanding Research Award. This award aims to reward excellence in counselling and psychotherapy research by: enhancing awareness of the evidence base in counselling, psychotherapy and its guiding principles; improving the overall quality of counselling and psychotherapy research by example, and encouraging and inspiring future generations of researchers. The winner will be presented with a specially designed plaque at the BACP Research Conference in May 2016 and the deadline for submissions is Friday 29 January 2016. For details of how to apply, visit www.bacp.co.uk/research/resources/awards.php or email Angela Couchman at [email protected]

CPR journal to go online

From March 2016 your BACP research journal, Counselling & Psychotherapy Research (CPR), will become primarily an online journal. Printing and despatching 45,000 copies of CPR four times a year creates a substantial carbon footprint and moving to an online circulation for members will significantly reduce this. Members will have fast and secure access to CPR online and will be emailed contents alerts. Members who still wish to receive a print copy should notify [email protected] with your name and membership number before 31 December 2015.

Finding research funding If you are looking for funding to undertake a piece of research in counselling and psychotherapy, we have a webpage dedicated to keeping abreast of the current funding opportunities available. Whether you are looking to fund a PhD, a small scale or larger scale research project, please visit www.bacp.co.uk/research/Finding_Research_Funding/currentfundingopportun ities.php to see a full list of funding opportunities. We update this webpage monthly and, although we endeavour to cover as many funding opportunities as possible, some may be overlooked. If you are aware of any funding opportunities not listed on this page, email [email protected]

Visit the CPR journal website

CPR has its own website at cprjournal.com, where you can find research digests and practitioner notes, how to write and submit papers for CPR, glossaries of research terms and calls for papers. You can also sign up to the CPR e-bulletin to receive the latest digests. And if you’re on Twitter, follow @CPRjournal for the latest news. +++ BACP Professional conduct

BACP Professional Conduct Hearing

Findings, decision and sanction, Catherine Furnival-Small Reference No: 538185, Cumbria CA20

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

The Panel made a number of findings and it was unanimous in its decision that these findings amounted to Professional Misconduct in that Ms Furnival- Small contravened the ethical and behavioural standards that should reasonably be expected of a member/registrant of this profession.

The Panel found some mitigation and imposed a sanction.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/hearings.php

BACP Professional Conduct Hearing

Findings, decision and sanction, Mankind, Reference No: 108870 Hove BN3 1DG

The complaint against the above organisational member was heard under BACP’s Professional Conduct Procedure and the Professional Conduct Panel considered the alleged breaches of the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy and made a number of findings.

The Panel was unanimous in its decision that these findings amounted to Professional Malpractice, in that the service, for which Mankind was responsible, fell below the standards that would reasonably be expected of a practitioner exercising reasonable skill. The Panel found that Mankind had provided inadequate professional services.

The Panel found evidence of mitigation and imposed a sanction.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/hearings.php

BACP Professional Conduct Hearing

Findings, decision and sanction, Mo Smith, Reference No: 543554 Lincolnshire PE9

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

The Panel was unanimous in its decision that these findings amounted to Professional Malpractice in that the service for which Ms Smith was responsible fell below the standards that would reasonably be expected of a practitioner exercising reasonable care and skill. The Panel found Ms Smith had been incompetent and had provided an inadequate professional service.

The Panel found no evidence of mitigation and imposed a sanction.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/hearings.php

BACP Professional Conduct Hearing

Findings, decision and sanction, Elaine Squires, Reference No: 617107 Doncaster DN11

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

The Panel made a number of findings and it was unanimous in its decision that these findings amounted to Professional Malpractice in that the service for which Ms Squires was responsible fell below the standard that would reasonably be expected of a practitioner exercising reasonable care and skill. The Panel found that Ms Squires had provided an inadequate professional service.

The Panel found no evidence of mitigation and imposed a sanction.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/hearings.php

Sanction compliance

Elaine Squires, Reference No: 617107, Doncaster DN11

BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in this edition of the journal has been lifted. The case is now closed. This report is made under clause 5.2 of the Professional Conduct Procedure.

BACP Professional Conduct Hearing

Findings, decision and sanction, Jillian Walker, Reference No: 509755, Hertfordshire HP3

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

The Panel made a number of findings and it was unanimous in its decision that these findings amounted to professional malpractice on the grounds of Incompetence in that the services which Ms Walker provided to the Complainants fell below the standard reasonably expected of a practitioner exercising reasonable care and skill.

The Panel found some mitigation and imposed a sanction.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/hearings.php

Sanction compliance

Jillian Walker, Reference No: 509755, Hertfordshire HP3

BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in this edition of the journal has been lifted. The case is now closed.

This report is made under clause 5.2 of the Professional Conduct Procedure.

Withdrawal of membership

Lynda Anderson, Reference No: 615181, Edinburgh EH10 6UB

Information was disclosed to BACP, which was considered under Article 12.6 of the Memorandum and Articles of Association.

The nature of the information raised questions about the suitability of Ms Anderson’s continuing membership of this Association and it raised concerns about the following in particular:  Ms Anderson’s actions have brought, or may yet bring, not only this Association, but also the reputations of counselling/psychotherapy into disrepute.  The information further suggests that there may have been a serious breach, or breaches, of the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy.

The Article 12.6 Panel subsequently made a number of findings and it decided to implement Article 12.6 of the Memorandum and Articles of Association and Ms Anderson’s membership was withdrawn.

Any future application for membership will be considered under Article 12.3 of the Memorandum and Articles of Association.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/termination.php

Withdrawal of membership

Valerie Collins, Reference No: 574652, Derbyshire DE56 0TA

A sanction was imposed on Ms Collins following a Professional Conduct Hearing.

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

Withdrawal of membership

Anne-Marie Dennis, Reference No: 661500, Exeter EX1 1DL

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

The Panel made a number of findings and was unanimous in its decision that these findings amounted to serious Professional Malpractice in that the service for which Ms Dennis was responsible, fell below the standards that would reasonably be expected of a practitioner exercising reasonable care and skill. The Panel found that in this case Ms Dennis, displayed incompetence and provided an inadequate professional service.

The Panel found no evidence of mitigation. Having regard to BACP’s remit of public protection, the Panel was unanimous that Ms Dennis’ membership of BACP should be withdrawn.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/termination.php Withdrawal of membership

Laura How, Reference No: 740381 , Somerset BS26 2DA

A sanction was imposed on Ms How following a Professional Conduct Hearing.

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

Withdrawal of membership

Monika Jephcott, Reference No: 514976, East Sussex TN22 1BP

A sanction was imposed on Ms Jephcott following a Professional Conduct Hearing.

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

Withdrawal of membership

Wendy Mooney, Reference No: 618860, Kent CT1 3QE

Information was disclosed to BACP, which was considered under Article 12.6 of the Memorandum and Articles of Association.

The nature of the information raised questions about the suitability of Ms Mooney’s continuing membership of this Association and it raised concerns about the following in particular:  Ms Mooney allegedly engaged in a sexual relationship with a former client.  Ms Mooney failed to inform BACP of the termination of her contract.  Ms Mooney’s alleged actions have brought, or may yet bring, not only this Association, but also the reputations of counselling/psychotherapy into disrepute.  Ms Mooney’s alleged behaviour was incongruent with that which is expected of a member of BACP.  By virtue of her actions, Ms Mooney’s fitness to practise was allegedly impaired.  The information further suggested that there may have been a serious breach, or breaches, of the BACP Ethical Framework for Good Practice in Counselling and Psychotherapy.

The Article 12.6 Panel subsequently made a number of findings and it decided to implement Article 12.6 of the Memorandum and Articles of Association and Ms Mooney’s membership was withdrawn.

Any future application for membership will be considered under Article 12.3 of the Memorandum and Articles of Association.

Full details of the decision can be found at http://www.bacp.co.uk/prof_conduct/notices/termination.php

Withdrawal of membership

Raymond Stevens, Reference No: 521492, Kent TN14 7ED

A sanction was imposed on Mr Stevens following a Professional Conduct Hearing.

Mr Stevens failed to comply with the sanction and subsequently his membership of BACP was withdrawn. Any future application for membership of BACP will be considered under Article 12.3 of the Memorandum and Articles of the Association.

Sanction compliance

Claire Bergman, Reference No: 596232, West Yorks BD20

BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in the September 2015 edition of the journal has been lifted. The case is now closed.

This report is made under clause 5.2 of the Professional Conduct Procedure.

Sanction compliance

Robert Morrisey, Reference No: 705648, Rochdale OL16

BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in the July 2015 edition of the journal has been lifted. The case is now closed.

This report is made under clause 5.2 of the Professional Conduct Procedure. Sanction compliance

Kerry North, Reference No: 585063, Doncaster DN7

BACP was satisfied that the requirements of the sanction have been met. As such, the sanction reported in the July 2014 edition of the journal has been lifted. The case is now closed.

This report is made under clause 5.2 of the Professional Conduct Procedure. +++ Behind the pictures

Illustrator Daniel Haskett describes his creative process and what inspired his illustrations in our November issue

Do you consider yourself to have a trademark style? If so, how would you describe it? My style is very textured and doesn’t look digital although the final product is produced in Photoshop. I use a limited colour palette, which has an older feel to it with bright elements, and I steer clear of being too ‘vintage’ or nostalgic.

How would you describe the creative process you go through when working on your illustrations or does it vary? I first look around for photos that inspire me and if inspiration doesn’t strike me I will try to take photos while walking outside. For this brief, I was lucky enough to take photos of older African women on the streets of London, which helped a lot to find the right character, headdress and posture.

Then I do a lot of sketches, first in black and white then followed by colour. I always decide on three colours that compliment and contrast with each other before actually applying colour. I am always interested in creating a tension between the various colours.

I paint the different layers in black ink or paint and then scan them in where they are assembled in Photoshop, so I can add colour and a variety of textures to ensure a hand-printed look.

How do you come up with your ideas and what inspires you? When I first read a text, I write down the key passages and sentences that have a strong visual or conceptual element to them. Then I will revisit these excerpts the following day to discover which part of them stayed with me and appears to be the most important. Ideas come most easily when the writer has already used metaphors to explain and develop their point.

Inspiration comes mostly from photography from the second half of the 20th Century, when photography really became an art form and flourished as a means for expression and was no longer just a reproduction of reality.

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? Generally my ideas develop gradually, although sometimes I will have a picture that immediately comes to me. In this case, the retired therapist sitting in his chair was the main image I could see in my head when first reading the article. Can you describe what inspired your Therapy Today illustrations? The main inspiration was the atmosphere created within the articles. I wanted to create imagery that was quite dark and showed the mental strain that afflicted the African Caribbean women as well as the therapists entering retirement.

Did illustrating these particular subjects throw up any challenges? If so, what were they? There were two main challenges. The first was finding imagery of older black women who looked somewhat contemplative and weighed down by their experiences.

The other challenge was handling an article that addressed the resultant problems behind the growing bureaucratic machine that is the NHS. There are plenty of clichéd approaches to that kind of subject matter and I didn’t want to create an image that felt old and boring.

Can you describe in a nutshell what you were trying to convey with each image? With the African Caribbean imagery I was essentially trying to create two images from different perspectives that showed a black woman suffering alone in England with her mental health.

With the NHS piece I was trying to show how much the paperwork and ‘tick box’ mentality weighs down on therapists working within a healthcare environment.

Finally for the retirement article, I wanted to show a therapist in a dark office contemplating his future without work and moving into a perpetual holiday. I hope I created a mood that showed some of the anxiety that accompanies this move.

How do you feel about your finished work and do you have a favourite image? I am really happy with how everything turned out and especially with how the images sit in the layouts. I think my favourite image would be the therapist contemplating retirement because of the atmosphere and light that I created.

Apart from Therapy Today, where else might we see your work? The Guardian, Reader’s Digest, Carluccio’s 2015 Christmas packaging, Little Brown books and Vinn Goute, a Seychellian street food trader in London.

Daniel Haskett lives between Berlin and London. As well as working as a freelance illustrator, he teaches at Middlesex University each week and has a 20-month-old son in Berlin to keep him busy. Email [email protected] For more information about his work, visit www.danielhaskett.com, https://www.facebook.com/haskettillustrates or Twitter @danhaskett +++ 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

Cardiff/Newport/Barry Looking to reinvigorate your practice? Senior accredited counsellor and qualified supervisor offers integrative, creative supervision. £45ph (Concessions available). Free consultation session. Contact Jamie Rance 07975 832934; [email protected]; www.jamierance.co.uk

Essex/Hertfordshire border Supervision for individuals and groups. Long experience in statutory, voluntary and private sectors working with children, adults and couples. Contact Caroline Powell-Allen M.A., Registered Member MBACP (Snr Accred) on 01371 873270

Folkstone Senior accredited and experienced integrative supervisor, cognitive and psychodynamic, NHS and private, and support with accreditation. Groups and individuals. Contact Claire 07957 147301

Glossop/Tameside/Stockport/High Peak/Oldham/Manchester UKRCP MBACP (Snr Accred), highly experienced counsellor and supervisor. Over 15 years experience, person centred/integrative. Reasonable rates. Concessions available. Contact Janet 07809 227192; [email protected]

Hebden Bridge Qualified, experienced, seven-eyed model supervisor specialising in adult, children and young people caseloads. Online/f2f welcome. Student/volunteer reductions. Contact Jill 07531 194319; [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

London, NW6/NW3 Experienced, person-centred/integrative, Member MBACP (Accred) counsellor and qualified supervisor. Negotiable rates for trainees and those with low income. Contact Jonathan Rosen 07951 933671; [email protected]

Manchester Well experienced in private and voluntary sector, Manchester based, fully qualified PCA/CBT therapist is currently undergoing supervision training and able to offer free/low cost supervision sessions. Contact [email protected]

Milton Keynes/Bedford Intergrative supervisor with years of experience. Lynn Somerfield, integrative/transpersonal psychotherapist and supervisor, works London and Bedfordshire area. Contact Lynn 07762 738238; www.lynnsomerfield.co.uk

NW London, Hertfordshire and Buckinghamshire. Experienced Member MBACP supervisor and counsellor. Intergrative, person centred, CBT, EMDR. Reduced rates for trainees. Contact Teresa Townsend 07958 303487; [email protected]

Preston, Lancashire Experienced and qualified supervisor, trained in Shohet & Hawkins supervision model. Integrative therapist and have a working knowledge of most major methodologies. Contact www.thomfairclough.co.uk; [email protected] 07892 724023

Staffordshire Member MBACP (Accred). Qualified supervisor, integrative. Experienced provider of consultative support for supervisors and senior accreditation. F2F, telephone and online. Qualified to work with couples and families. Contact Carla Thompson 07890 425960; www.ctcounselling.co.uk

Telephone, Skype/FaceTime. BACP Member MBACP (Accred) supervisor with over 20 years experience offering supervision. Experienced in short-term, EAP and workplace counselling. Contact Marcia 07495 913789; [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] Placement

Find a placement in your local area on the placements noticeboard

Camden Volunteer counsellors (minimum 50 client hours experience) for CRI Counselling Service working with addictions. Person centred, CBT, integrative, systemic approaches. Training offered. Supportive team; clinical supervision. Contact [email protected]; 07500 220735

Crawley Horsham and mid-Sussex Volunteer placements for counsellors/psychotherapists. Our counselling service provides 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

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

Milton Keynes/Bedford/Chelmsford/Stevenage/Ipswich/Bury St Edmunds Looking for therapists working with medical staff (work stress, exam anxiety). Would prefer CBT base and EMDR but not essential. Start asap. Please contact [email protected]">[email protected] with your location, experience and qualifications.

Solace Women’s Aid Domestic Violence Counselling is looking for female volunteer counsellors. Qualified/ in final year of counselling diploma and 150 supervised clinical hours and knowledge of domestic violence. 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

Wales (North, mid and West) We are looking for accredited, volunteer counsellors to join Cynnal, the Churches’ Counselling service for clergy and their families. Contact Wynford 02920 302101

West Sussex 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

Are you a qualified relational counsellor interested in self-care? Are you willing to share those experiences for my research study? If so please contact [email protected]. Thanks

Do you work within IAPT? Ever worked with a deaf person or wondered what you would do if a deaf person was referred to you? Help us evaluate IAPT services for deaf people - http://www.nursing.manchester.ac.uk/iapt

Therapists with a parent who is a therapist. Participants sought for MA research. Must be qualified, practise talking therapy and have a parent who is/was a therapist. Contact [email protected]

Have you experience of a person centred therapist's self-disclosure of a mental health condition? If so would you be willing to talk about your experience? Please contact Chris Lewis 07828 463368; [email protected]

Masters research Seeking counsellors/therapists who identify your practice as relational, to explore how you experience and perceive the effect of client work within your personal life. Contact [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] Networking

Find a networking group to join in your local area

New peer support/networking group in Central Scotland. Looking for experienced, newly qualified and student practitioners to join, share and support. If interested contact [email protected]; 07787417872

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]

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